After soliciting and sifting through hundreds of pages of written testimony, hosting three public forums and devoting nearly two years of work to the project, the committee completed the report¹ and presented it to the ADA House of Delegates in October. While the House made it clear that the report’s 114 recommendations are "not official recommendations or policy of the American Dental Association," it passed a resolution calling for the ADA president to appoint a committee whose responsibility would be planning the report’s dissemination. In addition, the Board of Trustees of the ADA directed the President to distribute the report to the various councils, commissions and agencies of the ADA and request that they evaluate the recommendations with the prospect of developing actions to achieve the anticipated goals.

Why is this report important? It represents the commitment of its many contributors to excellence and to an understanding that the profession and its partners must set aside parochial agendas to fulfill their social responsibility. It presents a guiding vision for the profession, a vision in which all people—whatever their status, whatever their age, wherever they live—have a right to good oral health. And it outlines the ways in which the dental profession, the primary combatant against the oral diseases and disorders that can affect health and well-being throughout life, can make that vision a reality.

It is clear that the health of the nation, including oral health, will continue to improve in the coming decades. There is a greater awareness among the populace of the importance of lifestyle behaviors. Scientific analysis has identified wide variations in oral diseases and conditions among different segments of the population.

With the anticipated increase in the U.S. population and the fact that this population is aging and becoming more diverse, we will see significant alterations in disease patterns, cultural attitudes and expectations about health care. There has been an acceleration in the rate of scientific and technological advances that will affect the manner in which health care is delivered. The emphasis for the future is going to be on promoting health, rather than preventing disease. Through health promotion, the public will become more aware of the need for health care and, with dentistry’s increased effort, will learn that oral health is integral to general health.

Increasing the number of dentists’ hours by producing more dentists may not be the most cost-effective way to increase productivity and, subsequently, dental services.

This article offers a digest of some of the report’s primary topics and its recommendations regarding them:

– the dental work force and its present and future role in clinical practice and management;

– financing of dental services;

– access to dental services;

– dental licensure;

– the regulation of dental professionals.

	CLINICAL DENTAL PRACTICE AND MANAGEMENT I: THE WORK FORCE

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The key to meeting the needs of the public lies in having a responsive, competent and elastic work force. It is imperative to have the right number of providers in the right places to allow the American public access to the dental services that they need.

The adequacy of the dental work force continues to be an issue of great concern to all who are involved with the delivery of services to the public. The demographic changes in the United States make it imperative for dentistry to analyze the profession’s ability to provide services, the needs of the consumer public and the fit between the two.

There are many factors involved in assessing the dental work force and determining whether any changes in its composition should be recommended. These include not only the gross numbers of dentists and the anticipated size of the American population, but also issues such as the number of part-time practitioners, the diversity and geographic distribution of the dental work force and dentists’ productivity.

Work force demographics. The makeup of the dental work force has changed significantly in the last 20 years, as particularly demonstrated by the enormous increase in the number of female dentists. According to the ADA census of dentists, the total number of active private practitioners in the United States increased from 116,208 in 1982 to 152,151 in 1999—a 30.9 percent increase.¹ (Active private practitioners are defined as dentists whose primary and/or secondary occupation is full- or part-time private practice.) The number of female active private practitioners increased from 3,029 to 21,960 during this same period, an increase of 625 percent. In the early 1970s, there were few female dentists. By 1982, female dentists composed 2.7 percent of the dentist work force; by 1999, they composed 14.4 percent.

Even if the trend in percentage of female graduates has stabilized, the number and percentage of women practicing dentistry will continue to increase. The ADA’s Dental Workforce Model forecasts that 29.2 percent of active private practitioners will be female by 2020.²

The percentage of those working part time (defined here as spending less than 30 hours per week in the office) has increased for both sexes. In 1999, the percentage distribution of female part-time dentists was double that of their male counterparts^3–5 (Table 1).

