Use of dental hygienists and returns to scale in child dental care in Norway

Abstract The purpose of this study was to investigate, in the provision of dental care for children, technically and economically efficient combinations of dentists and dental hygienists and to study returns to scale by analyzing production functions. Data from 137 dental health clinics were analyzed. Output was registered as the number of 3–18-yr-old children to whom the clinic delivered complete dental care. Resource input was registered as hours spent by dentists, denial hygienists and dental assistants to deliver care to the children. The average clinic that employed dental hygienists used one hygienist hour per three dentist hours for child dental care. It would save dentist time, but not costs, to extend the use of hygienists. Increased use of dental hygienists might be economically efficient if the work distribution between the personnel groups were changed, for example, by delegating more examinations and preventive care to hygienists. There were technical opportunities for further substitution of dental hygienists for dentists both by introducing dental hygienists in the clinics that only used dentists in child dental care and by extending use of hygienists in clinics that already employed hygienists. This study found no productivity gain from centralizing treatment of children in large dental clinics.     

The dental safety net in Connecticut

BACKGROUND: Many poor, medically disabled and geographically isolated populations have difficulty accessing private-sector dental care and are considered underserved. To address this problem, public- and voluntary-sector organizations have established clinics and provide care to the underserved. Collectively, these clinics are known as "the dental safety net." The authors describe the dental safety net in Connecticut and examine the capacity and efficiency of this system to provide care to the noninstitutionalized underserved population of the state. METHODS: The authors describe Connecticut's dental safety net in terms of dentists, allied health staff members, operatories, patient visits and patients treated per dentist per year. The authors compare the productivity of safety-net dentists with that of private practitioners. They also estimate the capacity of the safety net to treat people enrolled in Medicaid and the State Children's Health Insurance Program. RESULTS: The safety net is made up of dental clinics in community health centers, hospitals, the dental school and public schools. One hundred eleven dentists, 38 hygienists and 95 dental assistants staff the clinics. Safety-net dentists have fewer patient visits and patients than do private practitioners. The Connecticut safety-net system has the capacity to treat about 28.2 percent of publicly insured patients. CONCLUSIONS: The dental safety net is an important community resource, and greater use of allied dental personnel could substantially improve the capacity of the system to care for the poor and other underserved populations.     

Geographic distribution of specialist orthodontists and orthodontic providers in Japan

ObjectiveThis study aimed to clarify the geographic distribution of specialist orthodontists and dentists who provide orthodontic services in Japan.MethodsWe obtained data on the populations of 1750 municipalities in Japan in 2010 by referring to the census. We obtained data on the number of dentists who mainly provide orthodontic services (specialist orthodontists) and the number of dentists, including general dentists, who provide orthodontic services (orthodontic providers), by referring to the Survey of Physicians, Dentists, and Pharmacists. Furthermore, we referred to the directory on the website of the Japanese Orthodontic Society (JOS) to obtain data on JOS-qualified orthodontists. To assess the distribution of specialist orthodontists and orthodontic providers, we used Lorenz curves and Gini coefficients.ResultsThe median value for the number of specialist orthodontists and number of JOS-certified orthodontists per 100,000 persons aged between 5 and 40 years old was 0, while that of orthodontic providers was 27.5. Gini coefficients for specialist orthodontists and JOS-certified orthodontists were 0.523 and 0.615, respectively. On the other hand, the Gini coefficient for orthodontic providers was 0.258.ConclusionsRegional inequalities in the availability of specialist orthodontists are high, and medical access to specialist orthodontic services may be limited in areas other than urban districts. In municipalities with a population of fewer than 50,000 inhabitants, the number of specialist orthodontists was very low, but orthodontic providers were relatively evenly distributed. Our research results suggested that studying the distribution of specialist orthodontists and orthodontic providers can provide valuable information for developing dental care policies.     

