Orthodontists routinely refer patients to oral surgeons or periodontists for exposure of impacted or ectopic teeth. Although other specialists perform these procedures, the orthodontist could have a legal responsibility to obtain informed consent, depending on how the referral orders are written. The purpose of this article is to discuss some considerations of the informed consent process for surgical exposure and alignment of impacted or ectopic teeth, and to suggest a template for an informed consent form for this use.
As part of the American Association of Orthodontists’ Risk Management Series in 2003, Dr David Musich recommended a customized, specific informed consent procedure for impacted canines when, concurrent with a patient’s orthodontic treatment, an impacted canine must be surgically exposed before it can be aligned orthodontically. Even though the patient will be referred to an oral surgeon or a periodontist for the exposure, the orthodontist could have a legal responsibility to obtain informed consent for the procedure, depending on how the referral order is written. Certain courts have noted that “a physician who formally orders a procedure has a duty to obtain the patient’s informed consent, even if [he/she] does not personally perform the procedure” (cit.omit.) (O’Neal v Hammer, 953 P.2d 561 [Hawaii Sup. Ct., 1998]).
From a risk management viewpoint, it is best to avoid, when possible, giving specific orders for a dental procedure to be performed by another specialist. For example, Jerrold recommended that, instead of writing a referral that asks the periodontist to “please evaluate tooth number 24 for a free gingival graft” or, worse, “please perform free gingival graft on tooth number 24,” you should be more general and write “please evaluate perio status of tooth number 24.” (Because various tooth numbering systems are in use, it is also a good idea to refer to the tooth by name.) In this way, you will not need to provide informed consent for the procedure. Additionally, you might not have the training or expertise to explain the inherent risks of the procedure ordered. Jerrold also suggested that you request and document that you have received a copy of the patient’s signed informed consent from the practitioner to whom you referred the patient.
Because we have not personally seen informed consent forms for surgical exposure of impacted or ectopic teeth given by orthodontists, the purpose of this article is to suggest a template for an informed consent form for exposure and alignment of impacted teeth. This template could be used as a guide, and clinicians can modify it for their own practices.
Stages of consent
Patients should be asked to give their informed consent for alignment of surgically exposed teeth at various stages of treatment ( Fig ). One form should be signed at the initial consultation. Later, when it is time to surgically expose the impacted tooth, the issue of surgical exposure of impacted teeth should be revisited, and a new form should be signed and sent to the oral surgeon or periodontist specifying the tooth or teeth to be exposed. The oral surgeon should have the patient sign a separate informed consent form and send a copy to the orthodontist. Having informed consent from both the orthodontist and the oral surgeon might seem a bit like wearing a belt and suspenders simultaneously, but it cannot hurt. In addition, Jerrold warned against obtaining a patient’s informed consent and then burying the form in the patient’s chart. Informed consent is a continuing process that reflects the changing ambience of orthodontic care rather than a single document signed before treatment.
If a panoramic radiograph shows impacted or ectopic maxillary canines in the mixed dentition, the orthodontist might decide to delay orthondontic treatment (except for possible extraction of the maxillary primary canines) until the patient is older because the roots of the maxillary lateral incisors could be resorbed by pushing them into the crowns of the erupting ectopic or impacted maxillary canines. Becker and Chaushu cited 2 articles showing that, with improved imaging with computed tomography scans, the estimated resorption of the maxillary lateral incisors due to impacted canines rose from 12% of patients in 1987 to 38% in 2000. More recently, using three-dimensional localization of maxillary canines with cone-beam computed tomography, Walker et al found that 92.6% of 27 impacted canines were palatal; maxillary lateral incisor resorption adjacent to an impacted canine was 66.7%.
1. Musich D.: Current concepts of risk management: a clinical update, Part II.Franklin E.Musich D.Ichida W.Risk management program, “Reducing malpractice exposure in your practice.”.2003.American Association of OrthodontistsSt Louis: 103 rd Annual Session (CD)
2. Jerrold L.: A matter of degrees. Am J Orthod Dentofacial Orthop 1998; 114: pp. 606-608.
3. Jerrold L.: Defending claims for lack of informed consent. Am J Orthod Dentofacial Orthop 2004; 125: pp. 391-393.
4. Becker A., Chaushu S.: Long-term follow-up of severely resorbed maxillary incisors after resolution of an etiologically associated impacted canine. Am J Orthod Dentofacial Orthop 2005; 127: pp. 650-654.
5. Ericson S., Kurol J.: Radiographic examination of ectopically erupting maxillary canines. Am J Orthod Dentofacial Orthop 1987; 91: pp. 483-492.
6. Ericson S., Kurol J.: Resorption of incisors after ectopic eruption of maxillary canines: a CT study. Angle Orthod 2000; 70: pp. 415-423.
7. Walker L., Enciso R., Mah J.: Three-dimensional localization of maxillary canines with cone-beam computed tomography. Am J Orthod Dentofacial Orthop 2005; 128: pp. 418-423.