Diversity. By the year 2020, the U.S. population is expected to grow to 332,145,221.⁷ The rate of growth is expected to be 10 percent per decade from 1990 to 2020. During this period, it is anticipated that 55 percent of the growth in the U.S. population will be due to immigrants and their descendants. Growth will be greatest among Hispanics and African-Americans.⁷

Since 1990, however, there has been a 23 percent decline in dental school enrollment of Hispanic, African-American and American Indian students.⁸ Asians/Pacific Islanders represented 24.5 percent of first-year enrollees in 1998. Consequently, as the U.S. population is becoming increasingly diverse, the future supply of dentists is becoming less representative of the population it will serve.

Enrollment in dental schools and participation of minority populations in the allied dental fields are far below what is desirable in trying to achieve balance with the public’s present and future ethnic distribution. It is imperative that efforts be made to increase the participation of the growing minority groups in the dental profession.

Programs to address this issue should include, but not be limited to, outreach programs in the kindergarten–12th grade educational environments, community outreach efforts, public education programs, mentorship associations, scholarships and other incentive programs. Alliances with organizations outside the dental profession would foster a team effort that extends to every level of the social structure and lend greater importance to the initiative.

Productivity. One of the factors that the dentist:population ratio ignores is dentists’ productivity. Improved productivity means that fewer dentists can produce the same amount of dental services that in previous years required a larger number of dentists. Ignoring productivity changes is likely to lead to serious miscalculations in work force policy.

In their recent study, Beazoglou and colleagues⁶ showed that the total output (total production of services) of the dental care delivery system tripled between 1960 and 1998. Change in dental output results from an increase in the number of dentists or from improved productivity per dentist.

Increasing the number of dentists’ hours by producing more dentists may not be the most cost-effective way to increase productivity and, subsequently, dental services. Once other factors are held constant, neither sex nor age is a significant factor in productivity. Female dentists are just as productive as male dentists, and older and younger dentists can produce at the same rate.

Geographic distribution. The distribution of dentists varies substantially by geographic area. Reports indicate that specific geographical areas are either currently experiencing or predicting declines in the number of practicing dentists.^9–11

There are rather pronounced geographic imbalances in the dental work force. One of the reasons for these geographic imbalances is the rapid shifts that are occurring in the U.S. population, which increased from 248.7 million to 281.4 million between 1990 and 2000—a 13.2 percent increase.^12,13

While the number of dentists increased nationally and for almost all states between 1993 and 1999, the dentist:population ratios declined in about one-half of the states during that time^1,12,13 (Figure 1). Several rapidly growing states—Arizona, Georgia and Nevada, for example—saw their dentist:population ratios decline although they registered large increases in the number of dentists. Their populations simply were growing too quickly for the increase in dentists to keep pace. Other states—such as Minnesota, Missouri, Michigan, Nebraska and Wisconsin—showed declines in their dentist:population ratios even though their populations were not growing as quickly as the national average. The number of active dentists in those states grew little or not at all.

View larger version (44K): [in this window] [in a new window]   Figure 1. Changes in the dentist:population ratio, 1993–1999. Sources: American Dental Association, Survey Center1; U.S. Department of Commerce, Bureau of the Census.12,13

Regional work force issues do exist and may become more pronounced in the future. However, given these widely varying work force conditions among the states, it is apparent that one overall national policy will not fit the specific needs of various states. States with a sufficient number of practitioners will require a different policy than those states in which the number of dentists is declining. Those latter states face potentially serious work force issues that should be addressed with their state-specific needs and circumstances in mind.

Solving work force problems. To ensure that dental services are available to all who need them, it is imperative to establish the adequacy of the dental work force. The work force differs across the country and within specific communities. Factors that must be considered when evaluating the adequacy of the work force in any geographic area include the socioeconomic status, race and ethnicity, disability status and disease patterns of the population. Other factors that affect the capacity of the dental work force are productivity, efficiency, extent of duties of allied personnel, new technology and techniques, and emerging research that alters the manner of diagnosis and treatment.

The national supply of dental services will increase substantially because of enhanced dental productivity. Dental output can be increased through more efficient use of allied dental personnel. These factors indicate that an increase in the aggregate number of dentists may not be necessary. Nevertheless, the nation must be ready to act if circumstances change.

