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ORTHODONTIC REFERRALS- DO ORTHODONTISTS AND DENTISTS
AGREE ON WHAT IS IMPORTANT?
Hillarie Ryann Hudson, D.M.D.
An Abstract Presented to the Graduate Faculty of
Saint Louis University in Partial Fulfillment
of the Requirements for the Degree of
Master of Science in Dentistry
2011
Abstract
Purpose: This study compared what referring dentists
perceived to be important or influential to what
orthodontists thought were important.
Methods: An online
survey was constructed and sent to 3,000 dentists and
3,000 orthodontists from the American Association of
Orthodontists.
It was subsequently mailed to 509
dentists to increase their response rate.
The survey
consisted of demographic questions and 40 qualities
evaluating referral practices with a visual analog scale.
Results:
The response rate for the orthodontic and
dental surveys were 97.5% and 34.3%, respectively.
Even
though 2/3 of dentists had more than three orthodontists
to choose from, 83% regularly referred to only 1-3
orthodontists.
Of the 40 variables tested, 29 (73%)
showed statistically significant differences between
dentists and orthodontists.
The greatest differences
pertained to the orthodontist’s treatment and philosophy.
Dentists and orthodontists agreed on the relatively
strong influence of the orthodontists’ oral hygiene
protocol.
The personal relationship between the dentist
and the orthodontist was considered only “slightly
influential.”
Dentists tended to response more similarly
as a group than orthodontists.
2
Conclusion:
Orthodontists do not have a good understanding of what is
important or influential to referring dentists.
3
ORTHODONTIC REFERRALS- DO ORTHODONTISTS AND DENTISTS
AGREE ON WHAT IS IMPORTANT?
Hillarie Ryann Hudson, D.M.D.
A Thesis Presented to the Graduate Faculty of
Saint Louis University in Partial Fulfillment
of the Requirements for the Degree of
Master of Science in Dentistry
2011
COMMITTEE IN CHARGE OF CANDIDACY:
Adjunct Professor Dr. Peter Buschang
Chairperson and Advisor
Assistant Professor Dr. Ki Beom Kim
Associate Clinical Professor Dr. Donald R. Oliver
ii
DEDICATION
I dedicate this study to my family and all those
people who have played a role in helping through my
education.
I would not be here if it wasn’t for you.
I
have my ideal career and life because of all the love and
support you gave me.
iii
ACKNOWLEDGEMENTS
I would like to acknowledge the following individuals:
Dr. Buschang for mentoring me through this process.
You gave so much guidance, time, effort, and
understanding to this project and me.
Thank you for
being so available and helpful.
Dr. Oliver for giving such great insight into the
minds of practicing orthodontists and dentists.
You
have given great guidance in making the survey as
inclusive and understandable as possible.
Dr. Kim for aiding in this project.
You have been
very supportive and have given me the positive
reinforcement I needed.
Dr. Jim Fisher for helping me understand the survey
process.
Your guidance helped form the foundation
of my project.
Dr. Behrents for giving me the opportunity to be in
this program and allowing my project to take place.
The many faculty, residents, orthodontists, and
dentists who participated in forming the survey.
The American Association of Orthodontists and Direct
Medical Data for distributing the surveys.
iv
QualtricsTM and their customer service for creating a
great online survey and helping me through the
process.
v
TABLE OF CONTENTS
List of Tables.......................................viii
List of Figures........................................ix
CHAPTER 1: INTRODUCTION.................................1
CHAPTER 2: REVIEW OF THE LITERATURE.....................2
Acquiring New Patients.......................2
Orthodontic Patient Trends...............3
Acquiring New Patient By Marketing.......5
Acquiring New Patient By Recommendation...
From Others...........................6
Acquiring New Patient By Dental...........
Referrals.............................7
Methods for Obtaining Information About...
Dental Referrals......................8
Surveys......................................9
Referral Patterns...........................14
Survey Categories...........................15
Communication...........................15
Treatment and Philosophy................16
Relationships...........................17
Patient Care............................18
Finished Results of the Dentition.......19
Oral Hygiene Protocol...................20
Orthodontic Office......................22
Summary and Statement of Thesis.............23
References..................................25
CHAPTER 3: JOURNAL ARTICLE............................30
Abstract....................................30
Introduction................................31
Materials and Methods.......................33
Survey Design...........................33
Demographics............................34
Survey Validity.........................35
Survey Distribution.....................35
Data Collection and Analysis............36
Results.....................................37
Response Rate...........................37
Demographics............................38
Orthodontic Referrals...................40
Differences Between Dentists and..........
Orthodontists........................42
Survey Trends...........................46
vi
Discussion.................................49
Response Rate..........................49
Demographics...........................50
Orthodontic Referrals..................50
Survey Questions.......................51
Clinical Relevance of the Present........
Study...............................57
References.................................58
Appendix A (Survey to orthodontists)................62
Appendix B (Survey to dentists).....................72
Appendix C (Results tables for survey categories)...83
Vita Auctoris.......................................91
vii
LIST OF TABLE
Table 1:
Summary of the variables tested from mail......
surveys.................................10
Table 2:
Communication with the Orthodontist..........83
Table 3:
Orthodontist’s Treatment and Philosophy......84
Table 4:
Finished Results of the Dentition............85
Table 5:
Patient Care.................................86
Table 6:
Oral Hygiene Protocol of the Orthodontist....87
Table 7:
Professional Relationship Between..............
Orthodontist and Dentist................88
Table 8:
Personal Relationship Between Orthodontist.....
and Dentist.............................89
Table 9:
Orthodontist’s Office........................90
viii
LIST OF FIGURES
Figure 1: Average new patient appointments..............4
Figure 2: Gender of respondents used in the study......38
Figure 3: Age of dentists and orthodontists used in the..
study...................................39
Figure 4: Practice locations of the respondents........40
Figure 5: Number of orthodontists in the referring.......
area....................................41
Figure 6: Number of orthodontists dentists regularly.....
refer to................................41
Figure 7: Domain differences between dentists and........
orthodontists..........................47
Figure 8: Influence of the domains to dentists.........48
Figure 9: Qualities that orthodontists and dentists......
responded very similar.................52
Figure 10: Qualities that orthodontists and dentists.....
responded the most different...........55
ix
CHAPTER 1: INTRODUCTION
In order for their practices to grow and survive,
orthodontists must attract new patients.
Various
strategies are being used, including external and
internal marketing, referrals from dentists, and
recommendations from others.1
Studies have found that
dentists are perhaps the most important means of
referring new patients to an orthodontist.
12,1,3-5
A
common way to determine what dentists are looking for
when referring to orthodontists is to use a survey or
questionnaire.1,6-12
Factors, such as, communication, the
orthodontist’s treatment and philosophy, the finished
dentition, patient care, oral hygiene protocol of the
orthodontist, professional or personal relationship, and
the orthodontist’s office have been shown to be
influential in the referral process.1,6-12
The purpose of
the present study is to reevaluate the qualities that
dentists have previously found to be important or
influential, and to determine how orthodontists respond
to questions about the same qualities.
The purpose is to
determine whether or not orthodontists understand what
their referring dentists want.
1
CHAPTER 2: REVIEW OF LITERATURE
Acquiring New Patients
Recently, more orthodontists have felt that the
economic downturn has affected the lack of growth in
their practice.13,14
This is one reason why orthodontists
have started taking action to acquire new patients.15
There are many techniques that can be used to attract new
patients.
An orthodontist can invest in advertising
through local media,15 direct mail,16 and the phone book.2
Building relationships with dentists through study
groups17 and gifts of appreciation15 are aimed at
increasing dental referrals.
Developing a good
reputation and relationship with patients can be done
through word of mouth16 and sponsoring or being active in
social or religious groups.2
Even non-personal factors
such as an appealing location or servicescape can attract
patients as they drive by the office.16,
18,19
The internet
is, also, a popular tool where a practice website and the
American Association of Orthodontist’s on-line “Find an
Orthodontist” can help a practice get noticed.16
to determine whether these various techniques are
effective, orthodontic patient trends need to be
considered.
2
In order
Orthodontic Patient Trends
The American Association of Orthodontists (AAO) had
Zimmerman Marketing Research create a Patient and Member
Census for 2008.16
This census included the United
States and the District of Columbia, Puerto Rico, and 6
provinces of Canada.
The 2008 census had a response rate
of 12% (1,107/8,903).
The AAO used this information to
identify the following trends based on past census data.
The following patient statistics mentioned in this
section came from the 2008 census:
The average number of orthodontic patients per
office dropped from 547 in 2006 to 503 in 2008.
Since 2001, the average number of new patient exams
has remained about the same.
However, the number of
new patient starts has declined (Figure 1).
In 2008, the average number of patients an
orthodontist sees per day is 48.
In 2008, orthodontists reported 351 active patients
ages 2-17 and 101 active patients 18 years and
older.
Less than half (45%) of the active patients 8-17
years of age were male.
More patients (53%) 18
years and older were reported as female.
3
Almost half of the orthodontists felt that they were
not as busy in 2008 compared to 2007.
Orthodontists were asked, “If you feel you could
comfortably see more patients each day, about how
many more patients could you see daily?”. Over half
responded saying that they could see 16 or more per
day.
450
400
350
New Patient Exams
New Case Presentations
300
New Patient Starts
250
200
2001
2004
2006
Figure 1. Average new patient appointments, adapted from
2008 AAO Patient & Member Census Study
4
2008
Acquiring New Patients By Marketing
A more common strategy a practice can use to gain new
patients and referrals is to market the practice.15,20
In
2009, Keim et al. surveyed orthodontists and found that
more respondents than ever before included different
marketing strategies such as: community activities,
gifts, and personal publicity.15
In 2009, Haeger used his
own orthodontic practice to determine which techniques
helped him gain new patients.2
A form made by Haeger was
given to all new patients asking them to indicate the
source(s) that made them select his office.
