|Year : 2019 | Volume
| Issue : 7 | Page : 2490-2495
A survey on orthodontic services provided by general dental practitioners
Poonam K Jayaprakash1, Palash Modi2, Pranav Sapawat3, RudraPratap Singh Thakur4, Tanuj Choudhari4, Jayant Chandrakar4
1 Department of Orthodontics and Dentofacial Orthopedics, Kothiwal Dental College and Research Center, Moradabad, Uttar Pradesh, India
2 Consultant Orthodontist, Phoenix Hospital, Panchkula, Haryana, India
3 Orthodontist, New Delhi, India
4 Orthodontics and Dentofacial Orthopedics, Maitri College of Dentistry and Research Center, Chattisgarh, India
|Date of Submission||06-May-2019|
|Date of Decision||07-May-2019|
|Date of Acceptance||28-May-2019|
|Date of Web Publication||31-Jul-2019|
Dr. Poonam K Jayaprakash
Department of Orthodontics and Dentofacial, Orthopedics, Kothiwal Dental College and Research, Center, Mora Mustaqueem, Moradabad - 244 001, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
The aim of this survey-based study was to recognize professional determinants that account for variations in the level of orthodontic services provided and which distinguish providers and nonproviders of orthodontic services. Multiple regression analysis revealed that four practitioner characteristics explained 43% of the variance in the number of orthodontic patients treated. Dentists who treated more orthodontic patients (1) treated more general practice patients, (2) frequently used multiple sources to keep up to date in orthodontics, (3) perceived their patient base to contain more children, and (4) were likely to have attended an orthodontic course. The null hypothesis that selected characteristics of dentists providing orthodontic services were no different from those of dentists not providing orthodontic services was rejected. The provision of orthodontic services was associated with a higher level of continuing orthodontic education and treating more general practice patients, especially children.
Keywords: General dental practitioners, orthodontic services, survey
|How to cite this article:|
Jayaprakash PK, Modi P, Sapawat P, Thakur RS, Choudhari T, Chandrakar J. A survey on orthodontic services provided by general dental practitioners. J Family Med Prim Care 2019;8:2490-5
|How to cite this URL:|
Jayaprakash PK, Modi P, Sapawat P, Thakur RS, Choudhari T, Chandrakar J. A survey on orthodontic services provided by general dental practitioners. J Family Med Prim Care [serial online] 2019 [cited 2019 Aug 18];8:2490-5. Available from: http://www.jfmpc.com/text.asp?2019/8/7/2490/263791
| Introduction|| |
Patient characteristics and the personal and practice characteristics of dentists have been hypothesized to influence the delivery of orthodontic services. Brown identified a number of practitioner characteristics that accounted for variations in the level of periodontal services provided in the general dental practice. A number of overseas studies have established that certain practitioner characteristics may differentiate providers from minimal or nonproviders of orthodontic service.,,,,,,,,,,, However, Taylor and Kerr  found that a number of these practitioner characteristics, that is, number of years since graduation, dentists' perception of their undergraduate training, and attendance at an orthodontic continuing education course, did not influence orthodontic service provision. Having identified variations among general dental practitioners in the level of orthodontic service provision, this study aimed to identify practitioner characteristics that account for variations in the level of orthodontic services provided and which distinguish providers and nonproviders of orthodontic services. The null hypothesis was that selected characteristics of dentists providing orthodontic services were no different from those of dentists not providing orthodontic services.
| Materials and Methods|| |
Four groups of general dental practitioner characteristics were hypothesized to be associated with variations in the provision of orthodontic services.
- Personal and practice characteristics, which include (a) sociodemographic characteristics, (b) undergraduate education characteristics, (c) continuing education characteristics, and (d) general practice characteristics.
- Dentists' attitudes toward orthodontics. Three areas were investigated: (a) dentists' attitude toward continuing education in orthodontics, (b) dentists' attitude toward the provision of orthodontic services, and (c) dentists' satisfaction with the level of orthodontic services they were providing.
- Dentists' knowledge of orthodontics (19 questions were used to form a knowledge scale).
