Early Orthodontic Treatment in Turkey: Perceived Training Adequacy and Self-Reported Practices Among Pediatric Dentistry Trainees and Specialists

Highlights

What are the main findings?

• Early orthodontic treatment was considered very important by most respondents, yet only 12.7% perceived their previous training as adequate.
• Treatment provision, reported barriers, and digital technology use varied; intraoral scanner use was more frequent among specialists than trainees.

What are the implications of the main findings?

• More structured, hands-on training may help pediatric dentistry trainees and specialists translate favorable attitudes into clinical practice.
• Clearer interdisciplinary referral pathways and targeted support for digital workflows may improve the consistency of early orthodontic care.

Abstract

Background/Objectives: Early orthodontic assessment may facilitate timely recognition and management of developing malocclusions. This study evaluated perceived training adequacy, attitudes, and self-reported early orthodontic treatment (EOT) practices among pediatric dentistry trainees and specialists in Turkey. Methods: This cross-sectional online survey included 205 participants recruited through convenience sampling. Of these, 98 non-providers reported reasons for not providing EOT, while 107 providers completed the clinical practice and digital technology sections. Data were analyzed using descriptive statistics, chi-square or exact tests, and rank-based tests for ordinal importance ratings. Results: Only 12.7% considered their EOT training adequate, although 97.6% desired further education; 52.2% reported providing EOT. Insufficient knowledge and lack of equipment were the leading reasons for non-provision. Among providers, crossbite was the most frequently encountered condition requiring EOT; removable expansion appliances were most frequently used; and child non-cooperation and clinician-perceived parental indifference were the leading barriers. Overall, 41.1% used at least one listed digital tool. Intraoral scanner use was more frequent among specialists than trainees (45.2% vs. 14.7%; p = 0.002). Conclusions: Respondents generally considered EOT important despite low perceived training adequacy and variation in self-reported practice. Structured clinical education and clearer referral pathways may be beneficial. Convenience sampling and self-reported outcomes limit generalizability and do not provide objective measures of competence.

1. Introduction

Malocclusion is common among children and adolescents [1]. Management of the developing dentition includes the early recognition of dental, skeletal, and functional disturbances and, when indicated, preventive or interceptive treatment during the primary or mixed dentition [2,3,4]. The appropriate timing and expected benefit of such treatment are malocclusion-specific; therefore, early orthodontic assessment does not necessarily imply immediate treatment. Because pediatric dentists routinely monitor craniofacial growth, tooth eruption, occlusal development, and oral habits, they are well positioned to identify developing problems, provide selected interventions within their competence, and refer patients for orthodontic care when appropriate [5].

Malocclusion and the need for preventive or interceptive orthodontic care have been reported among children in Turkey [6]. Although postgraduate pediatric dentistry education in Turkey has recently been evaluated, evidence focusing specifically on early orthodontic training and clinical practice remains limited [7]. International surveys have identified variation among pediatric dentists and trainees in the recognition of early orthodontic problems, selection of treatment timing and appliances, confidence in providing care, and referral patterns [8,9,10]. These findings cannot be assumed to represent the Turkish setting because postgraduate training, clinical resources, and service delivery differ across countries. To our knowledge, no prior study has examined the perceived training adequacy, attitudes, and self-reported early orthodontic practices of both pediatric dentistry trainees and specialists in Turkey.

Recent surveys in Sudan and Iraq have examined dentists’ knowledge, awareness, and self-reported orthodontic practice [8,10]. A 2025 survey of Indian pediatric dentists further considered perceptions, practice, and implementation challenges in interceptive orthodontics [11]. These studies provide useful context but assess different populations and instruments; their findings cannot directly quantify educational needs in Turkey. Family perspectives also matter: recent parent surveys have examined attitudes toward early assessment and intervention [12,13], whereas clinician questionnaires capture only clinicians’ impressions of family-related barriers. Digital records and customized appliances add another dimension to contemporary practice [14,15,16]. Describing the use of these tools alongside perceived training needs may help identify questions for future educational research, without implying that adoption itself demonstrates competence.

