ISSN: 2320-5407 Int. J. Adv. Res.

9(11), 331-336

Journal Homepage: -www.journalijar.com

Article DOI:10.21474/IJAR01/13747
DOI URL: http://dx.doi.org/10.21474/IJAR01/13747

RESEARCH ARTICLE
MALPRACTICE IN ORTHODONTICS - A REVIEW AND RECOMMENDATION TO OVERCOME THE
SAME

Dr. V. Bhaskar1, Dr. K. Rajasigamani2, Dr. K. Kurunji Kumaran3, Dr. Mohamed Arafath3, Dr. K.
Santhanakrishnan4 and Dr. S.N. Reddy Duvvuri4
1. Research Scholar, Prof., & Head Department of Orthodontics, RMDCH.
2. Research Guide, Prof., Department of Orthodontics, RMDCH.
3. Prof., Department of Orthodontics, RMDCH.
4. Associate Prof., Department of Orthodontics, RMDCH.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History This article aims to describe some of the potential risks of orthodontic
Received: 15 September 2021 treatment which when neglected can lead to a malpractice lawsuit.In
Final Accepted: 17 October 2021 orthodontic practice,categories vary from informed consent or
Published: November 2021 negligent non-disclosure,failure to diagnose,to gross negligence.This
study focuses on creating awareness about the importance of informed
consent before orthodontic procedure to avoid legal issues.Orthodontic
failures do occur sometimes but it should be identified earlier and
rectified.Consent should be seen as a process and any discussions
should be fully and legibly recorded in the patient records. Key words:
Malpractice, informed consent, hazards of orthodontic treatment,
Negligence.
Copy Right, IJAR, 2021,. All rights reserved.
……………………………………………………………………………………………………....
Introduction:-
In this current era of increasing consumerism, we need to be careful and aware of the medico- legal laws as patients
are becoming more consumer oriented. Orthodontist are surely not an exception when it comes to medical
malpractice lawsuits. Patient expectations from orthodontic treatment are much more as it enhances smile and facial
esthetics. There are well defined risks for the patient even with appropriate and skillfully executed treatment. There
are other risks for the practitioner, when the common orthodontic treatment failures are neglected which can be called
as Orthodontic Malpractice. This article aims to describe some of the potential risks of Orthodontic treatment which
when neglected can lead to a malpractice lawsuit.

Orthodontic Malpractice
Medical / Dental malpractice issues are generally based on the unintentional torts of negligence rather than intentional
torts such as assault or battery or strict liability. According to Winfield1,

“Negligence as a tort is the breach of legal duty to take care which result in damage, undesired by the defendant, to the
plantiff.”

The elements of cause of action for negligence in a medical or dental setting are those common to negligence in
general. They are
1) Duty, an obligation owed to the plantiff by thedefendant,
2) Breach of duty, failure of the defendant to meet the obligation owed to theplantiff,

Corresponding Author:- Dr. V. Bhaskar 331

Address:- Research scholar, Prof., & Head Department of Orthodontics, Rajah Muthiah Dental College
and Hospital, Annamalai University, Chidambaram-608002.
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3) Causation, (sometimes referred to as proximate cause), a close, causal link betweenthe breach of the duty
owed to the plantiff by the defendant and the injury suffered by the plantiff.
4) Damages, the sustaining of some compensable injury by the plantiff as a result ofbreach of the
defendant’sduty.

In orthodontic practice, the general categories could be

1) Informed consent or negligent nondisclosure
2) Failure to diagnose, failure to refer or negligentreferral
3) Bad result or failure to achieve a desired treatmentobjective
4) Improper withdrawal ofcare
5) Gross negligence

Breach Of Duty
A health care provider’s duty to inform generally requires disclosure of the nature of the patient’s condition or a
diagnosis; the nature and purpose of proposed treatment; the risks, consequences, and anticipated results of the
proposed treatment; the alternate treatments; the risks, consequences, and anticipated results of the alternative
treatment; and the probable or possible consequences of accepting no treatment 2.

A breach of duty to obtain informed consent may be established if the health care provider fails to address any of the
required elements of disclosure.

