Don't start without the charting.

Last year, the American Association of Orthodontists (AAO) Board of Trustees appointed President Lee Graber and me to a joint task force along with the current president of the American Academy of Periodontology and another practicing periodontist. Our charge was to determine how orthodontists can avoid being sued for periodontal problems that arise during orthodontic treatment. Is this a real problem? Most definitely! Here are the facts. According to conversations with the claims manager for the AAO Insurance Company, periodontal problems that develop or exacerbate during orthodontic treatment currently account for the largest portion of liability claims against orthodontists. The purpose of the task force was to determine how to avoid this trend. Lee Graber and I began a series of conference calls with the 2 periodontists. Our goal was to establish a protocol so that orthodontists can determine which adult patients are at risk of developing periodontal problems. Obviously, the first key is to have a thorough health history, consisting of specific questions that might uncover a risk for potential periodontal complications, such as smoking, diabetes, or past periodontal therapy. A second major ingredient in determining periodontal risk is to have appropriate intraoral radiographs. Most orthodontists take panoramic radiographs before treatment. These radiographs will show significant bone loss, but they are inadequate to diagnose subtle interproximal bone loss. And since the x-ray tube makes a curved path around the patient’s head during the radiographic exposure, it causes overlapping of some posterior contacts and further blurs the image of the crestal bone. The periodontists informed us that the gold standard for diagnosing posterior bone levels is a vertical bitewing. With this image, the x-ray beam passes through the occlusal surfaces of the posterior teeth, and therefore the distance from crestal bone to cementoenamel junction (CEJ) is accurate. In the maxillary and mandibular anterior regions, periapical radiographs are the best for evaluating bone levels. Usually, 3 maxillary and 3 mandibular anterior periapicals are necessary to make a thorough assessment. The periodontists advised that CEJ to bone levels of 5 mm