Orthodontic Retention: Part 3

In the two previous posts on orthodontic retention Dr. Cheryl DeWood Associate Professor at Midwestern University Dental School looked at:

1. When does the orthodontist’s responsibility for retention end?
2. What do I do with a patient whose orthodontist will not or cannot see him/her for retention?
3. What is the responsibility of the orthodontist with regard to retention?

In this final segment she answers the question that as a GP is my biggest concern.

4.  Should I consider being responsible for managing a patient’s retention myself?
Rather than compose a prolonged “if, then” statement, I’ve attached a decision tree diagram that summarizes the thought process I use to answer this question.  You’ll note that the first two steps in the decision tree relate back to our previous discussion about referring back to an orthodontic specialist for management of retention.  However, for most of the GP’s I talk with about this, the crux of the matter begins with the next step; whether to manage retention themselves.  Answering this question requires GP’s to come to terms with the fact that if they do not want to address the issue of retention, patients are left to their own resources; that’s what the first “see text” asterisk refers to.  My observation is that this is a relatively large area of unmet need; there are lots of post-ortho patients who, understandably, want to protect their investment, and not many orthodontists who are particularly interested in long-term follow-up.  That leaves you, as the GP, in the position of persuading your orthodontist to manage retention for your patients, or doing it yourself.  That’s a dilemma each GP needs to resolve individually, and something I encourage GPs to include in their discussions with the orthodontists to whom they refer.
But to continue; suppose you decide that you are willing to manage retention as part of the comprehensive care you provide for your patients.  We have already established that it is a defining characteristic of an ethical practitioner to refer when the needs of the patient demand the care, skill, and judgment of a specialist.  So, when does retention require specialty-level care?  The short answer is, (as might be inferred if you peek ahead at the decision tree) that it depends in part on whether the orthodontic result is reasonably stable.  I think it’s easier to determine stability when a patient has removable retainers; if removable retainers are worn on a limited basis (one or two nights a week or less) and it appears that there has been little or no tooth movement, it is reasonable to conclude that the orthodontic treatment result is stable.  In addition to the obvious indicator of alignment, other indicators of a stable orthodontic treatment result are balanced occlusion, snug interproximal contacts, and lack of fremitus.  Given these indicators, replacing a broken or worn retainer is a valuable service for patients, and comes with little risk to the GP.
In contrast to the patient who has been wearing removable retainers, a patient with a fixed retainer that is broken or missing, determining stability is more difficult.  By definition, a fixed retainer is in place 100% of the time, and it’s harder to know how likely it is that the teeth would move without it.  However, if a fixed retainer has been in place for years before it breaks or a bond fails, it is reasonable to conclude that the retainer simply wore out, and that a replacement retainer will work well.  In the case of a patient whose fixed retention has failed in a relatively short period of time, lack of stability could be a factor in its failure.  In such a case, consideration of the other stability indicators mentioned above is helpful.
In those cases where you decide to replace retainers, you should be aware that you assume responsibility for the patient’s orthodontic result thereafter.  While it is your intention to help your patients, managing retention, unfortunately, creates the potential for a perfect “no good deed goes unpunished” scenario.  I advise that you maintain a record of the patient’s condition, with photos at least, prior to making new retainers or even if you simply adjust an existing retainer.  It is also prudent to consider the patient’s general level of ownership with regard to his/her dental condition; a patient with a history of poor compliance overall may also have poor compliance with retainer wear.
If you suspect that a patient’s result is unstable, orthodontic retreatment may be indicated.  Of course, no patient likes to hear this, but, as you know already, you do your patient a disservice if you fail to advise them of any condition for which treatment is appropriate.  If the patient elects to have retreatment, then, again, you are at a “Finished” point in the decision tree.  However, a patient with an unstable result may decline retreatment, or the result may be unstable for reasons will not be helped by retreatment.  You’ll note that you have the same choices if you decide to manage retention in unstable situations; either fixed or removable retainers, but I think it is a helpful thought step to actually consider which you are dealing with.  By doing so, you can more appropriately assign a value to the service you are providing.  For example, you can reasonably expect that you will spend more time and effort managing the retention of a patient who is unstable, and that a higher fee may be appropriate.  For a stable patient, you will likely have little to do other than to provide the retainer and let it do its work.

Lest you think that I have over-thought all this, I’ll tell you the issue of retention is one that comes up all the time among my dental students, many of whom fall into the category of post-treatment ortho patients who can’t go back to their treating orthodontists.  It is a question that I hear frequently from my GP colleagues as well (not just you).  I think it’s a subject that merits more attention than it is generally given in the discussions between GPs and the orthodontists to whom they refer.  If nothing else, I hope this will be the impetus for some of those discussions to occur.