Straight to the Point – balancing patient demands and ethics

‘It couldn’t be more important’: With the rise in demand for cosmetic dentistry, this month Saba Quershi discusses how to balance these patient demands with the ethics of orthodontics.

I’ll be the first to admit that I was somewhat of a nerd at dental school.

You know the type…attended every single 8:30am lecture to produce wonderfully colour-coded notes which were then photocopied and distributed throughout the year group.

However, even I struggled with the ‘drier than a desert’ dental ethics module.

But, given the current demand for cosmetic dentistry, it couldn’t be more important.

The definition of dental ethics is: ‘The moral duties and obligations of a dentist towards his/her patients, professional colleagues and society.’ And it should, of course, be an integral part of treatment planning for all our patients.

As with any cosmetic treatment, many orthodontic patients will attend practices with very set ideas of what they would like to achieve. They will also know exactly how they want to achieve this, both in terms of appliance design and cost.

But these ideals may not align (pardon the pun) with ideal treatment options and long-term stability.

Increased access to frequently inaccurate oral health information, across a variety of social media platforms, adds to the challenge.

With this in mind, let’s have a closer look at some of the challenges we may encounter and how we might deal with them.

Treatment modalities

Interest in aligner treatment amongst patients has skyrocketed in recent years. In addition, direct-to-consumer (DTC) orthodontic companies have waded in to take advantage of this market.

I have had many patients who are desperate to have their teeth straightened, but are only willing to have this done with aligners. I’m sure I am not alone.

Whilst I agree that ‘all is fair in love and war’, and business…this places dental professionals in a tricky spot.

Do we provide less than ideal aligner treatment for patients who would benefit more from fixed appliances to, at least, protect their dental health by providing monitored treatment? Or do we fight tooth and nail for the ideal?


  • Discussions regarding the dangers of unmonitored orthodontic treatment, such as those provided by DTC aligners, should be had. The benefits of treatment with a dental professional are manifold, and these should be made clear
  • Whatever treatment option patients may request, informed consent cannot be obtained without discussing alternative treatments and the pros and cons of each modality
  • All clinicians must work within their area of competence
  • Where clinicians only provide aligner treatment, they should offer patients referral to an orthodontic specialist so that they can discuss their treatment options in full.

Compromised treatment plans

There are a few scenarios that spring to mind where compromised treatment may be considered in orthodontics. Particularly in times where treatment doesn’t go as planned and adult patients request ‘tweaks’ to their smile.

The former may be because of lack of patient co-operation, for example sporadic elastic wear, poor compliance with functional appliances or poor oral hygiene.


  • Inform patients when treatment becomes compromised as soon as it’s identified
  • Clear explanations of the benefit of wearing appliances and elastics correctly and an opportunity to improve compliance
  • Reiterate the importance of good oral hygiene and reduction of dietary sugar, as well as the risks of failure to comply
  • Discussion of possible alternative treatments where suitable
  • Discontinuation of treatment where patient co-operation has been exhausted or where there is a risk of damage to teeth.

Adult patients requesting purely cosmetic alignment of anterior teeth without any consideration of the effects of such movements on the occlusion or stability can be challenging to manage.

Where compromised treatment is deemed suitable:

  • Ideal treatment should still be discussed for informed consent
  • A discussion regarding which problems will be addressed should be have
  • Provide a thorough explanation of which problems will not be corrected
  • Explain the risks and benefits of each treatment option
  • In the short-term, bending to patients demands may appear to keep them happy. In the long-term, we may be setting ourselves up to fail.

Don’t be afraid to refuse treatment or suggest patients seek a second opinion elsewhere, should you have differing opinions regarding treatment goals.

Financial expectations

Even though provision of NHS orthodontics for all children changed some 20 years ago, patients and parents are still surprised to hear that NHS treatment may not automatically be available to their child.

This leads to a great deal of dissatisfaction and distrust of orthodontists, particularly if patients have been told they should qualify.

As to private patients, there must be an understanding that fees will vary between clinicians for a variety of reasons. In addition, they may need to attend several practices to find the clinician that they feel most comfortable with and confidence in.


  • Good communication with dental colleagues so they have a better understanding of the Index of Orthodontic Treatment Need (IOTN), by which orthodontists will assess patient qualification for NHS treatment
  • Clear explanations of the reasons for non-qualification under the NHS and provision of routes to appeal should patients be dissatisfied. In my experience, the latter is rarely required following explanation
  • Honest pricing strategies and payment plans allowing fees to be spread over the course of treatment. This will allow patients to explore their full range of available treatment options. Beware of rushing to undercut your competition every time. This is unlikely to work long-term. So, instead, build value into your fees so patients can see their investment is a worthwhile one.

Communication is key

Orthodontic treatment tends to run over a period of months, even years. Therefore, balancing patients’ expectations will always be challenging as expectations may change over the course of treatment.

By and large, patients considering orthodontic treatment have some awareness of what to expect with regards to the orthodontic process and treatment outcomes, expecting improved dental appearance and function.

But this may vary with the patient demographic.

Younger patients may overestimate treatment outcomes and underestimate the complexity of treatment. This is due to their perceptions of beauty and information accessed through social media.

So, as is often the case, communication is key.

It is not enough to simply ‘do no harm’.  We should be striving to provide the very best treatment outcomes for our patients and safeguarding their dental health.

Catch up on previous Straight to the Point columns:

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