Communication practices and preferences between orthodontists and general dentists
To evaluate similarities and differences in orthodontists' and general dentists' perceptions regarding their interdisciplinary communication. Orthodontists (N = 137) and general dentists (N = 144) throughout the United States responded to an invitation to participate in a Web-based and mailed survey, respectively. The results indicated that orthodontists communicated with general dentists using the type of media general dentists preferred to use. As treatment complexity increased, orthodontists shifted from one-way forms of communication (letters) to two-way forms of communication (phone calls; P < .05). Both orthodontists and general dentists reported that orthodontists' communication regarding white spot lesions was inadequate. When treating patients with missing or malformed teeth, orthodontists reported that they sought input from the general dentists at a higher rate than the general dentists reported (P < .005). Orthodontists' and general dentists' perceptions of how often specific types of media were used for interdisciplinary communication were generally similar. They differed, however, with regard to how adequately orthodontists communicated with general dentists and how often orthodontists sought input from general dentists. The methods and extent of communication between orthodontists and general dentists need to be determined on a patient-by-patient basis.ABSTRACT
Objective:
Materials and Methods:
Results:
Conclusions:
INTRODUCTION
Referrals from general dentists play an important role in the success of an orthodontic practice. Understanding why general dentists refer to specific orthodontists is very important in today's competitive environment. Previous studies have highlighted what factors are important to general dentists when choosing an orthodontist for referrals, including quality of care, cost, convenience, reputation of the orthodontist, patient satisfaction, and communication with the orthodontist.1–4 Because of the established significance of communication, it is important that orthodontists know how to provide general dentists with the information they desire.
A 2009 survey indicated that 75% of general dentists place equal importance on the overall satisfaction of the patient and the resulting occlusion and function, although their final referral decision is based on their own opinion of orthodontic treatment outcomes.3 The dentist likely wants to understand the orthodontic treatment objectives and plan, especially if the patient requires extractions, the restoration of a malformed tooth, or the replacement of a missing tooth. Despite some attempts to systematically determine which teeth should be extracted during extraction therapy5,6 and the widespread understanding of the available treatment options to restore or replace deformed or missing teeth,7–12 it is important that both the orthodontist and general dentist agree on the ultimate treatment goal so each provider can facilitate its attainment.
One area in which proper in-treatment communication is paramount is oral hygiene. Despite orthodontists' emphasis on good oral hygiene since the 1930s,13 white spot lesions (WSLs) continue to be a common finding in orthodontic patients. Studies have shown the prevalence of WSLs to fall between 25% and 97%.14–16 Although 66% of general dentists believe the patient is the most responsible party for preventing WSLs, 82% place at least part of the responsibility on the orthodontist.17 Furthermore, approximately one-third of general dentists believe the presence of multiple WSLs at the end of orthodontic treatment negatively influences their opinion of the orthodontist.18
The content and frequency of communication between the orthodontist and the general dentist are important, as is the media used to communicate. A 2004 study found that general dentists prefer to receive communication from the orthodontist via mail (89%), phone (60%), in person (21%), fax (17%), and e-mail (9%).1 With the advancement of technology, it is likely that these preferences have changed, as the ability to share and gather information instantly has allowed for faster and more efficient communication.19
Despite the importance of communication between orthodontists and general dentists, a comparison between how orthodontists and general dentists view the communication practices of orthodontists has not been made. The purpose of this study was to evaluate similarities and differences in orthodontists' and general dentists' perceptions regarding their interdisciplinary communication.
MATERIALS AND METHODS
A survey was developed to examine orthodontists' and general dentists' perceptions and preferences of how orthodontists communicate with general dentists. The survey was customized for orthodontists and general dentists so that the same questions were asked and formulated appropriately for each group. It consisted of four sections: demographics, types of communication used and preferred, adequacy of orthodontists' communication with general dentists, and circumstances when orthodontists asked general dentists for input. Figure 1 shows how the questions regarding the media used and preferred to be used to communicate were divided based on case complexity.