Marketing,
which included both internet and yellow pages, only
accounted for 2.3% of the sources.
The low percentage is
disconcerting considering that the percentage of
orthodontists with a practice website has increased from
25% in 2000 to 75% in 2008 according to the AAO Patient
and Member Census.16
Edwards et al. in 2008 constructed a
survey asking patients from eight offices in Virginia how
influential different forms of marketing were in
determining their selection of an orthodontist.
response rate was 97% (655/676).
The
The authors found that
well-educated people with a higher annual income felt
that orthodontists who advertise with newspapers,
magazines, or billboards provide treatment that is the
5
same or better than the standard of care.5
However,
marketing advertisements were a very small percentage
(12%) of the ways that patients or parents found the
office.5
The top two responses were dental and family or
friend referrals, respectively.5
Acquiring New Patients By Recommendations From Others
A great practice reputation can be a very helpful
source of new patients.
The AAO Patient and Member
Census reported that orthodontists felt that patients
younger than 17 years of age wanted treatment for
esthetic reasons because of parents and friends.16
In
1985, Gosney surveyed 2007 patients and their parents
about their desire for orthodontic treatment.3
was able to use 86% (207/240) of the responses.
Gosney
She
noted that parents’ wishes were listed as the third most
influential factor in suggesting orthodontic treatment
with the dentist’s and patient’s wishes being more
important.
3
When patients or parents seek an
orthodontist, many will often ask other friends or
acquaintances where they should go for treatment.2,11
To investigate how influential recommendations are
in obtaining new patients, a questionnaire was sent to
patients of physicians at West Berkshire Community Health
6
Council.
This questionnaire asked “did you try to find
out anything about the practice before you registered? If
so, how?”.11
or coworker.
About 24% of respondents had asked a friend
Around 51% of the responses involved asking
someone not related to the practice about the office.
Another question asked “what was the main reason that you
chose the practice that you’ve registered with?”
recommended by someone was second to location.
Being
11
Haegar’s personal survey found that 31.8% of his new
patients reported coming to his office because of the
recommendation of family and friends.1
Comparably,
almost half of the orthodontists surveyed from the AAO’s
Patient and Member Census felt that new patients found
their office by patient referrals and the other half
through dental referrals.16
Acquiring New Patients By Dental Referrals
General dental practitioners are the gatekeepers of
their patients.8,9
They are responsible for directing
their patients to the clinicians who can provide the best
treatment.21
Gosney found that the most influential
factor in the patients’ choice of where to start
orthodontic treatment was the advice of the dentist.3
has been reported by the AAO that up to 72% of new
7
It
patients come from dental referrals alone.16
The
percentage of new patients that have been referred by
dentists has been increasing from 57.6% in 1986 to 69% in
2008.16
In 2004, Keim et al. mailed 7,500 surveys to
American Dental Association (ADA) dentists and received
539 responses (7.2%).7
The authors found that 69.4% of
dentists refer their patients to more than one
orthodontist.
Other studies have also found that it is
common for dentists to refer to multiple orthodontic
providers.1,8
Given the importance of dental referrals,
it would be beneficial for an orthodontist to know why
dentists choose him or her verses a competitor.
Several
surveys have been done to evaluate the qualities that the
referring dentists look for in orthodontists.1,6-9
Methods For Obtaining Information About Dental Referrals
There are several methods that can be utilized to
obtain information from a target group.
When trying to
understand the reasoning behind dental referrals,
interviews and surveys are two of the more commonly used
methods.
Surveys can be distributed by paper or
electronically through fax or e-mail.
There are
advantages and disadvantages to each of the methods.
8
In 1991, Fitzpatrick, a professor in medical
sociology at the University of Oxford, wrote an article
pertaining to the assessment of patient satisfaction with
interviews and surveys.22
He developed a list of
advantages for the interview process.
An interviewer is
able to be sensitive to the patient’s concerns, flexible
in covering topics, can build rapport, clarify confusing
items, and able to do follow-ups.
It could even be
argued that an interview could obtain more accurate
information.
At the same time, a well-planned and
executed survey can also be a very successful.22
Surveys
Surveys or questionnaires are useful tools for
collecting data from individuals.22
In comparison with
interviews, Fitzpatrick noted that self-completed surveys
have the advantages of standardization of items,
eliminating interviewer bias, anonymity, low cost of data
gathering, and less need for trained staff.22
There are
three methods of survey distribution to large
populations: fax, mail, and e-mail.
While fax machines are not the preferred method of
distribution, they have their advantages.
Quick
distribution of the survey, removal of interviewer bias,
9
and completion of the survey by the respondent on his/her
own time.23
The disadvantages are that the cost is about
the same as mail and the fax machine is not considered
standard equipment for everyone.
The population that
would have access to a fax machine is smaller than the
population that uses mail or e-mail.23
Edwards et al. performed a literature review in 2002
to determine ways for increasing the response rate of
paper surveys.24
Table 1 is a summary of the results from
the analysis of 75 variables they evaluated.
Even though
Edwards et al. analyzed paper surveys, many of the
variables can also be used with electronic surveys.
Table 1: Summary of the variables tested from mail
surveys, adapted from Edwards et al. 2002.
Variables
Follow-up or Reminders
Decreased Increased
Response Response
Rate
Rate
X
Preliminary Notification
Length of Survey
Sponsorship (i.e.
University)
X
Return Envelopes
X
Postage
X
Personalization
X
Color
Providing Non-respondents
with a 2nd copy
X
Interesting Topic
X
Money Incentives
Sensitive Topics
X
Comment
Accelerated rate of
return
Shorter is better
X
X
X
10
X
X
Special delivery is
most effective
Ink or paper is
better
The number of e-mail surveys have been increasing
over the years.25
Considering that almost 70 million
American households (62%) have one or more computers and
slightly fewer have internet access at home (55%), e-mail
makes it easy to reach a large population.26 Over half of
25-64 year olds have internet access.
The percentage
drops to 29% for people 65 years of age and older.26
Age
demographics should be taken into account when
formulating a survey.
Another advantage is that e-mail surveys have a
quicker response rate than mailed paper surveys.23
They
also make it easier to change problematic wording or
addresses.
23
A literature review of 31 studies by
Sheehan et al. showed that e-mail and mail surveys
produced similar response rates.25
Conversely, Sheehan et
al. noted that the “response rates for e-mail surveys
have significantly decreased since 1986.”25
The average
response rate has declined from 61.5% in 1986 to 24% in
2000.25
Each method of distribution has areas that need
to be thought out carefully when constructing the proper
survey.
Another consideration with surveys is whether or not
the respondents are being honest in their answers.
11
An
older study by Kinsey in 1948 asked 231 spouses questions
that were later verified by the other spouse privately.27
He found that between 80-99% of responses were validated
as accurate.
The Denver Validity Study done in 1949 at
the University of Denver’s Opinion Research Center asked
questions about automobile ownership, presidential
elections, monetary contributions, library card
ownership, age, and home and phone ownership.28
The study
found that people who took their questionnaire answered
accurately on average 76.6% of the time.
The more
specific and well designed the questionnaire, the more
likely the respondents will use their personal beliefs to
answer, instead of global reactions (i.e., conventional
wisdom).22
If properly constructed and piloted, a questionnaire
should be a valid option.22
Utilizing the visual analog
scale (VAS) has been a reliable way to collect data in
surveys.19,29,30
An article by Miller and Ferris in 1993
describes how to prepare questions that use a VAS to
obtain the most reliable and valid responses.31
The use
of 100 mm lines, proper wording for the anchor choices,
and not superimposing numbers on the scale are some of
their suggestions to create a more valid tool.
The
advantages of VAS, according to Miller and Ferris, are
12
the following: quick and simple to construct and
administer, easily understood, easy to score, and
sensitive enough to detect small increments of change.
Another advantage is that it requires little motivation
or effort on the part of the respondent, which should
increase the response rate of surveys that use the VAS.
31
Beside accuracy, the response rate is also an
important factor in surveys.
A systematic review done by
Edwards et al. in 2002 tried to determine the factors
that made some mail-distributed surveys more successful
than others.24
They reviewed 292 randomized controlled
trials evaluating 75 different criteria.
The results
reported that response rates increased when using
monetary incentives, short questionnaires,
personalization, colored ink, including a stamped return
envelope, first class postage, having an interesting
topic, and originating from a university.
24
In 2002,
Truell et al. compared internet-based and maildistributed surveys.32
The study used the Business
Education Professional Leadership Roster to compile email and mailing addresses.
There were 306 surveys
randomly assigned to be distributed by either e-mail or
mail method.
Out the 153 surveys per method, 78 (49%) e-
mail and 81 (51%) mail surveys were returned usable.
13
There was no difference in the response rate.
However,
the internet-based survey did have a higher completeness32
and a faster response time.23,32 In the previously
mentioned studies that distributed surveys by mail, the
response rate ranged from 7.2-36.3%1,6,7
than the 53% Truell et al. reported.32
which is lower
If a monetary
incentive was included, the response rates increased to
45.6-60.4%.8,33,34
There is no consensus as to whether
survey length or pre-notification increases the response
rate.
However, follow-up contact and salience were
beneficial.25
Correlations reported by Sheehan et al.
showed that follow-ups and the year of distribution are
better predictors of increasing the response rate than
survey length, pre-notifications, and topic salience.25
Referral Patterns
Surveys have examined many possible characteristics
or qualities dentists use to choose an orthodontist.
A
few characteristics have been thought to be important and
influential enough to be repeatedly studied.
The quality
of treatment outcomes from either the patient’s or the
dentist’s perspective is of reoccurring importance.1,6,8
Other areas, such as, referring patients back to the
dentist1,7, certain aspects of occlusion6, responding
14
promptly1, caring attitude5, good reputation5, and no
waiting lists1,9,35 have also been reported as being very
important qualities in an orthodontist.