Although most dental care will continue to be provided by general dentists, there might well be a need for more practitioners in some specialties.

Flexibility is a desirable strategy for work force policy. If more dental capacity is needed, an attractive work force option is to adjust the number of allied dental personnel. This is a cost-effective means of generating additional dental services. However, dental hygienists and dental assistants are not available in sufficient numbers in some regions of the country. Open positions for dental hygienists in dental offices are difficult to fill, sometimes remaining vacant for extended periods.

Thus, recommendations contained in the Future of Dentistry report are directed to developing work force models that would be able to satisfy the oral health needs of the public and to continuously monitoring the work force size and capabilities.

Continued study of dental work force adequacy is essential. Studies should assess the number of dental care providers available to treat the public and should provide an in-depth analysis of the need for dental care as well as the demand for dental care. Research should address the capabilities and duties of the various members of the dental team and establish whether alterations must be made to ensure that the public can be adequately served.

Allied dental personnel. The dentist’s ability to expand the service capacity of his or her practice lies, in part, in the ability to delegate tasks to dental assistants and dental hygienists. Research from the 1970s has demonstrated that many functions could be delegated safely and effectively, and with a quality comparable to that of services provided by dentists.^14,15

Unfortunately, it is evident that there exists a shortfall in the number of qualified allied personnel for dental offices. Dentists in many areas of the country are finding it difficult to obtain the support necessary to operate their facilities so as to satisfy the demand from their patients. Beyond hygienists, the supply of dental laboratory technicians also is severely inadequate. It is important to ensure that there are sufficient numbers of allied personnel and that they are able to work in areas of the country where their services are required.

The increasing demand for preventive dental services requires greater use of personnel from the allied dental team. There are regional shortages of dental hygienists that increase the difficulty of fulfilling staffing needs. The lack of mobility of dental hygienists created by state licensure processes is another factor contributing to the staffing shortfall for dental hygienists. Varying levels of duties allowable in states cause discrepancies in training, ability and compensation. This, in turn, inhibits geographic mobility.

To encourage potential applicants to enter the profession, and to retain qualified hygienists and dental assistants, authorized duties should be commensurate in all venues. Furthermore, hygienists and dental assistants should be able to move from one state to another without having to undergo additional training, education or licensure.

	CLINICAL DENTAL PRACTICE AND MANAGEMENT II: THE FUTURE

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Table 2 shows patients’ use of selected dental services from 1959 to 1999 and demonstrates a move from restorative care to preventive care.^16,17 Such trends in the population’s disease patterns, along with changes in the population’s composition and advancements in the modalities of dental care delivery, make it necessary to envision the nature of dental practice during the next decade.

For example, research suggests that patient recall intervals may need to be determined on the basis of patients’ susceptibility to various oral diseases. Thus, as risk assessment strategies improve, patients at high risk of developing disease may require more frequent recall appointments than those at lower risk. Dentists will continue, in their treatment plan presentations, to educate patients about their oral diagnoses and associated treatment options, their risks of developing various oral conditions and the prognosis for those conditions.

The trends that have been observed over the past few decades in relation to the pattern of caries incidence should continue. The young people of today will continue to experience less caries as they advance to adulthood. As a result, the older adults, who will be retaining their teeth longer than in past decades, will require higher rates of diagnostic, preventive, periodontal, esthetic and endodontic care. That segment of the population that did not have the benefit of fluoride and other preventive modalities of care in their earlier years will continue to be high-level users of dental care.

As a result of easy access to information through electronic media, dental consumers will be more aware of the relationship among oral and systemic diseases, oral care products, technology and oral health clinical services. The anticipated increase in health promotion by the dental profession will make the public aware of the important role that oral health plays in general health.

There is no doubt that economic factors will, as always, play a major role in the demand for dental services. If the economy is strong over the long term, the desire for care will remain high, with an emphasis on elective and cosmetic care. A downturn in the economy could create market force changes that could decrease the demand for dental services and perhaps affect the ability of low-income or underserved populations to access care.