Accordingly, this cross-sectional survey aimed to describe perceived training adequacy, views on the timing and importance of early orthodontic treatment, self-reported clinical practices, treatment barriers, referral behavior, and digital technology use among pediatric dentistry trainees and specialists in Turkey. As secondary exploratory analyses, we examined whether perceived training adequacy and digital technology use differed by professional status and whether perceived importance of early orthodontic treatment differed across clinical experience groups. During revision, additional exploratory analyses compared training adequacy, importance ratings, further-training preference, and treatment provision between university-affiliated and non-university workplaces.

2. Materials and Methods

2.1. Study Design and Ethics

This descriptive cross-sectional study was conducted as an anonymous online survey from 28 May to 13 October 2025. The study was approved by the Ethics Committee of Sakarya University Faculty of Medicine (Decision No. 268; 21 May 2025) and was conducted in accordance with the Declaration of Helsinki. The first page of the survey described the study purpose, voluntary participation, anonymity, and data confidentiality. Participants provided electronic informed consent before accessing the questionnaire.

2.2. Participants and Recruitment

The target population comprised pediatric dentistry specialists and specialty or PhD trainees actively working or training in Turkey in 2025. Convenience sampling used professional networks and groups, social media, and email. Eligibility required membership in these professional groups, active work or training in Turkey, electronic consent, and questionnaire completion. Individuals outside these groups or not working or training in Turkey, those who did not consent, and those with incomplete questionnaires were excluded. No formal a priori sample-size calculation was performed. All 205 complete eligible responses received during the data-collection period were analyzed (75 trainees and 130 specialists). No directly identifying information was collected, and the survey was configured to permit one response per participant. The total number of eligible individuals who received or viewed the invitation was unknown; therefore, a response rate could not be calculated.

2.3. Survey Instrument and Branching Logic

The Turkish-language questionnaire was developed by the researchers with reference to the relevant literature and previous survey studies on early orthodontic treatment. Before the main survey, the draft questionnaire was pilot-tested among 10 pediatric dentists to assess item clarity, comprehensibility, and overall applicability. Based on pilot feedback, “none” and “no opinion” response options were added to relevant questions before the final questionnaire was administered. Pilot responses were collected separately and were not included in the main analytic dataset of 205 respondents. The final survey export contained 40 response fields, including three separate clinical scenario ratings, covering four domains: (1) demographic and professional characteristics; (2) perceived adequacy of previous orthodontic training and general views regarding early orthodontic treatment; (3) self-reported clinical practices, including encountered conditions, assessment and treatment approaches, appliance use, barriers, and referral behavior; and (4) attitudes toward early orthodontic treatment and the use of digital technologies. The items were single-choice, multiple-response, or individual five-point Likert-type questions; they were not combined to produce a composite scale or objective knowledge score. No orthodontist participated in questionnaire development or content assessment. The pilot exercise assessed clarity and applicability rather than formal content validity or psychometric properties.

The questionnaire did not provide participants with a standardized operational definition of early orthodontic treatment. Therefore, responses reflected participants’ own interpretation of its scope. In addition, specialty and PhD trainees were recorded as a single response category and could not be analyzed separately; both groups are collectively referred to as “trainees” in this article. Original Turkish item wording and observed response distributions are provided in Supplementary File S1.

Conditional branching was used. All 205 participants completed the general demographic, training, and attitude questions. Participants who reported not providing EOT answered the multiple-response item concerning reasons for non-provision (n = 98) and then exited. Providers proceeded to the subsequent clinical practice, attitude, and digital technology items (n = 107). Percentages used the eligible subgroup denominator. Structurally skipped items were not treated as negative responses. The digital technology item permitted multiple selections. No respondent selected both “no digital tool” and a listed technology; “none” was exclusive in the observed dataset.