Safety-net dental clinics

BACKGROUND: Federal policy supports and funds community-based clinics to provide health care to low-income and underserved groups. This study examines the role of community dental safety-net clinics in providing dental care for these populations. METHODS: The authors administered a cross-sectional survey of all identified safety-net dental clinics in Illinois. Seventy-one of 94 clinics responded (response rate, 76 percent), describing their history, operations, patients, staffing and dentist relationships. An in-depth analysis of 57 clinics presents comparisons of three categories of clinics, sponsored by community health centers (23), local health departments (21) and private services agencies (13). RESULTS: Clinics were distributed across the state; 80 percent were located in facilities with other health care providers, and all provided dental care to low-income and other underserved groups. Clinics provided more than 3100 annual dental visits, operated with limited staffing and budgets, and had referral relationships with local dentists. Clinics with full-time dentists or any dental hygienists had higher annual numbers of dental visits. CONCLUSIONS: These clinics provide dental care to groups with traditional access barriers. Although they represent a small portion of all dental care, their mission and role make them a key component of strategies to address the dental access problem. PRACTICE IMPLICATIONS: Local and state dental practitioners and coalitions seeking to expand dental access should consider their community dental safety-net clinics as partners. Efforts to expand theese clinics should include considering optimizing staffing for better dental productivity.     

Parents' satisfaction with their child's orthodontic care: a comparison of orthodontists and pediatric dentists

PURPOSE: The purpose of this study was to compare the quality of orthodontic care between orthodontists and pediatric dentists when measured by parental satisfaction. METHODS: Six pediatric dentists and 5 orthodontists participated in the study. Quality of care was measured using the peer assessment rating (PAR) occlusal index, treatment duration, and parental satisfaction. Parental satisfaction was evaluated using a 25-item questionnaire measuring 3 dimensions: (1) treatment process; (2) psychosocial effects of treatment; and (3) treatment outcomes. The questionnaire items were scored on a scale of "strongly disagree" to "strongly agree." RESULTS: At baseline, no differences were seen in the gender, starting dentition, and permanent teeth extractions of patients treated by the orthodontist and pediatric dentists. Statistically significant differences were seen in patients': (1) pretreatment age; (2) race; (3) primary teeth extractions; (4) treatment stages; and (5) pre-PAR scores. No statistically significant differences between orthodontists and pediatric dentists were observed regarding overall parental satisfaction or the dimensions of satisfaction. These results did not change after controlling for potential confounding factors such as patient's age, gender, starting dentition, treatment stage, extraction recommendations, pre-PAR score, treatment duration, and percentage PAR reduction. CONCLUSIONS: The quality of orthodontic care, when measured by parental satisfaction, was similar between orthodontists and pediatric dentists. This indicates that, as far as parents are concerned, pediatric dentists performed orthodontic treatment to the same high standard as orthodontists.     

Orthodontic education and practice in Canada: perceptions of the profession as shown in a recent survey

A questionnaire survey concerning the training and practice of orthodontics was mailed to 20 per cent of the licensed dentists and to dental specialists in the provinces of Ontario, Manitoba, Alberta, and British Columbia between March and August of 1987. The response rate was 49.4 per cent. Many dentists and orthodontists who completed the survey reported declines in patient load during the past three years. Dental schools are perceived to be providing inadequate orthodontic training, in both the undergraduate dental curriculum and in the area of continuing education. A desire for an increase in time, quality, and applications was expressed. Between 20.1 and 34.2 per cent of fully-banded orthodontic cases are being treated by general practitioners.     

Impact of Dental Therapists on Productivity and Finances: III. FQHC-Run, School-Based Dental Care Programs in Connecticut

In many developed countries, the primary role of dental therapists is to care for children in school clinics. This article describes Federally Qualified Health Center (FQHC)-run, school-based dental programs in Connecticut and explores the theoretical financial impact of substituting dental therapists for dentists in these programs. In schools, dental hygienists screen children and provide preventive services, using portable equipment and temporary space. Children needing dentist services are referred to FQHC clinics or to FQHC-employed dentists who provide care in schools. The primary findings of this study are that schoolbased programs have considerable potential to reduce access disparities and the estimated reduction in per patient costs approaches 50 percent versus providing care in FQHC dental clinics. In terms of substituting dental therapists for dentists, the estimated additional financial savings was found to be about 5 percent. Nationally, FQHC-operated, school-based dental programs have the potential to increase Medicaid/CHIP utilization from the current 40 percent to 60 percent for a relatively modest increase in total expenditures.     

