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 Table of Contents  
Year : 2022  |  Volume : 14  |  Issue : 2  |  Page : 79-84

Knowledge regarding orthodontic iatrogenics, challenges, and management strategies among orthodontists and orthodontic postgraduate students: A questionnaire survey

1 Department of Orthodontics and Dentofacial Orthopaedics, KLE's Vishwanath Katti Institute of Dental Sciences, Belagavi, Karnataka, India
2 Department of Public Health, Jawaharlal Nehru Medical College, KAHER, Belagavi, Karnataka, India

Date of Submission08-Apr-2021
Date of Decision28-Jun-2021
Date of Acceptance03-Jul-2021
Date of Web Publication26-Apr-2022

Correspondence Address:
Amit B Nilgar
514, Prajakta Shakti Marg, Shivbasav Nagar, Belagavi - 590 010, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijds.ijds_45_21

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Context: Negligence or improper care during orthodontic treatment results in various unwanted complications due to the orthodontic appliances. Iatrogenics is a situation that leads to reversible or irreversible damage to patients' health which is unintentionally induced by treatment. The knowledge and foresight to predict any iatrogenic incident will help an orthodontist to avoid any greater complications in the predicted outcome of orthodontic treatment. Aim: The aim of the study was to assess the knowledge of orthodontists and orthodontic postgraduate students regarding iatrogenics, its challenges, and management strategies. Settings and Design: An online questionnaire survey. Subjects and Methods: A predesigned pretested questionnaire on awareness, challenges, and management domains regarding iatrogenics, involved during orthodontic treatment, was circulated using Google Forms among orthodontists and orthodontic postgraduate students. Statistical Analysis Used: Responses of the participants were entered in excel and were assessed using descriptive and frequency statistics in SPSS (version 20). Results: It was observed that only 10% of participants had sufficient knowledge regarding iatrogenics which can possibly occur during any orthodontic treatment, its challenges as well as the management. Only half of the participants were trained to handle these kinds of situations. Conclusions: Orthodontists and orthodontic postgraduate students had an average to poor knowledge regarding iatrogenics involved in orthodontic treatment, its challenges, and management strategies.

Keywords: Challenges, iatrogenic causes, knowledge, management, orthodontists, questionnaire survey

How to cite this article:
Nilgar AB, Shukla T, Dhagavkar PS, Desai DV. Knowledge regarding orthodontic iatrogenics, challenges, and management strategies among orthodontists and orthodontic postgraduate students: A questionnaire survey. Indian J Dent Sci 2022;14:79-84

How to cite this URL:
Nilgar AB, Shukla T, Dhagavkar PS, Desai DV. Knowledge regarding orthodontic iatrogenics, challenges, and management strategies among orthodontists and orthodontic postgraduate students: A questionnaire survey. Indian J Dent Sci [serial online] 2022 [cited 2023 Nov 30];14:79-84. Available from: http://www.ijds.in/text.asp?2022/14/2/79/344071

  Introduction Top

Patients undergo orthodontic treatment for various purposes, of which dental esthetics is an important reason. Physical attractiveness as well as self-esteem is crucial factors which depend on dental esthetics.[1],[2] Orthodontic treatment has innumerable such benefits both functional and visual which usually outweigh their disadvantages, but these appliances also cause unwanted complications.

In 1996, Behrents defined iatrogenics as harm which is unintentionally induced by treatment.[3] This can even occur during any orthodontic treatment due to negligence of the orthodontist. The knowledge and foresight to predict and explain patients about any possible iatrogenics during an orthodontic treatment will not only help in dealing with them but also will form a baseline for an efficient and ethical practice.

  Subjects and Methods Top

A questionnaire survey was conducted on orthodontists and final-year orthodontic postgraduate students residing/practicing/studying in India for a period of 3 months from December 2020 to February 2021.

A minimum sample size of 80 was derived using the “Sample size for Frequency in a Population” formula.