Survey Categories
Communication
A very important aspect of the relationship between
a dentist and an orthodontist is the quality of
communication.
Several articles have been written to
help specialists interact with the dentist in order to
provide the best care possible for the patient.21,36,37
A
few articles have entire sections of the survey dedicated
to the importance of good communication.1,7,10
Keim et al.
included a form that they suggested orthodontists should
send to the dentists in their area to find personal
preferences.7
A short, informal survey done by Church-
Clark in 1991 asked dentists in the United States what
they wanted from their orthodontists.12
The study
revealed that good verbal and written communication was
the most important, followed by referring the patient
back to the dentist.12
The importance of communication
has been demonstrated in other professions other than
dentistry.
In a 1998 study by Bourguet et al., primary
care physicians were asked to rate the patient care and
15
communication by the referred specialist after the
patient had a consultation with the specialist.
When
written feedback was given by the specialist, patient
care and communication was perceived as more
satisfactory.
Physicians were most satisfied when both
verbal and written feed back were given.38
In summary, a
number of studies have found that the type and timing of
communication, as well as the information being
communicated, are very important to a doctor.1,7,10,12,38
It
can be said that even though good communication is
important to the referral process, quality of treatment
maybe one of the most influential determinants of
referrals.6
Treatment and Philosophy
It is understandable that the dentist’s opinion of
an orthodontist is influenced by the quality of treatment
seen in his or her patients.
A survey by Guymon et al.
in 1999 asked 2,000 dentists how important 33
characteristics were in a referral decision.
The
response rate of the mailed survey was 20.5% (415/2,000).
All questions pertaining to the quality of treatment
(e.g., philosophy, past experiences, agreement with
extractions, etc.) were thought to be of the greatest
16
importance.1
De Bondt et al. sent a survey to 634
dentists asking them about their referral patterns.
Even
though the survey did not include quality of treatment as
a variable, dentists noted that the standard of treatment
was very important and should be included in referral
studies.8
The study also found that agreement with the
orthodontist on the need for extractions is important for
referrals.1,8
Up to 97.5% of dentists have reported that
the quality of treatment is very important to the
relationship between a dentist and orthodontist.7
Relationships
The literature pertaining to the importance of
professional and personal relationship of dentists and
orthodontists is not consistent.6,7
Guymon et al. found
that the relationship between dentists and orthodontists
is not as important as other areas, such as quality of
treatment.
However, they also found that a superior
professional reputation of the orthodontist was very
important.1
Dentists apparently believe that friendships
with orthodontists are somewhat important or, at least,
applicable to the referral process.7,8
Orthodontists tend
to give gifts of appreciation to maintain a positive
relationship with the referring dentists.
17
Keim et al.
wrote a four part article about orthodontic practice
results based on a survey of orthodontists conducted in
2009.15
They reported that 74.5% of the respondents sent
gifts of appreciation as a practice builder.
However, it
has been reported that these gifts are usually rated low
in importance1,8,12 and effectiveness.39
Even though a
positive relationship is important, having a positive
relationship with the patient may be more important to
the dentist.
Patient Care
Out of 510 adult patients and parents surveyed by
Edwards et al., the most influential factors in choosing
an orthodontist were a caring attitude and good
reputation.5
Similarly, when patients of primary care
physicians were asked “what things are most important to
you in choosing a doctor?”, there were several responses
that dealt with doctor-patient relationships.
The most
important were that the doctor was friendly, easy to talk
to, and pleasant.11
According to Guymon et al., the one
“very important” characteristic that the dentists agreed
upon the most was that the patient should return happy.1
The top two factors considered “totally applicable”
to the referral process reported by de Bondt and his
18
coworkers were patient satisfaction and favorable past
experiences.8 Hall et al. distributed 1,000 surveys to
dentists in the Midwestern United States asking them
about the characteristics that are influential when
referring a patient to an orthodontist for treatment.6
The authors reported that 358 surveys were returned
(36.3%).
They found that the second and third most
important determinants in referring patients was the
patient’s opinion of the quality of treatment and the
patient’s satisfaction with the orthodontic experience,
respectively.
The study also found that patient
satisfaction, occlusion, and function were found to be
equally important by the dentists.6
Finished Results of the Dentition
Evaluating post-orthodontic occlusion is one of the
ways dentists judge the orthodontist’s treatment outcome.
The article by Hall et al. asked dentists how important
certain aspects of occlusion were when evaluating
orthodontic cases.6
The top four characteristics
considered strongly important were Class I canine, canine
guidance, no posterior interferences, and even contacts
of teeth, in that order.
Oltramari et al. evaluated the
stability of the finished occlusions of 20 Class II,
19
female subjects.40
They verified the importance of the
same characteristics Hall et al. found with the
literature Oltramari et al. reviewed.
Svedström-Oristo
et al. distributed a survey to orthodontic specialists
and dentists asking them to rank in order of importance
good function, long-term stability, acceptable
morphology, and appearance according to the patient and
dentist.41
survey.
Out of 93 subjects, 74 (80%) returned the
Good function and long-term stability were
ranked as the two most important characteristics.
This
contradicts articles showing that the dentist’s and
patient’s approval were more important.
It may be best
to directly ask the referring dentist what he or she
feels is important in final orthodontic occlusions.
Oral Hygiene Protocol
As dental care providers, dentists and orthodontists
share a special interest in the oral hygiene of their
patients.
A questionnaire sent by Hunt et al. asked both
dentists and orthodontists about the benefits of
orthodontic treatment.29
All of the orthodontists in
Northern Ireland and 150 dentists were included in the
study.
The authors found that dentists, particularly
longer practicing dentists, felt that one of the more
20
important benefits of orthodontic treatment is the
ability of patients to more easily clean their teeth and
the concomitant reduction in susceptibility of caries.29
Guymon et al. also reported that dentists felt it is
important that the orthodontist monitor and teach good
oral hygiene.1
Fortunately, there are many products that
can be used to improve patient hygiene, including sonic
toothbrushes, electronic water flossers42, interproximal
brushes43, topical fluoride44-46, and orthodontic sealants
or adhesives.47,48
All of these products help the patient
decrease the risk of decalcification or white spot
lesions (WSL).
One of the characteristics that is
important to dentists is whether or not the patient
returns with evidence of decalcification.6
Keim et al.
reported that 78.3% of the dentists that responded to
their survey expected the orthodontist to refer the
patient back to the dentist for periodic dental recall
appointments.7
The authors reported many comments that
were sent in with the surveys and one dentist replied by
saying, “Emphasizing routine dental cleanings and checkups is critical!”
7
21
Orthodontic Office
Orthodontists have been taught that location,
appearance of the office, and service are very
influential when trying to acquire new patients.
Bitner,
an Assistant Professor of Marketing at Arizona State
University, wrote an article in 1992 describing the
effects of the environment on people’s perception.18
She
noted that behavior can be influenced by the physical
surroundings of the environment.
The orthodontic office
provides nonverbal communication that can convey
information about the owner’s personality.
The
information that is perceived by the patients can produce
either an “approach” or “avoidance” reaction to that
particular setting.
A person with “approach” behavior
will spend more time and money in that setting, he or she
will return more often, and inquire more often about the
environment.
A positive environment can create success
for an office by influencing patients and parents to have
an “approach” behavior.
The items, layout, and ambiance
of the office can affect the perception of the
environment, especially if the person spends long periods
of time there.
18
A great deal of time and large amounts
of resources have been spent purchasing impressive
practices in the best locations in order to give the
22
perception of an “approach” atmosphere.
However, several
studies have noted that location, atmosphere, technology,
and marketing are not the most important factors in
choosing an orthodontist for either dentists, patients,
or parents.1,5-7,9
Dentists and parents may be more
concerned with a short waiting list than the location of
the office.1,9
As previously mentioned, Salisbury used a
questionnaire that asked physician’s patients “what was
the main reason that you chose the practice that you’ve
registered with?”.11
Location was the top choice.
The
same questionnaire asked what was important when choosing
a doctor.
The top choices were good hours, getting
appointment times when you want them, and a pleasant and
helpful front desk staff.11
It seems that there are many
differences between what orthodontists perceive to be
important to attract the attention of dentists and
patients and what the literature reports to be important.
Summary and Statement of Thesis
No previous study has evaluated both orthodontists
and dentists in order to better understand referral
practices.
Unless both groups are evaluated, there is
not a good way to know whether or not they truly
understand each other.
A recent study by Bedair et al.
23
surveyed orthodontists to find out their opinion of why
patients chose their practice.19
They showed that
orthodontists perceived that making the patient or parent
comfortable, having a caring attitude, and a good
reputation were the most important qualities to their
patients and parents.
However, the study only evaluated
the opinion of the orthodontists.
It may have been more
beneficial if it had also surveyed patients and compared
the responses to see if orthodontists actually understood
their patients.
Past literature has touched on a number of
parameters thought to be important for referring
dentists.
Until proper communication between the dentist
and the orthodontist is established, determining what is
needed from each other remains a guessing game.
If
orthodontists want to provide the best service for their
referring dentists, there needs to be an understanding
between the two.
The purpose of the present study is to
reevaluate the qualities previously reported by dentists
to be important or influential and to ask orthodontists
about the same qualities.
Do orthodontists understand
what their referring dentists want from them?
24
REFERENCES
1. Guymon G, Buschang PH, Brown TJ. Criteria used by
general dentists to choose an orthodontist. J Clin
Orthod. 1999;33(2):87-93.
2. Haeger RS. Increasing new patient starts by analyzing
referral sources and treatment coordinators. J Clin
Orthod. 2009;43(3):175-182.
