Workforce practices of orthodontists in Australia: now and in the future

In Australia, orthodontic treatment is principally carried out by orthodontists or general dental practitioners (GDPs). To be registered as an orthodontist in Australia, a dentist must have undertaken further training at an accredited Australian university or a recognised overseas institution.¹ The precise proportion of orthodontic treatment provided by orthodontists and GDPs in Australia is unknown. However, investigations conducted in Australia and abroad suggest that orthodontists remain responsible for the majority of orthodontic treatment, particularly for complex malocclusions, fixed appliance therapy or growing patients.^2–5

Several studies have indicated changes in the characteristics and working patterns of orthodontists in other countries. In the United Kingdom (UK), there appears to be an increasing number of male orthodontists leaving the workforce compared to a corresponding number of females who are reportedly entering the profession.^6,7 This so called “feminisation” of the orthodontic workforce is speculated to alter the supply of orthodontic treatment provision, as female orthodontists are reported to work fewer hours per week and take longer and more frequent career breaks compared to their male counterparts.^8,9 In the United States (US), there is a noted shortage in the number of orthodontists working in both academia and in rural areas, with this shortage expected to worsen into the future.^10,11 US trainee orthodontists have also been reported to be less likely to buy or open their own practices as their initial choice of employment, preferring to work in group practices or corporate companies.^12,13

These trends were reported over 10 years ago, and whether similar trends exist within the orthodontic workforce in Australia and internationally is unknown. The last Australian report on orthodontists’ working patterns was published almost 20 years ago and while it provided a snapshot of the workplace practices and demographic characteristics of orthodontists at the time, it did not speculate on how these workplace practices may change into the future.¹⁴ Recent studies investigating orthodontic treatment within Australia tended to focus on how and what populations received these services, with little emphasis on the workplace patterns of the providing orthodontists.^5,15

Studies from abroad suggest that the demand for orthodontic treatment is increasing.^16–18 However, as orthodontists retire and leave the Australian workforce, research is lacking regarding the entry into the workforce of newly qualified orthodontists. If the future workforce cannot meet the demand for orthodontic treatment, patients may increasingly seek orthodontic services from GDPs or direct-to-consumer (DTC) treatment providers. This may have potential ramifications for patients as the evidence suggests that orthodontists may be able to achieve higher quality treatment outcomes in less time compared to GDPs.¹⁹ In addition, while little research has been conducted on the potential harm of DTC aligners, several international organisations have warned of the possible risks when undergoing this treatment modality.²⁰

The aim of the present study was to investigate current and future workforce practices of qualified orthodontists (QOs) and trainee orthodontists (TOs) in Australia. The study also speculated on how the specialist orthodontic workforce in Australia may change in the future.

Following the removal of incomplete entries (28.8%; n = 77), 190 responses were recorded. This corresponded to response rates of 30.7% (n = 158) for QOs, 69.5% (n = 32) for TOs and 33.9% for the total eligible ASO membership.

The kappa value for components completed by QOs and TOs were 0.97 and 0.81 respectively, indicating good to excellent reliability for all components of the e-survey.

Metropolitan versus non-metropolitan practice

Almost half (48.3%, n = 75) of QOs respondents reported that they would only work in metropolitan areas compared with 34.3% (n = 11) of responding TOs. However, this difference was not statistically significant (p = 0.175). Figure 1 summarises the reported reasons why only working in metropolitan areas was chosen. QOs reported that there was “Enough work in metropolitan areas” (84%, n = 63) whereas “Prefer to be close to friends and family” was the most common reason for TOs (100%, n = 11).

Figure 1.

Factors reported to be relevant in decision of trainee and qualified orthodontists to only work in metropolitan areas.

Figure 2 shows the responses of the QO and TO respondents when asked what factors would most likely motivate them to work in non-metropolitan areas. Most of the TOs responded: “financial incentives” (54.5%, n = 6), whereas the QOs responded: “family or partner willing to relocate” (33.3%, n = 25). For QOs who responded: “other”, provided comments included “to grow the business”, “lifestyle change” while others commented that they “would never do it”.

Figure 2.

Factors which would most motivate trainee or qualified orthodontists to consider working in non-metropolitan areas.

Future trends

Using reported FTE units weighted against the respective response rates for QOs and TOs, Figures 3 and 4 demonstrate the predicted net changes in FTE units for the specialist orthodontic workforce over the next 10 years.

Figure 3.

Predicted FTE units entering and exiting the orthodontic workforce 2023-2033.

Figure 4.

Predicted net changes in FTE units for different types of orthodontic practice 2023-2033.

The survey data indicated that there will be a net loss of 47.07 FTE units from the specialist orthodontic workforce in five years’ time. In 10 years, the net loss will be slightly less at 40.69 FTE units (Figure 3).

Figure 4 demonstrates that over the next 10 years, non-metropolitan and metropolitan areas are predicted to experience a net loss of 39.96 and 0.68 FTE units respectively.

