1.  Dental Education in the United States and Related Public Policy Interests and Issues

Overview of Dental Education in the United States

Basic Dental School Curriculum: Since the 1920s, the education of dentists in the United States typically has consisted of 3 to 4 years of undergraduate (baccalaureate-level) university education, followed by 4 years of professional (predoctoral) training in dental school.  The 4 years of dental school generally are organized into basic science and pre-clinical instruction in the first 2 years of the curriculum and clinical science instruction in the latter 2 years.  Thus, the basic format for dental education, established shortly after the landmark Gies Report on Dental Education in the United States and Canada, (Gies, 1926) which highlighted the need for a separate (from medicine) university-based, science-grounded course of study for dentistry, has remained fundamentally unchanged for nearly 80 years.

Accelerating expansion of knowledge in the basic and clinical sciences and growing challenges in serving an increasingly diverse population has placed considerable pressure on dental schools to incorporate and translate new findings into the knowledge and skills that future practitioners need to meet the emerging needs of the population.  Medicine has long accommodated these pressures through universal incorporation of residency training programs that allows predoctoral education to focus primarily on knowledge acquisition and exposure to an array of clinical experiences and career possibilities, while acquisition of advanced clinical skills and treatment of more difficult patients occur in residency programs.  Dentistry has been reluctant to adopt universal residency requirements as a prerequisite for licensure (although some States are now moving in this direction).  Despite the lack of a requirement for dental residency training, a substantial proportion of dentists (equivalent to roughly 65 percent of the number of United States dental school graduates) currently enroll in dental specialty or general dentistry residency programs (Haden NK et al., 2003).

U.S. Dental Schools:  At present, basic (predoctoral) dental education ^[2] in the United States is provided in 56 dental schools.  Thirty-six are part of public universities; 15 are private schools (meaning they receive no direct State aid); and 5 are private, but State-related (meaning they receive a per capita enrollment subsidy from the State).  These 56 schools operate in 34 States plus the District of Columbia and Puerto Rico (Haden NK et al., 2003).  Arizona, Massachusetts, and the District of Columbia have only private dental schools; Wisconsin has only a private State-related school; Pennsylvania has one private and two private State-related schools; and Puerto Rico has one public dental school.  Of the remaining States, 20 have relatively little or no direct public investment in financing basic dental education programs (i.e., dental schools) and 16 have no direct means of educating dentists to serve their populations. ^[3]

During the latter half of the 1900s, the number of U.S. dental schools increased from 42 in 1950 to 47 in 1960, to 53 in 1970, and to 60 in 1980; however, between 1985 and 1995, the number of dental schools declined to 54 due to the closure of 6 private dental schools.  Moreover, reductions in class sizes in schools that remained open, combined with the closures noted above, resulted in the equivalent of 20 average-size schools being closed between the early 1980s and 1990s (out of a total of 60 schools).  Accordingly, the supply of U.S. dental school graduates decreased from a high of 5,756 in 1982 to 3,778 in 1993.  One additional private school has closed during the last decade, while 3 new private schools have opened–resulting in the current level of 56 schools and approximately 4,200 graduates.  Meanwhile, the U.S. population has continued to expand, age, and become more diverse throughout the entire period.

Figure 1 shows the location of the Nation’s dental schools and whether they are public, private or State-related.  A detailed chronology of the numbers of United States dental schools and dental school enrollees and graduates can be found in table 1. 

Figure 1. Location of United States Dental Schools, by Type of School, 2003

[D]

Source: American Dental Association  (ADA), Health Policy Resources Center, The Economics of Dental Education (Chicago: American Dental Association, 2004a).

Note:  *Graduate data are for the ending year of the academic year.

Source: American Dental Association, Council on Dental Education. Dental Students' Register. 2000/01 Survey of Predoctoral Dental Education. Academic Programs, Enrollment, and Graduates, Vol 1 (Chicago: ADA, 2002). Prior annual reports were also used.

Dental Residency Programs:  Dental residency programs provide advanced education for dentists who wish to become dental specialists or acquire additional training in general dentistry. ^[4]   A recent American Dental Education Association report (ADEA, 2004) identified 727 dental residency training programs in the United States in 2003, 355 at dental schools and 372 at sites other than dental schools, (e.g., hospitals).  These programs include 421 dental specialty programs, 204 general practice residency (GPR) programs, and 95 advanced education in general dentistry (AEGD) residency programs.  Total first-year resident positions in these programs number 2,838, roughly equivalent to two-thirds of the current number of graduating dentists (although some resident positions are occupied by non-United States dental graduates, i.e., foreign-trained dentists).  Residency training is required to practice in any of the nine recognized specialties of dentistry, but, somewhat ironically, is not required (except as noted below) for the predominant mode of practice that has the broadest potential scope of services–general dentistry.

