SPECIAL ARTICLE
Profiling providers of orthodontic services in general dental practice Richard M. Jacobs, DDS, MPH, MS, PhD,* Samir E. Blshara, BDS, DDS, D. Ortho, MS,* and Jane R. Jakobsen, BS, MA** Iowa City, Iowa
This study was designed to ascertain whether general practitioners who provide some orthodontic treatment to a relatively large proportion of their patients tend to limit themselves to the treatment of simple cases while they continue to refer more difficult cases or whether a high volume of orthodontic treatment is linked to an expanded scope of treatment and fewer referrals. Data pert.aining to volume, scope, and other correlates of orthodontic services in general practice were obtained through a survey of dentists currently in general practice in Iowa. Of 1159 questionnaires mailed out, 728 (62.8%) were returned. To determine how the values of recorded variables differ among the providers of high and low volumes of orthodontic services and to determine whether these differences are significant, X2 tests of independence were calculated. The results obtained were used to generate descriptive measures of the profiles of providers of a high volume of orthodontic services in general practice. These profiles indicated that providers of a high volume of orthodontic treatment (1) performed the same amount of limited orthodontic treatment as providers of a low volume of orthodontic treatment; (2) performed significantly more major orthodontic treatment; (3) used significantly more fixed appliances, functional appliances, and headgears, but not removable appliances; (4) took significantly more hours of continuing education in orthodontics; and (5) referred significantly fewer patients to orthodontic specialists. In view of the projected increase in the amount of orthodontics performed in general practice, these findings suggest that, in the future, relatively more major orthodontic treatment is likely to be provided by general practitioners. (AM J ORTHOD DENTOFACORTHOP 1991;99:269-75.)
R e c e n t surveys of the dental practice seem to indicate that the amount of orthodontic treatment rendered by general practitioners has been increasing. 1.2 In fact, according to some informed projections, in the near future we can expect to witness a drastic expansion of orthodontic services provided in general practice. For example, according to one current projection, "the next 10 years should bring about a 300 percent increase in the amount of orthodontics performed in general practice ''3 while, according to another projection pertaining to one geographic area, "up to 40 percent of clinical practice undertaken by d e n t i s t s . . , will involve some type of orthodontic therapy, by the mid1990's. ''4 Although it is difficult to determine with certainty how accurate these sweeping predictions will prove to be, these projections must be viewed as a reflection of trends that simply cannot be ignored. Among the many outstanding issues associated with
From the College of Dentistry, Universityof Iowa. *Professor, Department of Orthodontics. **Biostatistician. Department of Preventive and Community Dentistry. 811125573
these trends, none seems to be more important than the question of whether the projected increase in the volume of orthodontic treatment performed in general practice is likely to be associated with a change in the scope of orthodontic treatment rendered in general practice. Therefore a study of the projected changes in the delivery of orthodontic treatment by general practitioners should entail an effort to differentiate between (1) rendering some orthodontic treatment to an increasing proportion of patients and (2) providing more complex orthodontic treatment. In other words, an attempt should be made to ascertain whether general dentists who provide orthodontic treatment to an increasing proportion of their patients tend to limit themselves to simple cases while continuing to refer the more difficult, full-treatment cases or whether an increase in the volume of orthodontic treatment is linked to an expanded scope of treatment and fewer referrals. This is the fundamental question. The present study was designed to address this crucial question by conducting a survey of dentists in general practice and profiling (1) those general practitioners who provide orthodontic treatment to a large proportion
269
270
Am.J. Orthod.Dentofac.Orthop. March 1991
Jacobs, Bishara, and Jakobsen
Table I. Proportion of respondents performing
Table III. Average number of monthly patient
orthodontic treatment in general practice
referrals to orthodontic specialist
Sample and subsamples I Frequency Total sample Do no orthodontics Do some orthodontics Low volume of treatment* High volume of treatmentt
Sample population (%)
728 247 481 333
I00 33.9 66.1 45.7
148
20.4
* Less than 10% of patients receive orthodontic treatment. l 10% or more patients receive orthodontic treatment.
