CATEGORY 48 AUSTRALASIAN DENTIST CLINICAL Iatrogenic effects are unintended adverse outcomes or complications that occur as a result of medical or dental treatment. In orthodontics, these effects may involve the teeth, periodontal tissues, roots, temporomandibular joint, or oral soft tissues and can arise despite treatment being performed with therapeutic intent. These iatrogenic effects are reversible or irreversible harm caused unintentionally by treatment, and they can happen even in well-trained hands because orthodontics involves many variables, such as growth, biomechanics, patient cooperation, treatment planning, and retention. But the truth is that some cases are not true iatrogenics but a relapse, so the first step is to distinguish between treatment failure, relapse, and actual treatment-caused damage. With the advent of clear aligner therapy, clinicians now have alternatives to conventional fixed appliances for correcting malocclusions. While both treatment modalities are effective, neither is completely free from potential adverse effects, though the cause of iatrogenics differs in the two modalities. Root Resorption The major iatrogenic effect in Orthodontic treatment that can be considered the biggest red flag for continuing the treatment is external apical root resorption (EARR). Though mild resorption is often negligible and not so dangerous, a minority of patients do develop enough root loss to affect crown-root ratio and tooth mobility. Such cases are strongly linked to genetic susceptibility in comparison to mechanical and treatment-related risk factors. Risk factors: u When orthodontic force exceeds the normal limits u When treatment duration is prolonged beyond necessity u In intrusive tooth movements u Cases with previous dental trauma u Genetic predisposition u Abnormal root morphology Prevention: u Using light and controlled forces u Periodic radiographic monitoring u Reducing unnecessary treatment duration u Pause treatment if severe resorption is detected. Periodontal Damage The second major theme is that orthodontic tooth movement can damage periodontal health when the teeth are moved outside the alveolar envelope. The special emphasis is given to the lower incisor proclination, which when overdone, can lead to gingival recession, dehiscence, reduced stability, lip incompetence, and less pleasing facial balance. We can also say that nonextraction treatment is not always the safer option if it forces the incisors forward too much. Another key concept here is the gingival biotype: thick-flat gingiva is generally more tolerant, while thin-scalloped gingiva is more vulnerable. Therefore, thin biotypes warrant special caution, as labial movement of the lower incisors can reduce gingival height and expose the roots. When planning treatment, consider respecting soft-tissue thickness, bone support, and facial limits rather than simply trying to fit all teeth into the arch. Also, orthodontic treatment affects the supporting tissues negatively if oral hygiene is poor. And this makes patient compliance and periodic evaluation utmost important. Related complications: u Gingivitis u Periodontitis u Gingival recession u Bone loss u Black triangles due to papilla loss Important point: Orthodontic appliances themselves do not directly cause periodontal disease, but plaque accumulation around brackets can increase the risk. Prevention: u Strict oral hygiene instructions must be given u Periodontal evaluation must be done before treatment u Need to avoid excessive tooth movement outside the alveolar bone limits White Spot Lesions and Dental Caries White spot lesions are the most common iatrogenic complication faced by orthodontists, and they are treated as the earliest visible sign of enamel demineralization and caries risk. The reason is that fixed appliances make hygiene harder, thus resulting in plaque accumulation around the bracket. This can increase the acid production and lower the pH, which in turn results in demineralisation. In such cases, prevention is more important than later treatment, because lesions may persist for years even after natural remineralization. Why it occurs: The surface of the brackets retains plaque, which makes it difficult to maintain hygiene, thus increasing bacterial accumulation. Clinical presentation: u Chalky white lesions around brackets u Early enamel demineralization Prevention: u Using Fluoride – This can help in remineralisation. u Diet counselling – To reduce the acidrich/ sugary foods. u Good brushing technique u Professional cleaning during treatment Dr Geoff Hall Iatrogenic risks in aligners and fixed orthodontic appliances By Dr Geoff Hall, BDsc (Melb) Cert Orth (Uni of Penn) MRACDS (Orth), Diplomate – American Board of Orthodontics (ABO) Fig 1: White spot lesions due to Orthodontic treatment1
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