Orthodontics Is Not a Pediatric Specialty
Four years ago, the 1981 JCO Orthodontic Practice Study reported that the average orthodontic practice was starting 23 adult patients a year. Last year, the 1985 Study reported that the average practice was starting 30 adult patients a year. One can only conclude that orthodontists either have not acknowledged their need for increased case starts, have not recognized the great residual need for orthodontic treatment in the adult population, have not wanted to treat more adults, or have not been successful in stimulating referrals of adult patients.
While orthodontists should not be seeking adult patients merely for economic reasons, sometimes the right thing is done for the wrong reasons. So let's examine the economics of adult orthodontics. Orthodontists treat about 6% of the child population under 18 years of age, but only .5% of the adult population age 18-44 and only .3% of the adult population age 18-65. If orthodontists were to treat 2% of the adult population age 18-44, it would mean a substantial increase in the number of case starts. Instead of starting 150 cases a year (120 child patients and 30 adult patients), the average orthodontist would start 240 patients a year (120 child patients and 120 adult patients). Adults would then be 50% of the average case load. Alert practitioners are doing this now.
Furthermore, if there were a truly adult service, it is conceivable that it could justify a fee of $3500-5000 for adult orthodontic treatment. That would mean a gross income from 120 adult patients of $420,000-600,000. With a fee of only $2500,120 child patients would add $300,000, and an orthodontist's total gross income from a 50/50 adult/child practice might be $720,000-900,000. There is little doubt that there could be substantial economic rewards for bringing the benefits of orthodontic treatment to adults.
Then we read in Breece and Nieberg's study, published in this issue of JCO, that the chief factor motivating adults not to have orthodontic treatment is embarrassment. Although adults are frequently embarrassed by their unattractive malocclusions, they would also be embarrassed to wear orthodontic appliances. For many males, orthodontic appliances do not suit their "macho" image. For many adults of both sexes, orthodontic appliances are "kid stuff". For many adults, the appliances would inhibit or interfere with the performance of their jobs. Or they believe that they would, which can be the same thing.
Someday, progress in physics, chemistry, biology, and cybernetics may result in the development of marvelous ways to deal with this problem, but until that day arrives lingual orthodontics is the solution. With all its warts, lingual orthodontics is the Number One answer to embarrassment--which is the Number One deterrent to acceptance of orthodontic treatment by adults. Lingual orthodontics is as close as we can get today to entree to a market of adults who desire orthodontic treatment, but are refusing labial orthodontics.
Economics aside, and looking at our specialty as a health care service, we have an obligation to find ways to help people have the treatment they want and to satisfy a need that falls within our province. That is the primary reason we are licensed to practice. If we say that we can treat better from the labial and refuse to offer lingual treatment, we may feel justified--but we are depriving many adults of treatment, and we are satisfying ourselves and not those patients.
Right up through the '50s, orthodontists struggled for control of labial orthodontic appliances. As appliances improved, as understanding of orthodontic forces developed--and with experience and a lot of hard work--a coalition of dedicated clinical orthodontists, orthodontic companies, and orthodontic schools persevered in the development of labial orthodontics as successful, predictable, controlled tooth movement. It did not happen overnight. It took about 20 years.
Having the comfort of fine-tuned labial orthodontics, orthodontists are reluctant to start all over again with an appliance that needs the same kind of taming. But it must be done. That same coalition must rededicate itself to a repeat performance on the lingual side.
Clinical orthodontists must first accept that a mutual need exists--embarrassed adults need orthodontists and orthodontists need embarrassed adults. There will then be a period of years during which orthodontists will do what they do best--do whatever it takes to wrest satisfying results out of a difficult appliance, improvising and improving gradually along the way. Appliances will improve, understanding of lingual biomechanics will grow, and one day lingual orthodontics will be no more difficult than labial orthodontics is today. At that point, lingual orthodontics may well become the appliance of choice.
During this "difficult" period, orthodontists will be well rewarded for their dedication and hard work--rewarded in providing a needed, expanded service and rewarded financially in appropriately larger fees for lingual orthodontic treatment. Birds of a feather flock together. Practices that undertake lingual orthodontics in a positive manner quickly develop large lingual practices. Coincidentally, it also seems to result in an increase in labial patients in those practices.
With an extension of lingual and labial orthodontics to the adult population, it might not be too much to hope that adults may comprise 25% of the average orthodontic practice when we report on the 1987 JCO Orthodontic Practice Study. It would be a small enough movement, but in the right direction. Orthodontics is not a pediatric specialty.