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 benefits of early orthodontic treatment

Despite the recent recommendation by the American Association of Orthodontists and Dentofacial Orthopedics that orthodontists begin screening patients by age 7, it is the author's experience that the majority of orthodontists do not treat children prior to the eruption of permanent teeth and do not use functional appliances. This leads many general dentists to provide orthodontic services to their younger patients because local orthodontists do not or will not treat them. This article seeks to encourage all general dentists, pediatric dentists, and orthodontists to learn how to use functional appliances to significantly improve the health and appearance of younger patients.     

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.     

Early screening for orthodontic treatment Differences in assessments made by a consultant orthodontist and three public health dentists

The aim of the present study was to compare the differences in the assessments of occlusal and functional features, the need for and timing of orthodontic treatment and the complexity of treatment made by a consultant orthodontist and three public health dentists. The data comprised the examinations of 260 children aged 7–8 yr (87% of total age group of the community) attending the first grade of primary school in a medium-sized town in eastern Finland. The examinations were carried out according to agreed criteria. The main indications for treatment were Class II malocclusion, lateral crossbitc and crowding. When assessing treatment need, agreement between the orthodontist and the three dentists was fairly good (agreement in 69%, Kappa statistic 0.51), sensitivity for each dentist ranged from 0.86 to 0.97 and specificity from 0.72 to 0.92. The agreement on the timing of treatment was poor (agreement in 49%, Kappa statistic 0.18). In most cases of disagreement, the dentists would begin the treatment earlier than the orthodontist. The agreement on the complexity of treatment was rather poor (agreement in 61%, Kappa statistic 0.22). In most cases of disagreement, the treatment was regarded as more complex by the orthodontist than by the dentists. When dentists work with a consultant orthodontist, it seems justified to have the dentist screen the children at the age of 7–8 yr for early orthodontic treatment, but the orthodontist should assess the timing and complexity of treatment.     

The consultant orthodontic service--1996 survey.

OBJECTIVE: To evaluate the working patterns and facilities of the consultant orthodontist service. DESIGN: A cross-sectional survey. SETTING: Consultant orthodontist departments in the UK. SUBJECTS AND METHODS: All consultant orthodontists in the UK were sent a questionnaire that gathered information on the individual consultant, the facilities available, the new patients referred and patients under current treatment. RESULTS: The consultant orthodontist service provided treatment to a high number of patients who were in definite need of orthodontic treatment. A marked reduction in the use of removable appliances suggests improving standards of care and provision of more complex treatment. The caseload was high and a fair proportion of patients were returned to their referring dentists with treatment plans. The consultant service has not completely evolved into a service that provides treatment at a super-specialist level alone. CONCLUSIONS: There has been little change in the consultant orthodontist service over the past ten years. Arguably, this is because of the wishes of the purchasers and the shortage of trained orthodontic manpower as a direct result of poor manpower planning and lack of funds for post-graduate training.     

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.     

Influence of orthodontic appliances on visual attention to smiling faces by eye-tracking evaluation

The influence of wearing orthodontic appliances on visual attention to smiling faces is not well understood. The purpose of this study was to investigate how laypeople viewed a frontal posed smiling face with orthodontic appliances compared with orthodontists. Frontal posed smiling facial photographs of 10 female models without an appliance or wearing clear tray, ceramic, or metal appliances were taken, and areas of interest (AOIs) for the eyes, nose, and mouth were determined. Visual attention from 43 laypeople and 42 orthodontists was evaluated for each image using an eye-tracking system. Total fixation time for each AOI was calculated and analyzed by three-way repeated measures analysis of variance and Tukey–Kramer multiple comparison tests (P < 0.05). The layperson group spent significantly more time looking at the mouth with ceramic and metal brackets than without brackets, similar to the orthodontist group (P < 0.001 and 0.001, respectively). Though the orthodontist group spent significantly more time looking at the mouth with metal brackets than the mouth with ceramic brackets (P < 0.040), no significant difference was noted in the layperson group. Under all appliance conditions, the layperson group spent significantly more and less time looking at the eyes and mouth than the orthodontist group, respectively (P < 0.001 and 0.001, respectively). These findings suggest that it may help patients who will start orthodontic treatment to understand an individual’s interest in the appearance of the orthodontic appliance, and orthodontists to counsel patients at the orthodontic appliance selection stage during the diagnosis.     