Where, N = population size (for finite population correction factor) (Barreto and Feitosa[4]) =100

p = Hypothesized % frequency of outcome factor in the population = 50%

d = Confidence limits as % of 100 (absolute ± -%) =5%

DEFF = Design effect (for cluster surveys) =1

Z1−α/2 = Critical value at confidence level of 95%, α is 0.05, and the critical value is 1.96.

All orthodontists working as teaching faculty as well as in a clinical setup, and all orthodontic postgraduate students studying in either government or private dental institutes who gave consent were included in the study, while dentists with diploma in orthodontics, professionals, and/or students residing overseas and the 1st- and 2nd-year postgraduate students were excluded.

Data were collected using a predesigned questionnaire. The questionnaire was made in English language. A pilot study was conducted on 10% of the total sample size who were not included in the main study to assess the reliability of the questionnaire. The questionnaire was then validated by experts in the field of orthodontics and necessary modifications were made.

The questionnaire consisted of three parts

  1. Consent form

  2. It was the first page of the Google Forms, and the subsequent pages could be accessed only after the consent form was filled by the participants.

  3. Sociodemographic details

  4. It included details such as age, gender, the type of setup participants worked at or were presently studying, and the state they belonged to.

  5. Main questionnaire which was divided into three domains

    • Awareness domain – to test knowledge on the topic “Iatrogenics in Orthodontics”
    • Challenge's domain – to understand the problems encountered due to iatrogenics during orthodontic treatment
    • Management domain – to assess the skill of participants when dealing with iatrogenic problems.

E-mail ids of included participants were obtained, and the questionnaire was circulated among them online through Google Forms. The study participants were also contacted individually for responses. Strict confidentiality of the participants' information was maintained during the study by coding the names of all the participants.

Data entry was done in Microsoft Excel and it was analyzed in SPSS version 20 software by IBM, United States. Frequency and percentage were used to analyze the level of knowledge and attitude. Chi = square test was used to find associations.

  Results Top

A large number of study participants belonged to the age group of 21–30 years. Majority of them were females and most of them were students from a private institutional setup [Table 1].
Table 1: Sociodemographic distribution of study participants

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More than half (67.1%) of the participants were aware about the meaning of iatrogenics in orthodontics. Majority of them (71.8%) knew about the contributing factors and thought that it was necessary to create awareness about iatrogenics (88.2%), but only half of them (51.8%) were trained for dealing with iatrogenic incidents [Table 2].
Table 2: Distribution of participants in awareness domain

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In the challenges domain, 51.7% of the participants answered that iatrogenic incident during orthodontic treatments can occur due to multiple causes. It was noticed that only 51.8% and 62.4% of the participants knew about slow-release intraoral fluoride release devices and debonding forces, respectively, and hence there was less than average knowledge among the participants regarding advances in dentistry which might help in decreasing iatrogenic incidences [Table 3].
Table 3: Distribution of participants in challenges domain

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In the management domain, it was observed that 100% of the participants believed that it was essential to take a pretreatment consent from the patient, out of which 58.8% of them believed that the consent should ideally be signed by the patient if he/she is above 18 years of age and if below 18 years of age, then the parent or guardian should sign the consent. In situations where one has a mentally compromised patient, it was observed that 37.6% of the participants were of the opinion that the consent has to be signed by the nominated representative or relative or friend of the patient. About the precautions to be taken to avoid iatrogenic incidents, 57.6% of the participants answered that adequate time for diagnosis and treatment planning, formulating reminder methods for patients with orthodontic auxiliaries, and keeping a regular follow-up will help minimize iatrogenic incidents. Methods which were individually practiced to prevent damage to intraoral soft tissues included almost half (54.2%) of the participants cutting short the distal ends of orthodontic wires, use of bumper sleeves on wires that are long spanning, and giving the patients wax so that mucosal irritation can be avoided [Table 4].
Table 4: Distribution of participants in management domain

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Majority of the study participants (68.2%) had an average knowledge regarding iatrogenics in orthodontic treatment, its challenges, and management strategies while very few of them (10.7%) showed good knowledge [Figure 1].
Figure 1: Distribution of participants according to overall knowledge score

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  Discussion Top

In the present study, it was observed that majority of the participants only had average knowledge regarding iatrogenics in orthodontics and only half of the participants had received any training regarding this subject. Hence, it is extremely essential to implement various strategies to increase the cognitive as well as skill-based knowledge and awareness of orthodontic fraternity in this field.