Table II. Distribution of orthodontic activity in "high volume of orthodontic treatment" practices
Categories*
l
10-20 20-30 3040 40-50 >50% TOTAL
Frequency
l
Percentt
89 36 15 5 ~ 148
18.6 7.5 3.1 1.0 0.6 30.8
* Percent of patients receiving orthodontic treatment. ] Percent of "perform some orthodontics" subsample.
of their patients and (2) those general practitioners who refer a large number of their patients to orthodontic specialists. SUBJECTS AND METHODS
In the fall of 1989 a survey of all the dentists currently in general practice in the state of Iowa was conducted. Names and addresses were obtained from the list of dentists licensed in Iowa. Survey Instrument
A concise, one-page, questionnaire of the multiplechoice type was developed as a mail survey instrument. The questionnaire sought information about proportion of patients receiving orthodontic treatment and the number of patients referred to orthodontic specialists. These two variables were accepted as measures of the volume of orthodontic treatment rendered and the volume of patients referred to specialists. The questionnaire also sought information about the scope of orthodontic treatment, the type of orthodontic appliances used, and the following additional variables viewed as correlates of
Categories None 1-4 5-10 >10 TOTAL
Frequency 34 371 249 62 716
Sample population(%) 4.7 51.0 34.2 8.5 98.4
orthodontic services in general practice: dental school attended, number of years since graduation from dental school, number of hours of continuing education in orthodontics taken annually, distance to the nearest orthodontic office, and level of satisfaction with the amount of Orthodontic services rendered. The questionnaire, accompanied by an explanatory letter and a stamped, self-addressed envelope, was mailed to 1159 general dental practitioners licensed in Iowa. RESULTS
Of the 1159 questionnaires mailed out, 728 (62.8%) were returned. It should be noted that because of some incomplete questionnaires, and therefore missing daia, some variables contain fewer than 728 responses. It should also be noted that where multiple responses were appropriate, responses exceed 100%. The compiled raw data presented in Tables I to X reveal the following frequency distributions. Volume of orthodontic treatment. As shown in Table I, 247 (33.9%) of the respondents indicated that they provided no orthodontic treatment, whereas 481 (66.1%) of the respondents, i.e., approximately twothirds of the sample population, signified that they rendered some orthodontic treatment to their patients. Out of the latter group, 333 respondents (45.7% of the sample population) indicated that they provided orthodontic care to fewer than 10% of their patients. These general practitioners rendering some orthodontic treatment to a relatively small proportion of their patients were designated as providers of a "low volume of orthodontic treatment." On the other hand, the 148 (20.4%) of the respondents who indicated that they rendered some orthodontic treatment to 10% or more of their patients were designated as providers of a "high volume of orthodontic treatment." They represented the primary focus of this study. The frequency distribution of orthodontic treatment rendered by this group is shown in Table II. Volume of orthodontic referrals. As presented in
Volume99 Number3
Special article 271
Table IV. Scope of orthodontic treatment
Categories
Frequency
Sample population (%)
Preventive and/or interceptive Serial extraction Minor tooth malposition Crossbites Class I malocclusions Class 11 and/or Class III realocclusions
431 348 339 261 127 99
59.2 47.8 46.6 35.9 17.4 14.0
"Do some orthodontics" subsample (%)
89.6 72.3 70.5 54.3 26.4 20.6
Table V. Type of appliances used
Categories
Frequency
Sample population (%)
Removable Fixed Functional Headgear
288 147 144 38
39.6 20.2 19.8 5.2
Table III, only 4.7% of the respondents signified that they did not refer patients to orthodontists. The majority o f respondents (51%) refer one to four patients monthly, 34.2% refer five to 10 patients monthly, whereas 8.5% of the respondents refer more than 10 patients monthly. On the basis of this distribution, the last two groups referring five or more patients per month were designated as providers o f a "high volume of patient referral," whereas general practitioners referring fewer than five patients per month were designated as providers o f a "low volume of patient referral." Scope of orthodontic treatment rendered. Table IV reveals that o f 481 respondents who provide some orthodontic treatment, 89.6% perform preventive and/or interceptive procedures, 72.3% engage in serial extraction procedures, 70.5% treat minor tooth malpositions, 54.3% treat crossbites, 26.4% treat Class I malocclusions, and 20.6% of the respondents treat Class II and/or Class III malocclusions. Type of appliances used. As shown in Table V, 60.0% of those 481 respondents who perform orthodontic procedures use removable appliances, 30.6% use fixed appliances, 29.9% use functional appliances, and 7.9% use headgears. Dental school attended. Table VI indicates that 591 (81.4%) of the respondents attended the University o f Iowa Dental School whereas 135 (18.6%) attended outof-state dental schools.
