Nikolaos Ferlias

Background: Understanding the psychological and professional consequences of patient harm events is crucial for improving clinical practice and support systems. Aim: (1) To investigate the prevalence of self‐reported patient harm events involving orthodontic professionals, (2) to assess the psychological, physical, and professional impact of these events, and (3) to identify aspects of importance to mitigate the psychological and physical impact among orthodontic care providers involved in patient harm events. Materials & Methods: An online questionnaire‐based survey was conducted among orthodontic care providers, including orthodontists, dentists, hygienists, and dental assistants during two orthodontic conferences in Denmark. The questionnaire assessed respondents' experience with patient harm events, types of harm, the psychological and physical impact of being involved, and their working environment. Results: A total of 297 participants completed the survey, in which 45.9% ( n = 135) reported involvement in a patient harm event and 20.8% ( n = 61) experienced an event within the past year. Following a harmful event, significant psychological distress was reported by 49.2% ( n = 87) of professionals, while 21.5% ( n = 38) experienced physical symptoms and 8.8% ( n = 16) considered leaving their job. A fear of causing harm was also evident, with 32.4% ( n = 95) participants experiencing high to very high levels of psychological stress. Orthodontists reported greater stress related to the risk of causing harm compared to other orthodontic team members ( p = 0.001). Orthodontists involved in a patient harm event also reported greater psychological ( p = 0.002) and physical impact ( p = 0.001) than other clinical staff members. No significant differences were found based on age, gender or years of clinical experience. Respondents most frequently identified structured organizational support, supportive leadership, and peer support as key measures to mitigate the impact of patient harm events. Conclusion: Patient harm events may affect orthodontists and staff and potentially cause significant psychological and physical impact, emphasizing the need for structured support and peer programmes to enhance provider well‐being and patient safety.

Background: Patient safety, defined as the absence of avoidable harm, in orthodontics is still in its early stages of development. Knowledge on the subject is limited. Aim: (1) To conduct an incident analysis, (2) to measure avoidability, (3) to investigate the relationship between contributory factors and perceived avoidability of harm from orthodontic care, and (4) to suggest methods to mitigate potential patient harm incidents. Materials and Methods: Data were retrospectively collected from consecutively filed orthodontic‐related claims from the Danish Dental Compensation Association (DDCA) and included all approved‐for‐compensation claims from September 2019 to August 2024. Reason for filing the claim, harm category, and harm‐causing events were recorded. Incident analysis was conducted for each claim based on the Eindhoven criteria and AI‐assisted qualitative analysis. A large language model was used to identify and interpret the interplay between the contributory factors. Perceived avoidability of harm was based on a 6‐point rating system. Results: A total of 125 claims of approved patient harm were included and reviewed. Based on the Eindhoven incident analysis, the most frequent root causes were human related factors (monitoring, verification and clinical knowledge among others) followed by organizational factors (management priorities, protocols and workplace culture), illustrating complex interrelationships. The majority of claims (70.1%, n = 82) were avoidable harm, being rated as either probably avoidable in more than 50% of cases, high certainty of avoidability, or completely avoidable . While low‐avoidability harm events were characterized by few contributory factors, high‐avoidability cases were characterized by the involvement of numerous human and organizational failures. Conclusion: The analysis of 125 compensated orthodontic harm cases showed that 70.1% of the cases were deemed avoidable and most harms were multifactorial in nature, with human and organizational contributors playing the primary role. This multifactorial pattern provides new insights and forms a foundation for future patient‐safety initiatives in orthodontic practice and research.

Background: Patient safety is a fundamental prerequisite for high‐quality healthcare and central to clinical practice, including orthodontics. Despite the widespread emphasis on safety in healthcare delivery, knowledge specific to patient safety in orthodontics remains limited. Aims: (1) To analyse the reasons why patients file claims for compensation related to orthodontic care, (2) to summarise the events that lead to patient harm, and (3) to describe the types of harms associated with the provision of orthodontic care. Materials & Methods: Data from the Danish Dental Compensation Association (DDCA), a national compensation scheme established by law, were retrospectively extracted from the electronic database and included all patient‐reported claims between June 2017 and August 2024 related to orthodontic care. Results: A total of 644 patient‐reported orthodontic‐related claims were reviewed. Of these claims, 196 (30.4%) were recognized as patient harm and led to compensation. Orthodontic treatment was the most frequently reported source of harm (51.5%, n = 101), followed by delayed diagnosis (24.5%, n = 48) and retention‐related complications (9.2%, n = 18). Among the 196 approved claims, the most common harm was apical root resorption leading to tooth loss (14.8%, n = 29), followed by gingival or soft‐tissue injury (13.3%, n = 26), worsening of occlusion after treatment (9.2%, n = 18), and other harm such as diagnostic delays causing tooth damage (8.2%, n = 16). Conclusion: Harm events can occur at any stage during the orthodontic treatment process, including the diagnostic and planning stage. Orthodontic harm mostly occurs in the active phase of treatment and is frequently a result of root resorption, soft tissue damage, and worsening of the occlusion. There is a discrepancy in patient‐perceived harms and actual harm events that lead to compensation. This study highlights the importance of thorough risk assessment, optimal diagnostics and planning, clinical vigilance throughout treatment, and clear communication regarding potential side effects and patient concerns, particularly where perceptions of harm and compensability diverge.

