Hudson Thesis 2010

8/11/2019 Hudson Thesis 2010

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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 ofSaint Louis University in Partial Fulfillment

of the Requirements for the Degree ofMaster of Science in Dentistry

2011


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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 orthodontists treatment and philos ophy.

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. Conclusion:


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Orthodontists do not have a good understanding of what is

important or influential to referring dentists.


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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 Fulfillmentof the Requirements for the Degree of

Master of Science in Dentistry

2011


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COMMITTEE IN CHARGE OF CANDIDACY:

Adjunct Professor Dr. Peter BuschangChairperson and Advisor

Assistant Professor Dr. Ki Beom Kim

Associate Clinical Professor Dr. Donald R. Oliver


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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 wasnt for you. I

have my ideal career and life because of all the love and

support you gave me.


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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.


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TABLE OF CONTENTS

List of Tables.......................................viii

List of Figures........................................ix

CHAPTER 1: INTRODUCTION.................................1

CHAPTER 2: REVIEW OF THE LITERATURE.....................2Acquiring New Patients.......................2

Orthodontic Patient Trends...............3Acquiring New Patient By Marketing.......5Acquiring New Patient By Recommendation...

From Others...........................6Acquiring New Patient By Dental...........

Referrals.............................7Methods for Obtaining Information About...

Dental Referrals......................8Surveys......................................9Referral Patterns...........................14Survey Categories...........................15

Communication...........................15Treatment and Philosophy................16Relationships...........................17Patient Care............................18Finished Results of the Dentition.......19Oral Hygiene Protocol...................20Orthodontic Office......................22

Summary and Statement of Thesis.............23References..................................25

CHAPTER 3: JOURNAL ARTICLE............................30Abstract....................................30Introduction................................31Materials and Methods.......................33

Survey Design...........................33Demographics............................34Survey Validity.........................35Survey Distribution.....................35

Data Collection and Analysis............36Results.....................................37

Response Rate...........................37Demographics............................38Orthodontic Referrals...................40Differences Between Dentists and..........

Orthodontists........................42Survey Trends...........................46


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Discussion.................................49Response Rate..........................49Demographics...........................50Orthodontic Referrals..................50Survey Questions.......................51Clinical Relevance of the Present........

Study...............................57References.................................58

Appendix A (Survey to orthodontists)................62

Appendix B (Survey to dentists).....................72

Appendix C (Results tables for survey categories)...83

Vita Auctoris.......................................91


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LIST OF TABLE

Table 1: Summary of the variables tested from mail......surveys.................................10

Table 2: Communication with the Orthodontist..........83

Table 3: Orthodontists 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: Orthodontis ts Office........................ 90


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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


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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

orthodontists treatment and philosophy, the finished

dentition, patient care, oral hygiene protocol of the

orthodontist, professional or personal relationship, and

the orthodontists 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.


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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.


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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 cou ld you see daily?. Over half

responded saying that they could see 16 or more per

day.

Figure 1. Average new patient appointments, adapted from2008 AAO Patient & Member Census Study

200

250

300

350

400

450

2001 2004 2006 2008

New Patient Exams

New Case Presentations

New Patient Starts


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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. The

response rate was 97% (655/676). 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


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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 Gosney

was able to use 86% (207/240) of the responses. She

noted that parents wishes were listed as the third most

influential factor in suggesting orthodontic treatment

with the dentists and patients 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


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Council. This que stionnaire asked did you try to find

out anything about the practice before you registered? If

so, how?. 11 About 24% of respondents had asked a friend

or coworker. 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 youve registered with? Being

recommended by someone was second to location. 11

Haegars 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 AAOs

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 It

has been reported by the AAO that up to 72% of new


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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 patients 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,


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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. An


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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 mail-

distributed surveys. 32 The study used the Business

Education Professional Leadership Roster to compile e-

mail 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.


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There was no difference in the response rate. However,

the internet-based survey did have a higher completeness 32

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 which is lower

than the 53% Truell et al. reported. 32 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 patients or the

dentists perspective is of reoccurring importance. 1,6,8

Other areas, such as, referring patients back to the

dentist 1,7 , certain aspects of occlusion 6 , responding


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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 dentists 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


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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. Keim et al.


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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 importance 1,8,12 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


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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

patients opinion of the quality of treatment and the

pat ients 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 orthodontists 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,


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female subjects. 40 They verified the importance of the

same characteristics Hall et al. found with the

literature Oltramari et al. reviewed. Svedstrm-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 Out of 93 subjects, 74 (80%) returned the

survey. Good function and long-term stability were

ranked as the two most important characteristics. This

contradicts articles showing th at the dentists and

patients 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


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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 flossers 42 , interproximal

brushes 43 , topical fluoride 44-46 , 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 cleanin gs and check-

ups is critical! 7


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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 peoples 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 owners 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, layou t, 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


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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 physicians patients what was

the main re ason that you chose the practice that youve

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.


