Root resorption is a recognised risk associated with orthodontic treatment, with potentially significant long-term consequences for the patient. It is, therefore, not surprising that a proportion of the higher value orthodontic claims we deal with at Dental Protection will involve root resorption.
Our philosophy is to support safer practice in dentistry and to help members avoid problems arising in their professional practice. One of the many ways we look to support members in reducing risk is by sharing insights from our cases and claims, to help understand how problems may arise and, most importantly, how they can be prevented in the first place.
A review of claims, relating to orthodontic treatment in patients aged under 18 at the start of treatment, identified that approximately 10% had allegations relating to root resorption. Factors noted in the cases, which may have placed the patient at a higher risk of root resorption included ectopic/ unerupted canines, history of trauma prior to commencing treatment, and root shape.
It is important that, where there is a risk of root resorption, this is communicated to patients as part of the consent process. We have seen that alleged failings in the consent process were a dominant factor in over 50% of the claims reviewed. Predisposing factors that increased the risk of root resorption were present in many of the cases we supported. In this situation, it is important for clinical records to demonstrate that:
- The increased risk had been identified.
- The specific risks that a particular patient faced had been discussed and understood by the patient.
- The treatment plan proposed was appropriate.
- Alternative ‘lower risk’ alternatives had been considered and communicated to the patient.
- Appropriate monitoring of teeth was undertaken during treatment.
Experts will invariably opine on the above and these are the points on which claims involving root resorption may succeed or fail. Where predisposing factors are present, and the records only provide evidence that a patient had been provided with generic information about the risks, it is unlikely the warnings will be found to be sufficient to demonstrate that consent to treatment was valid.
Where a patient is successful in their claim, damages can be significant. For a young patient, tooth loss may result in damages to cover a lifetime of implant placement and restoration cycles, as well as reflecting the psychological impact.
Secondary factors in root resorption claims include allegations relating to inadequate monitoring, prolonged treatment and poor outcome. In around a third of the cases in our previous study where predisposing factors were noted, secondary allegations were made that there had been inadequate monitoring of the teeth during active treatment. When considering these allegations, experts will comment on whether monitoring was in line with any recognised guidance and teaching. Where there is a lack of consensus, the case will be assessed on whether the approach taken was reasonable at that time. For those treating patients with a known history of trauma, guidance such as that by Sandler et al (2021)1 would be of relevance and may be relied upon by experts.
Orthodontic treatment is not without risk, and for some patients the risks of treatment may outweigh the benefits. Ultimately, the decision on whether to proceed with orthodontic treatment rests with the patient, who must make this choice based upon balanced and objective information that has been shared by the treating clinician to help a patient understand the risks.
Identifying that significant root resorption has arisen is not only distressing for the patient but also generates significant anxiety for the clinician who has treated the patient. It is, however, important to remember that this finding will not necessarily result in a patient making a complaint or claim and they are less likely to do so if they had understood and accepted the risk of this arising at the outset.
Similarly, being the subject of a claim does not mean that the claim will need to be settled. In most of the cases we see, successful defence of a claim may depend upon the details within the records to support that consent was valid and clinical treatment was appropriate.
As a general guide, the following checklist may help in the defence of a claim but, perhaps more importantly, avoid a patient going down this route in the first place:
- Ensure any orthodontic assessment routinely includes an assessment of any potential risk factors for root resorption and documents both positive and negative findings.
- Where the assessment identifies a patient may be at a higher risk of root resorption, ensure that the records reflect the specific risk that patient faces and whether alternative treatment options, including no treatment at all, were discussed. Where risks are increased, ensure that any written information provided to the patient is tailored to reflect the identified increased risk.
- If it is proposed to monitor root health during treatment with radiographs, ensure that a clear note is made in the records as part of the treatment plan as to when any radiographs should be taken. This is particularly important in settings where a patient may be seen by multiple clinicians or where care is being transferred.
- In the event root resorption is identified, it is important to be open and honest with patients and ensure that not only is the presence of the root resorption discussed but also what steps may be necessary to mitigate any further exacerbation of the problem. Before continuing with further treatment, the consent process should be revisited, and records updated to reflect the discussions and options discussed.
- In the event teeth are subject to trauma after treatment has commenced, ensure any assessment and ongoing treatment reflects contemporary guidance and teaching. It is important to also revisit the consent process, to ensure the patient is involved in any further decision making, and aware of the risks and alternative options.
Yvonne Shaw
About the Author
Yvonne Shaw, Deputy Dental Director at Dental Protection.
References
- Guidelines for the orthodontic management of the traumatised tooth. Cara Sandler, Tumadher Al-Musfir, Siobhan Barry, Mandeep Singh Duggal, Susan Kindelan, Jay Kindelan, Simon Littlewood, Hani Nazzal J Orthod. 2021 Mar;48(1):74-81