- Dentists' practice characteristics (information for this section was obtained from the procedure log; 100 dentists provided information in the procedure log). The 100 respondents for whom log data were available were divided into two groups, based on the number of orthodontic patients seen over the period (not including those referred for treatment). Those who provided orthodontic services saw three or more orthodontic patients during the fortnight of the log, while the “nonprovider group” included those who saw either no orthodontic patients or only one or two orthodontic patients during the fortnight. It was predicted that there would be significant differences between these two groups with respect to demographic and educational characteristics. Even though more dentists were represented in the “nonprovider group” (64.5%) than in the “provider group” (35.5%), this division of the sample produced two samples of adequate size for analysis. The point of division was based on the assumption that this would more accurately separate providers from nonproviders of orthodontic services in this sample, even though the nonprovider group contained dentists who were minimal providers of orthodontic services. Since the log was taken over a period of 2 weeks whereas orthodontic patients are generally seen every 4 weeks, some of the dentists who did not see any orthodontic patients may have seen one or two if the log had been completed at a different time of the month. Statistical analysis, nonetheless, produced similar results when the sample was divided between dentists providing no orthodontic services and those providing some orthodontic services. The SPSS program 18 was used to analyze the data. Chi-square, correlations, and Student's t-tests were used to limit the number of variables collected that were subsequently used in multivariate analysis – multiple regression and discriminant analysis. The variables selected for the multivariate analyses were a number of those where the probability level was less than 0.05 when the variables were compared between the provider and nonprovider.
Review of literature
Orthodontic treatment provided by general dentists has been reported in the literature, but the results are conflicting. While Hilgers et al. found that pediatric dentists spent less than 10% of their time providing orthodontic treatment and Galbreath et al. similarly noted that general dentists spent less than 10% of their time providing orthodontic treatment, a study by Koroluk et al. showed that a large percentage of pediatric and general dentistry practitioners provided comprehensive orthodontic treatment (62% and 17.9%, respectively). In another study, 76.3% of general practitioners were found to provide basic orthodontic treatment and 19.3% provided comprehensive orthodontic treatment. General practitioners who showed a profile of high-volume orthodontic services were found to treat more difficult cases and there was a projected increase in the amount of orthodontic treatment performed in general practice. Thus, the anticipated increase or decrease in orthodontic treatment in general practice is debatable and has been discussed in most of the previously mentioned articles.
General dentistry practitioners usually decide whether, when, and where to refer the patient. They are considered to be gatekeepers for specialist dental care. If referrals are made before the patient is ready for treatment, this may result in unnecessary appointments. However, if referrals are made after the “ideal” time, the treatment may be more complex and lengthy. A study in England revealed that one reason for an excessive length in the waiting list of new orthodontic patient consultation is the unnecessary referral of patients by general practitioners. In a study by Parfitt and Rock who surveyed 30 general practitioners for their treatment plan accuracy and referral pattern, only 14% of general practitioner treatment plans agreed with the gold standard. According to Berk et al., when the treatment need assessment scores of orthodontists, general dental practitioners, and pediatric dentists are compared, it was found that all three groups exhibited high levels of agreement on orthodontic treatment needs.
Dental students in the United States were surveyed to determine their ability to recognize malocclusions and measure their diagnostic skills. The study concluded that 4 years of undergraduate education did not improve the students' orthodontic diagnostic skills. Among the British dental schools that were studied, 75% did not expect their new graduates to be able to formulate an orthodontic treatment plan. They also believed that undergraduate training should be concentrated more on the diagnosis and recognition of a dental malocclusion, rather than on the formulation of a treatment plan.
A survey of orthodontists suggested that early orthodontic intervention is the norm among practitioners in the United States, but practice characteristics affected treatment timing. Another survey showed that a majority of orthodontists recommended that the first assessment of an occlusion should be carried out before the age of 7 years and that cross bites should be preferably applied during primary- and early-mixed dentition stages. In West Sussex, while 52% of dentists were able to correctly identify which type of orthodontic provider they refer to, only 20% of them were able to determine the appropriate time of orthodontic referral. Carty et al. assessed the performance of the referral management system compared to a previous paper-based referral system and to determine whether referrals reflected the patients' malocclusion and met current guidelines.
| Results|| |
[Table 1] summarizes the practitioner characteristics investigated and the level of statistical significance reached when these variables were compared between the provider and nonprovider groups. Nineteen variables, including dummy variables, were initially used in the multivariate analyses of the results. The ordinary least square regression analysis found that only four variables were significant in explaining variations in the number of orthodontic patients seen by the general dental practitioners during the fortnight of the log, that is, the dependent variables. The adjusted R2 for this regression was 0.43, indicating that the combination of these independent variables explained 43% of the variance in the dependent variable. Variables that were found to be significant in the discriminant analysis showed that the provision of orthodontic services was associated with the following:
|Table 1: Practitioner determinants that were investigated and the level of significance obtained when comparing these variables between the provider and nonprovider groups|
Click here to view
- Higher number of general practice patients seen
- Higher perceived number of children in the dentists'
- Higher frequency of use of sources to keep up to
- Working in the outer rather than the inner suburbs
- Not working for the government
- Not working in the city
- Better attitude toward the provision of orthodontic
- Orthodontics not being a regular part of the under-
- Not wanting to treat fewer orthodontic cases
- Higher perceived orthodontic need of the dentists'
- Higher referral level to specialist orthodontists.