A research was conducted by Barreto and Feitosa on 100 subjects for a 6-month long time period by evaluating pre- and post-treatment records and dividing the patients into various groups. It was found that more than 50% of the cases were affected by iatrogenics or relapse which illustrates the increased frequency of such incidents.[4] Thus, decreasing them should be a priority. The study also reported patients with some degrees of iatrogenics who were originally treated by dentists trained according to all required standards. Majority of the participants in this study agreed that iatrogenic incidents occur even when the orthodontist is well trained.[4]

According to Greco, the large number of orthodontics training courses resulted in dentists whose attitudes were not consistent with health promotion and this seriously affected the patient's treatment and outcomes.[5]

As expressed by Barreto and Feitosa, orthodontic records of patients with iatrogenic problems should be impeccable.[4] Nearly all participants (95.3%) in the current study agreed that it was important to keep previous and current records of patients who had iatrogenic problems. The study also concluded that personalized informed consent should be the principal instrument to be adopted while treating orthodontic patients with iatrogenic problems to ensure that treatments are clear and transparent.[4] In the present study, multiple responses were obtained when the participants were asked about consent forms and who should sign it indicating confusion regarding the legal aspects and precautions to be followed while treating iatrogenic cases was not clear.

Sanders in his study had found that patients did not pose any significant periodontal risk when orthodontic treatment was done using optimum forces, if the patients had excellent oral hygiene and no preexisting periodontal disorders.[6] In agreement to this, only 5.9% of the participants in this study had answered that periodontal problems were caused due to orthodontic iatrogenic incidents, while very few (17.6%) had encountered periodontitis as iatrogenics during orthodontic treatment in their clinical practice. Orthodontic iatrogenics cannot be attributed to one single cause.

Gencay et al. presented a case report of the inadvertent use of coiled spring which caused resorption of labial alveolar bone plate and stripping of gingival tissue,[7] but majority of the participants in this study agreed that root resorption after orthodontic therapy rarely results in significant morbidity and that cessation of active forces also ceases root resorption.

Meeran in their article recognized that orthodontic patients were at a higher risk of decalcification or caries. They stated that the incidence of accidental tooth fracture can be avoided by applying debonding forces lower than 13 MPa and that there is a minimal risk of harmful side effects on the marginal tissue as long as movement of teeth is within the envelope of the alveolar process.[8] More than half of the participants in this study agreed that the incidence of white spot lesions (WSLs) indicating decalcification was higher in patients 5 years after completing the orthodontic treatment, while less than half of the participants (37.6%) were aware about the optimum force which could be applied during debonding.

Majority of the participants also agreed that, in patients with fixed orthodontic appliances, lozenges containing xylitol can significantly reduce the acidity of dental plaque as stated in the study by Meeran.[8]

Sangamesh and Kallury also stated that orthodontic patients have significantly more WSLs than nonorthodontic patients. The authors also found sufficient evidence to suggest that glass ionomer cement is more effective than composite resin in preventing WSL.[9]

Ozcelik et al. had presented cases on iatrogenics in orthodontics which concluded that they were mainly caused due to improper placement of the orthodontic appliances.[10]

Most of the participants in this study agreed that, when the roots of teeth are paralleling divergent, the severity of a black triangle formed due to the coronal and gingival relation decreases. Syed et al. in their review on iarogenic damage to the periodontium caused by orthodontic treatment procedure stated that black triangle or open gingival embrasure can occur as a complication in about 1/3 of all adult patients undergoing orthodontic treatment.[11]

Various studies have shown that the use of fluoride in toothpastes or rinses helps reduce decalcification and WSLs during orthodontic treatment.[12],[13] Nearly half of the participants (48.2%) in this study were unaware of the recently developed slow-release intraoral fluoride release devices which are very effective in remineralizing the incipient lesions and preventing WSLs after orthodontic treatment which shows that the knowledge regarding recent developments in this field was insufficient.

