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When Patients Go Off the Rails

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When Patients Go Off the Rails

How orthodontists handle the unreasonable few

Every orthodontist eventually encounters that patient, the one who turns routine care into a nightmare. Maybe it’s someone who throws tantrums in the clinic, insists treatment should be faster, or starts hinting about lawsuits the moment things don’t move as quickly as they’d like. It’s the kind of situation that tests your patience, professionalism, and every bit of communication skill you have.

One orthodontist recently shared an all-too-familiar story: a deep bite case that had been fully corrected, with lower braces placed afterward to address moderate crowding. Treatment had been progressing for a year, right on track, but the patient grew increasingly agitated that the lower incisors weren’t straightening fast enough. Despite clear expectations from the start, the patient became confrontational, verbally aggressive, and even hinted at legal action.

The advice from peers was consistent: These cases are rarely winnable in the traditional sense, but they can be managed with care and documentation.

Most orthodontists agreed that the first line of defense is meticulous recordkeeping. Every conversation, photo, and progress note matters. When behavior becomes volatile, having a record of discussions about timelines, treatment goals, and biologic limitations can make all the difference. One seasoned practitioner suggested sitting down with the patient—along with a staff witness—to review the consent form, the expected duration of treatment, and the reality that tooth movement is controlled by biology, not by willpower or impatience. Clarify that you are providing the appropriate level of care and that no orthodontist has an incentive to prolong treatment unnecessarily.

Another common recommendation was to notify your professional liability carrier early. Even if the situation doesn’t escalate, it’s better to have them aware and ready to guide you. Patients can make legal threats at any point during or after treatment, but prompt communication with your insurer ensures you have protection and documentation in place should things turn serious.

The topic of refunds drew mixed opinions. While it might seem easier to issue a refund to end the drama, many clinicians cautioned against doing so unless advised by your insurance provider or legal counsel. Some shared stories where a full refund failed to appease the patient, who continued posting negative reviews anyway. Others regretted refunding patients who had clear psychiatric or behavioral issues, as it offered no real resolution. The general advice is not to pay for peace unless it comes with a formal release agreement that legally ends the doctor-patient relationship.

Release-from-care agreements, where recognized, can be an effective option. These forms formally terminate treatment and can limit future liability, but they must be used correctly and under the guidance of your malpractice provider. Depending on your region, your insurance society or professional association may have sample templates available.

Orthodontists also stressed the importance of protecting your staff. Verbal aggression or intimidation toward team members is never acceptable. Make it clear to the patient that such behavior won’t be tolerated and that continued hostility will result in dismissal from the practice. Setting firm but professional boundaries demonstrates leadership and reassures your team that their well-being comes first.

Finally, several practitioners pointed out a truth many clinicians eventually learn: A small percentage of the population simply cannot be satisfied. Some of these patients may have undiagnosed psychological or mood disorders that make them poor candidates for orthodontic care.

No amount of logic, empathy, or technical skill can bridge that gap.

In those moments, the best you can do is protect yourself, your team, and your reputation through documentation, professionalism, and clear communication. Orthodontic treatment depends as much on trust as it does on mechanics, and without mutual trust, even the best treatment plan is doomed to frustration.

Have you ever had to end treatment early or dismiss a difficult patient? How did you navigate the situation while keeping your practice protected and your sanity intact? 
What’s your take?

Share your thoughts in the comments below.

Hot Topic articles draw inspiration from active online discussions among orthodontists. Written by the editorial team with the assistance of AI, each piece is thoughtfully developed and refined under full editorial oversight.
Orthotown Magazine
November 2025
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