The null hypothesis that selected characteristics of dentists providing orthodontic services were no different practice date in orthodontics services graduate course patient base from those of dentists not providing orthodontic services was rejected by both multivariate analyses at a significance level of P < 0.01.
| Discussion|| |
Limitations of the study
- Numerous variables were collected from the questionnaire; however, due to the sample size, not all could be used in the multivariate analyses of the results. Student's t-tests, Chi-square, and correlation were used to limit the number of variables; however, in doing so, variables that may have been significant in the multivariate analyses may have been missed.
- The reliability of the procedure log and questions developed for use in this study had not been previously tested, and comparison of some of the variables measured with other studies was impossible.
- The orthodontic procedure log ran for only 2 weeks, whereas orthodontic patients are generally seen monthly. Consequently, dentists may have been grouped differently, that is, into provider or nonprovider groups, if the log had continued for 1 month.
Dentists' professional characteristics
The mean age of dentists in this study was 40 years. Although it has been found that females work, on average, fewer hours per year than males, and this study found that the provision of orthodontic services was associated with the number of hours worked, there was no statistical difference between the orthodontic service provision of male and female dentists. Discriminant analysis suggested that orthodontics not being part of the undergraduate dental course was significantly correlated with the provision of orthodontic services. Approximately 36% of the dentists surveyed had attended a continuing education course in orthodontics. Freer and Foster  reported that 12.6% of their sample had attended an orthodontic refresher course in the past 5 years.
Gorczyca et al. and Jacobs et al. found that the number of orthodontic procedures provided increased with the number of hours of orthodontic continuing education attended. A similar relationship was found in this study, where dentists in the provider group appeared more likely to have attended a continuing education course in orthodontics and to have attended more courses than dentists in the nonprovider group. A variety of materials can be used to keep up to date in orthodontics, for example, journals and textbooks. The scale measuring dentists' involvement in keeping up to date in orthodontics explained 17% of the variance in the number of orthodontic patients seen in general dental practice. The majority of dentists surveyed were in private practice. About 46% of the dentists surveyed were in solo practice. Working for the government was the only practice situation variable associated with the provision of significantly fewer orthodontic services than in solo practices. An increased number of children in the dentists' patient base was associated with the provision of orthodontic services. This relates well to the log data, where the majority of patients seen for orthodontic services were between 10 and 14 years of age. An increased perceived need for orthodontic treatment in the dentist's patient base was also associated with the provision of orthodontic services.
Dentists' attitude and knowledge related to orthodontics
The scale measuring dentist's attitude toward continuing education in orthodontics was significantly different between the provider and nonprovider groups; dentists in the provider group had a better attitude toward continuing education. However, this variable was not significant in influencing the provision of orthodontic services or discriminating between providers and nonproviders, in the multivariate analyses. The scale assessing dentists' attitude to the provision of orthodontic services was found to be significant in discriminating a dentist who was a provider of orthodontic services from one who was not, suggesting that a better attitude to the provision of orthodontic services was associated with the provision of orthodontic services.
