Executive Summary

Rationale

Recent publications including the first-ever United States Surgeon General’s Report on Oral Health and emerging scientific literature underscore the inter-relatedness of oral health and general health, and the critical importance of broad access to basic dental services.  Ironically, these findings come amidst an ongoing, decade-long decline in the United States dentist-to-population ratio, growing numbers of dental health profession shortage areas, rising student indebtedness, widespread dental school faculty vacancies and mounting financial pressures in U.S. dental schools.  Renewed appreciation of these matters along with growing public concerns about disparities in oral health and access to care have raised questions about the adequacy of the supply and training of dentists.  These concerns have spawned interest among State and Federal officials about the public policy aspects of dental education.

This report, produced for the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) by the National Conference of State Legislatures (NCSL), was developed to inform State and Federal officials about key issues concerning the structure and financing of dental education and, in particular, to highlight salient public policy considerations.  The report’s primary focus is on predoctoral dental education (i.e., programs that award D.D.S. or D.M.D. degrees to graduates of U.S. dental schools).  However, efforts have been made to relate predoctoral dental education issues to broader workforce and access concerns, and to include discussion of the potential for dental residency programs to help prepare future practitioners to meet emerging population needs and expand access to dental services for underserved populations. 

The report is organized into five sections:

• Part one provides an overview of dental education in the United States and relevant public policy interests. 
• Part two highlights important features of dental education financing, trends in financing and emerging challenges. 
• Part three examines dental workforce issues and emerging challenges along with limitations of traditional approaches. 
• Part four offers considerations for addressing dental education and inherent public interests as matters of broad public policy.  Examples from three States are highlighted.
• Part five presents a summary and recommendations. 

Related data concerning dental education programs and States’ dentist workforce profiles are included in an accompanying figure and tables.

Key Findings

• Public policy makers–particularly State policy makers–and the public at large have long-standing interests in dental education that relate to public safety, practitioner competency and general availability of basic dental services.  Changes prompted by the landmark 1926 Gies Report fundamentally transformed dental education into the university-based system that still exists today.  However, the ability of the prevailing educational model to adequately impart the knowledge and skills necessary for dental school graduates to meet the oral health needs of an increasingly diverse and expanding population has been questioned by leaders within academic dentistry, the dental profession and other interested parties.
• Predoctoral dental education ^[1] in the United States is provided in 56 dental schools–36 are part of public universities; 15 are private schools; and five are private, State-related.  These 56 schools operate in 34 States plus the District of Columbia and Puerto Rico.  Twenty States have relatively little or no direct public investment in financing basic dental education programs (i.e., dental schools); and 16 States have no direct means of educating dentists to serve their populations.
• 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 during the 1980s, the closure of seven private dental schools and significant downsizing in remaining schools 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. 
• Total reported expenditures (excluding research) per full-time dental student equivalent for the 54 schools reporting data for FY2002 averaged $70,501 per year.  Reported costs vary by type of school with reported average total expenditures of $78,010 per student per year for public schools, $58,222 for private schools, and $45,899 for private-State related schools.  Clinical instruction is the major driver of dental education costs.
• Federal support for dental education was largely confined to short-term funding some 30-40 years ago and has been reduced significantly over the past 2 decades, to the point where less than 1 percent of predoctoral dental education revenues in 2001 came from Federal funds.  State and local government support for dental education in public dental schools declined by 25 percent in recent years, from 66 percent of total dental school revenues in 1991 to 49 percent in 2001, 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.  Declines in public funding for dental education are widely viewed as a significant factor in the closing and downsizing of U.S. dental schools over the past two decades and an impending crisis in dental education.
• Loss of Federal support, declining State appropriations and limitations of student-generated clinical revenue has resulted in greater reliance on tuition and fees over the past 2 decades.  The American Dental Education Association reports that indebtedness for dental school graduates averaged $118,720 in 2003, with public school graduates averaging $105,350 and private/State-related school graduates averaging $152,525.  The primary driver of student indebtedness has been escalating tuition costs which now exceed $50,000 per year in some private dental schools and $25,000 for in-State tuition in some public dental schools.
• Many are concerned about the impact of these changes on the affordability of dental education–particularly for economically disadvantaged students–and subsequent career and practice decisions.  Dentists with substantial levels of student debt (as a result of rising tuition levels) are unlikely to participate in public programs such as Medicaid that generally provide relatively low levels of reimbursement.  At least in the short term, dental schools are likely to continue to attract students because of the relatively good rate of return on investment in dental education.  However, rising dental education costs that translate into rising levels of student indebtedness are likely to influence who attends dental school as well as the segments of the population that dentists are likely to treat upon graduation.
• Vacant budgeted full-time dental school faculty positions have increased since 1992 for both clinical and basic science positions.  Vacant clinical science positions increased from 139 in 1992 to 245 in 2000–a 76.3 percent increase.  Falling sources of revenue–including public support for dental education–and resultant declining faculty salaries compared to the incomes of dentists in private practice are viewed as major contributors to widespread vacant dental school faculty positions. 
• Overall, 35 percent of the Nation’s dentists are over the age of 55, with 9 percent over the age of 65.  Furthermore, the proportion of practicing dentists who are women has risen from fewer than three percent in 1982 to 12 percent in 1990 and 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.  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. 
• The number of Dental Health Professions Shortage Areas designated by the 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 Dental Health Professions Shortage Areas.
• In 1995, the Institute of Medicine (IOM) called for the creation of a sufficient number of graduate dental education (residency) positions to accommodate all dental school graduates by 2005.  The IOM recommendation stems from analyses conducted by an expert panel on dental education, and essentially parallels prior recommendations by leaders within academic dentistry.  Implementation of universal requirements for dental residency training holds significant potential to address limitations inherent in current dental education programs, enhance the capacity of the future dental practitioners to meet the oral health care needs of an increasingly diverse U.S. population, and provide a mechanism for expanding access to care for underserved populations.
• Residency training as a prerequisite for practicing as a physician has been mandatory in medicine for some time, but State authorities generally have resisted taking this step for dentistry.  However, Delaware has such requirements for dentistry; and New York has enacted legislation that will require dentists to complete an accredited residency program as a prerequisite for initial dental licensure beginning in 2007.  Other States have initiated or are considering allowing a dental residency experience as an alternative to a clinical board examination as a prerequisite for licensure. 