2.4. Statistical Analysis

The original analyses used IBM SPSS Statistics version 26.0 (IBM Corp., Armonk, NY, USA); additional analyses during revision used Python version 3.13.5 with SciPy version 1.17.0. Categorical variables were summarized as frequencies and percentages. Multiple-response options were analyzed as separate binary variables, so summed percentages could exceed 100%. Pearson chi-square tests were used when expected frequencies were adequate; Fisher’s exact tests were used for sparse 2 × 2 tables. Exploratory comparisons considered training adequacy and digital tool use by professional status. Perceived importance was retained on its original 1–5 ordinal scale and compared across four experience groups using the tie-corrected Kruskal–Wallis test. The earlier score-5-versus-1–4 analysis was replaced to avoid information loss. Workplace comparisons grouped university hospitals, a private university, and a combined university/private workplace as university-affiliated (n = 116); private clinics, an oral health center/hospital, and an own practice were classified as non-university (n = 88). One response that did not identify a workplace was excluded only from workplace comparisons. Importance by workplace was examined with a two-sided Mann–Whitney U test; training adequacy and EOT provision were assessed using Pearson chi-square tests. Further training preference was assessed using the Fisher–Freeman–Halton exact test, enumerating all tables with fixed margins. All inferential analyses were exploratory, two-sided, and unadjusted for multiple testing; p < 0.05 was the nominal threshold.

3. Results

3.1. Participant Characteristics

The majority of participants were female (91.2%) and aged 20–40 years (87.4%). Most worked in university hospitals (55.6%), followed by private clinics (37.6%). Table 1 summarizes demographic and professional data.

Table 1. Demographic and professional characteristics (n = 205). Counts and percentages refer to all respondents. Trainees combine specialty and PhD students; “Other” includes four free-text workplace responses, one of which did not identify a workplace.

Variable	Category	n (%)
Age	20–30	94 (45.9)
	31–40	85 (41.5)
	41–50	23 (11.2)
	≥51	3 (1.5)
Sex	Female	187 (91.2)
	Male	18 (8.8)
Education	Trainee	75 (36.6)
	Specialist	130 (63.4)
Experience (years)	0–2	52 (25.4)
	3–5	69 (33.7)
	6–10	53 (25.9)
	≥11	31 (15.1)
Workplace	University hospital	114 (55.6)
	Oral health center	10 (4.9)
	Private clinic	77 (37.6)
	Other	4 (2.0)

3.2. Training Views and Self-Reported Practice

Only 12.7% of participants considered their orthodontic training sufficient; 54.6% rated it as insufficient and 32.7% as partially sufficient. Most participants (80.5%) rated early orthodontic treatment as very important (score 5 on a 1–5 scale). When asked to select the preferred age range for starting treatment, 47.3% selected 6–8 years and 25.4% selected 7–10 years (Table 2). Nearly all participants (97.6%) expressed a desire for further education. Perceived training adequacy did not differ significantly between trainees and specialists (Pearson χ²(2) = 4.133, p = 0.127). Training was considered sufficient by 8.0% of trainees and 15.4% of specialists, partially sufficient by 40.0% and 28.5%, and insufficient by 52.0% and 56.2%, respectively.

Table 2. Perceived training, attitudes, and provision of early orthodontic treatment (n = 205). Percentages refer to all respondents. Importance ranges from 1 to 5. Age categories reproduce the overlapping choices in the administered questionnaire and indicate preferences, not correct answers.

Question	Response	n (%)
Training sufficient?	Yes	26 (12.7)
	No	112 (54.6)
	Partially	67 (32.7)
Preferred age range for EOT	2–6 years	36 (17.6)
	6–8 years	97 (47.3)
	7–10 years	52 (25.4)
	8–11 years	20 (9.8)
Importance of EOT (1–5)	1	1 (0.5)
	2	0 (0.0)
	3	7 (3.4)
	4	32 (15.6)
	5	165 (80.5)
Desire further training	Yes	200 (97.6)
	No	2 (1.0)
	Undecided	3 (1.5)
Perform EOT	Yes	107 (52.2)
	No	98 (47.8)

