Introduction
The purpose of this study was to evaluate patients’, parents’, and orthodontists’ perspectives on orthodontic treatment duration and techniques for accelerating the rate of tooth movement.
Methods
Adolescent patients (n = 200) and their parents (n = 200), and adult patients (n = 50) from a multidoctor practice were personally surveyed regarding treatment duration and acceptance of appliances and techniques to enhance the speed of orthodontic treatment, and how much increase in fees they were willing to pay for these. Members of the American Association of Orthodontists were surveyed electronically regarding their willingness to use these techniques and appliances and the costs they were willing to pay for them.
Results
A total of 683 orthodontists replied to the electronic survey (7.5%). Approximately 70% of the orthodontists who replied to the survey were interested in adopting additional clinical procedures to reduce treatment time. No significant association was found between practice characteristics and interest in adopting clinical procedures to reduce treatment time. The invasiveness of the procedure was inversely related to its acceptance in all groups surveyed. Most orthodontists are willing to pay only up to 20% of their treatment fee to companies for the use of technologies that reduce treatment time, and most patients and parents were willing to pay only up to a 20% increase in fees for these approaches. Orthodontists thought that increases in the rate of tooth movement could pose a problem for fee collection.
Conclusions
Orthodontists and patients alike are interested in techniques that can accelerate tooth movement. Similarities between all groups were found regarding the acceptance of different approaches to accelerate tooth movement and the percentage of the orthodontic fee that would be paid for these techniques. Less-invasive techniques had greater acceptability in all groups.
One of the most challenging aspects of orthodontic treatment is its often prolonged duration. Aside from the burden of prolonged treatment on patients and parents, it can also result in pathologic changes, including root resorption. Shortening treatment duration might help to prevent undesired treatment sequelae and increase patient satisfaction. Recently, a number of procedures and techniques with the potential to reduce treatment times have been developed.
Procedures aimed to reduce treatment duration fall into 3 major categories. The first is biologic, through local or systemic administration of drugs. The second category is mechanical or physical stimulation such as vibration and low-energy lasers. The final category is surgically facilitated orthodontic treatment, such as dentoalveolar distraction, alveolar surgeries to undermine interseptal bone, and alveolar corticotomies.
The application of biologic substances to accelerate the rate of tooth movement has been reported in a number of animal studies. Although the local delivery of these biologic compounds could become standard practice in clinical orthodontics in the future, more evidence is needed to evaluate their safety, efficacy, and specificity to the dentoalveolar tissues.
Physical stimulation is another approach to accelerate tooth movement with significant appeal because of its less-invasive nature. One such method of physical stimulation is the application of vibratory forces. Recent animal studies evaluated the effect of vibration in a tooth-movement model in rats and found a statistically significant increase in the displacement of molars subjected to vibration and an orthodontic force when compared with an orthodontic force alone.
Corticotomy-facilitated tooth movement has become the most popular surgical method, shown both clinically and in animal models to temporarily enhance the rate of tooth movement. A recent split-mouth clinical study in patients having first premolar extractions reported approximately double the rate of canine retraction during the first month on the corticotomy side. It appears that with an increased surgical insult, a more significant enhancement in the rate of tooth movement is obtained. Nonetheless, more extensive surgery would likely deter a patient from consenting to this type of procedure.
Recently, a form of corticotomy has been developed that might be more appealing to patients, involving a minimally invasive flapless procedure of localized bone injury. The technique, termed piezocision, consists of vertical interproximal incisions apical to the interdental papilla on the labial aspect using a microsurgical blade to penetrate the cortical plate. Based on initial evidence, this technique has been reported to enhance the rate of orthodontic tooth movement similarly to corticotomies with a significantly less-invasive approach.
Another alternative to shorten treatment time is the precise delivery of mechanics using technologies that customize the orthodontic appliance to each patient. Recently, some evidence has shown that these precise customized appliances can reduce treatment time. Although this approach has the potential for high patient acceptance, it does add a significant cost to treatment and might ultimately limit its use.