3. Gosney MB. An investigation into some of the factors
influencing the desire for orthodontic treatment. Br J
Orthod. 1986;13(2):87-94.
4. Pietilä T, Pietilä I. Parents' views on their own
child's dentition compared with an orthodontist's
assessment. Eur J Orthod. 1994;16(4):309-316.
5. Edwards DT, Shroff B, Lindauer SJ, Fowler CE, Tufekci
E. Media advertising effects on consumer perception of
orthodontic treatment quality. Angle Orthod.
2008;78(5):771-777.
6. Hall JF, Sohn W, McNamara JA. Why do dentists refer to
specific orthodontists? Angle Orthod. 2009;79(1):5-11.
7. Keim RG, Gottlieb EL, Nelson AH, Vogels DS. JCO survey
of referring dentists. J Clin Orthod. 2004;38(4):219-223.
8. de Bondt B, Aartman IHA, Zentner A. Referral patterns
of Dutch general dental practitioners to orthodontic
specialists. Eur J Orthod. 2010;32(5):548-554.
9. McComb J, Wright J, O'Brien K. Dentists' perceptions
of orthodontic services. Br Dent J. 1995;178(12):461-464.
10. Waring DT, Harrison JE. Reply letters following
orthodontic consultations: an audit of Merseyside general
dental practitioners' satisfaction. Prim Dent Care.
2007;14(2):53-58.
11. Salisbury CJ. How do people choose their doctor? BMJ.
1989;299(6699):608-610.
12. Church-Clark B. Getting and keeping dentist
referrers. J Clin Orthod. 1991;25(10):633-638.
25
13. Gottlieb EL, Nelson AH, Vogels DS. 1995 JCO
Orthodontic Practice Study. Part 3. Practice growth. J
Clin Orthod. 1995;29(12):743-752.
14. Keim RG, Gottlieb EL, Nelson AH, Vogels DS. 2009 JCO
Orthodontic Practice Study. Part 3: Practice growth and
staff data. J Clin Orthod. 2009;43(12):763-772.
15. Keim RG, Gottlieb EL, Nelson AH, Vogels DS. 2009 JCO
Orthodontic Practice Study. Part 1 Trends. J Clin Orthod.
2009;43(10):625-634.
16. American Association of Orthodontists. 2008 AAO
Patient and Member Census Study. 2009.
17. Kubisch RG. Building relationships with general
dentists. J Clin Orthod. 1996;30(2):99-105.
18. Bitner MJ. Servicescapes: The Impact of Physical
Surroundings on Customers and Employees. J Marketing.
1992;56(2):57-71.
19. Bedair TM, Thompson S, Gupta C, Beck FM, Firestone
AR. Orthodontists' opinions of factors affecting
patients' choice of orthodontic practices. Am J Orthod
Dentofacial Orthop. 2010;138(1):6.e1-7; discussion 6-7.
20. Gottlieb EL, Nelson AH, Vogels DS. 1995 JCO
Orthodontic Practice Study. Part I. Trends. J Clin
Orthod. 1995;29(10):633-642.
21. Mavreas D, Athanasiou AE. Orthodontics and its
interactions with other dental disciplines. Prog Orthod.
2009;10(1):72-81.
22. Fitzpatrick R. Surveys of patients satisfaction: I-Important general considerations. BMJ.
1991;302(6781):887-889.
23. Oppermann M. E-mail surveys--potentials and pitfalls.
Marketing Res. 1995;7(3):28-33.
24. Edwards P, Roberts I, Clarke M, et al. Increasing
response rates to postal questionnaires: systematic
review. BMJ. 2002;324(7347):1183.
26
25. Sheehan KB. E-mail Survey Response Rates: A Review. J
Comput-Mediat Comm. 2006;6(2):0-0.
26. U.S. Department of Commerce, Economics, and
Statistics Administration, U.S. Census Bureau. Computer
and Internet Use in the United States: 2003. 2005.
Available at: http://www.census.gov/prod/2005pubs/p23208.pdf [Accessed October 11, 2010].
27. Kinsey AC, Pomeroy WR, Martin CE. Sexual Behavior in
the Human Male. Am J Public Health. 2003;93(6):894-898.
28. Parry HJ, Crossley HM. Validity of Responses to
Survey Questions. Public Opin Quart. 1950;14(1):61-80.
29. Hunt O, Hepper P, Johnston C, Stevenson M, Burden D.
Professional perceptions of the benefits of orthodontic
treatment. Eur J Orthod. 2001;23(3):315-323.
30. Gould D, Kelly D, Goldstone L, Gammon J. Examining
the validity of pressure ulcer risk assessment scales:
developing and using illustrated patient simulations to
collect the data. J Clin Nurs. 2001;10(5):697-706.
31. Miller MD, Ferris DG. Measurement of subjective
phenomena in primary care research: the Visual Analogue
Scale. Fam Pract Res J. 1993;13(1):15-24.
32. Truell AD, Bartlett JE, Alexander MW. Response rate,
speed, and completeness: a comparison of Internet-based
and mail surveys. Behav Res Methods Instrum Comput.
2002;34(1):46-49.
33. Beltramini RF. Professional Services Referrals: a
Model of Information Acquisition. J Serv Mark.
1989;3(1):35-43.
34. Asch DA, Christakis NA, Ubel PA. Conducting physician
mail surveys on a limited budget. A randomized trial
comparing $2 bill versus $5 bill incentives. Med Care.
1998;36(1):95-99.
35. Kennedy F, McConnell B. General practitioner referral
patterns. J Public Health Med. 1993;15(1):83-87.
27
36. Kokich VO, Kinzer GA. Managing congenitally missing
lateral incisors. Part I: Canine substitution. J Esthet
Restor Dent. 2005;17(1):5-10.
37. Kokich VG. Maxillary lateral incisor implants:
planning with the aid of orthodontics. J. Oral
Maxillofac. Surg. 2004;62(9 Suppl 2):48-56.
38. Bourguet C, Gilchrist V, McCord G. The consultation
and referral process. A report from NEON. Northeastern
Ohio Network Research Group. J Fam Pract. 1998;46(1):4753.
39. Keim RG, Gottlieb EL, Nelson AH, Vogels DS. 2009 JCO
Orthodontic Practice Study. Part 2. Practice success. J
Clin Orthod. 2009;43(11):699-707.
40. Oltramari PVP, Conti ACDCF, Navarro RDL, et al.
Importance of occlusion aspects in the completion of
orthodontic treatment. Braz Dent J. 2007;18(1):78-82.
41. Svedström-Oristo AL, Pietilä T, Pietilä I, Alanen P,
Varrela J. Morphological, functional and aesthetic
criteria of acceptable mature occlusion. Eur J Orthod.
2001;23(4):373-381.
42. Kossack C, Jost-Brinkmann P. Plaque and gingivitis
reduction in patients undergoing orthodontic treatment
with fixed appliances-comparison of toothbrushes and
interdental cleaning aids. A 6-month clinical singleblind trial. J Orofac Orthop. 2005;66(1):20-38.
43. Kaklamanos EG, Kalfas S. Meta-analysis on the
effectiveness of powered toothbrushes for orthodontic
patients. Am J Orthod Dentofacial Orthop.
2008;133(2):187.e1-14.
44. Lovrov S, Hertrich K, Hirschfelder U. Enamel
Demineralization during Fixed Orthodontic Treatment Incidence and Correlation to Various Oral-hygiene
Parameters. J Orofac Orthop. 2007;68(5):353-363.
45. Farhadian N, Miresmaeili A, Eslami B, Mehrabi S.
Effect of fluoride varnish on enamel demineralization
around brackets: an in-vivo study. Am J Orthod
Dentofacial Orthop. 2008;133(4 Suppl):S95-98.
28
46. Mitchell L. Decalcification during orthodontic
treatment with fixed appliances--an overview. Br J
Orthod. 1992;19(3):199-205.
47. Buren JL, Staley RN, Wefel J, Qian F. Inhibition of
enamel demineralization by an enamel sealant, Pro Seal:
an in-vitro study. Am J Orthod Dentofacial Orthop.
2008;133(4 Suppl):S88-94.
48. Evrenol BI, Kucukkeles N, Arun T, Yarat A. Fluoride
release capacities of four different orthodontic
adhesives. J Clin Pediatr Dent. 1999;23(4):315-319.
29
CHAPTER 3: JOURNAL ARTICLE
Abstract
Purpose: This study compared what referring dentists
perceived to be important or influential to what
orthodontists thought were important.
Methods: An online
survey was constructed and sent to 3,000 dentists and
3,000 orthodontists from the American Association of
Orthodontists.
It was subsequently mailed to 509
dentists to increase their response rate.
The survey
consisted of demographic questions and 40 qualities
evaluating referral practices with a visual analog scale.
Results:
The response rate for the orthodontic and
dental surveys were 97.5% and 34.3%, respectively.
Even
though 2/3 of dentists had more than three orthodontists
to choose from, 83% regularly referred to only 1-3
orthodontists.
Of the 40 variables tested, 29 (73%)
showed statistically significant differences between
dentists and orthodontists.
The greatest differences
pertained to the orthodontist’s treatment and philosophy.
Dentists and orthodontists agreed on the relatively
strong influence of the orthodontists’ oral hygiene
protocol.
The personal relationship between the dentist
and the orthodontist was considered only “slightly
influential.”
Dentists tended to response more similarly
30
as a group than orthodontists.
Conclusion:
Orthodontists do not have a good understanding of what is
important or influential to referring dentists.
Introduction
In order for practices to grow and survive,
orthodontists must attract new patients.
When the
American Association of Orthodontists (AAO) compared the
2008 census data against past census data, they found
that the number of new patient starts was declining, even
though the number of new patient exams has remained
approximately the same.1
Orthodontists in 2008 also
reported that they do not feel as busy as in 2007.
