As the FOD report^1p38–42 states, the problem is compounded by predictions regarding dentists’ career plans and the inevitable graying of the largest majority of dentists. In the state of Washington, Washington State Dental Association’s 2001 Survey of Dentists reveals that our dentists are significantly older than the national average for dentists. Maybe our healthy northwestern lifestyle allows us to live and practice longer. That same lifestyle also maybe leading more dentists to earlier retirements. The survey disclosed that half of our dentists plan to retire by 2013, and that is an emerging crisis. (Copies of the survey, conducted by the University of Washington Center for Health Workforce Studies, are available from WSDA. E-mail requests to "dave{at}wsda.org".) The FOD report^1p39 indicates that there are similar problems in many states.

As the FOD report^1p37 also points out, a more precise focus in meeting patient demand is mostly a question of dental office productivity. This is a much more complex problem that involves issues of training, technology, reimbursement and regulation of dental practice, in addition, of course, to the personal practice objectives of each dentist (specialty, general, boutique, niche).

1 American Dental Association. Future of dentistry: Today’s vision, tomorrow’s reality. Chicago: American Dental Association, Health Policy Resources Center; 2001.

Dr. Staubach: It is indicated in the FOD report that "there is no overall shortage of dentists in the work force, but rather a maldistribution." At the present time there is no overall shortage of dentists. Yes, there is a definite case of maldistribution. I have been witnessing a continuous migration of dentists toward the more affluent suburban and, perhaps, urban areas. For example, we in York County, Pa., have tried for years to have specialists in dentistry (for example, endodontists, oral and maxillofacial surgeons) come to our area, where services provided by these dentists are in great demand. Most specialty groups gravitate to the well-heeled counties such as Bucks County.

On a local level, the general practitioners are centered in the more upscale communities rather than center city York and its juxtapositioned neighborhoods.

Q The diversity of the dental work force does not reflect the composition of the U.S. population. What step(s) would you suggest to increase the number of under-represented minorities entering the various dental professions?

Dr. Harms: Although the dental work force has become much more diverse in some areas (the number of female dental school graduates has more than doubled from 1982–1999), a number of minority groups are still under-represented. The Future of Dentistry Oversight Committee spent a great deal of time discussing this issue, which we believe ties directly to access in some areas. I believe that this is one of our most difficult problems to solve, and it requires a joint effort with our public education system. Past attempts to recruit students of diversity to dental school at the college level have not proven successful. I believe that we need to begin planting the seed with minority populations at the elementary school level, by working with local school districts. Dentistry is a wonderful profession, and its flexibility, the ability to work in an independent manner and the fact that we are able to help people every day could be highlighted. Perhaps scholarships could be offered to those willing to pursue dental school.

The best way for dentistry to capture the intellect and hearts of minority students is to begin to treat them as a part of the profession’s dental practice family.

Dr. Casamassimo: Current attempts to recruit minority students to dentistry have found and will continue to find marginal success due to a very limited and highly mined applicant pool. Every segment of society that mirrors the same disproportionate societal reflection as dentistry is competing for the same small pool of qualified people from the minority community. Significant resource allocation is devoted to this competition, and, unfortunately, the edge belongs to professions and careers without the "front-end" economic or time investment of dentistry and to those that are more in the mainstream.

The obvious ethical and logical answer to this problem is to cultivate the applicant pool so as to interest these young people in dentistry. The Future of Dentistry report correctly recommends a sea change to address this issue with collaboration with all communities of interest, but this will not be easy. The obstacles that inner city and poor rural school systems have today in providing equal opportunity for under-represented and disadvantaged students from kindergarten through high school will not go away. Dentistry will have to reach deep into the potential pool of applicants and find ways to provide assistance and direction well before secondary school. Ironically, these same students we hope to interest in dental careers often have the poorest oral health¹ and have little exposure to our caring profession. As hard as it may be for some readers to accept, the best way for dentistry to capture the intellect and hearts of minority students is to begin to treat them as a part of the profession’s dental practice family. This will require both a better system of access and a real welcome, which is not always the case for low-income patients.² They will watch, learn, experience the sense of caring and want to be a dentist. Many of us have planted the flame of dentistry in the heart of a young person—these were once just males, but now are females in increasing numbers. Why can’t they also be young people of color? If we answer the question of disparities in oral health, then we will have the beginning of the answer to how to increase the diversity and representation of society in dentistry.