Orthodontic attitudes toward national health insurance.

Data were obtained by surveying North Carolina orthodontists by means of a mailed questionnaire. Their responses were coded to make possible analysis by computer and were compared to responses from a national sample of dentists in the 1975 Survey of Dentists. Both North Carolina orthodontists and dentists nationwide agreed that some form of dental care should be provided if a national health insurance system were established. Compared to the dentists surveyed nationwide, the orthodontists favored a wider range of coverages but advocated providing a narrower scope of dental services. They indicated more strongly their general belief that a government health program would lead to regulation outside the private sector. The orthodontists disagreed more strongly with the claim that government health programs could provide more people with high-quality dental care. Both groups anticipated that comprehensive dental care in a national health insurance system would result in fixed fees set by the government. Only 62 percent of the orthodontists polled were familiar with HMOs. Of this group, nearly 90 percent chose not to contract with these organizations.     

The B.S.S.O. M.Orth. Prize of the Royal College of Surgeons of England 1998

Abstract

Aim: To determine the relationship between treatment need assessment scores of orthodontists, general practitioners, and pediatric dentists.

Study design: Observational.

Sample: Ten general dental practitioners, 18 orthodontists and 15 pediatric dentists reviewed 137 dental casts and recorded their opinion on whether orthodontic treatment was needed.

Results: We found a high level of agreement between pediatric dentists, orthodontists and general practitioners (Kappa range 0.86–0.95). Between the groups, the amount of agreement was lower.

Conclusions: Orthodontists, general dental practitioners, and pediatric dentists in this sample exhibit high levels of agreement on orthodontic treatment need.     

Distribution of orthodontic services and fees in an insured population in Washington.

Previous attempts to quantify the amount and type of orthodontic therapy provided by nonorthodontists in the United States have relied on survey data. Although there are advantages to surveys, such as control over survey recipients and inclusion of specific questions, they also have limitations, such as low response rates, response bias, and recall bias. This study used insurance claims data from a large dental benefits provider in Washington to assess the distribution of orthodontic services and fees among various dental providers. All orthodontic claims allowed by Washington Dental Service in 2001 were retrieved, along with treatment codes, fees, and demographic information for both patients and providers. A total of 102,984 orthodontic claims were included in the study. General dentists submitted 7.0% of these claims, orthodontists submitted 90.9%, and pedodontists submitted 1.9%. Orthodontists submitted higher average fees for space maintainers, first payments, and records. The percentage of orthodontic treatment preformed by general dentists and pedodontists in this claims-based study was substantially less than what has been previously reported in survey-based studies. Additionally, a smaller percentage of general dentists and pedodontists in this study performed comprehensive treatment, compared with previous studies. This study illustrates the value of insurance claims data to assess the provision of orthodontic care.     

Efficacy of training dental students in the index of orthodontic treatment need.

Orthodontic studies over several decades have found generally inconsistent opinions among dentists when evaluating orthodontic treatment need. There has also been recent concern that dental school education does not sufficiently prepare dentists to diagnose malocclusion and make appropriate referrals of potential orthodontic patients. The purpose of this study was to investigate the efficacy of using the index of orthodontic treatment need (IOTN) as a tool to improve dental students' ability to assess orthodontic treatment need. Fourth-year dental students were randomly divided into control, sham-control, and experimental groups stratified for mean grade point average. On 2 occasions, the subjects evaluated 30 orthodontic study models with a gold standard previously established by an expert panel of 15 orthodontists for orthodontic treatment need. The experimental group reevaluated the models after IOTN instruction. Kappa statistics, sensitivity, and specificity were calculated for each subject. Analysis of covariance (ANCOVA) showed that the experimental group had significantly higher agreement with the expert panel after IOTN training than did either control group. IOTN is a promising teaching aid for improving educational outcomes for orthodontic referral.     

