Orthodontists and Orthodontic Residents’ Education: Effect on Professional Attitudes and Behavior

Introduction

The most visible mission of dental education is to develop future professionals. With advances in science and technology and increasing needs of the patient, there is a shift toward greater accountability to the society. This, in turn, increases the responsibility of the education system as a whole.

Terrell and Beaudreau^[1] argued that Dental Colleges are meant to take up the responsibility of preparing dental professionals in such a way that they accept their civic responsibility of providing care for needy patients. Several studies of dental students found that the providers of education better evaluate their educational preparation to provide care to needy patients.^[2]

The absence of competent dental education can lead to a lack of confidence in the ability to effectively treat patients from certain groups, and this lack of confidence might ultimately affect provider’s willingness to treat or quality of treatment.^[3] Burtner and Dick^[4] found negative (poor) attitude of dentist in providing care to the patients with special needs as cleft lip and palate. In turn, positive attitude becomes part of the motivation to provide care for these patients.^[5] In India, no research so far has analyzed whether postgraduate orthodontic education has correlation with professional attitude in the management of cases of severe skeletal malocclusion as cleft lip and palate, growth modification cases, and surgical orthodontic cases.

Thus, a study was planned to analyze the degree to which orthodontic residents and orthodontic practitioners (both have studied the same syllabus) perceived that their postgraduate orthodontic education has prepared them to treat cases of severe skeletal malocclusion as cleft lip and palate, skeletal malocclusion in growing patients by growth modification, and skeletal malocclusion in nongrowing patients using orthodontic surgical approach and whether this education affected their professional attitude and behavior in providing care to these cases.

Materials and Methods

This research was approved by the Institutional Ethics Committee.

Data were collected from 100 orthodontic residents and 100 practicing orthodontists who are members of orthodontic society. A questionnaire was mailed to randomly selected orthodontist and orthodontic residents. The validity of the questionnaire was tested by face validity (discussing with fellow orthodontist) and from a psychometrician (expert in questionnaire).

The survey from both groups assessed the respondents’ demographic and practice characteristics as well as their educational experiences concerning providing care for three patients groups [Table 1]. The three groups were patients with cleft lip and palate, growth modification, and orthodontic-surgical malocclusion patients. In addition, the respondent’s professional attitude concerning the treatment of these patients groups was assessed. The residents were asked to indicate their behavioral intentions concerning providing care for these patients in their future professional lives. Practicing orthodontist was asked about their current professional behavior concerning care to these patients.

The survey included six educational items designed to elicit the respondent’s perception of the quality of their theory-based and clinical-based education about treating patients of the three groups [Tables 2 and 3].

The second analysis included responses to 15 items concerning attitude toward treating patients for cleft lip and palate, growth modification, and orthodontic-surgical malocclusion patients.

One additional consideration was that the orthodontist reported their actual professional behavior concerning the treatment of patients while the orthodontic residents reported their intentions to treat these patients in their future professional lives. If the actual number of patients treated by the residents at the time of the survey had been included in these analyses, this variable would not have reflected the residents’ own motivation for treating because during residency programs the students treated assigned patients and cannot freely choose whom they would like to treat. Therefore, the respondents indicated their behavioral intentions concerning treating these patients in the future because research has found that behavioral intentions are the best predictors of future behavior. To construct a behavioral indicator, the numerical responses of the orthodontists concerning how many patients from a certain group “ I like to treat” were provided on five-point answer scale ranging from “disagree strongly” to “agree strongly.” The responses “1” to “3”(disagree strongly, disagree, and neutral) were categorized as an indication of not being likely to treat these patients, and the responses “4” and “5” (agree and agree strongly) were categorized as having a behavioral intention to treat these patients. By categorizing the actual professional behavior of the orthodontist and the behavioral intentions of the orthodontic residents, a behavioral-dependent variable was created [Tables 4 and 5].

Data were analyzed with SPSS version 20 (IBM, Armonk, NY). Factor analyses were used to construct educational and attitudinal indices. The reliability of these scales was determined by computing a Cronbach’s alpha reliability coefficient for each scale. Descriptive statistics (percentages and means) were used to provide an overview of the distribution of respondents’ answers concerning the concept of interest [Tables 1-3]. Correlation analyses with Pearson correlation coefficients were performed to determine whether the educational background responses and the attitudinal responses correlated as predicted [Table 5].

Results

Table 1 provides an overview of demographic and practice characteristics of the residents and orthodontists participating in this study. This table shows that while both groups of respondents males were more, the percentage of female residents was larger than the percentage of female orthodontists (39% vs. 24.39%) Residents were, of course, on average, significantly younger than orthodontists (26.86 years vs. 34.86).