Respondents were asked to rate their concern for eight issues regarding the future of the orthodontic workforce in Australia (Table V). “Not enough orthodontists in academia” was rated as a “major concern” by most QOs (52.5%, n = 82). Table VI indicates the themes categorised according to respondent comments of other concerns regarding the future of the orthodontic workforce in Australia. Only the QOs provided comments.

Table V.

QOs and TOs concerns about the future of orthodontics in Australia

	QOs			TOs
	Neutral n (%)	Minor concern n (%)	Major concern n (%)	Neutral n (%)	Minor concern n (%)	Major concern n (%)
GDPs practicing orthodontics	13 (8.2)	74 (46.8)	71 (44.9)	4 (12.5)	15 (46.8)	13 (40.6)
Too many orthodontists	57 (36.5)	83 (53.2)	16 (10.2)	14 (43.7)	12 (37.5)	6 (18.7)
Not enough orthodontists in academia	21 (13.4)	53 (33.9)	82 (52.5)	11 (34.3)	10 (31.2)	11 (34.3)
Too few patients	62 (39.7)	78 (50)	16 (10.2)	13 (40.6)	14 (43.7)	5 (15.6)
DTC appliances	27 (17.3)	86 (55.1)	43 (27.5)	10 (31.2)	10 (31.2)	12 (37.5)
Corporate orthodontic practices	33 (21.1)	76 (48.7)	47 (30.1)	5 (15.6)	15 (46.8)	12 (37.5)
Not enough orthodontists in non-metropolitan areas	32 (20.5)	71 (45.5)	53 (33.9)	15 (46.8)	13 (40.6)	4 (12.5)
Artificial intelligence	43 (27.5)	90 (57.6)	23 (14.7)	13 (40.6)	12 (37.5)	7 (21.8)

DTC, Direct to consumer; GDP, General Dental Practitioner; QOs, qualified orthodontists; TOs, trainee orthodontists.

Table VI.

Qualified orthodontist concerns about the future of orthodontics in Australia (n = 19)

Theme	n (%)
Cost of specialist training	1 (5.2%)
Not enough trainee orthodontists interested in practice ownership	1 (5.2%)
Insufficient orthodontists	3 (15.7%)
Operating costs of practice ownership	2 (10.5%)
Lack of interest in specialty training	1 (5.2%)
Low quality orthodontic care driven by marketing	3 (15.7%)
Not enough orthodontists in academia	1 (5.2%)
Overseas orthodontists working in Australia without proper qualification	2 (5.2%)
Public not aware/appreciative of specialist orthodontic qualifications	2 (5.2%)
Shortage of orthodontists in non-metropolitan areas	2 (10.5%)
ASO not doing enough for members	3 (15.7%)
Staffing issues	3 (15.7%)

ASO, Australian Society of Orthodontists; N, number.

The aims of the present e-survey were to determine the current and future workforce practices of QOs and TOs in Australia. This is the first Australian survey undertaken and the findings provide valuable information regarding orthodontic practice both now and into the future. The information gathered can indicate whether the specialist orthodontic workforce will continue to meet the needs of patients seeking orthodontic care. In a world of increasing globalisation, the findings from the present study may also provide insight into trends which may also be occurring on a global level and hold some relevance to the orthodontic professions in other countries.

The findings of the present study suggested that the specialist orthodontic workforce in Australia is likely to experience a net loss in FTE units over the next 10 years, with a potentially larger drop occurring between 2025 and 2028. As orthodontists are responsible for the majority of orthodontic treatment carried out in Australia, this net loss in FTE units is likely to place a strain on the existing workforce and potentially reduce the availability of specialist orthodontic service provision in Australia.^2–4 In response to a reduction in FTE units, public demand for orthodontic treatment may be met by GDPs, DTC treatment providers or changing models of orthodontist service delivery. How and whether this potential shift in orthodontic service provision may affect patients is just speculation at this time, but the evidence suggests it may result in poorer treatment outcomes.^20,25,26

The loss in FTE units is likely to largely affect non-metropolitan areas with a predicted reduction of 28.5% and 0.2%, respectively, over the next 10 years. This is despite Australian Bureau of Statistics projections that populations in non-metropolitan areas will increase by 9.5% over the same timeframe.²⁷ In response to the reduction of specialist orthodontic services in non-metropolitan areas, tele-orthodontics may play an important role.²⁸

Tele-orthodontics enables orthodontists to remotely monitor a patient’s treatment progress through, for example, scans made using a smart phone which will potentially reduce the number of in-office visits.²⁸ However, the over-reliance on tele-orthodontics may erode rapport between patients and orthodontists, as well as exposing patients to cybersecurity issues with sensitive information transmitted through the internet.²⁸ Research has also suggested that approximately 15% of patients are ‘dissatisfied’ with tele-orthodontics and prefer in-office orthodontic visits.²⁹

In the present study, the reasons why QOs and TOs choose to work in non-metropolitan areas were mainly “prefer to be close to friends and family” and “enough work in metropolitan areas”. These findings appear to correspond with a systematic review regarding GDPs, in which social and professional isolation, increased workload, decreased access to education for their children, provided fewer job opportunities for a partner and an inability to integrate into the local community were reportedly major barriers to working in non-metropolitan areas.³⁰ Research into GDP working patterns also suggested that job security may be another concern when moving to non-metropolitan locations as these areas may not have sufficient patient numbers to adequately financially support a full-time practitioner.³¹