Perception of treatment need among orthodontic patients compared with professionals

The aim was to evaluate estimated need for orthodontic treatment, as judged from intraoral photographs, among orthodontic patients and professionals. Twenty consecutive prospective orthodontic patients, 20 consecutive orthodontically treated patients, 10 randomized general dentists, and 10 orthodontists participated. Seventy pairs of anonymous intraoral photographs of dentitions with varying degrees of objective treatment need were randomly arranged in a notebook. The general dentists and orthodontists rated orthodontic treatment need on a visual analog scale in a similar way among themselves and were more reserved than both patient categories, who also scored similarly among themselves. Professional raters also had similar inter- and intra-rater reliability among themselves, and it was higher than in either of the patient categories. Treatment providers appear to be more restrictive, consistent, and reliable in their judgement of orthodontic treatment need from intraoral photographs than the target group, patients positive toward orthodontic treatment.     

Professional perceptions of the benefits of orthodontic treatment

The aim of this study was to assess general dental practitioners' and orthodontists' perceptions of the benefits of orthodontic treatment. A specially designed questionnaire was sent to a random sample of 150 general dental practitioners (GDPs) and all orthodontists in Northern Ireland (excluding hospital practitioners) with a postgraduate qualification (n = 29). There was a 93 per cent response rate by the general dental practitioners and all but one specialist practitioner returned the questionnaire. The questionnaire comprised 14 visual analogue scales (VAS) whereby participants were asked to rate the importance of various possible dental health and psychosocial benefits of orthodontic treatment. In addition to the VAS, the influence of dentist variables such as number of years since qualification, orthodontic cases completed, referral rates and attendance at postgraduate lectures were examined. When ratings on the 14 dental health and psychosocial scales were examined overall, GDPs rated an improvement in self-esteem while orthodontists considered an improvement in physical attractiveness as the most important benefit of orthodontic treatment. Even though psychosocial variables received the highest ratings, examination of the mean ratings (and 95 per cent confidence intervals) revealed that some dental health factors were also rated highly by both groups. While the results do indicate an encouraging awareness of the psychosocial benefits of orthodontic treatment, they also suggest that both GDPs and orthodontists have an unrealistic expectation of the dental health gain likely to result from orthodontic treatment.     

Preventing and treating white-spot lesions associated with orthodontic treatment: a survey of general dentists and orthodontists

BackgroundThe authors investigated the prevention and treatment of white-spot lesions (WSLs) during and after orthodontic therapy from the perspective of general dentists and orthodontists.MethodsThe authors administered a cross-sectional survey to general dentists (n = 191) and orthodontists (n = 305) in Virginia, Maryland and North Carolina.ResultsSixty-nine percent of general dentists and 76 percent of orthodontists recommended in-office fluoride treatment for patients with severe WSLs immediately after orthodontic treatment. Sixty-nine percent of general dentists reported that they had treated WSLs during the previous year, and 37 percent of orthodontists reported that they had removed braces because of patients' poor oral hygiene. Sixty percent of orthodontists referred patients with WSLs to general dentists for treatment. Eighty-five percent of orthodontists responded that they encouraged patients to use a fluoride rinse as a preventive measure. More than one-third of general dentists indicated that severe WSLs after orthodontic treatment could have a negative effect on their perception of the treating orthodontist.ConclusionsWSLs are a common complication of orthodontic treatment and their presence can result in a negative perception of the treating orthodontist by the patient's general dentist.Clinical implicationsGeneral dentists and orthodontists should work together to prevent the development of WSLs in their patients. Treatment with fluoride supplements and motivating and training patients to practice good oral hygiene will help achieve this goal. Treatment after debonding should include the topical application of low concentrations of fluoride.     