Recommendations

The broad strategies for Federal and State policy development to enhance dental education and advance the public’s interests in having access to safe, competent practitioners prepared to address the oral health needs of a broad range of individuals include the following:

1. Link public support for dental education to public policy concerns (using approaches similar to those that have been adopted in the three State examples highlighted in Section IV).
2. Expand Federal and State programs that address dental student indebtedness and faculty shortages.
3. Develop and support a national strategy for implementing universal dental residency (PGY-1) training in order to accelerate system changes that will better serve the public’s interests.
4. Develop and maintain publicly available Federal and State data sources that adequately support workforce analyses and policy development.

Summary

The costs of acquiring dental education now far exceed the resources of the vast majority of United States 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 over 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 have recently surfaced for tying 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.

States and the Federal government have joint public interests in ensuring an adequate supply and distribution of qualified dental practitioners to meet the oral health care needs of the public.  Of particular concern to public policy makers are those members of the public who face significant barriers to accessing services (i.e., those who traditionally have been underserved–individuals with low income, developmental disabilities or medically compromising conditions; young children and the elderly; and those in remote rural or many inner-city areas).  The Nation also faces growing challenges in assembling an adequate dental workforce to provide dental services in military and public health facilities.  Building new dental facilities (e.g., in community health centers) may be a necessary antecedent for expanding care for underserved populations; however, new facilities without an adequate supply of dentists will not produce the intended results or prove to be a responsible use of public funds.  State and Federal efforts to address this concern have been sporadic, uncoordinated and largely inadequate.

Therefore, 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, SCHIP, and Medicare; and
• Which public policy interventions are necessary to ensure the availability of essential dental services to underserved segments of the population.

Leaders in the field of dental education, dental practice and related health policy have reached a considerable degree of consensus about what needs to be done to make dental education function in a manner that serves the longstanding fundamental interests of the public.   What remains is for leaders from the public policy domain–both at the Federal and State levels–to partner with professional leaders and vested stakeholders to purposefully address dental education as an essential National resource, as a National enterprise, and as a matter of broad Federal and State public policy.

Financing Dental Education: Public Policy Interests, Issues and Strategic Considerations

Introduction

Recent publications, including the United States Surgeon General’s Report on Oral Health (HHS, 2000), and an emerging base of scientific literature underscore the inter-relatedness of oral health and general health and the critical importance of broad access to basic dental services.  Ironically, these findings come amid an ongoing, decade-long decline in the dentist-to-population ratio, growing numbers of dental health profession shortage areas, and widespread faculty vacancies in dental schools.  Renewed appreciation of these matters, along with growing public concerns about disparities in oral health and access to care, have raised questions about the adequacy of the supply and training of dentists.  These concerns, in turn, have spawned interest among State and Federal officials about the public policy aspects of dental education.

This report, produced for the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) by the National Conference of State Legislatures (NCSL), was developed to inform State and Federal officials about key issues concerning the structure and financing of dental education and, in particular, to highlight salient public policy considerations.  The report’s primary focus is on predoctoral dental education–i.e., programs that award D.D.S. or D.M.D. degrees to graduates of United States dental schools.  However efforts have been made to relate predoctoral dental education issues to broader workforce and access concerns, and to include discussion of the potential for dental residency programs to help prepare future practitioners to meet emerging population needs and expand access to dental services for underserved populations. 

The report is organized into five sections. 

• Part one provides an overview of dental education in the United States and relevant public policy interests. 
• Part two highlights important features of dental education financing, trends in financing and emerging challenges. 
• Part three examines dental workforce issues and emerging challenges along with limitations of traditional approaches. 
• Part four offers strategies and policy considerations for addressing dental education and related public interests as matters of broad public policy. 
• Part five presents a summary and recommendations. 

Related data summaries concerning dental education programs and States’ dentist workforce profiles appear in the accompanying tables.