Recently, more orthodontists have started implementing
strategies to gain new patients than previously seen.2,3
The various strategies being used to attract new
patients include external and internal marketing,
recommendations from others, and referrals from
dentists.4
For example, the use of websites has
increased from 25% in 2000 to 75% in 2008.1
Advertisement is also important; orthodontists who
advertise are perceived to provide treatment that is the
same or better than the standard of care.5
However, it
has been shown time and time again that dentists are
31
perhaps one of the most important sources of new
patients.4,6-8,5
Since 1986, the percentages of new
patients referred by dentists have been increasing.1
Surveys have consistently shown that communication
is very important to primary care givers, dentists and
physicians.6,9,10,11,12
Guymon et al. found that the quality
of treatment was of the highest importance.6
Dentists
expect that orthodontic treatment will produce good
function, long-term stability,13 and improved oral
hygiene.14
Dentists expect the orthodontist to refer the
patient back for periodic dental recall appointments.6,9
While the literature pertaining to its importance is
conflicting,6,15,16
the relationship between dentists and
orthodontists is also applicable to the referral
process.9,17
The relationship between the patient and the
orthodontist may be even more important.6,5,18
The office
environment also plays a role; patients learn about the
orthodontist’s personality through the layout and
ambiance of the office.19
Hall et al. showed that patient
satisfaction, occlusion, and function were equally
important to the dentists.15
Even though there are
numerous referral studies telling orthodontists what
dentists want, only one was comprehensive6 and no study
32
has determined whether orthodontists have a mutual
understanding of their referring dentists.
The primary purpose of the present study was to
compare what referring dentists say is important to the
referral process to what orthodontists think is
important.
It is the first study to ask both groups the
same questions, making it possible to more accurately
estimate their relative importance.
This study is also
more comprehensive than others, evaluating 40 items
pertaining to eight different domains.
Materials and Methods
Survey Design
An online survey was developed to determine how
closely dentists and orthodontists correspond concerning
the qualities thought to be important or influential when
dentists refer their patients (See Appendices A and B).
Each survey began with a set of five demographic
questions.
Dentists were also asked six additional
questions about their referral patterns.
The primary
part of the survey consisted of eight categories of
questions, 3-9 questions per category, with a total of 40
questions.
The categories that were evaluated by both
33
dentists and orthodontists include: communication,
orthodontist’s treatment and philosophy, finished
occlusal results, patient care, oral hygiene protocol of
the orthodontist, professional relationship, personal
relationship, and the orthodontist’s office.
All answers
were recorded using a 100 mm visual analog scale with
anchors.
Most of the questions (87.5%) had been asked in
previous surveys.2,4-6,9,10,14-18,24,27-29,34-37
questions came from Beltramini.28
The format of the
The Behavioral and
Social Sciences Institutional Review Board at Saint Louis
University approved this study before it was started.
Demographics
Random samples of orthodontists and dentists
practicing in the United States were used for the survey.
There were questions to ensure that participants had
practiced a minimum five years, were 65 years old or
younger,29 and were currently practicing.
Participating
dentists also had to be primarily responsible for
referring their patients, had to have more than one
orthodontist in the area, and had to actually refer
patients to an orthodontist.
34
Survey Validity
A pilot study was conducted using eight orthodontic
residents and three faculty from Saint Louis University,
a marketing expert from Saint Louis University, along
with six dentists and six orthodontists from different
cities in the Midwestern region in the United States.
All 24 subjects took the survey and provided feedback
concerning confusing questions, problems with the survey
program, and suggestions to improve the survey.
Survey Distribution
The initial distribution of the survey was performed
by third parties.
Dental Medical Data (DMD)30 randomly
selected 3,000 dentists’ e-mail addresses to send the
survey link via e-mail.
Due to the low response rate
from the DMD distributed e-mails, the survey was
redistributed to 510 dentists using letter mail.
Ten
dentists from each state and Washington D.C. were
randomly selected using the American Dental Association
(ADA) member directory.31
The envelope mailed included a
cover letter with wording that resembled the e-mail used
previously, the survey in paper form, and a return
envelope with postage.
The survey was terminated one
month after the first e-mails or mailings went out.26
35
The American Association of Orthodontists (AAO)
approved the survey content and distributed 3,000 e-mails
to randomly selected orthodontists.
Two weeks later, a
reminder e-mail was sent to orthodontists only.
Data Collection and Analysis
Both the e-mail and paper version of the survey
responses were recorded using the QualtricsTM program
(Qualtrics Lab Inc., Provo UT).32
All of the responses
were analyzed by SPSS 18.0 (SPSS Inc, Chicago, IL).33
Because the responses to the survey questions were not
normally distributed, they were described using medians
and interquartile ranges (i.e. 25th, 50th, and 75th
percentile).
The interquartiles reflect the middle 50%
of the responses for that question; the median represents
the 50th percentile response.
To better interpret the 0-
100 visual analog scale, 0 was determined to be not
important or influential, 33 was slightly important or
influential, 66 was moderately important or influential,
and 100 was considered very important or strongly
influential.
Gender and group differences were analyzed using the
Mann-Whitney U tests.
A p-value of <.05 was considered
statistically significant in this study.
36
Results
Response Rate
The response rate of the orthodontic e-mail survey
was 97.5% (2,926/3,000).
Of these 2,926 replies, there
were 2,445 (81.5%) surveys completed.
After the
demographic restrictions were applied and unfinished
surveys were removed, 1,440 orthodontic surveys were used
for this study (48%).
Out of the 3,000 dental e-mails
that were sent, 150 e-mails were opened and 43 surveys
completed.
The response rate for the dental e-mail
survey was 28.7% (43/150).
The response rate for the
dental mail survey was 36% (183/509).
One mailing
address was not corrected by the one month deadline so
there were 509 mailed surveys. The total response rate of
the dental surveys combined was 34.3% (226/659).
After
demographic restrictions were applied and late surveys
were removed, 155 dental surveys were used for this study
(23.5%).
37
Demographics
The percentages of male and female respondents were
similar in both the dental and orthodontic groups (Figure
2).
Approximately 82% of dentists and orthodontists who
replied were males.
Females comprised approximately 18%
of the replies.
100%
82%
83%
75%
Dentists
Orthodontists
50%
18%
25%
17%
0%
Male
Female
Figure 2. Gender of respondents used in the study
The age distributions of the dentists and
orthodontics were different (Figure 3).
Dentists 55-59
years of age responded the most; 73% of the dentists who
responded were 45 years of age or older.
The
orthodontists’ ages were more evenly distributed.
38
30%
25%
Dentists
Orthodontists
20%
15%
10%
5%
0%
30-34
35-39
40-44
45-49
50-54
55-59
60-65
Age Groups
Figure 3. Age of dentists and orthodontists used in the study
Practice location were grouped into regions based on
the American Dental Association’s (ADA) Distribution of
Dentists in the United States by Region and State, 2007
(Figure 4).
Most dentists who responded came from the
South Atlantic and West North Central regions (16%).
orthodontic respondents came primarily from the South
Atlantic region (18%), the East North Central region
(16%), and the Pacific region (16%).
39
The
Pacific (AK, CA, HI, OR, WA)
Mountain (AZ, CO, ID, MT, NM, NV, UT)
Orthodontists
West South Cental (AR, LA, OK, TX)
Dentists
West North Central (IA, KS, MN, MO, ND, NE, SD)
East North Cental (IL, IN, MI, OH, WI)
East South Central (AL, KY, MS, TN)
South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)
Middle Atlantic (NJ, NY, PA)
New England (CT, ME, NH, RI, VT)
0%
4%
8%
12%
16%
Figure 4. Practice locations of the respondents
Orthodontic Referrals
Approximately 80% of dentists regularly refer to
more than one orthodontist.
Almost one half of the
dentists were able to refer to either 2-3 or 4-5
orthodontists (Figure 5).
Around 20% of the dentists
referred to only one orthodontist (Figure 6).
The
majority of dentists (63%) regularly refer to 2-3
orthodontists.
40
20%
10%
23%
One or Less
24%
2 to 3
4 to 5
6 to 9
10 or more
19%
24%
Figure 5. Number of orthodontists in the
referring area
2%
2%
20%
13%
1
2 or 3
4 or 5
6 to 9
10 or More
63%
Figure 6. Number of orthodontists dentists
regularly refer to
41
Approximately half of orthodontists reported that
50% of the referrals received each month were dental
referrals.
Approximately 50% of the dentists indicated
that they sent between 1-5 referrals to orthodontists per
month.
An additional 25% of dentists indicated that they
sent up to ten referrals per month.
Approximately 48% of
the dentists indicated that they do not treat any of
their patients orthodontically.
Differences Between Dentists and Orthodontists
Overall, twenty-nine of the forty questions (73%)
showed statistically significant differences between what
the dentists and orthodontists reported as being
important or influential.
Seven of the nine communication questions showed
statistically significant differences between dentists
and orthodontists (See Appendix C, Table 2).
Updates on
treatment progress, communications after treatment has
been completed, detailed reports of the treatment plan,
use of photographs, and the dentist’s involvement in
forming the treatment plan were all much more important
for dentists than orthodontists.
Both orthodontists and
dentists felt that prompt responses and referral back to
42
the dentist were very important, even though
orthodontists slightly overestimated the importance of
each.
Orthodontists did accurately perceive how dentists
felt about the importance of communication before
orthodontic treatment starts and about getting the
dentist’s approval before removal of the orthodontic
appliances.
For the questions pertaining to the orthodontists'
treatment and philosophy, dentists and orthodontists only
agreed about the importance of having treatment completed
to the dentist's approval (See Appendix C, Table 3).
Of
all the questions asked, the greatest differences between
dentists and orthodontists involved the importance of
performing early treatment, the dentist’s concern about
premolar extraction, and mounting casts of cases with
substantial restorative needs.