"Do some orthodontics" subsample (%)
60.0 30.6 29.9 7.9
Table Vl. Dental school attended population
Categories
Frequency
(%)
University of Iowa Other than University of Iowa
59 1 13_._55
8 1.2 18.5
TOTAL
726
99.7
Table VII. Number of years since graduation from dental school Categories
>-30 20-29 I0-19
Profiling providers of orthodontic services in general dental practice Richard M. Jacobs, DDS, MPH, MS, PhD,* Samir E. Blshara, BDS, DDS, D. Ortho, MS,* and Jane R. Jakobsen, BS, MA** Iowa City, Iowa
This study was designed to ascertain whether general practitioners who provide some orthodontic treatment to a relatively large proportion of their patients tend to limit themselves to the treatment of simple cases while they continue to refer more difficult cases or whether a high volume of orthodontic treatment is linked to an expanded scope of treatment and fewer referrals. Data pert.aining to volume, scope, and other correlates of orthodontic services in general practice were obtained through a survey of dentists currently in general practice in Iowa. Of 1159 questionnaires mailed out, 728 (62.8%) were returned. To determine how the values of recorded variables differ among the providers of high and low volumes of orthodontic services and to determine whether these differences are significant, X2 tests of independence were calculated. The results obtained were used to generate descriptive measures of the profiles of providers of a high volume of orthodontic services in general practice. These profiles indicated that providers of a high volume of orthodontic treatment (1) performed the same amount of limited orthodontic treatment as providers of a low volume of orthodontic treatment; (2) performed significantly more major orthodontic treatment; (3) used significantly more fixed appliances, functional appliances, and headgears, but not removable appliances; (4) took significantly more hours of continuing education in orthodontics; and (5) referred significantly fewer patients to orthodontic specialists. In view of the projected increase in the amount of orthodontics performed in general practice, these findings suggest that, in the future, relatively more major orthodontic treatment is likely to be provided by general practitioners. (AM J ORTHOD DENTOFACORTHOP 1991;99:269-75.)
R e c e n t surveys of the dental practice seem to indicate that the amount of orthodontic treatment rendered by general practitioners has been increasing. 1.2 In fact, according to some informed projections, in the near future we can expect to witness a drastic expansion of orthodontic services provided in general practice. For example, according to one current projection, "the next 10 years should bring about a 300 percent increase in the amount of orthodontics performed in general practice ''3 while, according to another projection pertaining to one geographic area, "up to 40 percent of clinical practice undertaken by d e n t i s t s . . , will involve some type of orthodontic therapy, by the mid1990's. ''4 Although it is difficult to determine with certainty how accurate these sweeping predictions will prove to be, these projections must be viewed as a reflection of trends that simply cannot be ignored. Among the many outstanding issues associated with
From the College of Dentistry, Universityof Iowa. *Professor, Department of Orthodontics. **Biostatistician. Department of Preventive and Community Dentistry. 811125573
these trends, none seems to be more important than the question of whether the projected increase in the volume of orthodontic treatment performed in general practice is likely to be associated with a change in the scope of orthodontic treatment rendered in general practice. Therefore a study of the projected changes in the delivery of orthodontic treatment by general practitioners should entail an effort to differentiate between (1) rendering some orthodontic treatment to an increasing proportion of patients and (2) providing more complex orthodontic treatment. In other words, an attempt should be made to ascertain whether general dentists who provide orthodontic treatment to an increasing proportion of their patients tend to limit themselves to simple cases while continuing to refer the more difficult, full-treatment cases or whether an increase in the volume of orthodontic treatment is linked to an expanded scope of treatment and fewer referrals. This is the fundamental question. The present study was designed to address this crucial question by conducting a survey of dentists in general practice and profiling (1) those general practitioners who provide orthodontic treatment to a large proportion
269
270
Am.J. Orthod.Dentofac.Orthop. March 1991
Jacobs, Bishara, and Jakobsen
Table I. Proportion of respondents performing
Table III. Average number of monthly patient
orthodontic treatment in general practice
referrals to orthodontic specialist
Sample and subsamples I Frequency Total sample Do no orthodontics Do some orthodontics Low volume of treatment* High volume of treatmentt
Sample population (%)
728 247 481 333
I00 33.9 66.1 45.7
148
20.4
* Less than 10% of patients receive orthodontic treatment. l 10% or more patients receive orthodontic treatment.
