3.  Dentist Workforce Issues and Emerging Challenges

Overview of the U.S. Dental Care Delivery System

Number and Characteristics of Dentists: The ADA reported that 152,151 U.S. dentists were engaged in either full- or part-time private practice in 1999.  This number translates to a ratio of 1,873 people per active practicing dentist, up from 1,808 people per dentist in 1994.  Because only about 85 percent of dentists are primary care dentists (i.e., general dentists or pediatric dentists), the ratio becomes roughly 2,200 people per primary care dentist.  The population-to-dentist ratio, which has been increasing since 1994, is expected to begin increasing even more rapidly starting in 2010-2015, when dentists who graduated during peak dental school enrollment years begin to retire from the workforce.  Without the increase in enrollments that occurred as a result of Federal initiatives to expand dental class sizes and renovate dental school physical plants from the late 1960s to late 1970s (which added roughly 25,000 additional dentists–beyond historic trends in dental school enrollment), prevailing population-to-dentist ratios would be approximately 15 percent higher.

Overall, 35 percent of the Nation’s dentists are over age 55, with 9 percent over age 65.  Furthermore, the proportion of practicing dentists who are women has risen from fewer than 3 percent in 1982 to 12 percent in 1990 and to 13 percent in 1997, and is projected to increase to 22 percent by 2010 and 28 percent by 2020.  Older dentists and women dentists tend to practice fewer hours than their younger, male counterparts (Walton SM et al., 2004).  These workforce changes, combined with projected increases in the U.S. population, are likely to substantially exacerbate the challenge of providing broad access to dental services within the coming decade. 

Distribution of Dentists and Dental Health Professions Shortage Areas: The distribution of dentists varies considerably across States and regions.  Larger and more affluent States have more dentists.  This reflects the fact that dentists locate in areas where there is greater demand for their services.  The distribution of dentists across regions is projected to change somewhat during the next 20 years.  The New England and Mid-Atlantic regions are expected to average 10 to 15 more dentists per 100,000 people than the national average through the year 2020 (AADS, 1989).  The ratio for the South Atlantic region is expected to increase to the national average by 2010, and the Pacific region is expected to go from higher than average to below the national average. 

The number of officially designated Dental Health Professions Shortage Areas (DHPSAs) has been increasing, as detailed below.

• The number of Dental Health Professions Shortage Areas designated by the U.S. Health Resources and Services Administration (HRSA), Bureau of Health Professions grew from 792 in 1993 to 2,041 in 2002. 
• In 1993, HRSA estimated that 1,400 dentists were needed to provide services to residents in designated underserved areas; by 2002, the number of dentists required to meet corresponding population service needs had grown to more than 8,000.
• Recent data indicate that more than 40 million people live in DHPSAs   (Haden NK et al., 2003).

Delivery System Components:  Approximately 90 percent of the Nation’s dentists provide services in the private practice sector of the dental care delivery system.  The vast majority of private dentists operate independently owned solo or two-person practices.  More than 80 percent of dentists are general dentists, and roughly 3 percent are pediatric dentists.

Safety net facilities such as dental schools, community-based clinics, migrant and rural health centers, school-based or school-linked programs, and mobile vans that target underserved populations primarily in inner-city and rural areas are relatively few in number, but represent important access points for those who have difficulty obtaining care through the private sector.  Efforts to expand care through safety net facilities–including a significant new initiative by the Federal government to include dental clinics in all new Federally qualified health centers (FQHCs) or FQHC expansions–face growing challenges in recruiting and retaining dentists because of salary structures that generally cannot compete favorably with incomes derived from private practice.  Building clinics is relatively straightforward; staffing them is a decidedly more difficult challenge, in light of the current workforce situation and levels of student indebtedness. 

The dental care delivery system has been relatively conservative in its use of allied clinical personnel.  Most States allow dental hygienists to provide a limited scope of preventive services, usually under the supervision of a licensed dentist.  A small number of States also allow expanded-duty personnel with additional training to provide basic restorative procedures. 

In light of changing disease patterns, workforce and population trends, and concerns about access for growing numbers of low-income children and adults, disabled individuals, the elderly and other vulnerable populations, public officials have begun to focus on the optimal use of various types of health care personnel to deliver oral health services in more diverse settings in the future.  For example, some States have started to train physicians and other primary care personnel to provide oral health assessments and preventive services for infants and young children.   Engaging additional health care personnel (other than dentists) in the delivery of preventive oral health services may help reduce the incidence or severity of dental disease in certain segments of the population over time.  However, the need for dentists’ services is unlikely to decline in the foreseeable future and is likely to increase as the population continues to grow, diversify, age, and retain teeth for longer periods of time.