For some time, Delaware alone has required graduation from a dental residency as a prerequisite for licensure.  However, New York has recently enacted legislation that will require dentists to complete an accredited postdoctoral general practice or specialty dental residency program of at least 1 year's duration (often referred to as PGY-1) as a prerequisite for initial licensure in New York State beginning in 2007 (NYSDA, 2004).  Thus, new State legislation will eliminate clinical examinations in favor of universal residency training as a requirement for dental licensure in New York.  Other States (e.g., California, Connecticut, and Minnesota) have initiated or are considering allowing a dental residency or PGY-1 experience as an alternative to a clinical board examination as a prerequisite for licensure.

Differences Between Dental and Medical Education and Routes to Professional Practice:With the exceptions noted above, most States allow graduates of U.S.-accredited dental schools to sit for State or regional board examinations that are needed to obtain a license to practice dentistry (i.e., without first completing a residency).  Medicine has long required residency training as a prerequisite for practicing as a physician; for the most part, however, dentistry and State licensing agencies have resisted taking this step.  Nevertheless, there appears to be growing acceptance and appreciation–at least among many educators and public policy makers–of the value of a residency experience with respect to preparing practitioners to meet the future oral health needs of the population. 

The lack of a residency requirement for dentistry has meant that basic dental school curricula have been structured heretofore to attempt to prepare students for direct entry into practice upon graduation.  The limitations of this approach, cited in major critiques of dental education programs (IOM, 1995; Kennedy and Crall, 1992), are beginning to be more widely acknowledged.  Concerns about the limitations of the traditional approach to educating dentists, which has remained fundamentally unchanged since the early part of the 20^th century, include:

• Growing difficulties in incorporating an expanding basic and clinical science knowledge base and the range of clinical experiences necessary to serve the needs of an aging and increasingly diverse population within the constraints of dental school curricula; 
• Growing disparities between the extent of clinical competencies afforded by dental school curricula and the scope of procedures performed by practicing dentists;
• Difficulties in converting clinical training components that focus primarily on the acquisition of technical/procedural skills into programs that focus on comprehensive patient care and utilization of allied dental personnel;
• Limited exposure to diverse patient populations in diverse clinical settings (especially in community-based settings outside dental schools);
• An inordinate emphasis on preparing students to pass clinical board examinations at the expense of patient-centered care; and
• Little or no opportunity for selective focus on areas of interest outside essential competencies in the predoctoral dental curriculum (Kennedy and Crall, 1992; Kennedy and Tedesco, 1999).

Additional consequences of the failure to adopt residency training as a prerequisite for practice include:

• The need to assess professional competencies for entry into clinical practice after a limited period of clinical education (generally 2 years or less in many schools);
• Licensure examinations that generally rely on criteria relevant to general dentistry even though over 20 percent of dentists practice as dental specialists;
• A reliance on using patients for dental licensure examinations;
• Failure to adequately define an essential core set of clinical competencies (skills) for graduates of all predoctoral dental education programs; and
• Failure to recognize the predominant mode of dental practice–general dentistry–as a legitimate specialty of dentistry, with the attendant failure to develop a valid academic discipline and faculty base to serve as the foundation for basic professional education in general dentistry.

Public Interests in Dental Education

Safety and Competency of Practitioners: Public policy makers–particularly State policy makers–and the public at-large have longstanding interests in dental education that relate to public safety, practitioner competency and general availability of dental services.  Prior to the late 1800s, no special educational prerequisites existed for the study of dentistry and practically no legal restrictions on its practice (Gies, 1926).  Beginning in 1886, however, States began to regulate dental practice and place educational restrictions on individuals who sought to practice dentistry within their jurisdictions.  These changes led to increased enrollment in dental schools and the opening of many new schools–a good number of which were proprietary commercial operations of dubious quality.  Changes brought about by recommendations contained in the landmark 1926 Gies Report (Gies, 1926) fundamentally transformed dental education into the university-based system that exists today.  However, the ability of the prevailing model (which allows dental school graduates to enter general practice without additional residency training) to adequately impart the knowledge and skills necessary to meet the oral health needs of an increasingly diverse and challenging population has been the subject of considerable debate.

Access to Services: States and the Federal government also have joint public interests in ensuring an adequate supply and distribution of qualified dental practitioners to meet the oral health care needs of the general public.  Of particular concern to public policy are those members of the public who face significant barriers to accessing services and have been underserved–individuals with low incomes, developmental disabilities or medically compromising conditions; young children and the elderly; and those in many rural or inner-city areas.  The extent and effectiveness of Federal and State policies and programs to achieve the goals of adequate distribution of providers and broad access to basic dental services has been modest.