Clinical practices. The structure of the profession, while remaining similar to what we see today, may undergo some subtle changes. Although most dental care will continue to be provided by general dentists, there might well be a need for more practitioners in some specialties. The consumer public’s greater understanding of the health issues presented to them could well lead to more interest in and self-referral to specialty treatment.

It is anticipated that orthodontic care for both children and adults will continue to thrive. The need for periodontal services will increase, as will the demand for regenerative and cosmetic periodontal plastic surgery. The demand for endodontic services will remain high as many patients opt to maintain teeth rather than accept extractions.

Prosthodontic services will continue to be a major part of dental practice. While the percentage of the population that is completely edentulous will decline, it is anticipated that the absolute number of people with at least one edentulous arch will increase. Thus, the need for traditional removable prosthetic services will not decrease in the short term. Similarly, fixed prosthodontic services will continue to be in demand. With the increase in the number of dental implants placed, the restorative needs will grow commensurately.

The scope of practice of oral and maxillofacial surgery will continue to expand. With the advances in surgical techniques and the additional depth of training available in newly designed programs, there will be significant overlapping with the medical disciplines.

Should the possible link between periodontal disease and aspects of general health be established, the importance of dentists in clinical oral medicine will grow. Collaborations with physicians and other health care providers will become more important and widespread.

Thus, while technical and diagnostic capabilities may grow rapidly, the mix of services required by the public will not be as quickly altered. Dentists can anticipate a continuation of the modalities of care that they now provide while observing a gradual alteration in the mix of services that will be required.

Technological advances. The nature of dental office operation, both managerial and clinical, will continue to be affected by the rapid advancement in technology. While many offices are now comfortable with the use of computer technology for administrative functions and some simpler diagnostic services, the explosion of new approaches to dental care that are based in emerging technology will require greater sophistication on the part of the practitioner.

Data collection and documentation will become a valuable new tool for the dental practice. The communication of data will evolve so that all patient information will be instantly accessible by and transferable between dentists and other health care professionals. As a result, a major challenge for dental practice managers will be to achieve a coordinated, systematic and secure approach to the integration and application of information technology. Many of the issues in sharing data and setting up such systems are not solely technical in nature, but rather involve legal, economic and political considerations.^19,20

Computers will serve as decision-support tools in planning treatments that require the integration of multiple disciplines and types of clinical information. Software programs will help dentists filter, evaluate and prioritize information essential for establishing suitable treatment plans. As more patient data are stored on computers, outcomes analyses of patient records will become possible at three levels: patient, practice and population. Computers will aid dentists in the assessment of a patient’s health status over time.

In summary, dentists of the future will have to be far more computer-literate than today’s practitioners. The use of new technology will allow a higher level of care with greater efficiency and productivity. While the patient population will benefit from these advances, it will be a challenge for the profession to incorporate the advances into everyday dental practice.

	FINANCING OF DENTAL SERVICES

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While it is well and good to anticipate the improvement in dental care delivery and the efforts to solve the work force discrepancies that plague our profession, it would be shortsighted to ignore the importance of ensuring adequate financing for needed dental care. While most Americans can and do access dental services, and the dental care delivery system efficiently provides care for those who demand it, important barriers impede access for many people.

Four basic sources of funding for dental care are employer-based prepayment plans, direct patient payment, public prepayment and free care from the provider. Today, self-pay and private prepayment account for nearly equal amounts of payment for dental care, each at about 47 percent of the total.¹

It is anticipated that the present state of private dental prepayment will remain relatively stable in the next five to 10 years, with a small aggregate decline in volume. The continued reorganization of the financing of medical care might ultimately have a substantial impact on dental financing. Within the structure of dental prepayment, the percentage of the privately insured population with preferred provider organization plans will increase (as the trend shown in Figure 2^21,22 indicates), and indemnity and dental health maintenance organization enrollment will decline. In addition, there will be some increase in direct reimbursement and more interest in medical savings accounts.