Among participants who provided early orthodontic treatment (n = 107), 88.8% reported frequently encountering patients requiring such care. Crossbite was the most frequently encountered condition requiring early orthodontic treatment (81.3%), followed by habit-related problems (66.4%) and crowding (65.4%). Most providers recommended early orthodontic treatment either most of the time (53.3%) or always (43.0%). Of the 98 participants who did not provide early orthodontic treatment, 76.5% identified self-reported insufficient knowledge about EOT, and 58.2% identified inadequate clinical equipment as reasons for not providing treatment. Among providers, child non-cooperation (71.0%) and clinician-perceived parental indifference (47.7%) were the most frequently reported treatment barriers. Removable expansion appliances were the most commonly used appliance (63.6%) (Table 3).

Table 3. Selected clinical practices and barriers by eligible respondent group.

Variable	Response	n (%)
Reasons for not providing EOT (n = 98; multiple responses)	Self-reported insufficient knowledge	75 (76.5)
	Inadequate clinical equipment	57 (58.2)
Most frequently encountered anomalies (n = 107; multiple responses)	Crossbite	87 (81.3)
	Habit-related problems	71 (66.4)
	Crowding	70 (65.4)
	Open bite	48 (44.9)
Treatment barriers (n = 107; multiple responses)	Clinician-perceived parental indifference	51 (47.7)
	Child non-cooperation	76 (71.0)
	Treatment cost	44 (41.1)
	Long treatment duration	44 (41.1)
Most frequently used appliance (n = 107)	Removable expander	68 (63.6)
	Habit-breaking appliance	22 (20.6)
	Myofunctional appliance	12 (11.2)
	Fixed expander	4 (3.7)
	Clear aligner	1 (0.9)

EOT, early orthodontic treatment. Percentages for multiple-response items were calculated using the eligible subgroup and may sum to more than 100%. Encountered conditions, reasons for non-provision, and barriers allowed multiple responses; the most frequently used appliance was a single-choice item. Family-related barriers reflect clinicians’ perceptions.

Among participants who provided early orthodontic treatment (n = 107), 44 (41.1%) reported using at least one of the listed digital tools, whereas 63 (58.9%) selected no digital tool. Intraoral scanners were used more frequently by specialists than by trainees (45.2% vs. 14.7%; p = 0.002). Specialists were also less likely to report using no digital tool (49.3% vs. 79.4%; p = 0.003). No statistically significant group differences were found for artificial intelligence-supported analysis software, 3D-printed appliances, clear aligner systems, or digital patient-monitoring systems (Table 4).

Table 4. Digital technology use among participants providing early orthodontic treatment, by professional status.

Technology	Trainees (n = 34)	Specialists (n = 73)	p-Value
Intraoral scanner	5 (14.7)	33 (45.2)	0.002 *
AI-supported analysis software	1 (2.9)	2 (2.7)	1.000
3D-printed appliances	3 (8.8)	5 (6.8)	0.707
Clear aligner systems	4 (11.8)	11 (15.1)	0.771
Digital patient monitoring	2 (5.9)	2 (2.7)	0.590
No digital tool	27 (79.4)	36 (49.3)	0.003 *

EOT, early orthodontic treatment; AI, artificial intelligence. Provider denominators were 34 trainees and 73 specialists. Multiple tools could be selected; “none” was exclusive in the observed data. Two-sided Fisher’s exact tests were exploratory and unadjusted for multiple comparisons. * p < 0.05 indicates statistical significance.

Importance ratings on the original 1–5 scale differed across experience groups (tie-corrected Kruskal–Wallis H(3) = 11.912, p = 0.008; Table 5). Score-5 proportions were 75.0%, 85.5%, 69.8%, and 96.8% across successive experience groups. This non-monotonic pattern does not establish a progressive increase with experience.

Table 5. Perceived importance of EOT by years of experience.