Comparison of perception of necessity of orthodontic treatment between orthodontists and dentists at dental check-ups with DAI

PurposeThe aims of this study were to examine the gaps in the perception of the necessity of orthodontic treatment between orthodontists and dentists, and identify the items influencing perception using the Dental Aesthetic Index (DAI).Materials and methodsBoth dentists and orthodontists assessed the necessity of orthodontic treatment in the 693 junior and senior high school students, and orthodontists examined the occlusion of the students with DAI. The data were analyzed with Student's t-test, Bonferroni multiple comparison test and decision analysis.ResultsIn the orthodontist’ perception, clearly significant differences were observed in all DAI items between necessary and unnecessary groups. However, maxillary missing teeth, mandibular missing teeth, spacing and diastema did not show a clear difference in the dentists’ perception. In the comparison of perception between orthodontists and dentists, crowding, largest anterior maxillary irregularity and largest mandibular irregularity showed significant differences. Decision analysis demonstrated that crowding was the most important item for both orthodontists and dentists.ConclusionThere were two types of gaps in the perception of the necessity of orthodontic treatment. The first one is an individual difference among the dentists, which is related to the evaluation of missing teeth and space in the dental arches. The other is recognized as gaps in the perception between orthodontists and dentists, which are related to the amounts of crowding. It is important to realize the difference of perception and improve the mutual understanding to prevent overlooking malocclusion.     

The delivery of orthodontic care in New Zealand. Part I: Analysis of a census of orthodontists.

A two-part study was undertaken to determine the supply of orthodontic services in New Zealand. Part I focuses on services supplied by specialist orthodontists. A companion paper will describe the amount and characteristics of orthodontic services supplied by dentists. All orthodontists in New Zealand in 1999 were surveyed to provide information on practice location and days practiced in 1996 (the year of the last population Census), and the amount and type of orthodontic treatment carried out in the year 1 July 1998 to 30 June 1999. The response rate was 78.9 percent. Data from 1996 were used to establish and quantify the location and distribution of orthodontists in New Zealand, and their spatial relationship to 12-year-olds and 10- to 14-year-olds using Geographic Information Systems. The information from 1998-1999 was used to determine the amount and variety of services provided by orthodontists and the makeup of their patient base. Nearly two-thirds of orthodontists had a branch practice. Over 50 percent of the 10- to 14-year-old population resided within 5 km of an orthodontist, and nearly three-quarters within 10 km. Disparities between regions existed in the supply of specialist orthodontic services. The catchment areas of main urban areas had more than three times the supply of orthodontists to 12-year-olds than did the secondary and minor urban areas combined. The mean average active patient load was 371, and the mean number of full upper and lower fixed appliances placed was 130.3 during the year of the study. Nearly half of all patients had been referred from dentists, approximately one-quarter were self-referred, and a quarter had been referred by dental therapists. Adults comprised 12.1 percent of the patient load of orthodontists; 60 percent were female.     

Provision of orthodontic care to adolescents in South Australia: The type, the provider, and the place of treatment

There are many pathways involving different providers and locations that individuals may take in obtaining orthodontic services. The aim of this study was to document the provision of orthodontic services and establish the pathways taken toward fixed orthodontic treatment by adolescents in South Australia. Data were collected on the use of orthodontic services by a cohort of adolescents enrolled in the School Dental Service at age 13 years and again at age 15 years. By age 15 years, 83.2 per cent of the adolescents had received orthodontic consultations, 27.3 per cent had received fixed orthodontic treatment and 41.4 per cent had received other forms of orthodontic treatment (extractions, space retainers or removable appliances). The majority of fixed orthodontic treatment was supplied by orthodontists in the private sector, while extractions and removable appliances were provided mainly by public sector general dentists. Most individuals used services in both the public and private sectors and the most frequent pathway taken by the adolescents receiving fixed orthodontic treatment involved consultation in both the public and private sectors, non-fixed orthodontic treatment in the public sector and fixed orthodontic treatment in the private sector. The findings indicate wide access to orthodontic consultation and a high uptake of fixed orthodontic treatment once the adolescent sought private sector orthodontic consultation. Orthodontic care was seen to be an interactive process between public sector general dentists and private sector orthodontists.     

