As We Enter the '90s
Beginning in the late 1960s, orthodontists were aware of an unfavorable whipsaw effect of decreasing births and increasing numbers of orthodontists. For a predominantly child service-- only 5 percent of orthodontic patients were adults for most of that period-- this caused a diminishing of the potential number of child patients per orthodontist in the '70s and early '80s, as diminishing numbers of children to be shared by an increasing number of orthodontists reached orthodontic age.
Population
From 1954 to 1964, annual births topped 4 million. This was the height of the baby boom. Annual births declined after that until 1974 when they began to increase, reaching more than 3.8 million births in 1987 according to the Census Bureau, and close to 3.9 million in 1988. Such numbers have to be good news for orthodontists. However, since it takes at least eight to 10 years for a newborn to reach an age suitable for orthodontic treatment, the effect of the increased births could not begin to be felt in orthodontic practice until around 1985, and not to a substantial effect until later.
If women born in 1954-1964 continue having babies into their 30s, it is likely that we will see a birth rate of around 4 million a year from 1990 until 1999. That should mean increased numbers of potential child orthodontic patients from 2000 to 2010 or 2015.
After 1999, the baby boomers of the high annual birth years will more or less fade out of the childbearing picture. A decline in annual births can be expected after that, until children born in the boomlet of the '9Os reach childbearing age, around 2005. We might then see another echo boomlet from 2005 to 2020, possibly itself culminating in a higher number of births in 2024-2034. So the cycle will provide ups and downs as far as availability of child orthodontic patients is concerned.
Some negatives in population demographics have also been reported. There has been a startling rise in the number of unwed mothers. Thirty percent of the mothers of 1987 newborns were unmarried. Since single parents are generally identified as the new poor, it seems likely that a large percentage of 1987 and 1988 newborns' parents will be unable to afford orthodontic treatment for their children. Countering this is the report that one-third of the childen born in 1987 were born to women in their 30s. These older parents may be more able to afford orthodontics.
There has also been a great increase in the employment of women. More than half of the women in the United States are employed, creating large numbers of so-called "latchkey children" who arrive at a parentless home after school. Together with the increased numbers of divorced parents, this creates a potential management problem in orthodontics. Latchkey children have been reported to be twice as likely to abuse alcohol, tobacco, and marijuana as other children, and a greater risk for emotional difficulties. The number of latchkey children is estimated to be between 2 and 6 million and rising. One can only speculate what such behavior may mean with regard to acceptance of and cooperation with orthodontic treatment.
Number of Orthodontists
The number of orthodontic graduates of university programs reached a high-water mark of 360 a year in 1974, declined to 260 a year by 1980, and has remained around 250-260 a year. The number of graduates of non-dental-school orthodontic programs has been increasing slightly, reaching 33 in 1988.
To determine the net number of additional orthodontists per year, subtract from the total number of graduates those who do not enter private practice and the number of practicing orthodontists who retire or die.
In 1988, 222 U.S. citizens graduated from university orthodontic programs and 33 from non-dental-school programs. Some of these graduates went into teaching, public health, military service, and other careers. There were also 29 foreign graduates who presumably returned to their countries of origin. According to AAO reports, around 100 practicing orthodontists are retiring each year. It would be reasonable to assume that there may be a net increase in the number of practicing orthodontists of about 100 a year. While this may be less than in past years, there was still an increase in the total number of practicing orthodontists from about 7,500 in 1980 to about 8,400 in 1989, and, of course, there are also additional pedodontists and general dentists each year who undertake orthodontic treatment.
1974 was a turnaround year for the ratio of the number of births to the number of orthodontists-- annual births began to increase and the number of orthodontic graduates to decrease. The ratio has been improving since that time. Barring an unforeseen large increase in the annual number of orthodontic graduates, the ratio should continue to improve for at least the next 10 years, but it would be unwise to disregard the constantly increasing competition among orthodontists, GPs, and pedodontists.
A mitigating circumstance in the '80s has been the increase in the percentage of adults in the average orthodontic practice. However, respondents to the 1989 JCO Orthodontic Practice Study reported no increase in the preceding two years. In fact, there appeared to be a slight decrease. It would be a mistake to take the potential increase in the number of child orthodontic patients that will occur in the '90s as a signal to reduce practice-building efforts, especially among adults.
Aggressive practice building will be required in the '90s if the average orthodontist is to hope to increase net income. In the 1989 Study, we noted a decrease in the average orthodontist's standard of living, with a 2 percent increase in net income in 1987-1988 against a 9 percent increase in the Consumer Price Index. With high-tech orthodontic products, more sophisticated sterilization, the need for computers, and competition for better employees have come greatly increased expenses. The overhead rate has reached 56 percent in the average practice, and it is likely to continue to increase if insufficient attention is paid to increasing gross income through increased case starts and increased fees.
If an assumption is made that a 50 percent overhead rate would be desirable, the $200,000 in expenses reported for the average practice in the 1989 JCO Practice Study would have to have been balanced by $200,000 in net income to achieve it. That would have meant an average gross income of $400,000 instead of the reported $350,000. It would have taken an additional 50 case starts in the past two years to reach that average gross income. The average practice reported that it could handle another 50 case starts per year without adding to staff or facilities.
Expenses have been rising at an average rate of around 20 percent for each two-year interval between practice studies. If a 50 percent overhead rate is a reasonable goal, that dictates a constant need to increase case starts for the foreseeable future. Despite an improving ratio of the number of children to the number of orthodontists in the '90s, greater success--even survival--will come only to those who plan to manage practice, staff, and patients, and plan to promote the practice for increased case starts.