Table II. Distribution of orthodontic activity in "high volume of orthodontic treatment" practices
Categories*
l
10-20 20-30 3040 40-50 >50% TOTAL
Frequency
l
Percentt
89 36 15 5 ~ 148
18.6 7.5 3.1 1.0 0.6 30.8
* Percent of patients receiving orthodontic treatment. ] Percent of "perform some orthodontics" subsample.
of their patients and (2) those general practitioners who refer a large number of their patients to orthodontic specialists. SUBJECTS AND METHODS
In the fall of 1989 a survey of all the dentists currently in general practice in the state of Iowa was conducted. Names and addresses were obtained from the list of dentists licensed in Iowa. Survey Instrument
A concise, one-page, questionnaire of the multiplechoice type was developed as a mail survey instrument. The questionnaire sought information about proportion of patients receiving orthodontic treatment and the number of patients referred to orthodontic specialists. These two variables were accepted as measures of the volume of orthodontic treatment rendered and the volume of patients referred to specialists. The questionnaire also sought information about the scope of orthodontic treatment, the type of orthodontic appliances used, and the following additional variables viewed as correlates of
Categories None 1-4 5-10 >10 TOTAL
Frequency 34 371 249 62 716
Sample population(%) 4.7 51.0 34.2 8.5 98.4
orthodontic services in general practice: dental school attended, number of years since graduation from dental school, number of hours of continuing education in orthodontics taken annually, distance to the nearest orthodontic office, and level of satisfaction with the amount of Orthodontic services rendered. The questionnaire, accompanied by an explanatory letter and a stamped, self-addressed envelope, was mailed to 1159 general dental practitioners licensed in Iowa. RESULTS
Of the 1159 questionnaires mailed out, 728 (62.8%) were returned. It should be noted that because of some incomplete questionnaires, and therefore missing daia, some variables contain fewer than 728 responses. It should also be noted that where multiple responses were appropriate, responses exceed 100%. The compiled raw data presented in Tables I to X reveal the following frequency distributions. Volume of orthodontic treatment. As shown in Table I, 247 (33.9%) of the respondents indicated that they provided no orthodontic treatment, whereas 481 (66.1%) of the respondents, i.e., approximately twothirds of the sample population, signified that they rendered some orthodontic treatment to their patients. Out of the latter group, 333 respondents (45.7% of the sample population) indicated that they provided orthodontic care to fewer than 10% of their patients. These general practitioners rendering some orthodontic treatment to a relatively small proportion of their patients were designated as providers of a "low volume of orthodontic treatment." On the other hand, the 148 (20.4%) of the respondents who indicated that they rendered some orthodontic treatment to 10% or more of their patients were designated as providers of a "high volume of orthodontic treatment." They represented the primary focus of this study. The frequency distribution of orthodontic treatment rendered by this group is shown in Table II. Volume of orthodontic referrals. As presented in
Volume99 Number3
Special article 271
Table IV. Scope of orthodontic treatment
Categories
Frequency
Sample population (%)
Preventive and/or interceptive Serial extraction Minor tooth malposition Crossbites Class I malocclusions Class 11 and/or Class III realocclusions
431 348 339 261 127 99
59.2 47.8 46.6 35.9 17.4 14.0
"Do some orthodontics" subsample (%)
89.6 72.3 70.5 54.3 26.4 20.6
Table V. Type of appliances used
Categories
Frequency
Sample population (%)
Removable Fixed Functional Headgear
288 147 144 38
39.6 20.2 19.8 5.2
Table III, only 4.7% of the respondents signified that they did not refer patients to orthodontists. The majority o f respondents (51%) refer one to four patients monthly, 34.2% refer five to 10 patients monthly, whereas 8.5% of the respondents refer more than 10 patients monthly. On the basis of this distribution, the last two groups referring five or more patients per month were designated as providers o f a "high volume of patient referral," whereas general practitioners referring fewer than five patients per month were designated as providers o f a "low volume of patient referral." Scope of orthodontic treatment rendered. Table IV reveals that o f 481 respondents who provide some orthodontic treatment, 89.6% perform preventive and/or interceptive procedures, 72.3% engage in serial extraction procedures, 70.5% treat minor tooth malpositions, 54.3% treat crossbites, 26.4% treat Class I malocclusions, and 20.6% of the respondents treat Class II and/or Class III malocclusions. Type of appliances used. As shown in Table V, 60.0% of those 481 respondents who perform orthodontic procedures use removable appliances, 30.6% use fixed appliances, 29.9% use functional appliances, and 7.9% use headgears. Dental school attended. Table VI indicates that 591 (81.4%) of the respondents attended the University o f Iowa Dental School whereas 135 (18.6%) attended outof-state dental schools.
"Do some orthodontics" subsample (%)
60.0 30.6 29.9 7.9
Table Vl. Dental school attended population
Categories
Frequency
(%)
University of Iowa Other than University of Iowa
59 1 13_._55
8 1.2 18.5
TOTAL
726
99.7
Table VII. Number of years since graduation from dental school Categories
>-30 20-29 I0-19