The present study found that “financial incentives” and “family or partner willing to relocate” were the factors most likely to motivate QOs or TOs to work in non-metropolitan areas. However, an investigation of general dental students suggested that alternative ways of improving the uptake of workers in non-metropolitan areas included fostering a “prior rural exposure”.³⁰ This involves a non-metropolitan upbringing and participation in clinical placements in non-metropolitan areas. It has been suggested that a “prior rural exposure” provides general dental students with an insight into the realities of working and living in non-metropolitan areas and may provide opportunities to build support networks that would streamline their pathway to working and acclimatising to these environments in the future.³⁰ Therefore, a strategy to promote the recruitment and retention of orthodontists in non-metropolitan areas may include increasing the intake of trainees with a non-metropolitan upbringing or introducing clinical placements in non-metropolitan areas during specialist training.

The findings of the present study indicated that TOs were more likely to pursue private employment over practice ownership or partnership/associateship positions. It is therefore considered that over the next 10 years, there may be a potential net loss of 74.11 and 12.12 FTE orthodontists in “solo owner” and “partnership/associateship” positions compared to a net gain of 35.35 FTE orthodontists in “private employee” positions. This was comparable to the findings of a survey of orthodontic residents in the US, where it was found that 46% of the residents intended to work as private employees compared to 20% who intended to pursue practice ownership.³² The rising cost of specialist orthodontic training programs in the US is suggested as the reason why TOs are increasingly choosing private employment over practice ownership and may also explain why a similar trend is occurring in Australia.³² Other contributing factors may include a perceived lack of business management skills and work-life balance disruptions, which have been found to be associated with the decline in practice management for general medical practitioners in Australia.^33,34 In future, the shift away from solo ownership may manifest as larger multi-clinician orthodontic clinics which are increasingly owned by corporate bodies.³⁵ How corporatisation of orthodontic care will impact on orthodontic treatment provision and outcomes is unknown. However, the Australian Dental Association has stated that “dental practices should be owned or at least effectively controlled by dentists” as “there is a potential conflict of interest between the responsibilities of an employed dentist and corporate owners of dental practices”, a sentiment which may be extended to orthodontic clinics.³⁶

In the present study, “not enough orthodontists in academia” was selected by responding QOs as an issue of major concern. Despite this, responses from TOs found that in the short term, it was intended that 5.6% of their weekly hours would be spent working in university or academic positions before transitioning to 11.6% in the long term. Over the next 10 years, this may potentially translate to a net gain of 8.52 FTE units for higher education positions. This is relevant as it suggests that TOs are showing a greater interest in university or academic positions and future shortages in this field may be less likely as studies abroad may suggest. For instance, a declining interest of orthodontic trainees in the US to pursue a career in academia was reported in 2020.³² The rising cost of education in the US was again posited as a reason why this might be the case.³² It should be noted, however, that surveys of orthodontic trainees in the US asked whether respondents were intending to pursue full-time academic positions only, and may not have accurately represented respondents who wished to pursue part-time employment, as in the present survey.^11,32

Approximately a quarter of responding QOs were female. This corresponded to the reported proportion of the ASO which is female (31%).³⁷ In comparison, a relatively higher proportion of responding TOs to the e-survey were female (n = 14, 40.6%). This may suggest that a trend for “feminisation” was occurring within the specialist orthodontic workforce as has been reported in other parts of the world.^6,7 Female orthodontists are reported to work fewer hours per week and take longer and more frequent career breaks.^8,9 Interestingly, this was not the case in the present study which found that males and females both produced approximately 0.83 FTE units/clinician.

The present study had limitations. Of note, the lower response rate which was achieved for QOs (30.7%) when compared to similar e-surveys conducted in Australia.^14,38 Additionally, the number of survey responses which were commenced but not completed (n = 77, 28.8%) may have been influenced by factors related to survey length, poor visual presentation and unstable internet connection.³⁹ The overall lack of input by the profession could be a reason why orthodontic research continues to lag behind medical research and serves as a reminder that greater participation in future surveys is required to ensure better validity of results.^40,41 In addition, while there was good test-retest reliability of the e-survey, planned working and retirement intentions may not always be the same as actual working and retirement intent. However, a systematic review of physician patterns regarding expected retirement age, found that generally the age physicians expected to retire tended to agree with their actual age of retirement.⁴² Furthermore, when speculating on future trends in FTE units, it was assumed that the hours worked and time proportioned between different types of practice would remain the same for TOs.

Despite these limitations, the present study is the first to report on the current and planned working intentions of both QOs and TOs in Australia. It will provide valuable information in the planning of orthodontic treatment provision and baseline data for future relevant research.

Almost one-third (29.9%) of the current specialist orthodontic workforce is expected to retire over the next 5 years

Shortages in specialist orthodontic supply are likely to affect non-metropolitan areas more than metropolitan areas

Trainee orthodontists are increasingly preferring private employment positions over practice ownership or partnership/associateship positions