Despite all of these promising approaches, patients’, parents’, and orthodontists’ perceptions of these procedures are unknown. Furthermore, the acceptability of these procedures based on their efficiency and cost has not been explored. In this questionnaire-based study, we evaluated patients’, parents’, and orthodontists’ knowledge and perceptions of each of these treatment procedures. The specific procedures investigated consisted of invasive (locally injected intraoral drugs, corticotomies, piezocision) and noninvasive (customized appliances, vibration devices) methods. The objective of this survey was to determine the perceptions of adolescent and adult patients, parents, and orthodontists on additional treatment procedures for reducing orthodontic treatment time.
Material and methods
Approval from the institutional review board of the University of Connecticut was obtained before the study. Two questionnaires were used to evaluate (1) orthodontists’ perceptions and (2) adult patients’, adolescent patients’, and their parents’ perceptions regarding treatment duration, appliances, and techniques available to accelerate orthodontic tooth movement. The questionnaire for the orthodontists was approved and distributed via e-mail by the American Association of Orthodontists to all 9160 active members in the United States and Canada with a link through Survey Monkey (Portland, Ore). The e-mail was accompanied by an introductory cover letter and an information sheet ( Appendix A , online only) that contained a brief description of all clinical procedures that could accelerate the rate of tooth movement to ensure full understanding of the questions. Three weeks after the initial mailing, the American Association of Orthodontists sent a reminder e-mail. Completing and submitting the online survey implied consent. No identifiable information was collected.
The questionnaire for orthodontists consisted of close-ended items on demographics and addressed their willingness to adopt the procedures described in the survey and the fees they would be willing to charge and pay for the different techniques and procedures ( Appendix B , online only). The questionnaire for the adolescent patients included close-ended questions on demographics, length of orthodontic treatment, and willingness to undergo the different procedures. Rank-order questions for the procedures were also included ( Appendix C , online only). The questionnaire for the adult patients and parents was analogous to that of the adolescents but also contained questions regarding the percentage of the treatment fee they were willing to pay for these techniques and adjuvant procedures for reducing treatment times ( Appendices D and E , online only).
Adolescent patients (13-17 years of age), their parents, and adult patients (18 years and older) were recruited from 2 orthodontic offices from a multidoctor practice in 2 communities of middle-to-upper socioeconomic status. All patients and parents were approached by the office staff members and asked about their willingness and interest in participating in this voluntary and anonymous questionnaire-based survey. The following were the inclusion criteria for participation in the survey: currently in orthodontic treatment or initiating treatment soon, and ability to speak and read English. Exclusion criteria were active or prospective patient less than 13 years of age, and patients or parents of adolescents with craniofacial deformities or medically handicapping conditions.
Once the patients and parents stated their interest in participating, the study coordinator approached them to obtain verbal consent or assent before the survey. During the surveying process, the study coordinator (S.P.) reviewed the information sheet ( Appendix A , online only), explained each procedure, and was available to answer any questions while the participant completed the questionnaire. The survey for the adolescent patients did not include questions regarding costs of the different techniques.
The survey period for the orthodontists was from October 2011 through February 2012. Surveys for the patients, parents, and adolescents were conducted from May to June 2011. The results for each question were based on the surveys that had a valid response because some orthodontists, patients, and parents did not answer some questions.
Statistical analysis
Simple descriptive statistics were used to summarize the data. Frequency distributions were used for categorical variables, and means, standard deviations, and percentile distributions were used for continuous data. Demographic characteristics of the study participants were examined. These characteristics included sex, race, country of practice, and age (for orthodontists). Age, sex, race, highest level of education attained in the family, and household income were the demographic characteristics of interest for the parents of adolescents having orthodontic treatment, the adolescent patients, and the adult patients who participated in the study. Responses of the 4 survey instruments (practicing orthodontists, parents of adolescents having orthodontic treatment, adolescent patients, and adult patients) were tabulated by the primary variables of interest (including willingness to use different treatment techniques, willingness to pay for reducing treatment time, and preference for different procedures). The association between practice characteristics (including practice income levels, methods of payment by patients, and satisfaction with treatment time) and interest in adopting additional clinical procedures to reduce treatment time by orthodontists was examined by chi-square tests when appropriate. All tests were 2-sided, and a P value of <0.05 was deemed to be statistically significant. All data were deidentified of unique identifiers and imported to an SPSS data sheet. All analyses were conducted using SPSS software (version 20.0; IBM, Armonk, NY).