Objective: This cross‐sectional study examined differences in orofacial features and oral health‐related quality of life in previously treated young adults with either idiopathic condylar resorption (ICR) or TMJ involvement from juvenile idiopathic arthritis (JIA). Material and Methods: The study included 17 patients with ICR and 15 patients with JIA‐related TMJ involvement, all treated at the Section for Orthodontics, Aarhus University Craniofacial Clinic, Denmark and the Department of Oral and Maxillofacial Surgery, Aarhus University Hospital, Denmark. Data compared came from a standardised radiological examination with cone‐beam computed tomography, a standardised clinical orofacial examination and a completed oral health‐related quality of life questionnaire (OHIP‐14). Validated methodologies were used to evaluate TMJ and dentofacial morphology. Results: The ICR patients reported a markedly higher number of TMJ pain symptoms, affected jaw function and difficulties in chewing food. The ICR group showed significantly more pronounced aberrant dentofacial morphology in relation to mandibular inclination, anterior/posterior face height ratio and mandibular sagittal position. No statistically significant differences were detected in the severity of condylar deformity between ICR and JIA patients. The oral health‐related quality of life was significantly more negatively affected in the ICR group compared to the JIA group in the following domains: physical pain, psychological discomfort and psychological disability. Conclusion: The present study illustrates more severe TMJ signs and symptoms, a greater degree of dentofacial deformity and negatively affected oral health‐related quality of life in the ICR group when compared with the JIA group. The same degree of TMJ deformity was found in both groups. Our findings contribute valuable insights towards establishing diagnostic criteria for ICR patients and improving the differential diagnosis of JIA‐related TMJ involvement.

Background: Knowledge about patient safety in orthodontics is scarce. Lack of standardisation and a common terminology hinders research and limits our understanding of the discipline. This study aims to 1) summarise current knowledge about patient safety incidents (PSI) in orthodontic care by conducting a systematic literature search, 2) propose a new standardisation of PSI terminology and 3) propose a future research agenda on patient safety in the field of orthodontics.Methods: A systematic literature search was performed in the main online sources of PubMed, Web of Science, Scopus and OpenGrey from their inception to 1 July 2023. Inclusion criteria were based on the World Health Organization´s (WHO) research cycle on patient safety. Studies providing information about the cycle’s steps related to orthodontics were included. Study selection and data extraction were performed by two of the authors.Results: A total of 3,923 articles were retrieved. After review of titles and abstracts, 41 articles were selected for full-text review and 25 articles were eligible for inclusion. Seven provided information on the WHO’s research cycle step 1 (“measuring harm”), twenty-one on “understanding causes” (step 2) and twelve on “identifying solutions” (step 3). No study provided information on Steps 4 and 5 (“evaluating impact” or “translating evidence into safer care”).Conclusion: Current evidence on patient safety in orthodontics is scarce due to a lack of standardised reporting and probably also under-reporting of PSIs. Current literature on orthodontic patient safety deals primarily with “measuring harms” and “understanding causes of patient safety”, whereas less attention has been devoted to initiatives “identifying solutions”, “evaluating impact” and “translating evidence into safer care”. The present project holds a proposal for a new categorisation, terminology and future research agenda that may serve as a framework to support future research and clinical initiatives to improve patient safety in orthodontic care.Registration: PROSPERO (CRD42022371982).

Safe delivery of care is a priority in dentistry, while basic epidemiological knowledge of patient safety incidents is still lacking. The objectives of this study were to (1) classify patient safety incidents related to primary dental care in Denmark in the period 2016–2020 and study the distribution of different types of dental treatment categories where harm occurred, (2) clarify treatment categories leading to "nerve injury" and "tooth loss" and (3) assess the financial cost of patient-harm claims. Data from the Danish Dental Compensation Act (DDCA) database was retrieved from all filed cases from 1st January 2016 until 31st December 2020 pertaining to: (1) The reason why the patient applied for treatment-related harm compensation, (2) the event that led to the alleged harm (treatment category), (3) the type of patient-harm, and (4) the financial cost of all harm compensations. A total of 9069 claims were retrieved, of which 5079 (56%) were found eligible for compensation. The three most frequent categories leading to compensation were "Root canal treatment and post preparation"(n = 2461, 48% of all approved claims), “lack of timely diagnosis and initiation of treatment” (n = 905, 18%) and “surgery” (n = 878, 17%). Damage to the root of the tooth accounted for more than half of all approved claims (54.36%), which was most frequently a result of either parietal perforation during endodontic treatment (18.54%) or instrument fracture (18.89%). Nerve injury accounted for 16.81% of the approved claims. Total cost of all compensation payments was €16,309,310, 41.1% of which was related to surgery (€6,707,430) and 20.4% (€3,322,927) to endodontic treatment. This comprehensive analysis documents that harm permeates all aspects of dentistry, especially in endodontics and surgery. Neglect or diagnostic delays contribute to 18% of claims, indicating that harm does not solely result from direct treatment. Treatment harm inflicts considerable societal costs.