Citation: The Angle Orthodontist 85, 6; 10.2319/111714-826.1
After receiving approval from the Institutional Review Board at Virginia Commonwealth University and the American Association of Orthodontists, the survey was sent to orthodontists (N = 1,000) and general dentists (N = 1,000).
The American Association of Orthodontists e-mailed the survey to orthodontists throughout the United States who were randomly selected from its database of active members. A follow-up e-mail was sent 4 weeks later to increase participation. Because there was no way to track who responded to the first e-mail, the recipients were asked in the second e-mail to not participate if they had already done so.
A third party (Virginia Commonwealth University Mailing Service) mailed the paper survey, along with a return-addressed stamped envelope, to general dentists throughout the United States who were randomly selected from the American Dental Association website. The mailed surveys were numbered so that the third party could track participants and mail the survey again to the dentists who had not returned the survey 4 weeks after the original mailing.
Responses were summarized using counts and percentages or means and standard deviations as appropriate. Unless otherwise noted, either χ2 or repeated-measures logistic regression was used for all comparisons. All calculations were done with SAS software (JMP pro version 10, SAS version 9.3, SAS Institute Inc, Cary, NC).
RESULTS
A total of 137 orthodontists and 144 general dentists responded to the survey (response rates of 13.7% and 14.4%, respectively). Table 1 shows the demographic characteristics of the participants. The two groups were predominantly male and typically practiced in a suburban environment. Slightly fewer orthodontists practiced solo than did general dentists (64% vs 69%, P = .0032), and the only respondents who worked in academics were orthodontists (6% vs 0%, P = .0032). General dentists who responded were older (mean age = 52 years old vs 47 years old) and had practiced more years than the orthodontists who responded (mean age = 25 years old vs 17 years old; P < .0001).
Media Used to Communicate
Table 2 shows the types of communication general dentists said they actually received and preferred to receive from orthodontists and what orthodontists said they sent to general dentists. The results are divided based on case complexity.
Regarding the average patient, general dentists received most types of communication at a statistically similar frequency to what they preferred to receive from the orthodontists (Figure 2). Letters were the only form of communication that was received at a frequency significantly higher than what was preferred (P < .05). However, letters were also most commonly received and most commonly preferred to be received by general dentists.
Citation: The Angle Orthodontist 85, 6; 10.2319/111714-826.1
Figure 3 compares the type of communication general dentists preferred to receive to the type of communication orthodontists reported that they provided for the average patient. General dentists preferred to receive a letter more than any other type of communication, and orthodontists reported that they sent letters with a similar frequency (P > .05). General dentists preferred less often to receive an e-mail (35%) and at a significantly lower frequency than orthodontists sent them (56%; P < .05).
Citation: The Angle Orthodontist 85, 6; 10.2319/111714-826.1
With regard to the more complex patient, what the general dentists preferred to receive and what they actually received did not always coincide. Figure 4 indicates that general dentists received letters and phone calls at a much higher frequency than they preferred (P < .05). General dentists received e-mails, in-person contact, and faxes at similar frequencies to what they preferred (P > .05).
Citation: The Angle Orthodontist 85, 6; 10.2319/111714-826.1
Figure 5 shows that orthodontists reported that they made phone calls (86%), sent e-mails (54%), and met in person (71%) regarding complex patients significantly more often than the general dentists preferred (59%, 28%, and 36%, respectively; P < .05). However, they mailed letters at a frequency (71%) that was not statistically significantly different from that which general dentists preferred to receive (56%).