General dental practitioners' interest in orthodontics has been found to be associated with the provision  and expanding provision  of orthodontic services. One of the questions in the attitude to orthodontic service provision scale asked the practitioner to indicate whether or not they found providing orthodontic services interesting. Approximately 80% of the dentists surveyed stated that they found orthodontic service provision interesting. Assessment of dentists' satisfaction with the level of orthodontic services they were providing revealed that a minority of dentists wanted to treat fewer malocclusions or less difficult malocclusions. This was similar to the finding of Jacobs et al. where less than 4% of the dentists surveyed wanted to “do less” orthodontics. Approximately 40% of the sample in this study would have liked to treat more orthodontic cases. Not wanting to treat fewer orthodontic cases was found to be associated with the provision of orthodontic services. This shows that dentists who were orthodontic providers wanted to maintain their current level of service provision or increase it. This increase may also be associated with the treatment of more difficult malocclusions, since less than 10% of orthodontic service providers wanted to treat less difficult malocclusions. This may indicate a future expansion in the amount and scope of orthodontic services provided in general dental practice. Similar findings were reported in America by Jacobs et al. The expansion of orthodontic services in general dental practice has been associated with increased income derived from orthodontic service., One of the questions in the attitude to orthodontic service provision scale asked the practitioner to indicate whether or not they believed providing orthodontic services was financially rewarding. Approximately 60% of the dentists surveyed stated that they believed orthodontic service provision was financially rewarding. There was a statistically significant difference between the provider and nonprovider groups (P < 0.05). Dentists in the provider group appeared more likely to believe that orthodontic service provision was financially rewarding. No previous study assessing dentists' orthodontic knowledge could be found. Consequently, comparison to other studies is not possible. The scale measuring dentists' orthodontic knowledge was significantly different between the provider and nonprovider groups. Dentists in the provider group had a better orthodontic knowledge. However, this variable was not significant in influencing the provision of orthodontic services or discriminating between providers and nonproviders, in the multivariate analyses. The mean number of hours worked per fortnight and the number of general practice patients seen in this study were comparable to the results from other studies., Variables assessing practice productivity were significantly different between the provider and nonprovider groups. Dentists providing orthodontic services worked longer hours in general dental practice and saw more orthodontic patients than dentists in the nonprovider group. Orthodontic services, including referrals tospecialist orthodontists, accounted for 4.6% of orthodontic provider dentist's time and 0.8% of nonprovider dentist's time. In this study, a Student's t-test did not reveal a significant difference between the provider and nonprovider groups for the number of patients referred to a specialist orthodontists. This was in contrast to the results of Jacobs et al. who found that dentists who provide more orthodontic services refer significantly fewer patients to orthodontic specialists.
| Conclusion|| |
Dentists in the nonprovider group, those who saw fewer than three orthodontic patients during the fortnight of the log, made up 64.5% of the sample. Dentists in the provider group, those who saw three or more patients, made up 35.5% of the sample. There were statistically significant differences between the provider and nonprovider groups. The practitioner characteristics that were significantly different between the two groups were in the areas of personal and practice characteristics as well as dentists' knowledge of and attitude toward orthodontics. The null hypothesis that selected characteristics of dentists providing orthodontic services were no different from those of dentists not providing orthodontic services was rejected. Two measures related to continuing education in orthodontics were found to be significantly and positively correlated with the provision of orthodontic services. These were (1) orthodontic continuing education course attendance and (2) the frequency of use of various sources of information to keep up to date in orthodontics. This latter variable was also found to be significant in distinguishing providers from nonproviders of orthodontic services. General dental practitioners who perceived their patient base to consist of more adults saw significantly fewer orthodontic patients and were more likely to be classified as nonproviders than those general dental practitioners who perceived their patient base to contain more children. Other factors found to be significant in distinguishing providers of orthodontic services from nonproviders included not working in the city, working in the outer suburbs, not working for the government, a better attitude toward orthodontic service provision, orthodontics not being a regular part of the undergraduate course, not wanting to treat fewer orthodontic cases, a higher perceived orthodontic need of the dentists' patient base, and a higher referral level to specialist orthodontists.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Manasse RJ, Dooley RJ. Correlates of the orthodontic aspects of the general dentist's practice. J Dent Educ 1980;44:543-6.
Moore RN, Erickson LC. Predoctoral and continuing education in orthodontics: Opinions of Nebraska Alumni. J Clin Orthod 1988;22:152-6.
Gorczyca AM, Jones JE, Douglass CW. Orthodontic treatment provided by general practitioners and pedodontists in Massachusetts. J Clin Orthod 1989;23:346-52.
Konchak PA, McDermott RE. Orthodontic education and practice in Canada: Perceptions of the profession as shown in a recent survey. Can Dent Assoc J 1990;56:537-9.
Jacobs RM, Bishara SE, Jakobson JR. Profiling providers of orthodontic services in general dental practice. Am J Orthod Dentofacial Orthop 1991;99:269-75.
Richmond S, Shaw WC, Stephens CD. Orthodontics in the general dental services of England and Wales: The provision of treatment. Br Dent J 1991;172:150-2.
Spencer AJ, Lewis JM. Service-mix in general dental practice in Australia. Aust Dent J 1989;34:69-74.
Brown L. Factors influencing the provision of periodontal services by general dental practitioners. Melbourne, Victoria: Department of Preventive and Community Dentistry, University of Melbourne, 1987. MDSc thesis.
Little RJ. A survey of attitudes and professional activities of graduates of the University of British Columbia and the University of Washington presently engaged in general dental practice. Seattle, Washington: University of Washington, 1974. PhD dissertation. Cited in McLain JB, Profit WR. Oral health status in the United States: Prevalence of malocclusion. J Dent Educ 1985;49:386-96.