Potential Hazards Of Orthodontic Treatment

Improvement in dental health, function, appearance and self esteem are some of the recognized benefits from
Orthodontic treatment. Inspite of these benefits, orthodontic treatment carries with it the risks of tissue damage,
treatment failure and increase predisposition to other dental disorders. Some patients are at more risks than others and
these patients should be informed prior bout the adverse effects, identified earlier and managed appropriately to prevent
any consequences.

The potential hazards of orthodontic treatment are three-fold:

1) Tissuedamage
2) Treatmentfailure
3) Greater predisposition to dentaldisorders

Tissue damage:
Both the intraoral and extraoral tissues are at risk of damage during orthodontic treatment.

EnamelDamage:
With fixed appliances, it was reported that around 0-30μm of enamel is lost due to etching, bonding and then
debonding and residual adhesive removal on the tooth. In a cross-sectional study, it was reported that 50% of
individuals undergoing orthodontic treatment had non- developmental enamel opacity, compared to 25% controls3.
Another study found that, even after 5 years of orthodontic treatment, patients had a significantly higher amount of
enamel opacities than untreated controls4.

Enamel demineralization and white spot lesions occurs during orthodontic treatment and patients should be informed
about this potential risk and every step should be taken to prevent white spot formation. Patients should be advised
about oral hygiene maintenance and fluoride applications before and during treatment.

EnamelFractures:
Sometimes small cracks in the enamel surface are seen after removal of orthodontic appliances. These cracks serve as a
stagnation area for the development of caries, cause partial tooth fracture or may discolor. These are more often seen
with chemically bonded ceramic brackets and patients should be informed about these during the consent process.
Zachirsson et al5 found that the prevalence of pronounced cracks in relation to the total number of cracks was 6% for
debonded teeth and 4% for untreated teeth.

Periodontal Problems:
Gingival inflammation following orthodontic treatment is almost a common problem in all patients. This is mainly
due to difficulty in maintaining oral hygiene leading to increase in plaque formation and change in oral microflora.

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Another concern is with adult patients who seek orthodontic treatment with pre-existing periodontal problems. In
these patients, orthodontic forces should be kept to aminimum in the view of shortened rootsupport.

Patients with systematic conditions like diabetics and epilepsy should be informed about the potential risk of gingival
hyperplasia and loss of bone which might occur during the treatment in order to prevent the dento -legal issues.

RootResorption:
Root resorption with orthodontic treatment is inevitable which is usually minimal, affecting the apical 1-2mm only.
This doesn’t compromise the long-term prognosis of the teeth. Severe resorption of more than one quarter of the root
length occurs only in about 3% of the individuals6.

Risk factors associated with an increased incidence and severity of root resorption include the pre-treatment root form
or length, previous dental trauma and the type of mechanics used. Teeth with blunted, pipette shaped, or short roots are
at increased riskof resoprtion7,8.

PulpDamage:
Orthodontic patients can experience transient pulpal damage causing pain and discomfort in the first few days of
appliance adjustment which usually settles within a week. Pulpal death following orthodontic treatment is occasionally
reported but if there was previous trauma to the pulp of a tooth, there is slightly higher risk of pulpal damage.

Soft tissueDamage:
Soft tissue damage occurs from direct injury to the oral tissues by fixed or removable appliances. Patients may suffer
from mouth ulcers due to rubbing of the lips and cheeks on the brackets, bands or cleats. The oral tissues quickly
toughen up to a new appliance but wax can be used for temporary relief. TPA and lingual arch can cause trauma to
the palate or tongue.

Injury fromappliances:
Appliances are designed to have a maximum amount of strength and a minimum amount of injury potential.
Nevertheless, accidents can occur and a patient can be injured bysharp parts of the appliances. It is also possible for a
patient to swallow or inhale small parts of the appliance that fall into the back of the throat at any time, including
routine office visits.

Headgear can cause injury if its displaced either during sleep or rough play. The headgear bow is not only sharp but
also covered in oral bacteria. To minimize the risk of injury, headgear now has safety features that stop it from being
accidentally displaced or recoiling back into the face or eyes. Patients should be given both written and oral safety
instructions after fitting headgear.

