December 07, 2020

What risks should we inform our patients about?

Orthodontic treatment is not without risk.  We must inform our patients about as many risks as reasonable. But which ones are essential. This new paper lets us know.

When we discuss treatment with our patients, we need to inform them of all reasonable risks.  There have been several important court rulings in the UK, USA and Australia that have recommended that we give our patients a reasonable amount of information on the risks of their treatment.  In effect, we need to practise shared decision making.

However, we also need to consider that the evidence base for some of our risks is not high.  This concept brings us to the idea of forming a reasonable professional community standard. This problem was the subject of this exciting new paper.

A team from Cardiff, Wales did this study. The American Journal of Orthodontics published the paper.

Professional consensus on orthodontic risks: What orthodontists should tell their patients

John Perry et al.  AJO On-Line DOI:

What did they want to do?

They wanted to:

“Gain a professional consensus on the risks that should be discussed as part of consent for orthodontic treatment”.

What did they do?

They did a fascinating study using the Delphi technique.  We also used this in a study that developed a Core Outcome Set for orthodontics. A Delphi is a method of gathering information about a subject by collecting the opinion of a group of people.

The authors did this study in several stages:

  • Firstly they did a structured literature review to identify risks associated with orthodontic treatment. They identified papers from literature searches. Two of the authors then extracted the risks from the papers.
  • They included the risks that they identified in the first round of a Delphi survey. They asked members of the British Orthodontic Society to take part in the online survey. In the first part, the respondents looked at the list of risks and scored their importance using a scale from 1 to 9.  Score 1 was not important, and a score of 9 was completely critical.  They then classified the risks against a predetermined definition of consensus. This enabled them to identify the risks that would go forward to the second round.
  • They then analysed this data to provide information on the overall quartiles of the scores. This information was then included in the second round of the online Delphi along with a reminder of their score for each respondent. They asked the respondents to review their score and make any changes bearing in mind the scores of the complete panel. They then applied the definition of consensus again to identify the final selection of risks.
What did they find?

After the second round of the Delphi, they identified the following risks:

  • Demineralisation/Caries
  • Relapse
  • Length of treatment
  • Root resorption
  • Pain/discomfort
  • Consequences of doing nothing
  • Appliances breaking
  • Failure to achieve the desired tooth movements.
  • Gingivitis
  • Ulceration

When they looked at their response rate, they sent out 1479 requests to participate. Three hundred forty-five members responded (23% response). Three hundred twenty-one responded to the second round (74% response).

What did I think?

This study was not the “usual” type of orthodontic research paper. As a result, I thought that it was interesting and very relevant to our clinical practice.  The authors used the Delphi technique to obtain information from a large sample of orthodontists. This method is a significant strength of the paper.  The authors also made the very relevant point that poorly trained operators and direct to consumer providers are likely to lack the necessary education to explain these risks.

They also felt that we could use this information to develop risk communication tools to help our patients come to informed decisions about their treatment choices.


One potential shortcoming of this study was the response rate. While some may feel that this is low. The authors pointed out that this was similar to the response rate for other Delphi techniques. As a result, it is acceptable.  I also wondered if the list would be different for orthodontists outside of the UK.  It certainly is possible to repeat this study in other countries.

In general, I thought that this was a fascinating and valuable contribution to the literature.

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Have your say!

  1. This is indeed a critical research project that provides us with a better-supported list of risks that have to be discussed with our prospective orthodontic patients. The depth of the discussion for each of these topics should be tailored to the individual patient characteristics.
    I would also like to remind us that we think our patients, at least adults, understand better that they actually do what is conveyed to them during the informed consent process (

  2. Kevin,
    Could you not say that inappropriate/mistreatment by the operator/provider is also a risk of treatment?
    Yours aye,
    Bill Reay

  3. Great post. I will read the article closely tonight but the concept of highlighting the real risks that we should review with out patients is really needed.

    Happy Holidays!!!

  4. Risk involved may be aspiration of brackets ,bands and elastic over-rings. Some time burning of tongue ,gingivitis and mucosa with etchent.
    Eye injury with headgear outer bow.

  5. The number one and most common risk of arch expansion is future gingival recession.
    Much literature in peer reviewed journals to support this concept, as we are moving teeth beyond the already deficient bony housing to align them appropriately
    I wish there was a way to attach a jpg image to this blog – can show you umpteen appropriate cases.
    Would love to have the opportnity to review the periodontal complications as a result of expansion therapy, of course in the long-term
    Would also be happy to present a webinar (no charge) on the topic.
    Thanks for what you do.
    Colin Richman DMD ([email protected]

  6. I really don’t know what does this study add to our current knowledge. What did we miss?? nothing new.
    Ok, They used the Delphi.

    Until when we are going to have such safe, non influential papers.
    Honestly, orthodontuc journals are biased to certain authors from certain countries.

  7. Thanks! This is great info!
    I would like to know if someone is willing to share ‘wording’ commonly used for:
    • Consequences of doing nothing
    • Failure to achieve the desired tooth movements
    Our consent form is quite lengthy and we are due to review this document with the goal of keeping it succinct and thorough.
    Thanks again,

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