  Conclusions Top

It can be thus concluded that orthodontists and orthodontic postgraduate students had average-to-poor knowledge about iatrogenics in orthodontics. Only half of them had received any training to handle iatrogenic situations and practiced any preventive measures to avoid iatrogenic incidents while treating orthodontic patients. Knowledge regarding advances in dentistry which might help in decreasing the incidences of iatrogenics was also average. However, results of the study cannot be extrapolated due to it being carried on a small scale. Interventional studies can be planned to assess any change in knowledge regarding the subject. Including iatrogenics as a subject in undergraduate and postgraduate curriculum, conducting workshops lectures as well as case-based presentations and educating dentists about developing an efficient record keeping systems can be done to increase the awareness and knowledge regarding iatrogenics.

Ethical clearance

Ethical Clearance was obtained form the Institutional ethics committee of Vishwanath Katti Institute of Dental Sciences Belagavi.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kerosuo H, Hausen H, Laine T, Shaw WC. The influence of incisal malocclusion on the social attractiveness of young adults in Finland. Eur J Orthod 1995;17:505-12.  Back to cited text no. 1
Gazit-Rappaport T, Haisraeli-Shalish M, Gazit E. Psychosocial reward of orthodontic treatment in adult patients. Eur J Orthod 2010;32:441-6.  Back to cited text no. 2
Behrents RG. Iatrogenics in orthodontics. Am J Orthod Dentofacial Orthop 1996;110:235-8.  Back to cited text no. 3
Barreto GM, Feitosa HO. Iatrogenics in orthodontics and its challenges. Dental Press J Orthod 2016;21:114-25.  Back to cited text no. 4
Greco PM. The time is now. Am J Orthod Dentofacial Orthop 2013;143:449.  Back to cited text no. 5
Sanders NL. Evidence-based care in orthodontics and periodontics: A review of the literature. J Am Dent Assoc 1999;130:521-7.  Back to cited text no. 6
Gencay K, Tuna EB, Yaman D, Ozgen M, Demirel K. Iatrogenic orthodontic dental trauma: A case report. Quintessence Int 2013;44:631-4.  Back to cited text no. 7
Meeran NA. Iatrogenic possibilities of orthodontic treatment and modalities of prevention. J Orthod Sci 2013;2:73-86.  Back to cited text no. 8
Sangamesh B, Kallury A. Iatrogenic effects of orthodontic treatment – Review on white spot lesions. Int J Sci Eng Res 2011;2:2-16.  Back to cited text no. 9
Ozcelik O, Haytac MC, Akkaya M. Iatrogenic trauma to oral tissues. J Periodontol 2005;76:1793-7.  Back to cited text no. 10
Syed R, Kumar Pradeep YG, Shriparna B, Prabhu SS, Chandrashekar BM, Rakesh MP. Iatrogenic damage to the periodontium caused by orthodontic treatment procedure: An overview. Dent Open J 2015;9:234-28.  Back to cited text no. 11
Geiger AM, Gorelick L, Gwinnett AJ, Benson BJ. Reducing white spot lesions in orthodontic populations with fluoride rinsing. Am J Orthod Dentofacial Orthop 1992;101:403-7.  Back to cited text no. 12
Boyd RL. Comparison of three self-applied topical fluoride preparations for control of decalcification. Angle Orthod 1993;63:25-30.  Back to cited text no. 13


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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