Experience (Years)	n	Score 1	Score 2	Score 3	Score 4	Score 5
0–2	52	1 (1.9)	0 (0.0)	2 (3.8)	10 (19.2)	39 (75.0)
3–5	69	0 (0.0)	0 (0.0)	0 (0.0)	10 (14.5)	59 (85.5)
6–10	53	0 (0.0)	0 (0.0)	5 (9.4)	11 (20.8)	37 (69.8)
≥11	31	0 (0.0)	0 (0.0)	0 (0.0)	1 (3.2)	30 (96.8)

EOT, early orthodontic treatment. Ratings were retained on the original 1–5 scale. Percentages use the number in each experience group. Tie-corrected Kruskal–Wallis H(3) = 11.912, p = 0.008; exploratory comparison without adjustment for multiple testing.

Exploratory workplace comparisons included 116 university-affiliated and 88 non-university respondents; one unclear workplace response was excluded. Perceived training adequacy (p = 0.749), importance ratings (p = 0.981), desire for further training (p = 0.228), and EOT provision (p = 0.239) did not show statistically significant differences (Supplementary Table S1). These findings do not establish equivalence between settings.

4. Discussion

To our knowledge, this is the first survey to examine perceived training adequacy, attitudes, and self-reported early orthodontic practices among both pediatric dentistry trainees and specialists in Turkey. The findings indicate a marked discrepancy between the high importance assigned to early orthodontic treatment and the perceived adequacy of participants’ previous training. Although 80.5% rated EOT as very important, only 12.7% considered their training sufficient. Among non-providers, 76.5% reported insufficient knowledge about EOT and 58.2% reported inadequate clinical equipment. These findings are broadly consistent with international surveys reporting variation in knowledge, clinical skills, appliance selection, and confidence in managing early orthodontic problems [8,9,10]. A recent Indian survey similarly found that structured training needs and implementation barriers persisted despite favorable attitudes toward interceptive orthodontics [11]. Importantly, the present results reflect perceived training and self-reported practice rather than objectively measured competence.

The most frequently selected age range for initiating early orthodontic treatment was 6–8 years (47.3%), followed by 7–10 years (25.4%). This item should be interpreted cautiously because there is no single optimal age for all forms of early orthodontic treatment. Treatment timing depends on the specific dental, skeletal, or functional problem, its severity, eruption stage, and the child’s growth and cooperation [2,3,4]. In addition, the response ranges in the questionnaire overlapped. Consequently, these responses should not be classified as correct or incorrect and cannot be used as a stand-alone measure of orthodontic knowledge. They more appropriately describe clinicians’ general timing preferences.

Among the 107 participants who provided early orthodontic treatment, crossbite was the most frequently encountered condition requiring early orthodontic treatment (81.3%), followed by habit-related problems (66.4%) and crowding (65.4%). Removable expansion appliances were the most frequently reported appliance category (63.6%), whereas habit-breaking, myofunctional, fixed expansion, and clear aligner appliances were selected less often. The prominence of crossbite and removable expansion may reflect the types of developing occlusal problems encountered in pediatric dental practice and the treatment modalities with which respondents were most familiar. However, the survey did not collect case-level diagnostic information, malocclusion severity, appliance indications, or treatment outcomes. It therefore cannot determine whether the reported appliance choices were clinically appropriate for individual patients. Recent systematic review evidence also supports the effectiveness of early correction of functional unilateral posterior crossbite during the mixed dentition period [17].

Clinician-perceived child non-cooperation (71.0%) and clinician-perceived parental indifference (47.7%) were the most frequently reported barriers among clinicians providing treatment, followed by treatment cost (41.1%) and long treatment duration (41.1%). Moreover, 79.4% reported that parents requested additional information when treatment was recommended. This pattern resembles the recent Indian pediatric-dentist survey, in which lack of parental understanding, compliance problems, difficulty managing child cooperation, and cost were also prominent barriers [11]. Parent-focused research likewise indicates that treatment initiation is shaped not only by awareness but also by the child’s age, perceived malocclusion severity, and professional consultation [12,13]. Together, these findings support clearer family communication and behavioral support. Nevertheless, the present study surveyed clinicians rather than parents or children; clinician-perceived parental indifference and child cooperation were assessed indirectly and should not be interpreted as verified patient-reported barriers.