Orthodontist
underestimated the dentist’s concern about premolar
extractions and early treatment.
Dentists reported that
both qualities were influential.
The largest statistical
difference between dentists and orthodontists pertained
to the importance of mounting casts of cases with
substantial restorative needs, which orthodontists,
again, underestimated.
43
The five questions pertaining to finished results of
the dentition all showed statistically significant
differences between dentists and orthodontists (See
Appendix C, Table 4).
However, none of the differences
were greater than 14 percentage points.
Orthodontists
overestimated the importance of finishing in Class I
canines, and underestimated the importance of Class I
molars, treating to a central relation position,
finishing with canine guidance or group function, and
having even, simultaneous contacts of the posterior
teeth.
Even though three out of the four questions
pertaining to patient care showed statistically
significant differences between dentists and
orthodontists, the actual differences were small (See
Appendix C, Table 5).
While there was agreement about
the importance of on-time appointments, orthodontists
significantly overestimated the importance of
relationships with the patient and the family, patient’s
happiness with the quality of treatment, and with on-time
case finishing.
While both groups thought that the questions
pertaining to oral hygiene were important, orthodontists
slightly overestimated the importance of referring back
44
to the dentist for hygiene needs (See Appendix C, Table
6).
Orthodontists and dentists agreed about the
importance of actively promoting good oral hygiene and
taking steps to prevent decalcification.
Of the four questions pertaining to professional
relationships between dentists and orthodontists,
orthodontists significantly overestimated the importance
of having a positive professional reputation, and,
especially, giving gifts of appreciation to the dentists
(See Appendix C, Table 7).
The two groups agreed that a
positive professional relationship with the dentists’
staff was very influential, and that hosting “lunch and
learns” was only slightly influential.
Of the questions pertaining to the relationships
between the orthodontist and dentist, orthodontists
significantly overestimated the importance of belonging
to the same social or religious groups, and having family
friendships (See Appendix C, Table 8).
Neither group
thought that it was even slightly important for them to
be living in the same neighborhood.
Of the six questions pertaining to the
orthodontist's office, four showed statistically
significant differences between dentists and
orthodontists (See Appendix C, Table 9).
45
Orthodontists
overestimated the importance of having a modern and
attractive office, offering free consultations, having a
convenient location, and especially marketing.
Orthodontists and dentists did agree that the use of
technology and the availability of patient parking were
moderately important.
Survey Trends
Based on the overall averages computed for each of
the eight domains, the orthodontist’s treatment and
philosophy domain showed the greatest differences (27
percentage points) between the dental and orthodontic
responses (Figure 7).
Communication, office, and
personal relationships between the orthodontist and
dentists showed similar group differences (10 points).
Orthodontists and dentists agree more closely about the
importance of professional relationships (8 points) and
finished results (6 points).
Orthodontists and dentists
agree most closely on the importance of the patient care
(4 points) and hygiene (1 point) domains.
46
Treatment and Philosophy
Personal Relationship
Office
Communication
Professional Relationship
Finished Occlusion
Patient Care
Hygiene
0
5
10
15
20
25
NOT Important
30
VERY Important
Figure 7. Domain differences between dentists and orthodontists
Dentists showed great differences between the eight
domains in terms of their relative importance or
influence for making referral decisions.
By far, the
most important domain for the dentist, in terms of
referrals, was oral hygiene (Figure 8).
Although not as
important as hygiene, dentists thought that patient care,
quality of the finished results and communications were
moderately to very important.
The quality of orthodontic
treatment was considered to be moderately important for
47
referrals.
The orthodontist's office and the
professional relationships between the dentist and the
orthodontist were considered to fall somewhere between
slightly and moderately important.
Personal
relationships between the dentist and orthodontist were
not even considered to be slightly important.
Hygiene
Patient Care
Finished Occlusion
Communication
Treatment and Philosophy
Office
Professional Relationship
Personal Relationship
0
10
20
30
40
NOT Important
50
60
70
80
90
100
VERY Important
Figure 8. Influence of the domains to dentists
48
Discussion
Response Rates
The present study’s response rate for orthodontists
was 97.5%.
This rate is among the highest previously
reported for specialists (5-97%).6,9,10,14,15,17,18,20-22,28,34-36
This was unexpected because sample sizes of 150 or less
tend to have higher response rates than larger
samples.14,20,34
The extremely high orthodontic response
rate in the present study could be due to the fact that
orthodontists felt that the survey was evaluating issues
they wanted to know more about.
Salient topics have been
previously shown to increase the response rate.25,37
Also, having the AAO and a university affiliation may
have affected the respondents in a positive manner.23,25
The overall response rate for the dentists was 34.3%,
but this needs to be qualified.
It does compare well
with surveys evaluating sample sizes of approximately
500.17,18,36
Based on comments returned with the mailed
dental surveys, the topic also appeared to be salient to
the dentists.
The lower dental e-mail response rate
could have been due to the third party (Direct Medical
Data) that was used to distribute the survey.
Given that
only 0.5% of the e-mails were opened by the dentists,
they either chose not to respond because they did not
49
identify with those who sent the e-mail, or it was sent
to an account not used by the dentists.
Demographics
Gender and age distributions were similar to those
reported for dentists in the ADA’s Distribution of
Dentists in the United States by Region and State, 2007
and for orthodontists by the AAO.1,38,39
The orthodontic
practice distribution reported in this study was within
5% of the AAO’s values.
However, four of the nine dental
regions were not within 5% of the ADA’s; the New England,
Middle Atlantic, West North Central, and Pacific were not
well represented.
Orthodontic Referrals
The present study found up to 80% of dentists
regularly refer to more than one orthodontist, which is
higher than previously reported.
In 2004, Keim et al.
reported that 69.3% of dentists referred their patients
to more than one orthodontist.9 In 1999, Guymon et al.
reported that 59% of the dentists referred to more than
one orthodontist.6
Also, the present study found that
48% of dentists do not perform orthodontic treatment
themselves, which is substantially less than the 86%
50
reported by Guymon and coworkers.6
There were also more
orthodontists in 2009 than in 1995 indicating that the
increase of dentists performing orthodontics influenced
the growth of their practices.2,3 From 1995 to 2009, the
percentage of orthodontists who felt that local economic
conditions had some influence on the lack of growth of
their practices increased from 48.4% to 68.8%.2,3
Survey Questions
The relative order of importance that dentists
attributed to the domains (Figure 8) corroborates
previous findings. Guymon et al. also reported that
quality of treatment, which included monitoring oral
hygiene and patient satisfaction, as the most important
domain.6
They also showed that personal relationships
was the least important domain.
Their communication
questions, which were the same as those in the present
study (responding promptly and involvement in the
treatment plan) showed very similar degrees of
importance.
Hygiene was the most influential domain in this study
for both dentists and orthodontists (Figure 9).
Hall et
al. also reported that the prevention of decalcification
was very influential for dentists making referral
51
decisions.15
Dentists also consider it important or
influential to refer patients back for hygiene needs6,9
even though de Bondt et al. reported that it was not
important for the referral process.17
Based on the
results of the present study, orthodontists should pay
special attention to their patients’ oral hygiene.
On-time for appointments
Promote good oral hygiene
Prevent decalcification
Hosts "Lunch & Learns"
Orthodontists
Dentists
Living in same area
Current and advanced technology
Availability of parking
0
20
40
60
NOT Important
80
100
VERY Important
Figure 9. Qualities that orthodontists and dentists responded very similar
(0=NOT Important/Influential, 100=VERY Important/Influential)
In contrast to hygiene, establishing a personal
relationship with the referring dentist was not deemed to
be influential to the referral process.
Both dentists
and orthodontists agreed that living in the same area did
52
not influence referring dentists (Figure 9).
Guymon et
al. also showed that having orthodontists as family
friends was not influential to the dentists’ referral
decisions.6
However, others have reported that dentists
felt personal friendships were applicable or, at least,
moderately influential.9,17,20,40
Every question of the domain pertaining to finished
results of the dentition showed statistically significant
difference between dentists and orthodontists (See
Appendix C, Table4).
The importance of Class I molars
and treating cases to a centric relation position were
also reported to be important by Hall and coworkers.15
As
shown in the present study, they also found that class I
canines, canine guidance, and contacts of posterior teeth
were all very important for dentists.15
Orthodontists
apparently do not appreciate how important the finished
occlusion is to dentists.
Orthodontists most commonly underestimated the
importance of questions about their treatment and
philosophy (Figure 7).
Most of the dentists (39%)
surveyed by Guymon et al. felt the dentist’s concern over
premolar extraction was very important to referrals.6
De
Bondt et al. reported that dentists felt that agreement
on extraction decisions were applicable to referrals.17
53
While dentists in the present study reported that the use
of bonded retainers for primary retention was somewhat
important for referrals, dentists surveyed by Hall et al.
considered it to be the least important.15
The questions
pertaining to the importance of early treatment and root
parallelism have not been previously asked, even though
dentists consider them to be moderately important.
Considering the large discrepancies in this domain,
orthodontists should communicate to dentists the purpose
of certain treatment decisions.
Similarly, dentists
should discuss their concerns about these procedures to
help orthodontists better understand the reasoning behind
these beliefs.
The largest single question showing differences
between the groups pertained to mounting cases for
substantial restorative needs (Figure 10).
Orthodontists
substantially underestimated the influence of mounting
cases on their referring dentists.
They felt mounting
cases was not even slightly influential.
While the
importance of this question to referrals has not been
previously surveyed, this finding indicates that
orthodontists might need to provide mounted models in
those exceptional cases that require subsequent
restorative care to be performed by the dentist.
