The Golden Age of orthodontics occurred in the 1950s and 1960s, when practitioners had more patients seeking care than they could start; some even had waiting lists as long as 6 months. Much has changed in the way treatment is delivered today, with the expanded use of well-trained auxiliary personnel and the availability of more efficient materials enhanced by technology. But do we have adequate data to determine who needs orthodontic treatment, and more importantly, are there enough orthodontists to get the job done? Some believe that there are not enough professionals to treat everyone in need, yet there are insufficient data to prove how many people in need would seek care even if it were available.

A 30-year longitudinal study of the population in Manchester, United Kingdom, discovered that people’s level of orthodontic care fell into 4 categories: those who needed treatment and received it, those who needed treatment and did not receive it, those who did not need treatment and never received it, and those who did not need treatment but received it anyway. These data came from a country in which much orthodontic treatment was funded by the government. From this single long-term study, you can see that the evaluation of unmet need is difficult to calculate based on the underlying populations. Financial and psychosocial reasons for not seeking professional orthodontic treatment might play a larger role in determining the public’s effective demand. According to L. Jackson Brown, president of a consulting firm employed by the American Association of Orthodontists (AAO) to study the issue of access to care, “Considering only unmet need without factoring in the role of economic, social, and cultural factors can lead to large miscalculations of the amount of orthodontic care that will actually be used, which in turn, can result in large miscalculations on the workforce.” So, when trying to calculate a more realistic amount of unmet need, including economic, social, and cultural factors might result in adjusting the workforce downward from other estimates.

To further assess the ability of the orthodontic workforce to meet the treatment requirements of the population, consultants Brown and Nash surveyed the AAO membership and compiled a final report entitled, “Final Report of the 2008 Demographic and Retirement Surveys of Orthodontists.” The data in this report are extensive and perhaps far reaching—a must-read for every professional interested in future practice. On average, orthodontists schedule 193 patients per week, including about 7 new patient starts. Twenty-five percent of the youngest orthodontists expect that their hours will increase over the next 2 years. Most orthodontists believe that they could sustain an increase of about 30% in new patients per week without jeopardizing quality of care. The additional workload would be accomplished by various methods:

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  Alter appointment scheduling (41.9%)

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  Personally become more efficient (39%)

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  Increase number of staff (37%)

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  Work more hours (20.9%)

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  Increase staff hours (15%)

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  Increase number of orthodontists (5.4%)

When asked about any increase in new patient starts they’ve experienced over the past 2 years, about 41% reported an increase of 1% to 5% or a decrease of 1% to 5%. Factors that shape the demand for orthodontic services are important for understanding orthodontic workforce issues. The demand for care stimulates the supply of orthodontic personnel, and, farther downstream, the need for dental schools and educators derives from the demand for dental services. According to Brown and Nash, population in the United States is projected by the US Bureau of the Census to grow from 310.2 million in 2010 to 439.0 million by 2050. This represents an increase of 127.0 million residents during the next 40 years. “However,” noted the authors of this report, “the most relevant age groups for orthodontics consist of 2 subgroups of the entire population. Orthodontic services are concentrated among teenagers and young adults. Over the last couple of decades, increasing numbers of young adults have also chosen to have orthodontic services; however, the percentage of individuals of that age class who receive orthodontic services is relatively small, compared to teenagers, and the percentages declined among those over 35.”

The consultants made it abundantly clear that the demand for our services is responsive to changes in orthodontic fees—the higher the fees, the lower the demand. Factors that positively influence demand include population size, prevalence of malocclusion, education levels, income, and prepayment coverage. Factors such as health history, ethnicity, sex, and age have more complicated effects on demand. The potential market for orthodontic services for adults in the United States is determined by the following fundamental factors:

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  The size of the population between 13 and 21.

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  The size of the young adult population between 22 and 45.

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  The extent and severity of the malocclusion.

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  The demand for orthodontic services.

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  The degree to which orthodontic services have been provided to teenagers before they become young adults.

On a personal level, I always preferred to think that orthodontists were somewhat immune to economic downturns, but, according to this report, I was wrong. The data show that visits to orthodontic offices generally followed the ups and downs of the overall US economy from 1998 to 2006. Both total visits and new case starts declined during the economic contraction that began in 2001. Both measures turned up in 2004 as the economy began to expand again. The swings in visits to orthodontic specialists showed similar trends but were more pronounced.

Unlike other dental specialties, the market for orthodontic services (1998-2006) is not as segmented between orthodontists and other dentists. Over 90% of all visits for full-mouth orthodontic procedures were to orthodontic specialists. “This means the market is more isolated than other specialty markets,” noted Brown and Nash. During the last period of economic tough times, general practitioners still focused on other procedures and left orthodontics to the orthodontists. Therefore, orthodontists felt the full force of the economy on the demand for their services. The current economic recession has also had a marked impact on orthodontists, with declines in both gross billings and net income since the third quarter of 2008. When the economy recovers, these perceptions are expected to reverse as they did after the last recession.

Regarding the numbers of specialists needed to meet future demands, the news is mixed. Of course, the US population will grow rapidly over the next 50 years, and one must also adjust the population-to-orthodontist ratio for the relevant age groups discussed in the Brown and Nash report. According to their data, ratios for the total population and for each age group decreased steadily during each decade. In the crucial age groups of 14 to 17 and 18 to 24, the ratios declined markedly. This means that the numbers of orthodontists are projected to grow more rapidly during the coming decades, relative to the subpopulations most likely to seek care. The authors concluded their lengthy report by noting that, in the future, the total number of orthodontists needed will be directly related to the number of new orthodontists who graduate from orthodontic specialty programs each year combined with the number of orthodontists who leave practice. This trend should be followed carefully by the profession.