Results
The demographic characteristics of the orthodontist participants are summarized in Table I . A total of 683 orthodontists across the United States (n = 617) and Canada (n = 49) consented to participate in the survey and completed it. Among the respondents, 160 practiced in rural areas, and 458 practiced in urban areas. The majority of the orthodontists were white men, 55 years of age or less, and in private practice.
| Characteristic | Response | n (%) |
|---|---|---|
| Sex | Male | 415 (82.7%) |
| Female | 87 (17.3%) | |
| Missing data | 181 | |
| Country of practice | United States | 617 (92.6%) |
| Canada | 49 (7.4%) | |
| Missing data | 17 | |
| Race | White | 452 (90.6%) |
| Black | 1 (0.2%) | |
| Hispanic | 17 (3.4%) | |
| Asian | 20 (4%) | |
| Pacific Islander | 2 (0.4%) | |
| Others | 7 (1.4%) | |
| Missing data | 184 | |
| Age (y) | 25-30 | 10 (2%) |
| 30-35 | 55 (10.9%) | |
| 35-40 | 62 (12.3%) | |
| 40-45 | 66 (13.1%) | |
| 45-50 | 51 (10.1%) | |
| 50-55 | 80 (15.8%) | |
| 55-60 | 60 (11.9%) | |
| 60-65 | 55 (10.9%) | |
| 65-70 | 47 (9.3%) | |
| 70-75 | 15 (3%) | |
| 75-80 | 4 (0.8%) | |
| Missing data | 178 |
A total of 665 participants responded to the questions on their number of offices and years in practice. Of these, 50.5% worked in 1 office, 32% worked in 2 offices, 10.8% worked in 3 offices, and 6.6% worked in more than 3 offices. Close to 48% had worked for more than 20 years, whereas 28.3% had worked for 2 to 10 years. With regard to the number of current cases in the practice (n = 652 responders), 52.3% had 100 to 500 patients, 25.3% had 501 to 750 patients, 11% had 751 to 1000 patients, and 11.3% had greater than 1001 patients. With regard to their role in the practice (n = 655 responders), 84% were owners, 10.5% were associates, and 5.5% were mentioned as “others.” Of the 650 responders, 50.9% were certified by the American Board of Orthodontics.
The demographic characteristics of the adult patients, adolescent patients, and parents are summarized in Table II . No patient was using any of the techniques described in the survey to decrease treatment time.
| Characteristic | Response | Adult patients (n = 50) (%) | Adolescent patients (n = 200) (%) | Parents (n = 200) (%) |
|---|---|---|---|---|
| Age (y) | Mean | 34.2 | 14.1 | 45 |
| SD | 12.8 | 1.4 | 5.2 | |
| Median | 33 | 14 | 45 | |
| 25 th percentile | 22 | 13 | 42 | |
| 75 th percentile | 43.7 | 15 | 48 | |
| Sex | Male | 13 (28.9%) | 88 (44.4%) | 36 (19.3%) |
| Female | 32(71.1%) | 110 (55.6%) | 150 (80.7%) | |
| Missing data | 5 | 2 | 14 | |
| Race | White | 43 (91.5%) | 189 (95%) | 179 (97.3%) |
| Black | 1 (2.1%) | 1 (0.5%) | 0 | |
| Hispanic | 1 (2.1%) | 3 (1.5%) | 2 (1.1%) | |
| Asian | 1 (2.1%) | 5 (2.5%) | 2 (1.1%) | |
| Pacific Islander | 0 | 0 | 0 | |
| Others | 1 (2.1%) | 1 (0.5%) | 1 (0.5%) | |
| Missing data | 3 | 1 | 16 | |
| Highest level of education attained in family | High school or less | 0 | 32 (16.3%) | 9 (4.9%) |
| More than high school but less than 4 years of college | 7 (15.2%) | 16 (8.2%) | 19 (10.4%) | |
| More than 4 years of college | 39 (84.8%) | 148 (75.5%) | 154 (84.6%) | |
| Missing data | 4 | 4 | 18 | |
| Total annual family income levels | <$10,000 | 0 | NA | 0 |
