Introduction
This study evaluated the trends in orthodontic practitioner choice over the past 15 years and explored the lay public’s understanding of different orthodontic practitioner options in the U.S., specifically, orthodontists compared with general dentists.
Methods
A survey was distributed to a representative sample of laypersons in the U.S. The response rate was 90.2%, and 727 completed responses were analyzed.
Results
A 28.2% shift away from orthodontists toward general dentists over the last 15 years was significant ( P <0.001). The 2 most frequently endorsed ways respondents found their orthodontic practitioners were a recommendation from another dentist (54.2%) and their family’s general dentist who offered orthodontic treatment in-house (22.9%). Respondents’ knowledge of orthodontists was limited; 85.0% believed that dentists who perform orthodontic treatment are also orthodontic specialists. Only 17.1% of respondents disagreed with the statement that “a dentist who advertises orthodontic treatment is an orthodontic specialist.” In addition, 89.7% were not aware that a dentist could not be called an orthodontist without separate training from an accredited residency program. Finally, 64.2% of respondents did not know that an orthodontist must complete more education than a general dentist.
Conclusions
Over the past 15 years, the percentage of orthodontic patients treated by general dentists has increased significantly. The public’s ability to differentiate between different types of orthodontic practitioners is poor, showing substantial confusion about orthodontists’ qualifications. Most respondents believed that orthodontists are best suited for their orthodontic treatment, but they rely heavily on their general dentists for orthodontic practitioner decisions.
Highlights
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In the U.S., the percentage of orthodontic patients treated by non-specialists has increased.
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A significant shift of 28.2% toward general dentists has occurred over the last 15 years.
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Most respondents believe that dentists who perform orthodontic treatment are orthodontists.
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Most patients were not aware that orthodontists complete additional education.
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Patients rely more on recommendations from general dentists than internet or advertising when choosing a provider.
The provision of orthodontic services by general dentists has long been a topic of interest. In the United States, orthodontic treatment falls within the practice scope of general dentists, but there is a restriction on the use of the titles orthodontist and specialist . Only dentists who have completed an additional 2-3 years of full-time training in a Commission of Dental Accreditation sanctioned U.S. or Canadian postgraduate orthodontic program may call themselves orthodontists or specialists. Although the treatment of orthodontic patients by nonspecialist practitioners is not new, the recent emergence of multiple clear aligner systems and elevated competition in the marketplace seems to have catalyzed the number of orthodontic patients being treated by nonspecialist practitioners. Direct-to-consumer (DTC) advertising by orthodontic product companies featuring products such as specific, clear aligner, or bracket systems rather than the status of the orthodontic practitioner seem to have encouraged this phenomenon even further.
Poole and Varner noted the “growing number of general dentists providing orthodontic treatment for the past 10 years” as the most important issue in the orthodontic specialty. Haegar and Colberg found that doctor skill and doctor knowledge were the 2 most important characteristics in determining satisfaction. Thus, choosing a qualified clinician is a critical element in the decision to undergo orthodontic treatment. Therefore, it is important for patients to appreciate the differences between practitioners.
Multiple studies have examined the factors behind a patient’s orthodontic purchase decision and the variables that influence an orthodontic patient’s selection of an orthodontic practice. , Recently, Olson et al evaluated the factors that influence potential orthodontic patients choosing between an orthodontist, general dentist, and DTC aligners for their treatment. A study by Wishney et al compared the public’s understanding of orthodontic specialists in Australia and Sweden. However, to date, no study has assessed changes in who is providing orthodontic treatment over time or laypersons’ understanding of the differences between orthodontic clinicians in the U.S.
In this study, we estimated the temporal trend in patients receiving orthodontic treatment from general dentists rather than orthodontists, a topic of interest to the orthodontic specialty. , , This study also explored laypersons’ understanding of the differences between orthodontic providers in the U.S., specifically, orthodontists compared with general dentists who provide orthodontic treatment.
Material and methods
A 13-question survey was created to assess the lay public’s experience with orthodontic treatment, as well as their understanding of the differences between orthodontists and general dentists who provide orthodontic treatment (see Supplementary Data ). The survey was developed by an expert panel, including 4 seasoned academic orthodontists, an orthodontic resident, and a research methodologist to ensure content validity. Readability was ensured by administering the survey to 3 different panels and modifying question wording and content on the basis of participants’ feedback. Accessibility was tested through the preview page of the survey building software, Qualtrics (Provo, Utah), and through the soft-launch process using 10% of the targeted sample.