Citation: The Angle Orthodontist 85, 6; 10.2319/111714-826.1
The differences between how general dentists preferred to receive communication and how orthodontists communicated based on case complexity are reported in Figure 6. General dentists preferred to receive in-person communication or a phone call at significantly higher frequencies when treating complex patients compared with when treating average/typical patients (36% vs 13%, 59% vs 40%, respectively; P < .05). The preference to receive a letter or e-mail decreased when shifting from an average/typical patient to a complex patient. However, this difference was significant only for letters (74% vs 56%; P < .05) and not for e-mails (35% vs 28%; P > .05). The orthodontists showed a similar trend in how their communication practices changed with case complexity. In-person and phone call communication showed significant increases for a complex patient vs an average/typical patient (71% vs 34%, 86% vs 51%, respectively; P < .05). They also communicated less frequently by letter or e-mail when working on a complex patient, although only the difference in how often letters were sent was significant.
Citation: The Angle Orthodontist 85, 6; 10.2319/111714-826.1
Adequacy of Communication
Both general dentists and orthodontists were asked a series of questions regarding how adequately orthodontists communicated with general dentists regarding extractions, patients' poor oral hygiene, and the development of WSLs during orthodontic treatment. The results are shown in Table 3.
With regard to how often orthodontists notified the general dentist when the orthodontist wanted teeth extracted, orthodontists reported that they did so at a higher frequency than the general dentists perceived. Specifically, 74% of orthodontists said they always notified the general dentists whereas only 56% of general dentists reported that they always received notification (P = .0036).
When asked about the adequacy of communication regarding poor oral hygiene, the difference between the responses of the two groups was small but statistically significant. According to the findings, 47% of the general dentists reported that orthodontists communicated inadequately whereas 53% said they did so adequately. This was in contrast to the 54%, 43%, and 2% of orthodontists who reported that they communicated about poor oral hygiene inadequately, adequately, and excessively, respectively (P = .0399).
Most of the respondents in both groups agreed that the level of communication regarding the development of WSLs was inadequate. The general dentists were more dissatisfied, with 70% compared with 57% of orthodontists reporting that the communication was inadequate (P = .0109).
Circumstances When Input Was Sought From General Dentists
The general dentists and orthodontists were asked a group of questions about what percentage of the time orthodontists asked general dentists for input regarding specific clinical situations. Table 4 summarizes the results.
Orthodontists reported that they asked for input from general dentists when treating patients with malformed teeth at a higher rate (56.9%, SD = 36.7%) than the general dentists reported (40.9%, SD = 37.9%; P = .0004). Furthermore, 49% of general dentists said that orthodontists asked for their input 25% of the time or less whereas 46% of the orthodontists said they asked for input 75% of the time or more.
When treating patients with missing teeth, orthodontists again reported that they asked for input from general dentists at a higher rate (62.0%, SD = 32.0%) than the general dentists reported (48.7%, SD = 38.8%; P = .0019). Only 1% of orthodontists reported that they never asked for input, whereas 19% of general dentists reported that they were never asked for input.
The orthodontists and general dentists agreed on the frequency that orthodontists sought input when orthodontists were approaching the end of treatment and could not obtain ideal results. Each indicated that this occurred roughly 44% of the time (P > .9).
DISCUSSION
Media Used to Communicate
The results from this study were both similar to and different from those of a previous study with regard to how general dentists preferred to receive communication from orthodontists.1 Both studies showed that general dentists preferred to receive a letter (mail) or phone call from the orthodontist more than any other type of communication. However, the previous study indicated that only 8.7% of general dentists preferred to receive an e-mail, whereas 28%–35% of general dentists preferred to receive an e-mail in the current study. This marked increase is likely due to the vast improvements in technology and more user-friendly interfaces that have developed since the first study was published in 2004.
