INTRODUCTION

In orthodontics, a successful practice requires a steady flow of new patients. All orthodontists depend on general dentists for referrals; two-thirds of new orthodontic patients are referred by general dentists, and the majority of orthodontists receive most of their referrals from five or six general dentists.¹

A referral has been characterized as the “trusted recommendation that steers new clients in the direction of that business.”² Orthodontists have recognized this major source of referrals with a variety of strategies, including, but not limited to, giving gifts. The number of orthodontists who give gifts to general dentists increased from 67.8% in 2005 to 75.3% in 2011.^3,4

Gift exchange underlies the human tendency to engage in networks of obligation, and it is recognized that gift giving is part of the foundation of human interaction.⁵ Gift-giving practices have been shown to establish some sort of psychological influence to give something in return. Data from studies in medicine have shown that physicians, even those who deny being influenced by gifts from pharmaceutical companies, shifted their prescribing practice in a manner that was neither evidence based nor cost effective.⁶

The practice of gift giving in the health care industry suggests that gift giving is primarily done to elicit more business.⁷ In the pharmaceutical industry, 31% of a pharmaceutical company's budget is for marketing and administration, while 14% is spent on research.⁸ Worldwide, pharmaceutical companies employ about 88,000 sales representatives, and they spend around $14 billion annually on physicians, that is, about $30,000 per physician.⁸ While small, inexpensive gifts are viewed as acceptable, there is concern that gift giving in direct response to referrals and as a practice to encourage continuing or increasing referrals may approach an ethical breach.^9–11

Although the relationship between gift-giving practices and clinical behavior is much better elucidated in medicine, orthodontists give gifts to dentists in hopes of increasing referrals.³ Almost 74.5% of orthodontists send gifts to referring general dentists,³ and, generally, these gifts are inexpensive, like cookies, cupcakes, or flowers. However, studies in medicine have demonstrated that physicians increase their rate of drug prescriptions after receiving inexpensive gifts or incentives from pharmaceutical companies.⁶ The aim of this study is to determine how often general dentists receive gifts from orthodontists, the value and kind of gifts received, and how general dentists perceive the motivation behind the gift.

MATERIALS AND METHODS

This research protocol was approved by the Ohio State University Behavioral and Social Sciences Institutional Review Board (protocol number: 2014B0394).

Validity is “the determination of whether a measurement instrument actually measures what it is purported to measure.”¹² The development of the questionnaire began with a review of the literature to examine current knowledge about gift giving from orthodontists to general dentists. Literature searches were conducted on PubMed, Google Scholar, Medline, and other databases. Validity was addressed by creating preliminary questions from current knowledge and practices in this field.^13–18 An initial questionnaire was constructed and reviewed for content validity by general dentists who worked part-time at the College of Dentistry. They were asked to review the questionnaire, to assess if the questions were relevant, and to suggest improvements. Seven general dentists participated. All comments from the validity assessment were compiled and discussed, and modifications were made to the questionnaire where appropriate.

RESULTS

For the reliability study, 75 surveys were returned by mail, which was a 43% response rate. Overall, the reliability for questions with continuous variables (Table 1) was excellent (ICC > 0.75). The reliability of all but two of the questions with ordinal or nominal data (Table 2) showed moderate to almost perfect agreement (K > 0.41).

Table 1. Intraclass Correlation Coefficient (ICC) of Questions With Continuous Variables

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Table 2. Kappa Values of Questions With Nominal or Ordinal Variables

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No questions exhibited poor reliability; all were used in the statewide survey. There were 261 responses to the statewide survey, 7 were not included in the analysis because they were either from dental specialists or the respondent did not fill out the survey. The responses from the remaining 254 surveys (19.5%) were entered for analysis. The results are summarized and presented in the attached tables (Tables 3 through 8).

Table 3. Participant Sex and Practice Location

^a Distribution-free confidence level.

^b Two participants had two offices in different areas.

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Table 4. Gifting and Referral Practices: Part I

^a CI indicates confidence level.

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Table 5. Gifting and Referral Practices: Part II

^a CI indicates confidence level.

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Table 6. Gifting and Referral Practices: Part III

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Table 7. Gifting and Referral Practices: Part IV

^a CI indicates confidence level.

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Table 8. Rank of Reasons Why the General Dentists Refer to an Orthodontist

^a CI indicates confidence level.

^b Rank of the highest percentage of participants for the choice as reason for referral.

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The majority of dentists reported that they received gifts annually, but a substantial number also reported that they received gifts quarterly and/or for special events. It is noteworthy that five dentists (1.9%) reported that they received gifts per referral (Table 6). There was a statistically significant positive correlation (P < .05) between gifts from orthodontists to general dentists (frequency and value) and the rate of general dentists' referrals to orthodontists (Table 9).

Table 9. Correlation Between Referrals and Gifts

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There was a statistically significant correlation (P < .05) between sex of the referring dentist and the annual number and value of the gifts. Female dentists received significantly more and higher value gifts than male dentists. There was no statistically significant difference between male and female dentists in number of referrals (Table 10).

Table 10. Correlation Between Sex and Number of Gifts, Value of Gifts, and Number of Referrals

*Statistically significant P < 0.05.