| $10,000-$40,000 | 7 (17.9%) | NA | 4 (2.3%) | |
| $40,000-$70,000 | 4 (10.2%) | NA | 15 (8.8%) | |
| $70,000-$100,000 | 9 (23.1%) | NA | 37 (21.8%) | |
| >$100,000 | 19 (48.7%) | NA | 114 (67.1%) | |
| Missing data | 11 | 30 | ||
| Duration of treatment ∗ | Not started | 8 (16.3%) | 19 (9.7%) | 33 (16%) |
| Less than 1 year | 17 (34.7%) | 52 (26.7%) | 72 (34.9%) | |
| 1-2 years | 16 (32.6%) | 79 (40.5%) | 62 (30.1%) | |
| 2-3 years | 4 (8.2%) | 31 (15.9%) | 31 (15%) | |
| >3 years | 4 (8.2%) | 14 (7.2%) | 8 (3.9%) | |
| Missing data | 1 | 5 | – | |
| Orthodontic treatment takes too long | Strongly agree | 3 (6.2%) | 26 (13.1%) | 6 (3%) |
| Somewhat agree | 13 (27.1%) | 83 (41.7%) | 44 (22.2%) | |
| Neutral | 25 (52.1%) | 68 (34.2%) | 107 (54%) | |
| Somewhat disagree | 7 (14.6%) | 20 (10%) | 35 (17.7%) | |
| Strongly disagree | 0 | 2 (1%) | 6 (3%) | |
| Missing data | 2 | 1 | 2 | |
| How long do you wish orthodontic treatment to last? | <6 months | 8 (16.3%) | 80 (40.8%) | 10 (5.6%) |
| 6-12 months | 21 (42.9%) | 65 (33.2%) | 46 (25.6%) | |
| 12-18 months | 13 (26.5%) | 41 (20.9%) | 63 (35%) | |
| 18-24 months | 5 (10.2%) | 7 (3.6%) | 50 (27.8%) | |
| >24 months | 2 (4.1%) | 3 (1.5%) | 11 (6.1%) | |
| Missing data | 1 | 4 | 20 |
∗ A parent might have a son or daughter in orthodontic treatment; hence, the cell counts will be more than the total global count of 200.
A total of 50 adult patients (18 years of age and older), 200 adolescents (13-17 years of age), and 200 parents participated in the study. The majority of patients and parents responding to the survey were white women and had started orthodontic treatment (patients). The majority of adult patients and parents mentioned that the highest level of education attained by them or in the family (for parents) was a 4-year college degree, with a family income of more than $100,000.
The financial attributes of the practice are summarized in Table III . The majority of orthodontists mentioned that their practice income was up to $400,000 annually, and they collected payments through private insurance plans.
| Characteristic | Response | n (%) |
|---|---|---|
| Practice income | Up to $400,000 | 350 (62.4%) |
| >$400,000 | 211 (37.6%) | |
| Missing data | 122 | |
| Methods of payment by majority of patients | State insurance | 11 (1.9%) |
| Private insurance | 242 (41.2%) | |
| Combination of state and private insurance | 104 (17.7%) | |
| No insurance | 158 (26.9%) | |
| Others | 72 (12.3%) | |
| Missing data | 96 | |
| Satisfaction of orthodontist with the amount of time patients are in active appliances | Very satisfied | 203 (33.4%) |
| Somewhat satisfied | 294 (48.4%) | |
| Neutral | 69 (11.3%) | |
| Somewhat dissatisfied | 37 (6.1%) | |
| Very dissatisfied | 5 (0.8%) | |
| Missing data | 75 |
Most orthodontists were satisfied with the duration of treatment for their patients ( Table III ). On the other hand, adult patients, adolescents, and parents were predominantly neutral regarding the duration of treatment ( Table II ). Furthermore, when asked about how long they would like the orthodontic treatment to last, most adolescents desired less than 6 months, with adults reporting 6 to 12 months, and parents reporting 12 to 18 months ( Table II ).
