By William H. DeKock, D.D.S., M.S. *
Athanasios E. Athanasiou, D.D.S., M.S.D., Dr. Dent. **
Takayuki Kuroda, D.D.S., Ph.D. ***

* WFO Secretary-General: practice limited to orthodontics, Cedar Rapids, Iowa, U.S.A.

** WFO Vice-President: Professor, Department of Orthodontics, School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece; practice limited to orthodontics, Athens, Greece

*** Past Member of the WFO Executive Committee; Professor and Chairman, Maxillofacial Orthognathics, Department of Maxillofacial Reconstruction and Function, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan

The goals of the World Federation of Orthodontists are multiple and focus on the improvement of the delivery of orthodontic health care to our patients around the world. At the birth of the WFO in 1995, the WFO Executive Committee decided to take steps to aid the development of orthodontics as we enter the 21st century. In order to accomplish the goals, we found we needed some baseline data on how orthodontic practice was currently defined. After an exhaustive review of available reports, we found that no single source had completed a thorough evaluation on the status of orthodontics. As a result, an evaluation instrument was developed to obtain the necessary data.

Projects of this scope require input from many individuals. Sixty-nine of the WFO's organizations worldwide completed a lengthy questionnaire. The WFO is deeply indebted to those who completed their questionnaires. Much effort was required to obtain and report data consistent with the project guidelines. The results represent the status of care for more than half of the world's population, some 3.3 billion individuals. By any estimate, this is the most comprehensive survey on orthodontics ever completed.

The paragraphs below provide a brief summary of information that will be further chronicled in upcoming reports in the orthodontic literature. Even though we practice in different political and socioeconomic settings, we can learn much from the experiences of our colleagues. Our challenge becomes to use this knowledge to improve the quality of care we mutually provide.

Lee W. Graber, D.D.S., M.S., Ph.D.
President of the World Federation of Orthodontists

Beginning in 1997, the WFO commissioned a study of its 81 affiliated organizations for the purpose of gathering information about the global orthodontic community. There is need on the part of orthodontists worldwide to gain information on how the specialty of orthodontics is practiced and the methods used by professionals in different countries and regions to deliver orthodontic care. The data collected may be useful in understanding the various orthodontic practice characteristics, thus, contributing to any efforts undertaken for harmonization, upgrading and progress. This study is the first of its kind.

The method used to gather information was a 14-page questionnaire prepared and approved by the WFO Executive Committee that was divided into six sections consisting of 60 questions. The sections corresponded to the subjects of Regulations and Definitions, Legislation, Education, Human Resources, Orthodontic Practice Environment, and Characteristics of the WFO Affiliated Organizations.

The questionnaire was mailed in 1997 to all 81 affiliated organizations that comprise the WFO. Sixty-nine organizations from 61 countries responded (response rate of 85 percent). Responses were received during the period of 1997 through 1999.

The responses were grouped into six geographical regions:

· Africa and the Middle East (8 countries),
· Central and East Asia (6 countries),
· Central and South America (12 countries),
· Europe (26 countries),
· North America (3 countries), and
· Oceania (Australia and New Zealand), Singapore, Malaysia, Philippines and Indonesia (6 countries).

Although these six regions are not all "homogenous" concerning the socioeconomic, political and population characteristics, they still represent a well-defined group of states, many of which have many similarities and common history. Percentage ranges listed in the report below refer to reported differences between the six geographical regions used in this study.

The total population represented by the survey was 3.3 billion ? approximately 54 percent of the world population of 6.1 billion.

With the authorization of the WFO Executive Committee, the authors of this study intend to present the detailed survey data in future issues of the WFO Gazette and orthodontic journals that have international readership. In the meantime, important highlights from the gathered information are briefly presented below.


Regulations and Definitions

Orthodontics is a well-recognized dental specialty in all parts of the world (83 to 100 percent). Orthodontists are announcing to the public their exclusive practice without any legal or ethical limitations (83 to 100 percent), but the number of countries that have a written definition for "orthodontics" or "dentofacial orthopedics" surprisingly varies (33 to 92 percent). Similarly, national, state or provincial laws are not used to recognize dental specialties in a significant number of countries.


Legislation

A formal university or hospital-based postgraduate program is usually required to receive the title of orthodontist (75 to 100 percent), and the duration of the programs ranges from 22 to 50 months. Preceptor programs (working with a qualified orthodontic specialist for a specific time) with or without examination at the completion of the training still exist in certain regions of the world (12 to 20 percent). Qualification of a dentist as an orthodontist by examination is a common, but not universal, method (25 to 83 percent).


