Advise Patients About Their Role in Maintenance

Avoid litigation by advising patients that wearing a retainer is key to maintaining alignment.

When orthodontic patients have their treatment completed, they are excited with the results. But they need to understand those results won’t remain without maintenance. You can help patients by assuring that they understand the importance of wearing their retainers and caring for them properly.

The Final Phase of Successful Orthodontic Care: Maintenance

The process of moving teeth is only the first step in achieving tooth alignment. The second, which often involves wearing a retainer, is maintenance. You can help patients be more satisfied with their results by educating them on the importance of this critical step.

Advise your patients that orthodontic treatment can help fix crooked teeth but can’t prevent changes from occurring after the first step is complete. Just as it took time to move teeth into proper alignment, it also takes time for the bone, ligaments, and surrounding tissues to adjust to the new placement and for the bite to stabilize. As a result, the risk of relapse in the first month after treatment is very high. And if a relapse occurs, teeth may take even longer to stabilize in future treatment.

The only proven way to avoid having teeth move back to their original positions is through wearing a retainer and ongoing maintenance. Progress in Orthodontics confirmed that retention procedures are “considered necessary to maintain the corrected position of teeth following orthodontic treatment and to mitigate against characteristic age-related changes.” Retainers apply gentle pressure to help keep teeth from drifting back to their original positions.  

Patients should also understand that teeth tend to shift throughout life as a normal part of aging. That's why wearing a retainer—sometimes indefinitely—is the most reliable way to maintain long-term results of orthodontic treatment. Made of plastic or metal, retainers can help keep teeth aligned after active orthodontic care is complete.

If your patients are still struggling to understand the importance of maintenance, try using a relatable analogy: When you buy a new car, it needs regular oil changes, tire rotation, and standard repairs to continue running properly. It's the same with the “new” positions of your teeth. Without regular maintenance, the teeth will gradually shift out of place and create problems. Your newly achieved smile and oral health could be lost.

The Proper Care of Retainers

Once your patients understand the importance of wearing their retainer, ensure they understand how to properly care for it.

There are different requirements for the care and wear of retainers, depending on the individual’s specific orthodontic needs. As an orthodontic specialist, you will be able to guide them on the best practices for their individual case.

When you discuss retainers, you may also want to educate them on the differences and the ways they can avoid problems:

• Fixed retainers are secured in place with bonding resin and can be more reliable for orthodontic care since they are worn 24/7. However, the obvious drawbacks to this type of retainer are maintenance costs related to its repair and/or bonding resin, as well as oral hygiene issues associated with fixed appliances.
• Removable retainers can be made of wire or plastic and should be worn as prescribed. The obvious drawback for this kind of retainer is that its success is dependent on the patient's compliance.

In either case, good oral hygiene is needed to assure the teeth and gums remain healthy. And patients should understand there may be temporary discomfort as they adjust to the appliance. If discomfort continues, however, they should have the retainer adjusted. In addition, if there are any other problems—loss, breakage, warp—patients should contact your office.

Orthodontic retention procedures and the possibility of retainer breakage were recently addressed in an AJO-DO survey. The results suggest prevention of such breakage could be handled through regular post-treatment checkups. Let them know that it's not unusual to require an adjustment or new retainer as part of standard maintenance due to normal changes that occur within the mouth as people age, such as gradual “uprighting”—the movement of front teeth on the lower jaw, which can cause the teeth to crowd and move closer to the tongue. Therefore, regular retainer checkups are necessary to assure teeth remain in place and no adjustments are needed.

Another part of educating patients is to provide guidance to help with compliance and successful maintenance:

• If the retainer is removable, it should be kept in its protective case whenever it's not being worn. Patients should keep their retainer case with them, so that the retainer is not stored in a pocket, purse, or napkin, where it may be more easily damaged or thrown away. It's also important that the retainer is kept away from pets and heat (boiling it in water or leaving it in a hot car could cause damage). Remind them to keep the retainer clean—perhaps by brushing it with toothpaste before and after removal or using an effervescent cleanser.
• If the retainer is fixed, it should still be cleansed through brushing and flossing; patients may also find interproximal toothbrushes helpful.

Educating the patient on all aspects of their retainers is important so they are aware of what’s required to keep their smiles healthy.

The Primary Way to Avoid Litigation

In summary, it's important to help patients understand that braces are only the first step to transforming and improving oral health. Maintaining their smile by wearing a retainer and having regular checkups is just as critical to achieving long-term orthodontic success. Remind them that “retainers are prescribed for two reasons: first, to allow the bone that holds teeth to rebuild after teeth have moved, and second, to maintain the healthy new positions of teeth after active treatment ends.”

While it is important that patients understand the need to wear their retainers to keep their teeth aligned, it is equally important for orthodontists to limit their long-term liability. As long as you continue to see patients in retention, you are still potentially liable for that patient.

AAOIC recommends setting a specific retention period that is included in your orthodontic fee and then formally dismissing your patients, returning them to their general dentist’s supervision (which includes third molar observation if still present). With fixed lingual retainers, give patients a choice whether to keep them or have them replaced with removable retainers. Inform patients they can be worn until they become loose. Tell them, when they do become loose (and they ultimately will), they can be removed by their general dentist or they can return to you for that additional service. Be sure to provide appropriate instructions on maintaining their orthodontic result for their lifetime. 

It is also important that the options for fixed retainers and dismissal instructions are clearly noted in the treatment record. That way, the statute of limitations can begin to run, which may help in the defense of a case if there is a problem with a patient in the future.

Educating patients about all their orthodontic treatment is the primary way to avoid litigation. Help them understand the importance of oral health while they are wearing braces and maintaining their smile by wearing a retainer. You may even want to have patients sign a document to acknowledge your discussion about the retainer. If they understand their role in successful treatment, they are less likely to be unhappy with the results or file a claim. Of course, if you ever face a professional liability case, the AAOIC is here to help. Learn more about the malpractice insurance selected by most orthodontists.