The delivery of orthodontic care in New Zealand. Part II: Analysis of a census of dentists

Part I of this study reported the level and distribution of the supply of specialist orthodontic services in New Zealand. This paper focuses on the amount and variety of orthodontic services supplied by dentists. A questionnaire sent to all dentists in New Zealand sought information on the amount and type of orthodontic treatment carried out between 1 July 1998 and 30 June 1999. The reply rate was 80.9 percent. The majority of dentists carried out some form of orthodontic treatment, predominantly of a minor nature. A small number provided significant amounts of treatment, both simple and complex. The majority of orthodontic treatment and the majority of comprehensive fixed-appliance treatment were undertaken by orthodontists. One-quarter of all orthodontic patients in New Zealand were treated by dentists, irrespective of the complexity of treatment. Nearly a fifth of all full fixed upper and lower appliances, and nearly a third of all single-arch fixed appliances were placed by dentists during the study period. In general, male dentists, dentists over the age of 40, those who had attended an orthodontic continuing education course in the previous 5 years, and those who referred fewer patients to an orthodontist carried out more procedures, including those of a complex nature; they also had a higher average active orthodontic patient load. Wanting to be more or less busy had little influence on the amount or complexity of treatment performed. Dentists in regions with a low supply of specialist orthodontic services provided more comprehensive fixed appliance treatment and had a higher orthodontic patient load. However, the presence or absence of an orthodontist in an urban area seemed to have little impact on the complexity of treatment or the orthodontic patient load of dentists. Despite fewer orthodontists in secondary and minor urban areas, dentists in these areas did not have a higher orthodontic patient load, but carried out a wider range of procedures and more complex procedures than those in main urban areas.     

Perceptions of soft tissue laser use in orthodontics: A survey of orthodontists,periodontists, and general dentists

Objectives:To compare attitudes of orthodontists, periodontists, and general dentists regarding the use of soft tissue lasers by orthodontists during the course of orthodontic treatment.Materials and Methods:An analogous survey was developed to evaluate and compare the current opinions of a representative sample (n  =  538) of orthodontists (61.3%), periodontists (24.3%), and general dentists (14.3%) regarding orthodontists'' use of soft tissue lasers.Results:The majority (84%) of orthodontists, periodontists, and general dentists regarded the use of a soft tissue laser by orthodontists as appropriate. When compared to orthodontists and general dentists, a lower percentage of periodontists indicated that soft tissue laser use by orthodontists was appropriate (P < .01). For each of the eight specific soft tissue laser procedures investigated, periodontists reported a significantly lower level of appropriateness than did orthodontists and general dentists (P < .01). Around 75% of the total sample believed that referral would not be affected by the use of soft tissue lasers by orthodontists.Conclusions:Orthodontists, periodontists, and general dentists differed in their opinions of the perceived appropriateness of soft tissue laser use by orthodontists, with periodontists reporting a lower level of appropriateness. Clinicians need to communicate effectively to ensure that orthodontic patients in need of adjunctive soft tissue surgery are treated to the accepted standard of care.     

Glove use by orthodontists: results of a survey in England and Wales.

Attitudes to glove wearing during treatment of patients were tested by distribution of a questionnaire to 2000 dentists known to be practising under the National Health Service regulations in England and Wales. Of the dentists who replied, 41 specialist orthodontists, representing approximately one-sixth of all orthodontists working in the general dental services in England and Wales, were identified. Results indicate that 39 per cent of these orthodontic respondents wore gloves routinely for all patients and procedures, while 49 per cent wore gloves for some patients or procedures, with 12 per cent never wearing gloves. Reasons given by the occasional glove wearers for not wearing gloves routinely included loss of tactile sensation, perceived small risk, lack of comfort, and restriction of movement. Six per cent of those who replied had experienced skin irritation considered to be associated with glove wearing, while latex gloves were preferred by 78 per cent of respondents who wore gloves.