An interesting study looks at orthodontic treatment harm.

One basic principle of health care is that we should not cause harm to our patients. Nevertheless, information on the harms we may cause in orthodontics is very limited. A new study from Denmark examined this question. I thought it provided useful information we could use with our patients.

A team from Aarhus and Copenhagen did this study. Orthodontics and Craniofacial Research published the paper. 

This paper is open access so we can all read it. 

What did they ask? 

They did this study 

“To analyse the reasons why patients file claims for compensation related to orthodontic care, to summarise the events that led to patient harm and to describe the types of harms associated with the provision of orthodontic care”. 

What did they do? 

They conducted a retrospective evaluation of data from the Danish Dental Compensation Association Database. This is a national no-fault compensation scheme. Patients who experience physical or medical injury in connection to dental treatment can apply for financial compensation under this scheme. 

Importantly, the scheme does not provide compensation for dissatisfaction with treatment outcome.

If a patient wants to make a claim, they complete a brief online form, which is submitted to expert examiners who review the case and determine whether harm has occurred. The case is then passed on to a legal officer who makes a final compensation decision. 

The investigators analysed data from patient-reported claims related to orthodontics between June 2017 and August 2024. 

They carried out a descriptive analysis to summarise the data. 

What did they find? 

The database recorded a total of 644 patient-reported claims. When they analysed these claims, 196 (30.4%) were recognised as treatment-related harms and eligible for compensation. 

When they examined patient claims that were both accepted and not accepted, they found that relapse after treatment was the most frequent reason for a claim (18.63%), followed by lack of treatment effect (12.58%) and worsening of the occlusion (8.54%).

They then identified the causes of the harms. These were the treatment itself (51.5%), delayed diagnosis (24.5%) and problems with retention (9.2%).

When they looked at the categories of harm from orthodontic care that were accepted for compensation, they found that the most frequently recognised harm categories were

– Apical root resorption resulting in tooth loss (14.8%)

– Gingival or soft tissue injury (13.3%)

– Worsening of the occlusion after orthodontic treatment (9.2%)

The overall conclusions were 

“Most of the harms arise in the active phase of orthodontic treatment and are frequently the result of root resorption, soft tissue damage, and worsening of the occlusion after treatment”. 

What did I think? 

This is an unusual study unique to Denmark because of its complaints system. I feel that this is an interesting development because it may remove the adversarial nature of claims. Importantly, claims are handled centrally, and both the claimant and the orthodontist/dentist can appeal the decision.

I could not determine liability for the compensation awarded. This information would have been useful.

Interestingly, the compensation claim did not necessarily indicate malpractice by the provider. I know this is certainly not the case in some countries. 

When I looked at the recorded harms, it was interesting that the most common were root resorption, gingival injury, or worsening occlusion. In some ways, this may not be surprising. However, it was notable that complaints of root resorption were upheld. I had thought that our formal consent procedures, which were very specific about root resorption, would negate such claims. Again, I am not sure whether this would be the case in other countries. 

The authors highlighted some weaknesses in this study and noted that the findings were only relevant to Denmark. Importantly, the database may not capture all claims made during that period, as some would not be submitted through the database. Thirdly, it wasn’t possible to distinguish specialists from generalists. This would certainly be very important information. 

Overall, I thought this paper provided robust and highly relevant information for our consent process and clinical practice. If I were still working clinically, I would make sure to emphasise the risks they recorded in our consent process.