The association between practice characteristics (including practice income levels, methods of payment by patients, and satisfaction with treatment time) and interest in adopting additional clinical procedures to reduce treatment time is summarized in Table IV . Although they were satisfied with treatment durations, most orthodontists were interested in adopting additional clinical procedures to reduce treatment times. However, no significant association was found between practice characteristics and interest in adopting clinical procedures to reduce treatment times.
| Characteristic | Response | Interest in adopting additional clinical procedures to reduce treatment time n (% within characteristics) | Chi-square P value | ||||
|---|---|---|---|---|---|---|---|
| Very interested | Somewhat interested | Neutral | Somewhat not interested | Not interested at all | |||
| Practice Income | Up to $400,000 | 111 (32.1%) | 165 (47.7%) | 49 (14.2%) | 12 (3.5%) | 9 (2.6%) | 0.34 |
| >$400,000 | 77 (37.2%) | 86 (41.5%) | 29 (14%) | 12 (5.8%) | 3 (1.4%) | ||
| Methods of payment by majority of patients | State insurance | 4 (36.4%) | 4 (36.4%) | 1 (9.1%) | 2 (18.2%) | 0 | 0.30 |
| Private insurance | 73 (30.7%) | 117 (49.2%) | 35 (14.7%) | 11 (4.6%) | 2 (0.8%) | ||
| Combination of state and private insurance | 37 (36.3%) | 42 (41.2%) | 13 (12.7%) | 5 (4.9%) | 5 (4.9%) | ||
| No insurance | 52 (33.5%) | 72 (46.5%) | 23 (14.8%) | 6 (3.9%) | 2 (1.3%) | ||
| Others | 28 (39.4%) | 27 (38%) | 13 (18.3%) | 1 (1.4%) | 2 (2.8%) | ||
| Satisfaction of orthodontist with the amount of time patients are in active appliances | Very satisfied | 60 (29.9%) | 90 (44.88%) | 38 (18.9%) | 9 (4.5%) | 4(2%) | 0.20 |
| Somewhat satisfied | 108 (37%) | 130 (44.5%) | 38 (13%) | 11 (3.8%) | 5 (1.7%) | ||
| Neutral | 21 (31.8%) | 26 (39.4%) | 12 (18.2%) | 5 (7.6%) | 2 (3%) | ||
| Somewhat dissatisfied | 8 (21.6%) | 24 (64.9%) | 1 (2.7%) | 2 (5.4%) | 2 (5.4%) | ||
| Very dissatisfied | 3 (60%) | 1 (20%) | 1 (20%) | 0 | 0 | ||
A set of questions captured information on the awareness of different treatment modalities that could reduce the treatment time. When all orthodontists (n = 683) were surveyed regarding methods to reduce orthodontic treatment time, most were aware of corticotomies and custom-made appliances. Techniques such as piezocision, intraoral vibrators, and locally injected drugs were familiar to only approximately a quarter of the orthodontists ( Table V ).
| Technique | n (%) of responders who are familiar with technique |
|---|---|
| Custom-made appliances | 470 (68%) |
| Piezocision | 173 (25.3%) |
| Corticotomies | 502 (73.5%) |
| Intraoral tooth vibrators | 182 (26.6%) |
| Locally injected drugs | 111 (16.3%) |
Among the 589 responders to the question on the amount of “reduction in treatment time that would be attractive to try these alternative treatment modalities,” 28.7% mentioned that a 20% to 30% reduction would be attractive, 30.2% stated that a 30% to 40% reduction in treatment time would be attractive, and 16% said that a 40% to 50% reduction would be attractive.
Table VI summarizes the willingness of patients, parents, and orthodontists to use or undergo or pay for the different treatments to reduce the duration of treatment. Specifically, the orthodontists were asked about their willingness to use a technique such as a corticotomy and, on the other hand, their willingness to pay for appliances such as customized appliances and vibrators ( Appendix B , online only). Adolescents were only asked questions related to willingness to use (undergo) the different procedures or appliances with no payment-related questions ( Appendix C , online only). Finally, the parents and patients were asked about their willingness to undergo surgical procedures (corticotomies, piezocision), use intraoral drugs and tooth vibrators, and pay for customized wires ( Appendices D and E , online only). Table VII summarizes the different treatments based on preference and not related to cost as ranked by patients and parents. Tables VIII and IX summarize the amounts of fee increases that parents and adult patients were willing to pay by percentage of treatment-time reduction.