National and State Dental Workforce Requirements–Policy Considerations, Models, Projections and Designation of Underserved Areas: If one accepts the premise that some level of basic dental services is required by all members of society (albeit in varying amounts and at different intervals over the course of individuals’ lifetimes), then consideration of national and State workforce requirements and, by extension, the financing of dental education constitute matters of broad public policy.  However, little evidence exists to suggest that Federal and State policymakers have consistently embraced this role.  Part of the problem stems from failure to define those dental services that are considered essential health services (as opposed to services that are not related to disease or medical necessity–e.g., cosmetic services). 

The limitations of models developed heretofore for producing projections of dental workforce requirements also have undoubtedly contributed to lack of progress in this area.  In the meantime, reports continue to document:

• Growing disparities in access to dental services for growing segments of the population;
• Increases in the number of designated dentally underserved areas–that collectively represent an acknowledged need for more than 8,000 dentists to serve more than 40 million individuals across the United States;
• Impending acceleration of increases in population-to-dentist ratios; and
• Faculty shortages that are likely to increase and further undermine the infrastructure of dental education.

Dentist Workforce Policy Considerations

Disconnects between National and State Dental Workforce Policy Interests and Support for Dental Education:Evidence of a connection between national policies and support for basic dental education is meager.  Except for the period between 1960 and 1980, Federal support for programs that provide basic dental education has generally been lacking.  As a result, responsibility for providing major financial support for dental education has largely been taken up by States, although considerable inconsistencies exist across States and over time.

As noted previously, 16 States have no dental schools.  Although these generally are States with relatively small populations, many have experienced considerable population increases during the previous decade.  Eleven of these States have arrangements with seven dental schools to reserve first-year positions for a limited number of their residents.  Several States, most with in-State dental schools, also have relatively large numbers of students who obtain dental education in States other than their State of residence–most notably California (with more than 250 such students), Utah (with approximately 150 students) and, to a lesser extent, Florida, New York and Washington (with between 50 and 100 students each) (ADA, 2004a).  Utah does not have a dental school, but leads the Nation in the number of dental students per population.  The other States have dental schools, and all but Washington have more than one school.

A comprehensive analysis of dental school enrollment and dentists’ practice location patterns and trends relative to dental school attended is beyond the scope of this project.  However, data collected as part of this project (tables 2 through 7) demonstrate:

• Considerable variation in the percentage of dental school first-year positions reserved for in-State residents across all dental schools as well as across public dental schools;
• Considerable variation in the percentage of applications from in-State residents across all schools;
• Considerable variation in the percentage of in-State enrollees across schools and over time;
• Relatively low levels of applications and enrollees from under-represented minority groups; and
• Considerable variation in the percentage of dentists in States that have no dental school who graduated from dental schools in adjacent States.

Notes:
2001 professionally active dentists graduated from dental school between 1986 and 1995.
1991 professionally active dentists graduated from dental school between 1976 and 1985.
States with at least one dental school as of 2001.
Source: American Dental Association.

Notes:
2001 professionally active dentists graduated from dental school between 1986 and 1995.
1991 professionally active dentists graduated from dental school between 1976 and 1985.
States with at least one dental school as of 2001.
Source: American Dental Association.

Notes: An “adjacent” State is defined as a State that shares a common physical border with the referenced State. Regional and interstate agreements that allow a State to purchase dental school seats in another State are not included in determining adjacency.
* The one “adjacent” State for Alaska is considered Washington.  California is considered to be the one “adjacent” State for Hawaii.  No State adjacent to Montana has a dental school; Washington is the closest State to Montana in terms of distance.
2001 professionally active dentists graduated from dental school between 1986 and 1995.
1991 professionally active dentists graduated from dental school between 1976 and 1985.
States with no dental school as of 2001.
Source: American Dental Association.          

Table 5.  Dental Education Characteristics of States with Dental Schools

Notes:
*  The designation process used by the Federal government to determine Federal dental HPSAs is undergoing review and possible change.
** Nationwide totals/averages do not include Puerto Rico.

Notes:
* The designation process used by the Federal government to determine Federal dental HPSAs is undergoing review and possible change.
#  =   Since 2002, Arizona and Nevada have opened their own dental schools.
WICHE = Western Interstate Commission on Higher Education promotes resource sharing, collaboration, and cooperative planning among 15 western States and their higher education institutions.  Member States include Alaska, Arizona, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, North Dakota, Oregon, Utah, Washington and Wyoming.  California and South Dakota are affiliate States.  
SREB = Southern Regional Education Board, based in Atlanta, Georgia.

Table 7.  Characteristics of Dentist Supply, by State

Notes:
* The designation process used by the Federal government to determine Federal dental HPSAs is undergoing review and possible change.
Sources:  ADA, HRSA.

Traditional Mechanisms for Addressing States’ Dentist Workforce Needs

Producing Dentists or Subsidizing Dental Education for State Residents: Perhaps the most common mechanism States use to address dental workforce needs is to support educational opportunities for State residents to obtain a dental education by way of one of the following:

• Direct production of dentists in public in-State dental schools (currently 30 States plus Puerto Rico);
• Regional arrangements to provide first-year positions and/or favorable tuition for students from States that have no dental schools (e.g., the Western Interstate Commission for Higher Education (WICHE) program, the Southern Regional Education Board (SREB) and the New England Consortium); or
• State subsidies for students from States that have no dental schools to attend dental schools in other States.