Information about the practice characteristics of the orthodontists showed that they had on average practiced for 7.71 years (ranges from 4 months to 40 years) and almost all orthodontists practiced in solo practice (90%).

Discussion

A number of studies have demonstrated the effect of dental education on the professional attitudes of future providers and on their actual professional behavior.^[3-5] The objective of this study was to explore the quality of postgraduate dental education and its impact on the professional behavior of orthodontic postgraduate students as well as practicing orthodontists.

Data were collected from practicing orthodontists and residents in orthodontics of dental colleges. The distribution of male versus female respondents in the two groups reflects that increasing number of female residents (39%) is entering orthodontic residency programs compared to the number of females among practicing orthodontists (24.39%).

The first objective of this study was to analyze the degree to which orthodontic postgraduate education has prepared residents and orthodontist to treat cases of special needs as cleft lip palate, surgical orthodontic cases, and growth modification cases. Majority of both residents and orthodontist said they were well prepared in theory and clinical education to treat growth modification. However, significantly smaller percentages agreed that their postgraduate education had prepared them to treat cleft lip and palate and surgical orthodontic cases. This data raises concern as not feeling well prepared could affect the provider’s professional confidence when they encounter these patients in their own practices or in turn would affect the quality of treatment. Important to note that the residency program which the orthodontist went through is the same today as which the residents are undergoing both with respect to clinical and theory hours.

The second objective of this study was to access whether this education has affected their professional attitude and behavior in providing care to cleft lip palate, growth modification cases, and surgical orthodontic cases. Concerning the residents and orthodontist attitude toward providing care for these patients group, the data show clearly that the respondents had positive attitude toward providing care for cleft lip and palate and surgical orthodontic cases than growth modification; however, when compared with the respondents’ educational experience, they were not well prepared both in theory and clinical education for cleft lip and palate and surgical orthodontic cases but were well prepared for growth modification. This indicates in conditions where the respondents want to provide care they are not well prepared and what they would less like to treat they are very well prepared. If this is so, it raises concern to the quality and the confidence with which the providers will manage these cases of cleft lip and palate and surgical orthodontics. From this finding, two questions are raised in view of educational experience. First, why the residents and orthodontist are well prepared in the management of growth modification; second, why in the management of cleft lip and palate and surgical orthodontic cases they are not well prepared. This alerts the dental educators to improve and to update the quality of education and to give more weightage in teaching to the malocclusions which need special orthodontic training as in cleft lip and palate and surgical orthodontic malocclusions to give quality results to these patients.

The central question of this study was whether there is a relationship between the quality of postgraduate dental education about providing care for growth modification, cleft lip and palate, and surgical orthodontic cases and professional attitude. Findings indicate no such relationship exists.

While this study focused on one particular dental specialty, orthodontics, and only three types of malocclusions, research should explore this question in other areas of orthodontics and also in other dental specialties as well. An answer to these questions could locate the missing link between education and patient care and could challenge postgraduate dental program faculty and administrators alike to reflect on their own program and the degree to which their programs contribute to reducing access to care problems.

If we go back to the history of orthodontics in India, the postgraduate training in this specialty started in 1960’s first at Mumbai. The syllabus since then has not changed. This study clearly shows it needs to be updated. The reason why both residents and orthodontists were well prepared theoretically and clinically in the management by growth modification is that in practical examination this is one of the exercises; hence, it shows examination-related preparation then professional as very few want to practice later. To prepare students in the management of cleft lip and palate cases, the residents should be given a posting (2 months) to the smile train center/plastic surgery department of the medical college, and it should be made compulsory to show one cleft lip and palate patient in the examination, treated/undergoing treatment. Of the three groups, the poorest educational experience was with orthodontic surgical cases. To improve the standards in this area, the syllabus should mention a minimum quota of cases for example 10 cases, which each resident should treat and one case to be presented in the examinations. Thus, if the syllabus and examination pattern are updated the purpose of postgraduate education will be served – to train in areas which the society needs care and where the orthodontist likes to treat with quality and confidence so that the motto of dental education “Service to humanity” is truly fulfilled.

Conclusions

Based on these findings, several conclusions can be drawn. First, residents and orthodontists largely agreed that their classroom- and clinic-based postgraduate dental education prepared them well to treat patients of growth modification; however, both residents and orthodontist indicated they are less prepared to treat cleft lip and palate and surgical orthodontic cases. Second, actual behavior concerning the treatment for all the three groups of patients was significantly higher with both residents and orthodontist showing willingness to contribute to reducing the access to care problems in the society. Finally, an inverse relationship was found between the teaching program and actual clinical practice behavior of the respondent. Faculty members and administrators in orthodontic postgraduate programs should realize the important contribution, and these educational experiences can make to increasing access to care for the needy patients’ populations.