| Appliance or technique | Group | Willingness to use/undergo/pay ∗ n (%) | % of treatment fee increase n (%) | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Responders (n) | Very willing | Somewhat willing | Neutral | Somewhat not willing | Not willing | Responders (n) | 0%-20% | 20%-40% | >40% | ||
| Customized appliances † | Orthodontists | 575 | 44 (7.7%) | 190 (33%) | 137 (23.8%) | 121 (21%) | 83 (14.4%) | 552 | 532 (96.4%) | 19 (3.4%) | 1 (0.2%) |
| Parents | 199 | 29 (14.6%) | 78 (39.2%) | 40 (20.1%) | 36 (18.1%) | 16 (8%) | 139 | 125 (89.9%) | 12 (8.6%) | 2 (1.4%) | |
| Adolescents | 197 | 97 (49.2%) | 63 (32%) | 25 (12.7%) | 6 (3%) | 6 (3%) | – | – | – | – | |
| Adults | 50 | 14 (28%) | 23 (46%) | 8 (16%) | 5 (10%) | 0 | 37 | 34 (91.9%) | 3 (8.1%) | 0 | |
| Intraoral vibrating devices ‡ | Orthodontists | 571 | 27 (4.7%) | 189 (33.1%) | 152 (26.6%) | 104 (18.2%) | 99 (17.3%) | 542 | 531 (98%) | 8 (1.5%) | 3 (0.5%) |
| Parents | 199 | 30 (15%) | 72 (36%) | 38 (19%) | 32 (16%) | 27 (13.5%) | 116 | 105 (90.5%) | 8 (6.9%) | 3 (2.6%) | |
| Adolescents | 199 | 43 (21.6%) | 75 (37.7%) | 55 (27.6%) | 19 (9.5%) | 7 (3.5%) | – | – | – | – | |
| Adults | 50 | 9 (18%) | 22 (44%) | 8 (16%) | 6 (12%) | 5 (10%) | 37 | 32 (86.5%) | 5 (13.5%) | 0 | |
| Corticotomies | Orthodontists | 538 | 25 (4.6%) | 114 (21.2%) | 71 (13.2%) | 180 (33.5%) | 148 (27.5%) | 440 | 329 (74.8%) | 89 (20.2%) | 22 (5%) |
| Parents | 200 | 5 (2.5%) | 17 (8.5%) | 21 (10.5%) | 76 (38%) | 81 (40.5%) | 60 | 51 (85%) | 8 (13.3%) | 1 (1.7%) | |
| Adolescents | 199 | 10 (5%) | 27 (13.6%) | 49 (24.6%) | 55 (27.6%) | 58 (29.1%) | – | – | – | – | |
| Adults | 49 | 2 (4.1%) | 6 (12.2%) | 8 (16.3%) | 18 (36.7%) | 15 (30.6%) | 22 | 19 (86.4%) | 2 (9.1%) | 1 (4.5%) | |
| Piezocision | Orthodontists | 526 | 18 (3.4%) | 81 (15.4%) | 164 (31.2%) | 139 (26.4%) | 124 (23.6%) | 417 | 346 (83%) | 58 (13.9%) | 13 (3.1%) |
| Parents | 198 | 5 (2.5%) | 33 (16.7%) | 24 (12.1%) | 62 (31.3%) | 74 (37.4%) | 69 | 62 (89.8%) | 6 (8.7%) | 1 (1.4%) | |
| Adolescents | 197 | 5 (2.5%) | 30 (15.2%) | 47 (23.9%) | 53 (26.9%) | 62 (31.5%) | – | – | – | – | |
| Adults | 50 | 5 (10%) | 5 (10%) | 9 (18%) | 12 (24%) | 19 (38%) | 22 | 19 (86.4%) | 3 (13.6%) | 0 | |
| Intraoral injected drugs | Orthodontists | 533 | 28 (5.3%) | 112 (21%) | 115 (21.6%) | 134 (25.1%) | 144 (27%) | 426 | 358 (84%) | 55 (12.9%) | 13 (3.1%) |
| Parents | 186 | 8 (4.3%) | 38 (20.4%) | 28 (15%) | 52 (28%) | 60 (32.2%) | 78 | 71 (91%) | 5 (6.4%) | 2 (2.6%) | |
| Adolescents | 196 | 22 (11.2%) | 44 (22.4%) | 51 (26%) | 41 (20.9%) | 38 (19.4%) | – | – | – | – | |
| Adults | 50 | 2 (4%) | 15 (30%) | 7 (14%) | 15 (30%) | 11 (22%) | 27 | 24 (88.9%) | 3 (11.1%) | 0 | |
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