Objectives: To describe the clinical and radiographic oro‐dental characteristics of patients with pycnodysostosis (PDO).Materials & Methods: A short interview and clinical examination of seven patients with PDO were performed as well as assessment of the temporomandibular joints and masticatory muscles using the diagnostic criteria for temporomandibular disorders, DC‐TMD form. A full set of records were taken including photos and intraoral scan. Finally, existing cone beam computed tomography (CBCT) images and radiographs were also studied.Results: All patients presented with bimaxillary micrognathia, five had a convex profile, and two had a straight profile. In addition, posterior open bite, Angle Class III molar relation with accompanying anterior crossbite and a grooved median palate were common findings. No patient showed symptoms of temporomandibular disorder (TMD) apart from some clicking. Finally, the main radiographic findings were the obtuse mandibular angle, the frontal bossing, the elongation of the coronoid/condylar process and the presence of hypercementosis with obliterated pulp chambers.Conclusion: The examined patients with PDO were characterized by dental crowding, malocclusion (anterior crossbite, posterior open bite), hypercementosis, obliterated pulp chambers and deviations in mandibular morphology. In conclusion, patients with PDO have a specific need for dental and orthodontic monitoring with focus on crowding and posterior open bite. The patients will benefit from a long‐term orthodontic plan including extractions.

Aim: To evaluate in vitro the differences of various Invisalign® attachments in their effectiveness during derotation of an upper second premolar in terms of forces and moments created and compare them to the 3Shape® box attachment as well as to no attachment at all.Materials and Methods: A Force System Identification (FSI) machine, comprising two load sensors, was used in this study. Sensor 1 was connected to the test tooth (i.e. upper second premolar) carrying a different attachment design, and the fixed sensor (Sensor 2) was connected to the base model. Once the corresponding aligner was passively seated on the teeth, 12 different setups (i.e. 11 different attachments and one setup with no attachment at all) were tested by rotating the test tooth 4.5° mesially and 4.5° distally, in increments of 0.45°.Results: The vertical rectangular attachments were able to generate the highest derotational moment on both mesial and distal rotations but also received the most side effects (intrusive force, torque, and tipping). The no-attachment setup performed least favorably in terms of derotational ability but exhibited the least side effects. In the y-axis, all attachments received a buccal root torque with a lingual force during disto-rotation and a lingual root torque with a buccal force during mesio-rotation.Conclusion: Attachments are necessary for derotating an upper second premolar. An aligner incremental change of more than 1° derotation can generate high moments. The vertical rectangular attachments perform best in derotations; however, they exhibit the most side effects. Finally, despite presenting the least side effects, derotation of a premolar with no attachment is not as efficient.

Aim: To assess the upper airway (UA) morphology in patients with pycnodysostosis with a 3D analysis, compare results with normative data and investigate the correlation of the total volume (TV) with other UA morphology variables.Materials and methods: Cone beam computed tomography (CBCT) images of eight Danish patients with pycnodysostosis (4 males and 4 females with a mean age of 31.8 years, SD: 16.3 years) were analyzed using Mimics^® (Materialise^®) and compared with a sex‐ and age‐matched control group (6 males and 8 females with a mean age of 33.6 years, SD: 18.6 years).Results: The distance from the tip of the epiglottis (E) to the Frankfurt horizontal plane (Fp) was significantly shorter in the pycnodysostosis group (P < .042). Regarding the cross‐sectional measurements, at the ‘maximum constriction’ (P < .005), the ‘upper airway limit’ (P < .001) and the ‘lower airway limit’ (P < .035) cross‐sections were significantly smaller in the pycnodysostosis group. The volumes ‘nasopharynx’ (P < .002) and ‘total airway’ (TV) (P < .01) were also significantly smaller.Conclusion: Patients with pycnodysostosis have a reduced total airway as well as nasopharyngeal volume compared with matched controls. Additionally, they have a reduced cross‐sectional area in the upper and lower borders of the UA, and the area of maximum constriction is also reduced. These factors might explain the high prevalence of obstructive sleep apnoea in pycnodysostosis.Total airway is positively correlated with total length and cross‐sections at all levels including the maximum constriction area as well as the anteroposterior dimension at the upper and lower airway borders.