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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?


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31. Miller MD, Ferris DG. Measurement of subjectivephenomena in primary care research: the Visual AnalogueScale. 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-basedand mail surveys. Behav Res Methods Instrum Comput .2002;34(1):46-49.

33. Beltramini RF. Professional Services Referrals: aModel of Information Acquisition. J Serv Mark .1989;3(1):35-43.

34. Asch DA, Christakis NA, Ubel PA. Conducting physicianmail 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 referralpatterns. J Public Health Med . 1993;15(1):83-87.


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36. Kokich VO, Kinzer GA. Managing congenitally missinglateral incisors. Part I: Canine substitution. J EsthetRestor Dent . 2005;17(1):5-10.

37. Kokich VG. Maxillary lateral incisor implants:planning with the aid of orthodontics. J. OralMaxillofac. Surg . 2004;62(9 Suppl 2):48-56.

38. Bourguet C, Gilchrist V, McCord G. The consultationand referral process. A report from NEON. NortheasternOhio Network Research Group. J Fam Pract . 1998;46(1):47-53.

39. Keim RG, Gottlieb EL, Nelson AH, Vogels DS. 2009 JCOOrthodontic Practice Study. Part 2. Practice success. JClin Orthod . 2009;43(11):699-707.

40. Oltramari PVP, Conti ACDCF, Navarro RDL, et al.Importance of occlusion aspects in the completion oforthodontic treatment. Braz Dent J . 2007;18(1):78-82.

41. Svedstrm-Oristo AL, Pietil T, Pietil I, Alanen P,Varrela J. Morphological, functional and aestheticcriteria of acceptable mature occlusion. Eur J Orthod .2001;23(4):373-381.

42. Kossack C, Jost-Brinkmann P. Plaque and gingivitisreduction in patients undergoing orthodontic treatment

with fixed appliances-comparison of toothbrushes andinterdental cleaning aids. A 6-month clinical single-blind trial. J Orofac Orthop . 2005;66(1):20-38.

43. Kaklamanos EG, Kalfas S. Meta-analysis on theeffectiveness of powered toothbrushes for orthodonticpatients. Am J Orthod Dentofacial Orthop .2008;133(2):187.e1-14.

44. Lovrov S, Hertrich K, Hirschfelder U. EnamelDemineralization during Fixed Orthodontic Treatment -

Incidence and Correlation to Various Oral-hygieneParameters. J Orofac Orthop . 2007;68(5):353-363.

45. Farhadian N, Miresmaeili A, Eslami B, Mehrabi S.Effect of fluoride varnish on enamel demineralizationaround brackets: an in-vivo study. Am J OrthodDentofacial Orthop . 2008;133(4 Suppl):S95-98.


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46. Mitchell L. Decalcification during orthodontictreatment with fixed appliances--an overview. Br JOrthod . 1992;19(3):199-205.

47. Buren JL, Staley RN, Wefel J, Qian F. Inhibition ofenamel 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. Fluoriderelease capacities of four different orthodonticadhesives. J Clin Pediatr Dent . 1999;23(4):315-319.


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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 orthodontists treatment and philos ophy.

Dentists and orthodontists agreed on the relatively

strong influence o f 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


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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


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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

orthodontists 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 comprehensive 6 and no study


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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


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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


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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 Qualtrics TM 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. 25 th , 50 th , and 75 th

percentile). The interquartiles reflect the middle 50%

of the responses for that question; the median represents

the 50 th 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


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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%).


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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.

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.

Figure 2. Gender of respondents used in the study

18%

82%

17%

83%

0%

25%

50%

75%

100%

Male Female

Dentists

Orthodontists


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Practice location were grouped into regions based on

the Am erican Dental Associations (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%). The

orthodontic respondents came primarily from the South

Atlantic region (18%), the East North Central region

(16%), and the Pacific region (16%).

Figure 3. Age of dentists and orthodontists used in the study

0%

5%

10%

15%

20%

25%

30%

30-34 35-39 40-44 45-49 50-54 55-59 60-65

Age Groups

DentistsOrthodontists


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Figure 5. Number of orthodontists in thereferring area

10%

24%

24%

23%

19%

One or Less

2 to 34 to 56 to 9

10 or more

Figure 6. Number of orthodontists dentistsregularly refer to

20%13%

2% 2%

63%

12 or 34 or 56 to 910 or More


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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 dentists 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


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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

dentists 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 dentis ts concern about

premolar extraction, and mounting casts of cases with

substantial restorative needs. Orthodontist

underestimated the den tists 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.