Pender N. Recent graduates' opinion on orthodontic training. MScD dissertation. University of Wales, 1979. Cited in Stephens CD, Orton HS, Usiskin LA. Future manpower requirements for orthodontics undertaken in the general dental service. Br J Orthod 1985;12:168-75.
Haynes S. Orthodontic treatment in the British National Health Service. A quantitative study of the contribution of specialist and general practitioners in Scotland 1966-1979. Eur J Orthod 1981;3:141-5.
Brown ID, Stephens CD, Usiskin LA. The effect of 'block' and 'longitudinal' orthodontic teaching: A survey of recently qualified graduates of two dental schools. Br J Orthod 1982;9:98-106.
Taylor GK, Kerr WJS. Orthodontics in general dental practice. A survey of attitudes in Glasgow. Br Dent J 1985;159:344-5.
Lawrence AJ, Wright FAC, DAdamo SP. The provision of orthodontic services by general dental practitioners. 1. Methods and descriptive results. Aust Dent J 1995;40:296-300.
Hilgers KK, Redford-Badwal D, Reisine S. Orthodontic treatment provided by pediatric dentists. Am J Orthod Dentofac Orthop 2003;124:551-60.
Galbreath RN, Hilgers KK, Silveira AM, Scheetz JP. Orthodontic treatment provided by general dentists who have achieved master's level in the academy of general dentistry. Am J Orthod Dentofac Orthop 2006;129:678-86.
Koroluk LD, Jones JE, Avery DR. Analysis of orthodontic treatment by pediatric dentists and general practitioners in Indiana. ASDC J Dent Child 1988;55:97-101.
Wolsky SL, McNamara JA Jr. Orthodontic services provided by general dentists. Am J Orthod Dentofac Orthop 1996;110:211-7.
Jacobs RM, Bishara SE, Jakobsen JR. Profiling providers of orthodontic services in general dental practice. Am J Orthod Dentofac Orthop 1991;99:269-75.
De Bondt B, Aartman IH, Zentner A. Referral patterns of Dutch general dental practitioners to orthodontic specialists. Eur J Orthod 2010;32:548-54.
O'Brien K, McComb JL, Fox N, Bearn D, Wright J. Do dentists refer orthodontic patients inappropriately? Br Dent J 1996;181:132-6.
Parfitt AA, Rock WP. Orthodontic treatment planning by general dental practitioners. Br J Orthod 1996;23:359-65.
Berk NW, Bush HD, Cavalier J, Kapur R, Studen-Pavlovich D, Sciote J, et al.
Perception of orthodontic treatment need: Opinion comparisons of orthodontists, pediatric dentists, and general practitioners. J Orthod 2002;29:287-91; discussion 277.
Brightman BB, Hans MG, Wolf GR, Bernard H. Recognition of malocclusion: An education outcomes assessment. Am J Orthod Dentofac Orthop 1999;116:444-51.
Rock WP, O'Brien KD, Stephens CD. Orthodontic teaching practice and undergraduate knowledge in British dental schools. Br Dent J 2002;192:347-51.
Yang EY, Kiyak HA. Orthodontic treatment timing: A survey of orthodontists. Am J Orthod Dentofac Orthop 1998;113:96-103.
Pietilä I, Pietilä T, Pirttiniemi P, Varrela J, Alanen P. Orthodontists' views on indications for and timing of orthodontic treatment in finnish public oral health care. Eur J Orthod 2007;30:46-51.
Jackson OA, Cunningham SJ, Moles DR, Clark JR. Orthodontic referral behaviour of West Sussex dentists. Br Dent J 2009;207:E18; discussion 430-1. doi: 10.1038/sj.bdj. 2009.979. Epub 2009 Nov 6.
Carty O, Toor H, Morris TA, Harrison JE. Orthodontic referral management systems: Do they make a difference? J Orthod 2019;46:39-45.
Freer TJ, Foster GA. Towards a revised undergraduate orthodontic curriculum. Aust Orthod J 1990;11:178-89.
Association of Pedodontic Diplomates. Survey of orthodontic services provided by pedodontists. Pediatric Dent 1983;5:204-6.
Dental Statistics and Research Unit, Australian Institute of Health and Welfare. Department of Dentistry, The University of Adelaide. Newsletter 111, Number 2, September 1992.
Spencer AJ, Lewis JM. The provision of periodontal services in general dental practice in Australia. Community Dent Health 1989;6337-47.