View larger version (33K): [in this window] [in a new window]   Figure 2. Percentage of dentists participating in preferred provider organization, or PPO, and capitation (dental health maintenance organization), plans in 1995 and 1997. Source: American Dental Association, Survey Center.21,22

Thus, it is important that the dental profession encourage the dental benefits industry to streamline its procedures, reduce administrative burden and policy limitations and provide greater flexibility for covered individuals in reimbursement for dental services.

Dentists are reporting increasing frustration in dealing with dental benefits companies. A growing number of dentists are distancing themselves from dental insurance companies, proclaiming themselves to be "insurance-free." Bureaucratic and administrative problems, excessive and time-consuming paperwork and telephone activity, "lost" submitted forms and radiographs, interference with treatment, fee restrictions and payment delays are among the reasons cited. It is difficult to determine how significant the "insurance-free" trend will become, but it appears to be gaining acceptability and momentum. If the dissatisfaction becomes more widespread, it will negatively affect the value of dental insurance in the future.

Dentistry must commence constructive dialogue with third-party carriers designed to develop a user-friendly attitude and more efficient administrative procedures in their dealings with providers and purchasers. In addition, the dental benefits industry should shorten its response time for including scientifically accepted new diagnostic and treatment options as reimbursable procedures in its plans.

	ACCESS TO DENTAL SERVICES

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To ensure that the American public will have access to dental care without artificial barriers established by virtue of a lack of coordination between the dental profession and the financing institutions, organizational partnerships must be established. Such partnerships, formed with the best interests of the public at heart, can solve the problems that encumber patients, dentists and dental benefits companies. With the full cooperation and enthusiastic efforts of these parties, dental care will become more easily accessible for a large segment of the American public.

However, there remains a significant portion of the American people who are unable to access care for other reasons. The guiding vision for the dental profession is that all Americans will be able to receive the dental care they need, regardless of their financial, geographic or health status or other special circumstances. The dental profession is eager and willing to assist in securing access for all Americans. Providing access to dental care for all requires the cooperation of every segment of society, including policy-makers, the dental profession and the general population. Most dentists provide free or discounted care to people who otherwise could not afford it. But charity alone is not enough. We as a society—policy-makers, the dental profession, community leaders and the public—must summon the political will to break down financial and other barriers that diminish access to care.

The economically disadvantaged. There are two groups of people with low incomes: those below the poverty level and those at 100 to 199 percent of the poverty level. (The latter group sometimes is referred to as "the working poor.") These two groups together total 91 million people, or 34 percent of the U.S. population.²³ Within both of these groups are found a disproportionate number of blacks, Hispanics, American Indians and recent immigrants.

The dental benefits industry should shorten its response time for including scientifically accepted new diagnostic and treatment options as reimbursable procedures in its plans.

To address the needs of these populations, public funding should be expanded that would cover basic dental services for the long-term unemployed. To ensure participation by providers and improve access, dentists should be reimbursed at market rates for their services. For the working poor, new programs, subsidized in part by public funding, should be developed through which employees could purchase insurance plans directly from risk pools if their employers do not offer them.

The disadvantaged in geographically isolated areas. Additional efforts are needed to increase availability of care for disadvantaged groups in geographically isolated areas. The dental profession should encourage dentists to provide services in these locales. To accomplish this, incentives must be offered to attract dentists to underserved areas. These could include loan forgiveness, tax credits or adequate reimbursement rates for government-funded dental plans.

Special populations and people with disabilities. Access for special populations and people with disabilities is difficult because of the special needs of these people and the complex management of their care. Many of these patients are homebound, institutionalized or unable to cooperate with care in a traditional dental setting. Financing for the care of this group of people will require reimbursement rates at levels that will attract providers to undertake the additional training necessary to treat these patients. In addition, educational programs to equip providers with the necessary specialized skills should be developed and widely implemented.

The solution to these problems should include the development of publicly funded or subsidized programs that would serve people with disabilities, recognizing their special needs. Outreach programs at the state and local levels should be developed to meet the needs of patients unable to receive care in traditional dental offices.