The orthodontists and the general dentists generally agreed on the amount each type of media was used by orthodontists when contacting the general dentists for all types of patients. These similarities indicated that general dentists received and paid attention to the orthodontists' communication and that the information reached its intended recipient. The biggest difference in the reported amounts of actual communication was with e-mail. Interestingly, orthodontists claimed to communicate by e-mail at a much higher rate than the general dentists indicated that they received e-mails. A possible explanation for this discrepancy might be that the e-mails got filtered into the spam mailbox and were never available for the general dentist to see. Also, if the general dentist received many e-mails per day, there was the chance that an e-mail from the orthodontist got lost in the multitude of e-mails through which the general dentist had to navigate and was either never opened or opened and later forgotten. Another explanation might be sample bias. Because of limitations in obtaining the same type of contact information for all participants, the orthodontists received the survey via e-mail and the general dentists received the survey via standard mail. If the orthodontists responded to a survey via e-mail, it can be assumed that they were comfortable using e-mail as a form of communication.
Providing the right form of communication to general dentists is a delicate balance for the orthodontist. Not using the preferred form has its obvious consequences, but using too many forms could desensitize the general dentist to the importance of the information communicated. Fortunately, orthodontists and general dentists agreed that the amount orthodontists used each type of media to communicate with the general dentist matched how general dentists preferred to receive communication.
For the more complex patient, the communication preferences and practices for each group changed similarly. General dentists no longer preferred to receive a letter at a rate higher than the other forms and placed equal weight on receiving a phone call. The orthodontists met this increase in expected communication. The shift from one-way to two-way forms of communication was understandable because complex patients often require high levels of coordination between practitioners to ensure that the patient receives the best possible outcome in a timely manner.
Adequacy of Communication
Most general dentists rated the orthodontists' communication as adequate with regard to patients who had poor oral hygiene yet inadequate with regard to patients who had developing WSLs. This was a surprising result because poor oral hygiene is a precursor to WSLs, so one might have assumed that the communication practices would have been similar. Perhaps this difference was because WSLs can develop in as little as 4 weeks.20 Even if orthodontists made the general dentists aware of poor oral hygiene when it first became a concern, the orthodontists might not have had the opportunity to inform the general dentists about WSLs if the patient saw the general dentist between orthodontic appointments.
Interestingly, most orthodontists rated their own communication about poor oral hygiene and developing WSLs as inadequate. Perhaps they attempted to handle these issues within their own practice without the help of the general dentist, or perhaps they did not want to admit to the general dentist when these issues occurred because of pride or for legal reasons. Regardless of the reason, this is an area where orthodontists can improve how they communicate with general dentists.
Circumstances When Input Was Sought From General Dentists
When treating patients with malformed or missing teeth, the orthodontists reported that they sought input from the general dentists at a higher rate than the general dentists claimed. This difference indicated that the management of missing or malformed teeth is an area where communication must be improved. Kokich and Spear21 discussed a series of questions about restoring missing and malformed teeth that must be answered before the removal of braces.21 According to these authors, a consensus can only be attained by adequate two-way communication between the general dentist and orthodontist.
CONCLUSIONS
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Orthodontists' and general dentists' perceptions of how often specific types of media were used for interdisciplinary communication were generally similar. When they were different, orthodontists indicated that each form of media was used at a higher frequency than did the general dentists.
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Orthodontists and general dentists did not agree on how adequately orthodontists communicated with general dentists and how often orthodontists sought input from general dentists.
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To ensure the highest quality of patient care, the methods and extent of communication between orthodontists and general dentists that is compliant with the Health Iinsurance Portability and Accountability Act need to be determined by both parties on a patient-by-patient basis.
Flow chart depicting how the questions regarding types of communication sent, received, or preferred to receive were divided.
Communication regarding the average/typical patient: What general dentists reported that they received compared with what general dentists preferred to receive. *P < .05.
Communication regarding the average/typical patient: What general dentists preferred to receive compared with what orthodontists reported that they sent. *P < .05.
Communication regarding the complex patient: What general dentists reported that they received compared with what general dentists preferred to receive. *P < .05.
Communication regarding the complex patient: What general dentists preferred to receive compared with what orthodontists reported that they sent. *P < .05.
Communication preferences and practices among general dentists and orthodontists regarding the average patient versus the complex patient. *P < .05.
Contributor Notes