1 U.S. Department of Health and Human Services. Oral health in America: A report of the surgeon general. Rockville, Md.: U.S. Department of Health and Human Services, National Institutes of Health; 2000. NIH publication 00–4713.

2 Mofidi W, Rozier G, King RS. Problems with access to dental care for Medicaid-insured children: what caregivers think. Am J Public Health 2002;92(1):53–8.[Abstract/Free Full Text]

Dr. Parrish: All of us were influenced by someone—usually a significant relative, friend, classmate, teacher or perhaps dentist—to consider dentistry as a career. Just continue to remind ADA members of the positive impact they can have in a young person’s life and the need and obligation we have to the profession to find likely prospects. If we are reminded to do this more often, more opportunities for this kind of seed-planting will occur. The next generation of dentists is often right in front of us among our patients and staff members. The component and constituent socities need to identify candidates and begin mentoring these individuals in the "predental" years to contribute valuable perspective, experience and support. Next, dentist mentors are always needed and welcomed at dental schools. At the end of the line, we also need to be reminded to share our blessings with contributions to foundations that provide scholarships. In many ways, this is a societal issue affecting many professions well beyond dentistry; with continued shifting demographics, it will require long-term commitment to make even some progress.

Dr. Staubach: The FOD report states, "Today’s dental workforce is not representative of the ethnic composition of the population. Furthermore, enrollment in dental schools and participation in the allied dental fields from minority populations is far below what is desirable in trying to achieve balance with the present and future ethnic distribution of the public. It is imperative that efforts be made to increase the participation of the growing minority groups into the dental profession."^1p10 The issue of diversity and under-represented minorities will not, in my view, be a significant element that addresses the maldistribution conundrum. Regardless of how diversified the dental work force becomes, minority dentists will continue to seek out opportunities that reward them best for their professional efforts. At one time or another, most dentists, regardless of ethnic or racial background, attend business management seminars. Unfortunately the gurus teaching these courses imbibe the seminar attendants with the notion, and I exaggerate of course, that unless your practice grosses less than a vary inflated sum you are not in the mainstream of success.

1 American Dental Association. Future of dentistry: Today’s vision, tomorrow’s reality. Chicago: American Dental Association, Health Policy Resources Center; 2001.

Q There is clear indication that the number of appropriately trained dental researchers is not sufficient to conduct the nation’s dental research agenda. What type of programs would you suggest that would attract more individuals to consider a career in dental research?

Dr. Staubach: The FOD reports that there is a clear indication that the number of appropriately trained dental researchers is not sufficient to conduct the nation’s dental research agenda. Too often the rewards for dental research are insufficient to attract well-qualified people into such an endeavor. The reward of accomplishment is, in many cases, not sufficient. I believe those who devote minds and efforts for the advancement of dental research should receive appropriate compensatory reward.

Dr. Parrish [Editor’s note: Dr. Parrish elected to answer this question and the final one, page 1234, with a single response; thus, the statement that follows here applies to both questions.]: Get them early! The solution to both of these problems ultimately lies in dental schools’ identifying and recruiting entering dental students from other areas of academia and research for specifically held "slots" within a given class (see Education Recommendation-19 in the FOD report^1p22). Whenever anyone already in dental school indicates an interest in either field through various opportunities (such as table clinics, summer research programs, junior dental students identified to teach freshmen and so forth), a faculty mentor needs to go immediately into action and nurture this interest. Private donations (corporate or individual) need to be set aside to assist newly-graduated faculty and researchers in their early years to pay off their student loans; don’t let them get into private practice just to pay off loans (see Education Recommendation-20 through -22 in the FOD report^1p22). More senior, near-retirement practitioners need to be recruited, taught to teach and placed with a faculty mentor to get them on board at the end of a career (see Education Recommendation-18 in the FOD report^1p21), in short, RECRUITING from a variety of sources.

1 American Dental Association. Future of dentistry: Today’s vision, tomorrow’s reality. Chicago: American Dental Association, Health Policy Resources Center; 2001.