Damage from Orthodonticmaterials:

Orthodontic materials can induce allergic reactions. Nickel

Nickel hypersensitivity occurs commonly in general population and nickel is found in stainless steel wires, brackets,
bands and headgear.

For sensitive patients, exposed metalwork should be covered with tape or plasters or headgear use should be
discontinued. Intra-oral signs and symptoms of nickel allergy are rare because the concentrations of nickel necessary to
provoke a reaction in the mouth are higher9. Intra-oral signs are highly variable and difficult to diagnose, like
erythematous areas or severe gingivitis in the absence of plaque.

Latex
Latex sensitivity may occur in response to contact with latex gloves or elastomeric ligatures and intra and extra –
oral elastics. In that case, steel ligatures or self ligating brackets should be used. Treatment plan must be modified
avoiding class II or class III traction.

Other materials
Other orthodontic materials that cause allergic reactions are composite and acrylic. Toxicity is due to unpolymerized
material and greatest immediately following polymerization, although cytotoxicity is still evident 2 years after
polymerization10. No- mix adhesives are more toxic than two paste adhesives.

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Treatment Failure
Failure to complete a course of orthodontic treatment is most common(4-23%)11. Its sequelae include
residual spacing and malalignment, traumatic overbite, residual overjet, crossbite and relapse.

Treatment may fail through incorrect diagnosis, incorrect management, patient non - compliance, increased
treatment duration, unexpected growth changes and relapse.

Incorrect diagnosis andmanagement:

A proper diagnosis at the start of the treatment is essential for a successful result. Proper treatment plan for a particular
case helps in achieving the best possible result and the orthodontist should keep himself upto date regarding latest
techniques available for a particular case. Treatment may fail because of incorrect diagnosis and treatment plan was
incorrectly formulated. Careful maintenance of records and documentation of each step is important to bring about the
appropriate result at the end of the treatment.

In situations when a case is transferred from another dentist or an orthodontist, correct diagnosis and maintenance of
records should be done and treatment should be done based on what is right for the patient and not continuation of what
the other dentist was treating. It leads to a lawsuit when an orthodontist just follows whatever treatment has been going
on without doing proper diagnosis.

Patientnon-compliance:
It is essential to talk to all orthodontic patients to establish whether they a need for a treatment and fully appreciate their
commitment- treatment times of perceive approximately 2 years, followed by a lengthy period of retention. They must
demonstrate good oral hygiene and be free from active dental disease at the start. Treatment duration might vary from
individual to individual as their reaction to orthodontic forces vary and this must be explained to the patient in the start
of the treatment.

A patient’s motivation to maintain good oral hygiene throughout treatment can decline. This may lead to early removal
of appliances to avoid damage to the teeth and supporting structures. When patients request their appliances to be
removed early for personal reasons treatment goals cannot be met. Sometimes patients have difficulty in tolerating the
appliances most appropriate for correction of their malocclusion. In such cases often a compromised treatment plan can
be established but not always.

Unexpected Growth changes and additional treatmenttime:

Unexpected turn of events might happen due to growth changes of the facial structures and teeth. If growth becomes
disproportionate, jaw relationships can be affected. If this occurs, original treatment objectives cannot be met. These
growth changes and other periodontal problems might lead to change in treatment plan which was previously
discussed and also leads to additional treatment time and cost.

Relapse:
The teeth positions at the end of orthodontic treatment are not perfectly stable and requires retention. The retainers
that the patient wears enhance the stability of the final result. Even then patient’s teeth don’t stay exactly where they
were at the end of the treatment. The teeth and jaw structures constantly change throughout one’s life and these
maturational changes that occur after orthodontic treatment changes the quality of end result. Wearing a retainer
reduces these changes to a minimum but still changes occur which may lead to relapse where the original problem re-
emerges.

Greater Predisposition To Dental Disorders

There is little relationship between orthodontic treatment and TMJ disorders. Studies have shown that there is no
association between the two12,13. Orthodontics cannot cure TMD and likewise does not appear to be associated with its
development. It is important to record if signs and symptoms of TMD are or have been present previously. This point
should be discussed with patient before the start of the treatment.