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 provision of orthodontic services by general dental practitioners. 1. Methods and descriptive results

Information regarding orthodontic service provision by general dental practitioners in Australia is limited. The aim of this survey was to determine the amount and variety of orthodontic services provided by general dental practitioners in the Melbourne Statistical Division, Victoria, Australia. A random sample of 307 dentists drawn from the Victorian Dentists Register was surveyed by mailed questionnaire: 218 (71%) replied. Data were collected using a fortnight log. During this time 59 per cent of the dentists saw at least one orthodontic patient; one dentist saw 66 orthodontic patients. Removable orthodontic appliances were used by 35 per cent of the dentists and fixed orthodontic appliances by 18 per cent. Twenty-six per cent provided comprehensive orthodontic treatment, 22 per cent aligned incisors, and 21 per cent corrected anterior cross-bites. The general dental practitioners surveyed provided a wide range of preventive and interceptive orthodontic services to generally a small percentage of their patients.     

Attitudes of a group of Brazilian orthodontists towards the diagnosis and management of primary headache (migraine): an electronic-based survey

Objectives

The aim of this study was to investigate the knowledge and attitudes of orthodontists in the diagnosis and management of migraine without aura.

Material and Methods

Participants were dentists, recruited among members of the Brazilian Association of Orthodontics and Facial Orthopedics (ABOR). An e-mail was sent to all ABOR members, with a link to a website, especially prepared for this research. Dentists were presented to a report of a fictional patient fulfilling diagnostic criteria for a primary headache disorder, known as migraine without aura. Participants were asked to describe how they would relieve the patient''s pain. Professional procedures were classified as "adequate" or "inadequate" according to the answers given.

Results

161 valid answers were received (18.8% response rate). Of them, 36% of the actions were considered to be "adequate" procedures, while 64% were "inadequate". The results yielded 12 main procedures, based on common characteristics. Eighty-two orthodontists suggested orthodontic treatment with or without orthognathic surgery, and some suggested using stabilization appliances prior to the orthodontic treatment.

Conclusions

The majority of participants proposed inadequate therapies, and 51% suggested orthodontic correction of occlusion, including orthognathic surgery. Educational activities on migraine should also target orthodontists.     

Cost and productivity analysis of orthodontic care in Finland

Abstract– The aim of the study was to investigate the costs of orthodontic care provided for children and adolescents up to the age of 18 by municipal health centers in Finland, and to study the productivity of these services. The data were gathered by a questionnaire sent to all health centers; 96% responded. The majority of respondents estimated the share of orthodontic care as 10% of the total gross costs of dental care, given that 14% of all dental visits were for orthodontic reasons. To study the productivity in individual health centers, the output was measured by the estimated number of completely treated patients. The cost of orthodontic treatment per completely treated patient was, on average, FIM 7358, ranging from FIM 1299 to FIM 24 751. The strongest explanatory factor for the average total costs of orthodontic clinics was the number of general dentists with little experience in providing orthodontic treatment. Other explanatory factors were the number of orthodontists or experienced dentists, the percentage of orthodontic tasks performed by auxiliary personnel, and the timing of treatment. Savings might be obtained by devolving treatment to orthodontists or experienced dentists in-stead of to dentists with little orthodontic experience, and by starting treatment early. The estimated optimal size for an orthodontic clinic was found to be a unit with 830 completely treated patients per year, but most of the orthodontic clinics were in fact much smaller with, on average, 133 completely treated patients per year.     

Gifts from orthodontists to general dentists

Objectives:To determine how often general dentists receive gifts from orthodontists, the value and number of the gifts they receive, and how they perceive the motivation behind the gift.Materials and Methods:This was a questionnaire-based study. A questionnaire was constructed and tested for validity and reliability. An electronic version of survey was sent via email to 1300 general dentists.Results:The validity and reliability of the survey was confirmed. Two hundred fifty-four valid responses were received (20%). Eighty-five percent of responding general practitioners reported that they received gifts from an orthodontist. Almost 100% reported that they referred patients to orthodontists. About one-third of the responding general practitioners reported that their office provided orthodontic care. There were statistically significant correlations between the number of annual patient referrals the general practitioners reported making and the number and value of the gifts they received from the orthodontists. Female general practitioners reported receiving a higher number of gifts of greater total value than male practitioners. General practitioners who reported providing orthodontic treatment did not differ from those who did not in the number of referrals they made annually and the number and value of the gifts they received. Quality of care was the most common reason general practitioners reported for their referral to an orthodontist. Forty-four percent of the responders reported that they received discounted orthodontic treatment.Conclusions:General practitioners refer patients to orthodontists and receive gifts from them. The number and value of the gifts reflects the number of referrals they make.     