54
Mount cases with restorative
needs
Concern about premolar extraction
Performing early treatment
Gifts of appreciation
Bonded retainers for primary
retention
Orthodontists
Dentists
Marketing
Dentist involved in forming
treatment plan
Family friends
0
20
40
60
80
NOT Important
100
VERY Important
Figure 10. Qualities that orthodontists and dentists responded the most different
(0=NOT Important/Influential, 100=VERY Important/Influential)
Dentists, as a group, were more consistent in their
responses to the questions than orthodontists.
Orthodontists often showed larger interquartile ranges
than dentists, indicating greater variation in their
responses.
For example, the orthodontists’ interquartile
range for the question pertaining to the influence of
parallel roots was 68 points.
to be more similar.
Dentists’ responses tended
It seems that, as a group, dentists
more closely agree about the importance or influence
55
various factors have on referrals.
It is important that
the majority of dentists have similar beliefs, so that
the results of the present study can be used to help
improve the referral process with most of the referring
dentists in the United States.
While the survey results pertaining to orthodontists
can probably be generalized to other orthodontists, the
ability to generalize to other dentists may be
problematic. In contrast to the orthodontists, who had
large numbers of respondents and an extremely high
response rate, the response rate and the absolute number
of dentists who responded were relatively low.
Whether
or not the 226 dentists who responded were representative
of the approximately 180,000 dentists practicing in the
United States remains questionable.38
However, the
demographics questions showed that the dentists from the
present study were similar to other dentists in terms of
gender, age, and practice location compared to the ADA
values.38
The fact that they responded similarly to
dentists who were asked similar questions in previous
surveys also validates that the results and suggests that
the findings can be generalized.
56
Clinical Relevance of the Present Study
Both dentists and orthodontists can use the results of
the present study to improve the referral process.
This
information can be used to help orthodontists understand
one of their biggest referral sources.
The specific
survey questions could be used by orthodontists as a
guide for discussions with their referring dentists; the
questions should help in understanding what is expected.
At the same time, dentists could use the survey items to
better understand what qualities orthodontists have
underestimated to be important.
Ultimately, the
orthodontic diagnosis and treatment plan of the patient
is the orthodontist’s responsibility.
The results of a
referral study should not persuade the orthodontist to
change his/her treatment just to obtain the approval of
referring dentists.
The results of the present study
should be used to develop better communication between
both clinicians.
As reported in this study and Keim et
al., a positive professional relationship is very
important.9
A better understanding between both
practitioners can only serve to improve this
relationship.
57
REFERENCES
1. American Association of Orthodontists. 2008 AAO
Patient and Member Census Study. 2009.
2. Keim RG, Gottlieb EL, Nelson AH, Vogels DS. 2009 JCO
Orthodontic Practice Study. Part 3: Practice growth and
staff data. J Clin Orthod. 2009;43(12):763-772.
3. Gottlieb EL, Nelson AH, Vogels DS. 1995 JCO
Orthodontic Practice Study. Part 3. Practice growth. J
Clin Orthod. 1995;29(12):743-752.
4. Haeger RS. Increasing new patient starts by analyzing
referral sources and treatment coordinators. J Clin
Orthod. 2009;43(3):175-182.
5. Edwards DT, Shroff B, Lindauer SJ, Fowler CE, Tufekci
E. Media advertising effects on consumer perception of
orthodontic treatment quality. Angle Orthod.
2008;78(5):771-777.
6. Guymon G, Buschang PH, Brown TJ. Criteria used by
general dentists to choose an orthodontist. J Clin
Orthod. 1999;33(2):87-93.
7. Gosney MB. An investigation into some of the factors
influencing the desire for orthodontic treatment. Br J
Orthod. 1986;13(2):87-94.
8. Pietilä T, Pietilä I. Parents' views on their own
child's dentition compared with an orthodontist's
assessment. Eur J Orthod. 1994;16(4):309-316.
9. Keim RG, Gottlieb EL, Nelson AH, Vogels DS. JCO survey
of referring dentists. J Clin Orthod. 2004;38(4):219-223.
10. Waring DT, Harrison JE. Reply letters following
orthodontic consultations: an audit of Merseyside general
dental practitioners' satisfaction. Prim Dent Care.
2007;14(2):53-58.
11. Church-Clark B. Getting and keeping dentist
referrers. J Clin Orthod. 1991;25(10):633-638.
58
12. Bourguet C, Gilchrist V, McCord G. The consultation
and referral process. A report from NEON. Northeastern
Ohio Network Research Group. J Fam Pract. 1998;46(1):4753.
13. Svedström-Oristo AL, Pietilä T, Pietilä I, Alanen P,
Varrela J. Morphological, functional and aesthetic
criteria of acceptable mature occlusion. Eur J Orthod.
2001;23(4):373-381.
14. Hunt O, Hepper P, Johnston C, Stevenson M, Burden D.
Professional perceptions of the benefits of orthodontic
treatment. Eur J Orthod. 2001;23(3):315-323.
15. Hall JF, Sohn W, McNamara JA. Why do dentists refer
to specific orthodontists? Angle Orthod. 2009;79(1):5-11.
16. Keim RG, Gottlieb EL, Nelson AH, Vogels DS. 2009 JCO
Orthodontic Practice Study Part 4. Additional breakdowns.
J Clin Orthod. 2010;44(1):19-27; quiz 45.
17. de Bondt B, Aartman IHA, Zentner A. Referral patterns
of Dutch general dental practitioners to orthodontic
specialists. Eur J Orthod. 2010;32(5):548-554.
18. Salisbury CJ. How do people choose their doctor? BMJ.
1989;299(6699):608-610.
19. Bitner MJ. Servicescapes: The Impact of Physical
Surroundings on Customers and Employees. The Journal of
Marketing. 1992;56(2):57-71.
20. McComb J, Wright J, O'Brien K. Dentists' perceptions
of orthodontic services. Br Dent J. 1995;178(12):461-464.
21. Keim RG, Gottlieb EL, Nelson AH, Vogels DS. 2009 JCO
Orthodontic Practice Study. Part 1 Trends. J Clin Orthod.
2009;43(10):625-634.
22. Bedair TM, Thompson S, Gupta C, Beck FM, Firestone
AR. Orthodontists' opinions of factors affecting
patients' choice of orthodontic practices. Am J Orthod
Dentofacial Orthop. 2010;138(1):6.e1-7; discussion 6-7.
23. Kanuk L, Berenson C. Mail Surveys and Response Rates:
A Literature Review. Journal of Marketing Research.
1975;12(4):440-453.
59
24. Miller MD, Ferris DG. Measurement of subjective
phenomena in primary care research: the Visual Analogue
Scale. Fam Pract Res J. 1993;13(1):15-24.
25. Edwards P, Roberts I, Clarke M, et al. Increasing
response rates to postal questionnaires: systematic
review. BMJ. 2002;324(7347):1183.
26. Truell AD, Bartlett JE, Alexander MW. Response rate,
speed, and completeness: a comparison of Internet-based
and mail surveys. Behav Res Methods Instrum Comput.
2002;34(1):46-49.
27. Keim RG, Gottlieb EL, Nelson AH, Vogels DS. 2009 JCO
Orthodontic Practice Study. Part 2. Practice success. J
Clin Orthod. 2009;43(11):699-707.
28. Beltramini RF. Professional Services Referrals: a
Model of Information
Acquisition. Journal of Services Marketing. 1989;3(1):3543.
29. U.S. Department of Commerce, Economics, and
Statistics Administraction, U.S. Census Bureau. Computer
and Internet Use in the United States: 2003. 2005.
Available at: http://www.census.gov/prod/2005pubs/p23208.pdf [Accessed October 11, 2010].
30. Direct Medical Data. Des Plaines, IL; 2001. Available
at: http://www.dmddata.com/data_lists_dentists.asp
[Accessed March 12, 2010].
31. American Dental Association. Find a Dentist. 2010.
Available at:
http://www.ada.org/ada/findadentist/advancedsearch.aspx
[Accessed August 23, 2010].
32. Qualtrics Lab Inc. Provo, Utah; 2010. Available at:
http://www.qualtrics.com [Accessed March 13, 2010].
33. SPSS Inc. SPSS 18.0. Chicago, IL Available at:
http://www.spss.com/?source=homepage&hpzone=nav_bar.
34. Gandhi TK, Sittig DF, Franklin M, et al.
Communication Breakdown in the Outpatient Referral
Process. J Gen Intern Med. 2000;15(9):626-631.
60
35. Kennedy F, McConnell B. General practitioner referral
patterns. J Public Health Med. 1993;15(1):83-87.
36. Oppermann M. E-mail surveys--potentials and pitfalls.
Marketing Research. 1995;7(3):28-33.
37. Sheehan KB. E-mail Survey Response Rates: A Review.
Journal of Computer-Mediated Communication. 2006;6(2):00.
38. American Dental Association Survey Center.
Distribution of Dentists in the United States by Region
and State, 2007. 2009.
39. Paladin P. RE: Reference Help & Stats.
2010.
40. Churchill GA. A Paradigm for Developing Better
Measures of Marketing Constructs. Journal of Marketing
Research. 1979;16(1):64-73.