Sixteen of the 20 States that have no State dental schools provide scholarships to State residents enrolled in dental school or per-student payments to specific dental schools where they have a special arrangement to accept students from their States (Bailit and Beazoglou, 2003).  The average level of scholarship or direct school subsidy varies, but generally allows students to pay a reduced out-of-State tuition rate that is close to the in-State tuition rate. 

Several State dental schools also accept significant numbers of out-of-State students.  Although these students usually have to pay higher out-of-State tuition, they still are heavily subsidized by the States in which the dental schools are located.  Seven schools fall into this category and collectively, they educate approximately 1,150 out-of-State students per year (Bailit and Beazoglou, 2003).

Reliance on Market Forces or State Residents Returning to Their Native States:  Some States that have no public dental schools provide little or no subsidy to students from their States to attend out-of-State dental schools, but have large numbers of students enrolled in such schools.  One such State has more than 500 State residents enrolled in out-of-State dental schools.  Another State with public dental schools has more than 2,000 State residents enrolled in private or out-of-State dental schools (Bailit and Beazoglou, 2003).  These are extreme examples of States that provide minimal subsidies for educating large numbers of dentists (in private or out-of-State public schools), many of whom return to their native State to practice.

Licensure Eligibility Regulations: It has become a common practice for States to use licensure regulations that broaden the range of dental board examinations that make a dentist eligible for licensure, make Foreign dental school graduates who complete U.S. dental residencies eligible for licensure, convey reciprocity or licensure by credentials to dentists who hold licenses in other States, and grant special licenses or provide incentives (e.g., limiting liability) for dentists who work in public health/safety net clinics to attract additional dentists.  However, absent changes in the production of dentists, these measures merely serve to influence the distribution of dentists; the gains in dentists achieved by some States are offset by losses in other States.

Dentist Recruitment Programs for Addressing the Needs of Underserved Areas: A limited number of States (e.g., North Carolina) also have active dentist recruitment programs for addressing the needs of underserved areas.  These programs typically seek to attract dentists to underserved communities by setting up clinical facilities that lower the dentists’ start-up or overhead costs or by offering loan forgiveness programs.

Loan Repayment or Loan Forgiveness Programs for Dentists:  A growing number of States have initiated loan repayment or loan forgiveness programs for dentists who agree to practice for stipulated periods of time in underserved areas or serve specified levels of individuals covered by public programs (e.g., Medicaid).  This option has been especially popular among rural States that do not have dental schools.

Emerging Challenges and Limitations of Traditional Approaches

Growth and Diversity of the Population: The demographic characteristics of the U.S. population are changing rapidly, with greater numbers of older, sicker and more ethno-culturally diverse people in need of dental services.  At the same time, there is growing recognition that the practice of dentistry is becoming increasingly complex, with new clinical and technologic information competing for time in overcrowded dental curricula with the time required to teach traditional clinical skills (ADA, 2001).  Furthermore, there is growing agreement that an additional year of education and clinical training would enhance the ability of future dentists to treat patients with complex needs.

Dental Service Needs Relative to the Overall Supply of Dentists’ Services: The substantial number of dental health professions shortage areas; limited access to dental services for individuals who are covered by public programs, are disabled or are living in institutional or residential settings (e.g., nursing homes); and difficulties recruiting dentists for community health centers, military and faculty positions serve as indicators of a growing need for concerted public action to address current and emerging oral health needs of the U.S. population.  Individual States have responded to emerging dental workforce issues by reducing barriers to licensure.  Although such changes may produce short-term improvements in the supply of dentists and services in some States, they are likely to exacerbate declines in services in other States and in already underserved areas (e.g., rural areas and inner cities), especially during a period of declining dentist-to-population ratios and professional demographic trends that portend reduced availability of dental services. 

Rising Educational Costs and Problems Inherent in Current Financing Schemes: The costs of acquiring dental education now far exceed the resources of the vast majority of U.S. families.  At the same time, dental schools are struggling to cover the costs of providing dental education in the face of declining public support and business models that generate gross imbalances between predoctoral program clinic revenues and costs of operation.  The result has been significant increases in tuition and fees and corresponding increases in student indebtedness during the past several years.  Although the return on investment to acquiring a dental education remains favorable, the debt levels that most students now acquire to finance their education are likely to influence their career decisions in ways that do not bode well for expanding access to dental services for underserved and vulnerable populations.  Proposals recently have  surfaced to tie additional training to debt reduction through service to underserved populations; however, the underlying vision has yet to be established in a broad public policy framework.

In light of these trends and the limitations of traditional approaches, a more proactive, systematic strategy seems to be necessary to address the shortcomings of the current system.  The following section outlines several strategies for overcoming these limitations.