Salient Public Policy Issues

The situation with respect to the number and distribution of dental schools in the United States is decidedly different from that which prevails for medical education, where all but 4 States have at least one medical school ^[5] and every State has numerous medical residency programs.  Not only do 16 States have no direct means to educate dentists to serve their populations, but several States have no dental residency programs.  This difference may reflect historical perspectives that have not regarded dental services and dental education as broad public policy interests.  Three salient public policy considerations that lead to that conclusion are summarized below.

Public Support for Dental Education:Although dental education plays a crucial role in preparing dentists and other health practitioners to meet the oral health needs of the public, a review of the history and financing of dental education in the United States suggests little regard for dental education as a matter of broad public policy.  For example:

• Federal funding for dental education has been highly variable and has significantly declined during the past 2 decades, to the point where less than 1 percent of predoctoral dental education revenues in 2001 came from Federal funds (ADA, 2004a). 
• State and local government support for dental education in the Nation’s 36 public dental schools declined by 25 percent in recent years.  Support declined from 66 percent of total dental school revenues in 1991 to 49 percent in 2001 (ADA, 2004a), and continues to fall. 
• State and local government support for dental education in private dental schools declined from 10 percent in 1991 to less than 3 percent in 2001 (ADA, 2004a). 

Declines in public funding for dental education are widely viewed as a significant factor in the closing and downsizing of United States dental schools during the past 2 decades and as an impending crisis in dental education.

Public Support for Dental Services: Access to health services is a major public policy issue for both State and Federal governments, one that continues to receive considerable attention.  However, similar to the situation with respect to dental education, a review of Federal and State involvement concerning access to dental services suggests little regard for access to oral health services as a matter of broad public policy.  Examples include:

• Dental services for children enrolled in Medicaid are designated as “optional services” and are required only by virtue of Early and Periodic Screening, Diagnostic and Treatment (EPSDT) provisions (CMS, 2004).
• The Federal legislation authorizing the Children’s Health Insurance Program (CHIP) designates dental services as “optional”.  And, although, 49 States have included dental benefits in their CHIP programs, recent history suggests that State budget pressures can lead to erosion or elimination of CHIP dental benefits. 
• Dental coverage for adults enrolled in Medicaid is essentially at the discretion of individual States and is nonexistent or extremely limited in more than 40 States. 
• Medicare does not provide coverage for dental services, except in relatively rare circumstances. 

Dental Workforce Issues:The availability of dentists is critical to ensuring the full range of services that are essential to meet the basic oral health needs of the public, and thus represents a broad public policy interest.  However, Federal and State involvement in matters concerning the adequacy of the dental workforce has been intermittent, uncoordinated, and inconsistent. 

• Substantial Federal funding initiated in the late 1960s to modernize dental school facilities and stimulate increases in the production of dentists resulted in a significant, albeit short-term, increase in dental school graduates from the mid-1970s to the early-1980s.  During that period, the number of U.S. dental school graduates increased from 3,775 in 1971, to roughly 5,300 per year during the latter half of the 1970s, to a high of 5,756 in 1983. 
• However, subsequent reductions in Federal funding for dental education combined with weak economic conditions and declining State support for dental education during the 1980s contributed to significant reductions in the production of  dentists thereafter.  Seven private dental schools closed their operations.  Moreover, a report issued by the Institute of Medicine (IOM, 1995) noted that dental school closures and downsizing during this period eliminated the equivalent of 20 dental schools in the United States.
• By 1985-86, fewer than 5,000 dentists were graduating from U.S. schools; by 1990, graduation levels had dropped below 4,000 per year and have increased only slightly since then (ADA, 2004a). 

Thus Federal efforts to influence the quantity of dentists in the United States were largely confined to short-term investments some 30 to 40 years ago. 

Federal and State efforts to influence the geographic distribution of dentists to ensure ready access to dental services by all segments of the population also have been inconsistent and only marginally effective.  For example, the Surgeon General’s Report on Oral Health (HHS, 2000) noted that, in FY 1999, the National Health Service Corps (NHSC) provided only 139 dental loan repayment awards at a time when there were approximately 1,200 designated dental health professions shortage areas in the United States.  Meanwhile, the U.S. population continues to expand, age, and become more diverse; the demand for dental services continues to rise; and public concerns are mounting about oral health disparities and access to basic dental services for growing numbers of children, adults and senior citizens throughout the United States.

Summary:  Emerging evidence that underscores the importance of oral health and access to basic dental services and concerns about disparities make this an auspicious time for State and Federal policymakers to exert leadership in this area.

Salient public policy issues that merit consideration and have important consequences for the future of dental education and broad access to services in the United States include:

• The extent to which dental education constitutes a general public good that warrants broad, sustained Federal and State support and monitoring;
• The extent to which dental services are essential health care services that warrant inclusion in public benefits programs such as Medicaid, CHIP and Medicare; and
• Which public policy interventions are necessary to ensure the availability of essential dental services to underserved segments of the population.