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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). Orthodontists


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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 orthodontists 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.


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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

Figure 7. Domain differences between dentists and orthodontists

0 5 10 15 20 25 30

Hygiene

Patient Care

Finished Occlusion

Professional Relationship

Communication

Office

Personal Relationship


NOT Important VERY Important


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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.

Figure 8. Influence of the domains to dentists

0 10 20 30 40 50 60 70 80 90 100

Personal Relationship

Professional Relationship

Office


Communication

Finished Occlusion

Patient Care

Hygiene



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Discussion

Response Rates

The present studys 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


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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 ADAs 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 AAOs valu es. However, four of the nine dental

regions were not within 5% of the ADAs; 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%


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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


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decisions. 15 Dentists also consider it important or

influential to refer patients back for hygiene needs 6,9

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 ora l hygiene.

In contrast to hygiene, establishing a personalrelationship 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

Figure 9. Qualities that orthodontists and dentists respo nded very similar(0=NOT Important/Influential, 100=VERY Important/Influential)

0 20 40 60 80 100

Availability of parking

Current and advanced technology

Living in same area

Hosts "Lunch & Learns"

Prevent decalcification

Promote good oral hygiene

On-time for appointments

OrthodontistsDentists



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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 Guym on et al. felt the dentists 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


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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.


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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 . Dentists responses tended

to be more similar. It seems that, as a group, dentists

more closely agree about the importance or influence

Figure 10. Qualities that orthodontists and dentists responded the most diff erent(0=NOT Important/Influential, 100=VERY Important/Influential)

0 20 40 60 80 100

Family friends

Dentist involved in formingtreatment plan

Marketing

Bonded retainers for primaryretention

Gifts of appreciation

Performing early treatment

Concern about premolar extraction

Mount cases with restorativeneeds

Orthodontists

Dentists



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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.


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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 orthodontists resp onsibility. 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.


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6. Guymon G, Buschang PH, Brown TJ. Criteria used bygeneral dentists to choose an orthodontist. J ClinOrthod . 1999;33(2):87-93.

7. Gosney MB. An investigation into some of the factorsinfluencing the desire for orthodontic treatment. Br JOrthod . 1986;13(2):87-94.

8. Pietil T, Pietil I. Parents' views on their ownchild's dentition compared with an orthodontist'sassessment. Eur J Orthod . 1994;16(4):309-316.

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APPENDIX B (Survey to dentists)


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APPENDIX

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Table 2 : Please Indicate How Important Each of the Following Qualities are to General DentistsREFFERING to Orthodontists (0= NOT Important, 100= VERY Important)COMMUNICATION WITH THE ORTHODONTIST Quartiles

Orthodo nt is t ' s Responses 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 100Overall 47% 70% 86%

Dent is t ' s Respon ses 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 99Overall 58% 80% 93%

**Statistically significant (p


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Table 3 : Please Indicate How Each of the Following Qualities I nfluence General Dentists REFFERING toOrthodontists (0= Does NOT Influence, 100= STRONG Influence)

ORTHODONTIST'S TREATMENT AND PHILOSOPHY Quartiles


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

Overall 20% 44% 69%


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

Overall 47% 71% 89%** Statistically significant (p


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FINISHED RESULTS OF THE DENTITION Quartiles

Orthodo nt is t ' s Responses 25th 50th 75thCases 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

Overall 48% 75% 93%


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



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PATIENT CARE Quartiles


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

Overall 75% 89% 97%


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



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ORAL HYGIENE PROTOCOL OF THE ORTHODONTIST Quartiles

Orthodo nt is t ' s Responses 25th 50th 75thOrthodontist 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

Overall 83% 95% 100%

Dent is t ' s Respons es 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

Overall 84% 94% 97%

** Statistically significant (p


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PROFESSIONAL RELATIONSHIP BETWEEN ORTHODONTIST AND DENTIST Quartiles

Orthodo nt is t ' s Responses 25th 50th 75thPositive 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

Overall 50% 67% 80%


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



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PERSONAL RELATIONSHIP BETWEEN ORTHODONTIST AND DENTIST Quartiles


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

Overall 5% 23% 57%


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



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ORTHODONTIST'S OFFICE Quartiles

Orthodo nt is t ' s Responses 25th 50th 75thOrthodontist 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

Overall 45% 72% 90%


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



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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 University-

Edwardsville in 2008. Currently, Hillarie is at Saint

Louis University and is planning on receiving her Masters

of Science in Dentistry in January 2011.

Hudson Thesis 2010

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