A discussion of orthodontic adverse effects and the signing of an informed consent document are important steps prior to the initiation of clinical orthodontic treatment procedures.
It has been demonstrated that patients may listen to an outline of possible dental or medical deleterious side effects, not really understand them, respond negatively when asked if they have any questions and then just routinely sign the consent form as a matter of habit.
This type of scenario invites misunderstandings down the orthodontic treatment “road” and experience shows there are usually at least a few bumps along this road for both patient and practitioner.
Clinical explanations of adverse effects may be met with nodding heads, but in many cases patients will have hardly a clue what the implications of say, “termination of treatment due to unexpected root resorption” or “exacerbation of temporo-mandibular joint disorder symptoms” may mean. Better to smooth out the road before traveling down it.
“I remind students that most of them possess the same limited understanding of medical language as many of their future patients, and I encourage them to always remember those feelings of confusion, uncertainty and anxiety.” Dr. Frank R. Serrecchia, Midwestern University
While practitioners may not use the sterile clinical language as mentioned above when talking about adverse effects of orthodontic treatment or dentistry in general to their patients, making sure the patient has at least a reasonable layman’s understanding may help both parties know that they are “on the same page”. This approach can help mitigate later misunderstandings if treatment or patient expectations come into question.
If there is doubt that informed consent may be misunderstood or only partly understood by a layman, a practitioner need only look at the American Association of Orthodontists informed consent (1) form. Although an excellent well thought out document, it informs the patient using dental jargon for the most part. Granted, this dental “language” may be required for legal purposes.
Arguably however, it is understandable that a patient might have some difficulties answering an honest “yes” to the signature acknowledgement, “I hereby acknowledge that I have read and fully understand the treatment considerations and risks presented in this form.”.
As mentioned earlier, patients routinely glance over these types of consent forms and sign them without really knowing the contents. They generally rely and trust what the orthodontist has told them and leave it as that.
Explaining Orthodontic Adverse Effects – Analogies, Metaphors and Similes
A common strategy when attempting to explain complex problems (2) in meaningful layman’s terms is the use of metaphors, similes and especially, analogies.
- Analogy: compares things so that a relationship between them can be understood.
- Simile: compares things by using “like” or “as”, e.g., an implant is like the root of a tooth.
- Metaphor: compares by saying “is”, e.g., An implant is a “tooth root replacer”.
These methods may be helpful when outlining the nature of orthodontic treatment adverse effects during informed consent discussions.
While each practitioner will have preferences for creating unique analogies (3), similes or metaphors for their own patients and case situations, some examples of possible analogies involving some adverse effects are offered as a starting point.
- Enamel decalcification – A suggested analogy is a comparison of how household products containing acid may erode, discolor or otherwise damage surfaces. This analogy can be combined with an explanation of how proper oral hygiene practices prevent acid from plaque and food debris from remaining in contact with the enamel around bracket edges, etc., causing “white spots”. Further, that in most cases any damage is usually temporary or can be easily treated micro –abrasion (“sanding”).
- Periodontal problems – A visual comparison of the attached gingival with a shirt sleeve may help patients understand the progression and damage of periodontal disease from poor oral hygiene practices. A normal attached gingiva equated with a tight sleeve around the wrist, a looser sleeve compared with inflammation and more of the wrist showing – gingival recession.
- Loss of pupal vitality – A plant may serve as an analogy where the pulp and periapical foramen blood vessels are compared with a plant. Pressure, crushing or cutting of the root (periapical vessels) causes eventual wilting and “death” of the plant.
- Temporomandibular Disorders (TMD) – Many patients are likely to have suffered a “sore jaw”. However, it might be helpful to relate the Temporomandibular Joint (TMJ) to a door hinge with a spring where repeated opening and closing of the hinge (TMJ) may cause the spring (muscles) to malfunction.
- Root resorption – Although the exact reasons for root resorption are not understood, a comparison of an icicle shrinking with warmer temperature may be a good visual for a layman’s understanding.
- Soft tissue damage – Any comparison of a hard object rubbing against a softer object could serve as an appropriate analogy for this adverse effect. One example might be how a carpet is damaged (traumatic ulcer) by excessive foot traffic.
- Occlusal adjustment – Regarding the need for occlusal equilibration, any analogy that relates sanding an object so that it fits together correctly with another object would be apt.
Another suggestion for appointments that involve informed consent is to have patients repeat back in their own words their “take” on what has been discussed regarding informed consent and adverse effects.
Use of Images
“A picture is worth a thousand words” is certainly true when attempting to explain dental terminology and procedures to laymen patients. The use of images and/or drawings combined with verbal analogic explanations may increase the chances for understanding by the patient.
If patients are having a difficult time understanding a concept, the use of photos (4), pictures and/or drawing a sketch may often be very helpful. No art degree is required here. A simple pencil drawing of a tooth root followed by shorter and shorter shrinking tooth root images should suffice to demonstrate root resorption.
A notebook, tablet or computer containing selected photos and/or pictures from the orthodontist’s own practice or internet sources might be worth a small investment in time and a larger later investment not only in patient education, but helping to prevent future patient misinterpretations.
The approach of using analogies, similes and metaphors for helping patients understand orthodontic adverse effects can be applied to other areas of treatment such as cephalometric analysis, wisdom tooth extraction etc.
Some practitioners may find this analogy, simile and metaphor patient communication method comes naturally to them, while others may find it difficult, cumbersome, seemingly unnecessary or awkward. However, the idea that good communication does enhance patient rapport (5), possible choice of an orthodontist (6) and/or prevent future “difficulties” may be a worthwhile incentive to practice a bit and give these ideas a “dental…….college” try.
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