Informed Consent Form For Orthodontic Treatment

The following information should be routinely provided to anyone considering orthodontic treatment, explained
properly by the orthodontist and consent should be obtained.
1. Discomfort caused by theappliance
2. Appointmentintervals

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3. Choice of Ceramic/metalbrackets
4. Removal of teeth as a part of treatmentplan
5. Decalcification, decay and gum disease that mightoccur
6. Requirement of preventive orthodontictreatment
7. Requirement of removable, functional or fixedappliances
8. Injury fromappliances
9. Root resorption associated with orthodontictreatment
10. Impacted teeth to be extracted or included as a part oftreatment
11. Ankylosed teeth and theirmanagement
12. Severely overlapped teeth and its associated untoward periodontaloutcomes
13. Camouflage or surgical orthodontic treatmentrequired
14. Soft tissue changes associated with orthodontictreatment
15. TMJ pain present before the start oftreatment
16. Specialized orthodontic treatment in TMJ ankylosis, syndromic and cleftcases
17. Devitalization ofteeth
18. Treatmentprogress
19. Additional treatment required during treatmentprogress
20. Late growth changes that might alter the treatmentresults
21. Success of treatment
22. Diastema and severely rotated teeth more chances for relapse and requires minorsurgical intervention and
permanentretention.
23. Retention phase required (Removable retainer / lingual bondedretainer)
24. Return of original problem /relapse
25. Necessity for retreatment ifrequired

Conclusion:-
Once an orthodontist explains all the potential risks to the patient, it leaves the orthodontist puzzled as whether the
patient would take up the treatment or not. The anxiety of the patient in taking up the treatment causes apprehension
to the doctor and hence most of the doctors leaves out certain information in order to avoid losing the patient. On a
legal background, this is wrong and might lead to a lawsuit. Irrespective of whether this would favor the doctor or
not, relevant information regarding the condition of the patient, treatment options, the risks and consequences should
be explained beforehand to the patient to lead a healthy and successful orthodontic practice in a longer run.

It can be seen that the risks associated with orthodontic treatment are many and varied. Orthodontic failures do
occur sometimes but it should be identified earlier and rectified. An orthodontist shouldn’t neglect any of the
details or risks of the treatment and should inform the patient about the possibilities of the risks and get an
informed consent in order to avoid any medico-legal lawsuit. Consent should be seen as a process and any
discussions should be fully and legibly recorded in the patient records. Hence, having a knowledge about
medicolegal background would help an orthodontist to practice in a confident and safe way which helps in
avoiding orthodontic malpractice from happening.

References:-
1. Rogers, W.V.H., J.A. Jolowicz and Percy Henry Winfield. Winfield And Jolowiczon Tort. 18 th ed.
London: Sweet and Maxwell.2010.
2. Peter H. Schuck, Rethinking Informed Consent. The Yale Law Journal 1994;103(4): 899.
3. Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white spot formation afterbonding and banding. Am J
Orthod 19882; 81: 93-98.
4. Ogaard B. Prevalence of white spot lesions in 19 year-olds: a study on untreated and orthodontically
treated persons 5 years after treatment. Am J OrthodDentofacOrthop 1989; 96:423-427.
5. Zachrisson BU, Skogan O, Hoymyhr S. Enamel cracks in debonded, debanded,and orthodontically
untreated teeth. Am J Orthod 1980; 77: 307-319.
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7. Linge BO, Linge L. Apical root resorption in upper anterior teeth. Eur J Orthod 1983;5: 173- 183.
8. Levander E, Malmgren O. Evaluation of the risk of root resorption duringorthodontic treatment: a study
of upper incisors. Eur J Orthod 1988; 10: 30-38.

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9. Magnusson B, Bergman M, Bergman B, Soremark R. Nickel allergy and nickel- containing dental
alloys. Scand J Dent Res 1982; 90: 163-167.
10. Tell RT, Sydiskis RJ, Davidson WM. Long-term cytotoxicity of orthodonticdirect- bonding adhesives.
Am J OrthodDentofacOrthop 1988; 93: 419-422.
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12. Kremenak CR, Kinser DD, Melcher TJ et al. Orthodontics as a risk factor for
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13. Sadowsky C. The risk of orthodontic treatment for producingtemperomandibular disorders: A
literature review. Am J OrthodDentofacOrthop 1992; 101: 79-83.

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