248 pp; 342 illus (234 color)

Contents
1 Classification of Undesirable Tissue, Organ, and System Effects Hypothetically Linked to Orthodontics: An Introduction
2 Enamel Color Alterations Associated with Orthodontics
3 Enamel Effects During Bonding-Debonding and Treatment with Fixed Appliances
4 Metabolic Profile of Orthodontic Patients Exhibiting Root Resorption: An Assessment of the Biologic Predisposition Hypothesis
5 Minimizing Orthodontically Induced Root Resorption
6 Damage to Tooth-Supporting Tissues in Orthodontics
7 Release of Wear and Corrosion Products from Orthodontic Alloys: A Review of Mechanisms and Biologic Properties
8 Polymers in Orthodontics: A Present Danger?
9 Pain and Discomfort in Orthodontics
10 Temporomandibular Disorders and Orthodontics
11 Orthodontic Treatment for the Medically Compromised Patient
12 Risk Management
13 Malpractice Aspects of Orthodontic Treatment in Patients with Periodontal Disease
14 Avoiding Malpractice Lawsuits: Lessons Learned from Actual Malpractice Case Histories
15 Practical Legal Advice for Avoiding Malpractice Lawsuits

Preface
Over the last two decades, a new and complex pseudo-discipline has evolved: litigation and malpractice. This unlikely blend of principles, derived from the broader health and law sciences, is man-made; it cannot be defined by natural rules, and its implications vary greatly. Although the risk of litigation due to medical and dental malpractice is much higher in the United States than in any other part of the world, fears regarding medicolegal involvement and risk management plague health service providers everywhere. Today, practitioners devote a significant amount of time and effort, probably equivalent to half of that devoted to education, to avoiding legal entrapment arising from often trivial omissions, such as failing to record on the patient file that the parents of the adolescent patient had “ample time to study the treatment plan” and that they “definitely have no question or concern.” This development has transformed the health care provider into a record-keeper homo malpracticus! To paraphrase Mark Twain: “Adam and Eve had many advantages besides escaping teething: the main one was that there were no malpractice cases at that time.”

It would be interesting to review the malpractice cases of the last decade and record the direct involvement of the clinician, conscious or involuntary, that resulted in harm to the patient’s well-being. It is difficult to explain the paradox that the delirious proliferation of malpractice cases in the US has been accompanied by an equally tremendous increase in fatal iatrogenic incidents, reaching the shocking number of 100,000 per annum! Logic would tell us that malpractice litigation would lead to higher standards of care by eliminating careless or reckless practitioners. Since this does not seem to be the case, perhaps future studies can critically analyze these indices to identify the underlying causes for both incident increases. Furthermore, the practitioner’s need for legal protection has led to an increase in the number of diagnostic procedures prescribed to comprehensively evaluate the pretreatment health status of the patient, thereby increasing malpractice coverage insurance premiums and the application of complicated, legalistic informed consent protocols.

In orthodontics, where the risk of harm is considerably limited compared to surgery or other invasive medical therapies, malpractice has taken on significant dimensions over the past decade, thus compelling the scientific community to issue guidelines to avoid the unfortunate incidents. This book has been written for the orthodontic community to achieve two basic aims:

1. To explore the etiopathology of various conditions that have been described to emanate from orthodontic treatment, and
2. To define the risk factors associated with the induction of pathologies, in an effort to isolate and eliminate them from the standard practice.

The first aim corresponds to Section 1 of the book, comprising 10 chapters that exhaustively review current knowledge on the association between orthodontic treatment procedures and materials and several adverse tissue or system reactions. These include the dental hard and soft tissues and systemic reactions. As these sections make clear, there is no consensus established on the direct association between any procedure or material and a potential harmful situation. To put it in lay terms, one can find evidence to substantiate both positive and negative involvement of specific procedures in pathology, and varying degrees of severity can be found in the condition induced. Several factors have contributed to what has become a very chaotic situation: contradicting studies; case reports describing severe effects that are nevertheless rare; variability in approaching research questions; and statistical or methodological flaws in studies that have found their way into publication, often because of less-than-qualified reviewing processes. Because of this situation, contingency fee plaintiff attorneys can manipulate the literature so that it will appear to substantiate their case to an uninformed jury—”It’s written in the journal.” Although the current litigious trend displays geographical and geopolitical boundaries, limited mainly to the US and Canada, the implications are that the editors of orthodontic journals should make every effort to seek the opinion of the best-qualified experts for the manuscript review process. Furthermore, an effort should be made to eliminate personal opinions that are not directly related to the results of the study. Unfounded and undocumented anecdotal statements too often serve as the basis for legalistic arguments and, when taken out of context, could alarm the public unnecessarily. The final chapter in this section offers specific examples of how to manage orthodontic problems in the presence of other disorders or abnormalities.

Section 2 addresses the first part of the title of the book, that is, risk management. Again, this is the first nontechnical guide to avoiding malpractice written from diverse perspectives: that of an orthodontist who is also an expert in litigations; an orthodontist-periodontist who has specialized in dental malpractice for more than two decades; an insurance specialist; and an attorney who has specialized in professional liability for the past 20 years. The chapters in this section are based on a program in Philadelphia in 2001, by the American Association of Orthodontics, which was sponsored by the AAO Insurance Company (AAOIC). The material summarizes cases tried in the past, tells you the dos and don’ts of treating patients, and formulates a risk-management plan for a safe practice, presenting simple steps that could prevent future complications. This section alone warrants a place on your reference library shelf.

To bring this volume to print, a team of 21 specialists has been assembled from 6 countries on two continents, representing different professional, academic, and research backgrounds and interests. We extend our gratitude to all the eminent scholars involved in this team effort for their contributions and to Quintessence for being the first publisher to realize the impact that risk management imposes on the average practitioner.

Edited by:

T. M. Graber, DMD, MSD, PhD
Theodore Eliades, DDS, MS, Dr Med, PhD
Athanasios E. Athanasiou, DDS, MSD, Dr Dent