Orthodontic re-treatment. A qualitative study of patients

A growing number of patients go to orthodontic practices to receive orthodontic re-treatment, but their reasons for seeking re-treatment are uncertain. By means of a standardized questionnaire this study investigates the patients'experiences with the initial orthodontic treatment, applied retention procedures, and the patients'expectations and motivational reasons for re-treatment. In total 100 patients were asked to complete the questionnaire, 88 of them actually filled it out. The study subjects showed an above average educational level, with a considerably higher percentage of females than males seeking re-treatment. Fixed appliances were used most frequently during the first course of treatment and most patients had been fitted with a removable retention plate or fixed retention wire at the conclusion of their first treatment; almost 40% of the patients did not receive any kind of retention appliance. Patients sought re-treatment mostly on their own initiative, as opposed to their initial treatment, when they were mostly referred by dentists or orthodontists. This revealed itself in patients' high levels of motivation for re-treatment. Moreover, patients appeared to have realistic impressions of the time and cost involved in re-treatment.     

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.     

Extent and provision of orthodontic services for children and adolescents in Finland

Abstract Orthodontic services for Finnish children and adolescents up to the age of 18 in 1992 were monitored by a questionnaire sent to all municipal health centres responsible for children's dental care in Finland, and 96% responded. All health centres provided some orthodontic treatment, but the percentage of 0–18-year-old children receiving treatment ranged from 1% to 19%. One-quarter of all dental visits of the 0–18-year-olds were in connection with orthodontics. The timing of treatment was early: the average age for starting was 9.5 years. In statistical analyses, the number of children receiving treatment was associated with the timing of treatment. At the age of 7, the most frequently used appliances were quad helix, removable appliance and orthopaedic headgear and, at the age of 13, fixed appliance and activator. Most treatments were provided by nonspecialists. The specialist expertise needed was usually purchased from an outside orthodontist by means of consultation contracts. Every fifth health centre, usually the largest, had employed one or more specialist orthodontists. The regional distribution of orthodontists was uneven, emphasizing regional variation in the delivery of orthodontic services.     

Software Reviews

Abstract

A postal questionnaire survey of consultant orthodontists in England and Wales was undertaken as part of a national audit of the care of children horn with cleft lip/and or cleft palate. A 100% response rate was achieved. The majority of respondents stated that they provide orthodontic treatment for cleft patients hut only 78% of these attend multi-disciplinary cleft clinics. Consultant orthodontists provide treatment not only in the form of appliances for patients born with clefts hut are also involved in the counseling of parents and coordination of regional data bases. Only 24% of hospital orthodontists are involved in the provision of presurgical appliances for cleft babies on a regular basis. The lack of rationalisation of orthodontic services and a low uptake of standardised record keeping protocols for cleft patients by consultant orthodontists gives cause for concern.     

Treatment of adults with lingual orthodontic appliances

With the advent of lingual orthodontic treatment, an alternative became available to the adult patient who preferred to avoid the unesthetic appearance of conventional orthodontic appliances. The newer brackets and archwires described in this article, in combination with the proven technique developed by the author and others, has made lingual orthodontic treatment a practical reality. The appliance has been shown to be as effective as labial counterparts in correcting all types of malocclusions. New laboratory and indirect bonding techniques have eliminated the need for intricate wire bending and have reduced patient chair time and overall treatment time. Because of the premature introduction of early lingual appliances, many dental practitioners mistakenly believe that lingual treatment is less effective than labial treatment. As more examples of successful treatment are seen, dental practitioners will be more apt to refer patients to orthodontists proficient in this technique. Many graduate orthodontic programs now are teaching this technique to their residents. About 3000 patients currently are starting treatment with lingual appliances each year. This represents only about 1 per cent of adult patients. It is projected that this slowly will climb to about 10 per cent of adult orthodontic treatment over the next 5 years. The increased cost of this treatment, coupled with the resistance on the part of many orthodontists to learn the new technique, seem to be the limiting factors.     

Profile of orthodontic services provided in private practice by general practitioners and specialist orthodontists for an insured population

In Australia, the proportion, volume and type of orthodontic care provided by general practitioners and orthodontists are largely unknown. The overall objective of this study was to create a profile of orthodontic services provided by general practitioners and orthodontists for a cohort of insured patients using private practices in New South Wales, Australia, from 1st January 1992 to 31st December 1995. Data were derived from claims records submitted by members of a health insurance fund for rebates for fees paid to private practitioners for orthodontic services they received during the study period. Distribution of the volume and type of service provided by general practitioners and orthodontists was compared using the Chi-squared test. Statistical significance was taken at the 5 per cent level. Orthodontic services were provided predominantly by orthodontists (80%). Fixed orthodontic treatment was provided almost exclusively (91%) by orthodontists. The majority of removable appliance services was provided by general practitioners. Orthodontists provided more orthodontic services in the capital city and other metropolitan areas, whereas general practitioners provided more orthodontic services in rural areas. Orthodontists provided more services to members in the highest socio-economic group, whereas general practitioners provided more services to members in the lowest socio-economic group.