The study was approved by the institutional review board at A.T. Still University, and a waiver of written informed consent was granted. An anonymous, online survey method was used to collect data from a representative sample of the U.S. population aged 18-60 years. Dynata (Plano, Texas), a web-based survey company, administered the survey to a sample selected so that it matched U.S. Census data for distributions of gender, ethnicity, age, and geographic location. This sample comprised respondents who had registered with the company. The survey company provided incentives to complete the survey to ensure the representativeness of the sample. To calculate the desired sample size, we specified a precision of 5% and a confidence level of 99%. The survey included questions with both binary and ordinal responses, so the calculation was on the basis of the more conservative (binary) response set and further assumed a maximum variability of 0.5. The calculation yielded an estimate of 760 respondents. As a routine part of enrollment with the survey company, consent to participate was obtained from participants.
A soft-launch of the survey was performed on November 3, 2019, using 10% of the targeted sample. The distributional characteristics (range and distributional normality) of responses from this sample were evaluated. They covered the full range of possibilities and were approximately normally distributed when applicable, so the full survey commenced on November 6, 2019. Responses were stored on secure servers.
Statistical analysis
Descriptive statistics, including mean (M) ± standard deviation (SD) and frequency (%), were calculated as appropriate. Cross tabulations and chi-square tests were used to evaluate relationships between categorical variables. Independent-samples t tests were used to evaluate differences for continuous variables. Kruskal-Wallis and Mann-Whitney tests were used for comparative analysis of ordinal data. Bonferroni corrections were used to address multiplicity. Logistic regression was used to evaluate the changes in the use of orthodontists over time. SPSS (version 25; IBM, Armonk, NY) was used for all analyses. An α of 0.05 (2-tailed) was selected as the criterion for statistical significance.
Results
In total, 928 invitations to participate in the survey were sent. Eleven respondents did not meet the inclusion criteria of age (18-60 years), and 74 were ineligible because the requested quota of 760 subjects consisting of the U.S. representative sample had been filled. Of the remaining 843 eligible respondents, 760 completed the survey by November 13, 2019, for a response rate of 90.2%.
Among the respondents, 383 (50.4%) reported that they or one of their immediate family members had undergone orthodontic treatment. When asked who had provided their treatment, 253 (66.1%) reported that they had seen an orthodontist and 97 (25.3%) received treatment from a general dentist. Eleven (2.9%) received treatment from a pediatric dentist, and 22 (5.7%) did not recall who provided their orthodontic treatment. For purposes of the analyses reported below, we excluded the 33 respondents in the latter 2 groups because the pediatric group was inadequately represented, and the group that did not know who provided their treatment did not inform the questions we sought to answer. The remaining complement, who reported that they had no experience with orthodontic treatment, comprised 377 (49.6%) of the respondents. After this, respondents who reported experience with orthodontic treatment (orthodontist or general dentist) will be referred to as the orthodontic experience cohort, and those with no orthodontic experience will be referred to as the no experience cohort. A total of 727 respondents were retained for analysis. Descriptive demographic statistics for respondents in the analytical sample are provided in the Table .
| Demographic categories | n (%) |
|---|---|
| Gender | |
| Male | 323 (44.4) |
| Female | 386 (53.1) |
| Other | 18 (2.5) |
| Age, y | |
| Mean ± standard deviation | 39.3 ± 13.1 |
| Range | 18-60 |
| Ethnicity | |
| African American | 115 (15.8) |
| Asian | 35 (4.8) |
| White | 482 (66.3) |
| Hispanic | 58 (8.0) |
| Other | 37 (5.1) |
| Education | |
| Primary and high school | 323 (44.4) |
| University | 335 (46.1) |
| Missing | 69 (9.5) |
| Yearly income | |
| <$24,999 | 223 (30.7) |
| $25,000-$49,999 | 143 (19.7) |
| $50,000-$74,999 | 95 (13.1) |
| $75,000-$99,999 | 97 (13.3) |
| $100,000-$149,999 | 101 (13.9) |
| >$150,000 | 68 (9.4) |
| Orthodontic treatment | |
| No | 377 (51.9) |
| Finished within the past 3 y | 143 (19.7) |
| Finished within the past 3-6 y | 41 (5.6) |
| Finished within the last 6-9 y | 39 (5.4) |
| Finished within the last 9-12 y | 28 (3.9) |
| Finished within the last 12-15 y | 20 (2.8) |
| Finished >15 y ago | 79 (10.9) |
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