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The survey responses to the question about the value of gifts they receive from orthodontists included values up to $20,500. Those values were from dentists who received free or discounted orthodontic care for themselves, their families, and/or their staff. We assumed an average value of $5000 for orthodontic care, and based on their responses, we divided respondents into two groups, one group that received orthodontic care and reported receiving gifts valued ≥$5000 (n = 22), and the other group that reported receiving gifts valued <$5000. There were no statistically significant differences (P > .05) between the two groups in the number of patients they referred to orthodontists. While the mean annual value of the gifts received, $860 (Table 4), is surprisingly high, it included the value of the free or discounted orthodontic treatment. If those dentists are removed from the analysis, the mean annual value of the gifts that the dentists reported receiving is $320.

Dentists who provide orthodontic care were compared with those who do not, and there was no statistically significant difference between the two groups (P > .05) in the number of their referrals to orthodontists or in the value and number of the gifts they received from orthodontists.

Dentists reported that, in their opinion, the top two factors affecting the number and value of the gifts they received from orthodontists were the number of referrals they made (63.1%) and their personal relationship with the orthodontist (57.9%). They also reported that, in their opinion, the motivation behind the gifts was primarily as a thank you for referrals (86.6%) and to encourage more referrals (75.0%).

DISCUSSION

In this study a valid and reliable questionnaire was developed and distributed to a large number of general dentists in the state to examine the number, frequency, and value of the gifts general dentists received from orthodontists and the dentists' perception of the motivation for these gifts.

Two limitations of this study are that it was limited to general dentists who were members of the Ohio State University Alumni Association and the low response rate. The response rate of 20% to the electronic survey is lower than the response rates for similar mailed paper surveys. This is in agreement with previously published literature indicating that mailed paper surveys have a higher response rate.^18,20,21 The sex distribution of the respondents was very similar to that of a study from the Netherlands.¹⁸

Of general dentists responding to this survey, 83% reported that quality of care and patient satisfaction were the most important reason in choosing an orthodontist to whom they refer. See Tables 8A through C. Similar to the results of the present study, other investigators have reported that quality of orthodontics was the most important factor in why dentists choose an orthodontist, and discounted orthodontic care to the referring dentist, family, and staff, as well as inexpensive treatment fees in general, were ranked as the least important reasons in making the referral decision.^18,20,22,23

An interesting finding of the study was that 36% of the responding general dentists reported providing orthodontic treatment in their offices (Table 4). This is in agreement with the results of a nationwide survey that reported that 38% of general practitioners perform orthodontic procedures. ²¹ However, Wolsky and McNamara reported that 76% of general dentists in Michigan provide orthodontic services^24. The current study and others have reported that the number of referrals to orthodontists in the area was not affected by whether or not the referring dentist provided orthodontic services.^22,24

The current study also found that the sex of the general dentist and the number of patient referrals might affect gift giving practices by orthodontists (Tables 9 and 10). However, the association between number of referrals and the number and value of gifts from the orthodontist does not imply causation. Nevertheless, 2% of the responding dentists did note that gifts were received per referral (Table 6).

In general, dentists responded most frequently that they viewed the gifts as a thank you for the referral, though they were conscious that gifts were also given to encourage further referrals. They also perceived that the number and value of the gifts they received reflected the number of referrals that they made (Table 5).

Some of these responses raise disquieting notes. Certainly, giving gifts per referrals raises some ethical questions. The American Dental Association and many state dental boards expressly forbid “fee-splitting.” A gift for each referral is certainly problematic in this regard. Another issue is the high number of general dentists, 44%, who reported that orthodontists provided free or reduced-cost treatment for themselves and/or their families and staff. This is a gift of significant value and might be viewed with some concern as this exceeds what is commonly viewed as an acceptable or appropriate value for a thank you gift.

Finally, the perception by dentists that the gifts are not just a thank you but also an incentive to encourage more referrals does not reflect well on the specialty. That this perception is supported by the correlation between the number of referrals the individual general practitioners made and the number and value of the gifts that they reported receiving gives credence to general dentists' perception.

The most encouraging part of this small but disturbing area is that by far the most frequent reason general dentists reported when choosing an orthodontist to whom they refer their patients is the quality of the care the orthodontist provides. However, even here one should be aware that studies of physicians' behavior have indicated that even as they professed not to be influenced by even low-value gifts that they received, their prescribing behavior changed in favor of the gift giver.⁶

The authors are of the opinion, based on their personal experience, that the discussion of professional ethics in orthodontic graduate programs does not include gift giving to general practitioners. That question was not addressed in our study and, if we are wrong, we are grateful for the opportunity to apologize. If the topic is addressed at all, it is probably within the context of a course on practice management and as part of practice building. We suggest that, in an admittedly very busy curriculum, the results of this study indicate that the ethics of gift giving to general practitioners might be a topic that belongs in the discussion of professional ethics, if it is not already there.

CONCLUSIONS

• The majority of general dentists referred to and received gifts from orthodontists.

• The number and value of these gifts seemed to be influenced by the number of referrals from the general dentist to the orthodontists.

• Dentists viewed the gifts they receive as a thank you for referrals and as an incentive to encourage more referrals.

• The dentists reported that they base their referral practice on the quality of care the orthodontists provide and the location of the orthodontists relative to the patients or the dentist's office.

• Based on general dentists' reports, providing orthodontic care by general dentists doesn't seem to affect the number of patients they refer to orthodontists.