61
APPENDIX A (Survey to orthodontists)
62
63
64
65
66
67
68
69
70
71
APPENDIX B (Survey to dentists)
72
73
74
75
76
77
78
79
80
81
82
25th
50th
75th
Before Orthodontic Treatment Starts
49
80
96
Updates on Treatment Progress
20
48
62
After Orthodontic Treatment has been Completed
50
80
99
Orthodontist Responds Promptly When Dentist Asks
95
100
100
Written Detailed Information of the Treatment Plan (Without Photographs)
30
60
90
Photographs Included in Reports
20
50
81
Dentist Involved in Forming the Treatment Plan with the Orthodontist
14
30
50
Dentist's Approval of the Dentition for Restorative Needs Before Removal of Braces
50
85
100
Orthodontists Refers Back to the Dentist for Restorative Needs
95
100
100
47%
70%
86%
25th
50th
75th
Before Orthodontic Treatment Starts
50
84
95
Updates on Treatment Progress
49
75
90
After Orthodontic Treatment has been Completed
79
91
95
Orthodontist Responds Promptly When Dentist Asks
84
93
95
Written Detailed Information of the Treatment Plan (Without Photographs)
52
80
94
Photographs Included in Reports
45
66
90
Dentist Involved in Forming the Treatment Plan with the Orthodontist
24
54
82
Dentist's Approval of the Dentition for Restorative Needs Before Removal of Braces
55
82
95
Orthodontists Refers Back to the Dentist for Restorative Needs
88
95
99
58%
80%
93%
Orthodontist's Responses
83
Overall
Dentist's Responses
Overall
**Statistically significant (p<.05) differences between orthodontists and dentists are shaded in grey.
APPENDIX C (Results tables for survey categories)
Table 2: “Please Indicate How Important Each of the Following Qualities are to General Dentists
REFFERING to Orthodontists” (0= NOT Important, 100= VERY Important)
COMMUNICATION WITH THE ORTHODONTIST
Quartiles
Table 3: “Please Indicate How Each of the Following Qualities Influence General Dentists REFFERING to
Orthodontists” (0= Does NOT Influence, 100= STRONG Influence)
ORTHODONTIST'S TREATMENT AND PHILOSOPHY
Quartiles
25th
50th
75th
Performing Early Treatment (i.e. Expansion, Class II appliances) Prior to Traditional Braces
25
50
78
Dentist's Concern About Premolar Extractions
14
39
60
Treatment Completed to the Dentist's Approval
50
80
92
Use of Bonded Retainers as Primary Retention Protocol
9
28
53
Parallel Roots After Orthodontic Treatment
21
55
89
Mounts Study Casts of Cases with Substantial Restorative Needs
2
10
39
20%
44%
69%
25th
50th
75th
Performing Early Treatment (i.e. Expansion, Class II appliances) Prior to Traditional Braces
64
84
94
Dentist's Concern About Premolar Extractions
49
75
92
Treatment Completed to the Dentist's Approval
55
84
95
Use of Bonded Retainers as Primary Retention Protocol
30
55
83
Parallel Roots After Orthodontic Treatment
54
76
89
Mounts Study Casts of Cases with Substantial Restorative Needs
29
54
82
47%
71%
89%
Orthodontist's Responses
84
Overall
Dentist's Responses
Overall
** Statistically significant (p<.05) differences between orthodontists and dentists are shaded in grey.
Table 4: “Please Indicate How Each of the Following Qualities Influence General Dentists REFFERING to
Orthodontists” (0= Does NOT Influence, 100= STRONG Influence)
FINISHED RESULTS OF THE DENTITION
Quartiles
25th
50th
75th
Cases Finished with Class I Molars
40
70
90
Cases Finished with Class I Canines
71
90
99
Cases Treated to a Centric Relation Position
27
61
90
Cases Finished with Canine Guidance or Group Function
51
80
93
Cases Finished with Even, Simultaneous Contacts of Posterior Teeth
50
76
91
48%
75%
93%
25th
50th
75th
Cases Finished with Class I Molars
65
80
90
Cases Finished with Class I Canines
65
78
90
Cases Treated to a Centric Relation Position
56
75
90
Cases Finished with Canine Guidance or Group Function
72
85
94
Cases Finished with Even, Simultaneous Contacts of Posterior Teeth
70
85
95
65%
81%
92%
Orthodontist's Responses
85
Overall
Dentist's Responses
Overall
** Statistically significant (p<.05) differences between orthodontists and dentists are shaded in grey.
Table 5: “Please Indicate How Each of the Following Qualities Influence General Dentists REFFERING to
Orthodontists” (0= Does NOT Influence, 100= STRONG Influence)
PATIENT CARE
Quartiles
25th
50th
75th
Orthodontist has a Positive, Friendly Relationship with Patient and Family
89
95
100
Patient and Family are Happy with the Quality of Orthodontic Treatment
91
98
100
On-time for Appointments
61
81
95
On-time Case Finishing
60
80
91
75%
89%
97%
25th
50th
75th
Orthodontist has a Positive, Friendly Relationship with Patient and Family
85
92
96
Patient and Family are Happy with the Quality of Orthodontic Treatment
88
94
99
On-time for Appointments
69
83
94
On-time Case Finishing
56
73
86
75%
85%
94%
Orthodontist's Responses
86
Overall
Dentist's Responses
Overall
** Statistically significant (p<.05) differences between orthodontists and dentists are shaded in grey.
Table 6: “Please Indicate How Each of the Following Qualities Influence General Dentists REFFERING to
Orthodontists” (0= Does NOT Influence, 100= STRONG Influence)
ORAL HYGIENE PROTOCOL OF THE ORTHODONTIST
Quartiles
25th
50th
75th
Orthodontist Actively Promotes Good Oral Hygiene
81
95
100
Orthodontist Takes Steps to Prevent Decalcification (i.e. Fluoride, Sealants, Hygiene Instruction)
77
91
100
Orthodontist Refers Back to the Dentist for Hygiene Needs
90
99
100
83%
95%
100%
25th
50th
75th
Orthodontist Actively Promotes Good Oral Hygiene
86
94
98
Orthodontist Takes Steps to Prevent Decalcification (i.e. Fluoride, Sealants, Hygiene Instruction)
81
93
96
Orthodontist Refers Back to the Dentist for Hygiene Needs
86
94
98
84%
94%
97%
Orthodontist's Responses
Overall
87
Dentist's Responses
Overall
** Statistically significant (p<.05) differences between orthodontists and dentists are shaded in grey.
Table 7: “Please Indicate How Each of the Following Qualities Influence General Dentists REFFERING to
Orthodontists” (0= Does NOT Influence, 100= STRONG Influence)
Quartiles
PROFESSIONAL RELATIONSHIP BETWEEN ORTHODONTIST AND DENTIST
25th
50th
75th
Positive Professional Relationship with the Dentist and His/Her Office Staff
81
91
100
Positive Professional Reputation of the Orthodontist
89
96
100
Orthodontist Gives Gifts of Appreciation to the Dentist
20
50
70
Orthodontist Hosts "Lunch and Learns" for the Dentist and/or the Staff
9
29
51
50%
67%
80%
25th
50th
75th
Positive Professional Relationship with the Dentist and His/Her Office Staff
85
94
96
Positive Professional Reputation of the Orthodontist
84
91
97
Orthodontist Gives Gifts of Appreciation to the Dentist
5
20
54
Orthodontist Hosts "Lunch and Learns" for the Dentist and/or the Staff
10
30
53
46%
59%
75%
Orthodontist's Responses
88
Overall
Dentist's Responses
Overall
** Statistically significant (p<.05) differences between orthodontists and dentists are shaded in grey.
Table 8: “Please Indicate How Each of the Following Qualities Influence General Dentists REFFERING to
Orthodontists” (0= Does NOT Influence, 100= STRONG Influence)
PERSONAL RELATIONSHIP BETWEEN ORTHODONTIST AND DENTIST
Quartiles
25th
50th
75th
Orthodontist and Dentist Live in the Same Neighborhood or Area
3
19
52
Orthodontist and Dentist Belong to the Same Social or Religious Group
3
18
49
Orthodontist and Dentists are Family Friends
8
32
70
5%
23%
57%
25th
50th
75th
Orthodontist and Dentist Live in the Same Neighborhood or Area
6
18
55
Orthodontist and Dentist Belong to the Same Social or Religious Group
4
10
24
Orthodontist and Dentists are Family Friends
5
10
26
5%
13%
35%
Orthodontist's Responses
Overall
89
Dentist's Responses
Overall
** Statistically significant (p<.05) differences between orthodontists and dentists are shaded in grey.
Table 9: “Please Indicate How Each of the Following Qualities Influence General Dentists REFFERING to
Orthodontists” (0= Does NOT Influence, 100= STRONG Influence)
ORTHODONTIST'S OFFICE
Quartiles
25th
50th
75th
Orthodontist Uses Current and Advanced Technology
59
80
90
The Office Design is Modern and Attractive
52
76
90
Orthodontist Offers Free Consultations
50
81
100
Office Location is Convenient for Patient and Family
70
85
98
Availability of Patient Parking
29
62
91
Orthodontist Does Marketing (i.e. Website, Gifts, Game Room, Advertisements)
12
45
73
45%
72%
90%
25th
50th
75th
Orthodontist Uses Current and Advanced Technology
60
79
90
The Office Design is Modern and Attractive
50
65
80
Orthodontist Offers Free Consultations
35
64
90
Office Location is Convenient for Patient and Family
63
80
90
Availability of Patient Parking
39
64
85
Orthodontist Does Marketing (i.e. Website, Gifts, Game Room, Advertisements)
6
20
46
42%
62%
80%
Orthodontist's Responses
90
Overall
Dentist's Responses
Overall
** Statistically significant (p<.05) differences between orthodontists and dentists are shaded in grey.
VITA AUCTORIS
Hillarie Ryann Hudson was born on December 4, 1983
in Alton, Illinois.
She moved to Decatur, Illinois
shortly after so her father, Dr. James Michael Hudson,
could start practicing orthodontics. Hillarie is the
daughter of Mick and Karen Hudson, sister to Heather
Hudson, and aunt to Romeo Hudson.
Hillarie graduated from Mt. Zion High School in
2002.
She also attended Richland Community College from
2000-2002.
Hillarie started at Olivet Nazarene
University in 2002, then attended Ball State University
in 2003 and Millikin University in 2004.
She received
her D.M.D. degree from Southern Illinois UniversityEdwardsville in 2008.
Currently, Hillarie is at Saint
Louis University and is planning on receiving her Masters
of Science in Dentistry in January 2011.
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