Elderly people. Utilization of and access to dental care services among elderly people have increased, resulting in much improved oral health. This trend is likely to continue. Although many of the elderly can budget for dental care without dental prepayment, others might access care to a greater degree if prepayment were available. There is evidence that employers are reducing retirement-based prepayment coverage for their former employees. The establishment of tax-deferred dental/medical savings accounts in which the proceeds could be used by elderly patients during their retirement would be a large step in solving this developing problem.

	DENTAL LICENSURE

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The issues revolving around initial licensure and mobility continue to be debated. With the imbalance in the dental work force, it is imperative that the process be designed to both encourage dentists and allied personnel to move to areas where they are most needed and to ensure that the public will continue to be assured of the competence of the professionals providing the care.

Currently, dentists undertaking initial competency examinations face a wide variety of requirements in various states and regions of the country. First and foremost, the standard of care for dentistry is the same for all regions of the United States and should be applied universally for all patients. In addition, regional differences in examinations make it difficult for dentists to prepare for the various requirements. Also, for dentists taking the examination at a location where they do not reside or where they did not train, it is especially difficult to find patients exhibiting the appropriate case-mix required by the examination administered at that location. Dental schools often are required to alter their curricula to prepare their students for initial examinations in other regions of the country—alterations not necessarily indicated by dental science.

Thus, it is recommended that the dental profession establish as a goal the equivalence or unity of all examinations and examining bodies.

Specialty licensure. The knowledge and clinical skills of general dentists and ADA-recognized specialists differ substantially. As dental specialists continue their education and practice, their clinical skills become further removed from those they acquired in their original training as general dentists. In many areas, additional examinations are required for a specialty license. The requirement that previously licensed specialists be reexamined as general dentists when relocating is an unnecessary burden that does not protect the public nor improve patient care. Such a requirement forces specialists to practice outside the scope of their specialty to retrain themselves for a general dentistry examination.

The dental profession should encourage all licensing boards to develop guidelines and procedures that allow for the examination of educationally qualified specialists in their respective areas of expertise without requiring concurrent examination for a general dentistry license.

Licensure by credentials. The dental profession has supported the freedom of movement of dentists within the United States. This is an important principle of personal and professional freedom. More importantly, without such potential mobility, addressing regional and local work-force imbalances is more difficult. While the dental profession has supported the concept of licensure by credentials in all states, progress has been slow in the past few years. It is important that efforts to achieve licensure by credentials in all states be intensified.

	REGULATION OF DENTAL PROFESSIONALS

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In recent years, regulatory activity has had a profound effect on the manner in which dentistry is practiced. Whereas some of this regulatory activity has been appropriate and welcome, much of it has been justly criticized as being insufficiently substantiated by scientific data. Any regulations pertaining to dental practice must be based on valid scientific principles. Regulations will be beneficial only if they add safety and value to the services provided and if compliance does not place an unreasonable burden on practitioners. The dental profession must remain a leader in developing and influencing legislative and regulatory activity affecting dentistry.

Dentistry, and all of its partners, must continue to be vigilant and proactive in identifying and researching potential hazards that might affect the safety of patients, the dental work force and the environment. In addition, where hazards have been identified, the profession must be actively involved in advocating scientifically valid solutions.

	CONCLUSION

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Looking to the future and predicting what the oral health needs of our citizens will be and how to address them are formidable tasks. It is equally difficult to discern the problems that will confront our profession.

The goal of the 2001 Future of Dentistry Report is to help the dental profession cope with inevitable change, both at home and on the world stage. The findings and recommendations it contains were prepared by experts who came together because of a mutual desire to improve oral health by improving oral health care. The report addresses all issues that touch the profession—no matter how sensitive—and insists that parochial views be set aside.

This article but scratches the surface of the issues facing the dental profession. In addressing some of the problems that most affect practicing dentists, it is intended to stimulate interest and discussion so that all members of the profession can contribute to the process of moving forward.

What trends have been noted and what recommendations for the future have been presented will not come as a surprise to most, nor will they require radical changes in direction. They are components of a road map for the future that will benefit the profession and the public it serves. It is imperative that the journey be undertaken to achieve the ongoing success of the dental profession in fulfilling its responsibility to ensure the best oral health for Americans.