Digital technology use was also evaluated only among participants who provided early orthodontic treatment. Overall, 41.1% reported using at least one of the listed digital tools, while 58.9% reported using none. Intraoral scanner use was more frequent among specialists than trainees (45.2% vs. 14.7%), and specialists were less likely to report using no digital tool. No significant group differences were observed for artificial intelligence-supported analysis, 3D-printed appliances, clear aligners, or digital patient-monitoring systems. Recent evidence supports the clinical utility of intraoral scanning for orthodontic records and highlights the expanding role of artificial intelligence in diagnosis and treatment planning, while also emphasizing the need for clinician oversight [14,15,16,18]. However, the present study did not assess clinical outcomes, access to technology, cost, or reasons for adoption. The observed group differences therefore should not be interpreted as evidence that digital tools improve treatment quality in this sample. These unadjusted comparisons were exploratory and were not corrected for multiple testing; statistically significant findings should therefore be interpreted cautiously.

Importance ratings differed across experience groups when all five ordinal levels were retained in the analysis. The highest proportion selecting score 5 occurred in the group with at least 11 years of experience, whereas the lowest occurred in the 6–10-year group. The non-monotonic pattern does not indicate a dose–response relationship. Group composition and unmeasured professional factors may contribute to this exploratory association.

The findings support consideration of more structured, hands-on interceptive orthodontic training within pediatric dentistry residency programs, together with continuing education on case selection, referral decisions, and digital workflows. Clear interdisciplinary referral pathways between pediatric dentists and orthodontists may also facilitate consistent patient management. Because family-related barriers were reported indirectly by clinicians, patient- and parent-centered educational strategies should first be informed by studies that directly assess families’ needs and treatment experiences. Future research should use broader multicenter or probability-based sampling, report response rates, employ validated instruments with non-overlapping response categories, and examine clinical decision-making and treatment outcomes in addition to self-reported practice.

This study has several limitations. Convenience sampling through professional networks and online platforms may have introduced selection bias, and the number of individuals who received the survey invitation was not available; therefore, a response rate could not be calculated. The predominance of female participants and university-based clinicians may further limit generalizability. All data were self-reported and may be affected by recall and social desirability bias. The researcher-developed questionnaire did not include a validated objective knowledge score, and formal psychometric validation was not performed. Some response categories, particularly the age ranges, overlapped. Conditional branching resulted in different eligible denominators for non-providers (n = 98) and providers (n = 107), and comparisons involving provider-only questions were consequently based on smaller subgroups. Finally, the cross-sectional design precludes causal inference, and the multiple exploratory comparisons increase the possibility of chance findings. Despite these limitations, the study provides baseline data from a convenience sample of pediatric dentistry trainees and specialists working in Turkey that may inform future validated surveys and targeted educational research. The absence of a standardized EOT definition may have affected respondents’ classification of themselves as providers, the conditions they considered to require EOT, and the appliances they reported using, thereby reducing comparability between responses. Non-provision of EOT should not itself be interpreted as inadequate care, because appropriate orthodontic referral may be a valid clinical approach. Differences in professional status and workplace may also influence access to digital tools and confound unadjusted comparisons. Workplace comparisons were unadjusted and cannot remove selection bias or establish equivalence. Future surveys should use defined sampling frames across institutions and regions, record invitation denominators, assess nonresponse where feasible, and consider mixed recruitment modes and formal instrument validation. Transparent reporting of online recruitment and completion follows the principles of CHERRIES [19]. Stress was not measured in this survey. Knowledge and equipment constraints, family communication, and child cooperation may create clinical demands, but their effects on clinician stress require direct assessment.

5. Conclusions

Among responding pediatric dentistry trainees and specialists in Turkey, EOT was widely considered important, but perceived training adequacy was low, and demand for further education was high. Non-providers commonly reported insufficient knowledge and equipment, while providers reported family-related barriers and variation in digital tool use. These findings identify perceived educational and resource needs within the responding sample; they do not establish objective competence, causal relationships, or nationally representative estimates.