Education

Large variations exist between the countries and regions surveyed. The smallest number of dental schools was present in the region of Africa and the Middle East (26), and the highest number was in the Central and South America region (216). In Europe and Africa and the Middle East regions, most of the dental schools are public. In the four other regions, however, 50 to 60 percent of the dental schools are private. The undergraduate dental curriculum lasts four to six years.

Although most of the orthodontic postgraduate programs are in Europe, North America, and Central and East Asia, there are acceptable standards in each region. One fourth of these programs in Central and East Asia and Europe are located in medical hospitals, the military service or facilities other than dental schools.

Postgraduate students may pay tuition (12 to 100 percent), receive a stipend (0 to 67 percent) or practice part-time while receiving their orthodontic education (17 to 48 percent). Different degrees (M.S. or Ph.D.) and diplomas or certificates are awarded to the successful students of various postgraduate orthodontic programs.

Approximately 1,800 orthodontic residents are accepted each year in the estimated 340 programs of the countries that provided relevant data.


Human Resources

The total population of the countries surveyed covers 54 percent of the world, nearing the number of 3.3 billion. The number of dentists and orthodontists are 962,000 and 31,000, respectively. The highest ratios of orthodontists in relation to population (per 100,000 inhabitants) were found in North America, Central and South America, and Europe (1.4 to 2.6).

With regard to the issue of where orthodontists received their graduate training, the following is noted: A reduced percentage of students practicing in the same region where they received their training was found only in North America. This was mainly because many foreign students tend to complete their orthodontic education in North America and subsequently return to their homelands.


Orthodontic Practice Environment

The number of responses and the differences in the availability of accurate data do not allow direct comparison of areas of the world in regard to the environment in which orthodontic specialists practice. Notwithstanding this weakness, the data gathered indicate some interesting information.

In response to the question of how orthodontic treatment is financed, the geographical regions of Europe and North America have the most involvement of third parties. In Europe, only 29 percent, on average, of the orthodontic treatment is totally financed from patient or parent funds. In North America, 48 percent of the patients provide all of the funds for their treatment. The situation is different in the rest of the regions. In both Central and South America and Central and East Asia, 83 percent of the treatment is covered totally by patient or parent funds. All regions, with the exception of Europe, had a small amount of treatment totally financed by the government. In Europe, 25 percent of the treatment, on average, is totally covered by the government.

There was little difference in the regions of the world in response to the question of whether orthodontists practice by themselves or with other orthodontists. In all regions, 70 percent or more practice by themselves or with other orthodontists. A much smaller number of orthodontists practice with general dentists or other specialists.

Very high percentages of orthodontists in Europe and North America carry malpractice insurance in contrast to about 10 percent of their colleagues in Central and East Asia and Central and South America.

Orthodontists in Africa and the Middle East, North America, Central and South America, and Europe do at least one-half of the full orthodontic treatment cases. In Central and East Asia, specialists perform roughly one-third of the full orthodontic treatment cases.

The highest percentage (80 percent) of comprehensive orthodontic care performed only with fixed appliances is in North America and the region of Oceania, Singapore, Malaysia, Philippines and Indonesia. The most removable appliance orthodontic care is done in Europe where 40 percent of the orthodontic treatment only involves removable appliances. In response to the question on care with a combination of removable and fixed appliance therapy, 60 percent received at least some fixed therapy in Europe, 90 percent in North America and in the region of Oceania, Singapore, Malaysia, Philippines and Indonesia, and 75 percent in the other regions.


Characteristics of the WFO Affiliated Organizations

The American Association of Orthodontists (AAO) and the German Orthodontic Society (GOS) are the oldest national organizations for the specialty of orthodontics. The AAO was founded in 1900, and the GOS was founded in 1908. The respective organizations from Japan, Australia and Argentina were founded in the first third of the 20th century. The foundation and function of the WFO provided interest, guidelines and stimuli for the formation of many new societies of orthodontic specialists throughout the world during the period of 1993 through 1999.

All WFO affiliated societies have bylaws, regulations or a constitution, and 36 of them publish their own scientific orthodontic journal. The membership of each society varies from 2 members to 13,000. Presently, the number of WFO fellows has exceeded the 5,700 mark.

Further analysis, evaluation and interpretation of the outcome of the present study may significantly assist the WFO, national and regional orthodontic societies, national dental associations, health policy planning organizations, providers of dental and orthodontic care (in particular), and governmental agencies with improving existing standards in legislation, education and treatment.

The World Federation of Orthodontists acknowledges all national WFO affiliated societies and their representatives involved in providing the information, the members of the 1995-2000 WFO Executive Committee for initiating, approving and supporting this project, Ms. Lorraine DuPont, WFO secretary, for providing all logistic support during the survey, and Drs. M.A. Papadopoulos, A. Karamouzos and A. Mavropoulos of the Department of Orthodontics, Aristotle University of Thessaloniki for the statistical elaboration of the data.