Dr. Casamassimo: The Future of Dentistry report has this issue right on target ... it’s all about the money. Its dental research work force recommendations are heavily weighted to address the financial issues afflicting the dental research work force. Dental research is closely tied to dental education with few National Institute of Dental and Craniofacial Research career researchers in comparison with the cadre of dental education–based researchers. The dentist-scientist program has had marginal effect on supply, with many highly trained and promising researchers heading for private practice and its financial rewards. Physician-scientists have the opportunity to reap not only the intellectual rewards of research, but compensation for clinical care. Sadly, a funded dental research fellow experiences only the most minute of "bumps" when he or she enters the world of dental education, with a salary not much more than the training stipend they leave behind. If the dental community is serious about maintaining the research infrastructure in this country, without looking overseas for a low-cost work force, the paradigm of compensation must be addressed in dental schools. This must go beyond loan forgiveness and address the wage paid a dental researcher. Furthermore, the expectations for research faculty—who teach, provide service and still compete aggressively for external funding—must be modified to make a research career viable. This means research "tracks" in dental schools, support and nurturing in the pretenure years, and acceptance as "equals" by academic colleagues as having a legitimate and equally demanding role as do clinicians and teachers. Finally, credibility and support must be directed to clinical, as well as basic, research.

Dr. Harms: Dental research efforts have been responsible for major breakthroughs in the diagnosis, treatment and prevention of dental disease. Future of Dentistry Oversight Committee Members agreed that continued research efforts are essential as is our ability to attract and keep enough appropriately trained researchers. One of the biggest barriers to overcome in this field is the disparity of income levels between researchers and private practitioners. I think that most dental students do not enter dentistry with research in mind. Perhaps recruiting an appropriate number of dental students with a research background would be helpful. Also, scholarships and loan forgiveness are always appreciated.

Q Much has been said about the increased use of allied dental personnel to meet potential shortfalls in the dental work force. What do you see as the role of allied personnel in the development of an adequate and "elastic" work force?

Dr. Parrish: We will never have a prayer of meeting the increased demand (population increases, more elderly, decreasing number of dentists) without the use of "dentist extenders." We have a huge pool of assistants who have been in practice for years. They could easily attend approved classes to learn (in a relatively short period) to scale healthy adult patients under the direct supervision of dentists. It should not take the two years of hygiene school (look to the military model). Another pool of experienced assistants can be taught to place amalgams and composites. If this can be done with a few months of training in our Washington hygiene schools, it certainly can be done by talented assistants who already have experience with the materials. (See "Strategy" under Broad Recommendation-4 in the FOD report.^1p8)

Many states have to loosen their tight reins on what hygienists can do. Certainly anesthesia is a "no-brainer" for those of us who have spent our entire careers working with excellent hygienists who can deliver safe, effective anesthesia as well as we can (and still is unethical in the ADA’s view). This is a resource we continue to waste. We are looking at "tiering" the credentialed hygiene license in our state so that the entering hygienist is safe to practice "traditional" hygiene, but can add further skills (anesthesia, placing restorations, etc.) by endorsement.

Finally, we need to eliminate barriers to licensure (for dentists, as well^1p85) to already-licensed hygienists so they can begin practice in another state easily without discouragement or wasting time as a result of a family move (see Clinical Practice Recommendation-7 in the FOD report^1p11). There are many out there who can be practicing part-time or full-time, if we would let them.

But the FOD report’s point about an elastic work force is well taken. We should not over-expand the dental schools as occurred in the 1970s. Some expansion now is needed (maybe 10 percent), but to overexpand will repeat problems.

The demand for treatment will change when baby boomer patients begin to die and take with them the need for large amounts of restorative dentistry that we don’t see in the succeeding generations (prevention actually works!).^1p32 Then we will need even more hygienists to take care of the routine periodontal care. We should be looking for every opportunity to expand the hygiene education base NOW.

1 American Dental Association. Future of dentistry: Today’s vision, tomorrow’s reality. Chicago: American Dental Association, Health Policy Resources Center; 2001.

Dr. Casamassimo: It is almost humorous when one objectively looks at the variability of auxiliary utilization in dentistry. We have dental assistants and hygienists doing a wide range of services from basic four-handed dentistry all the way to placement of restorations and sealants. Had we applied a legitimate objective and apolitical quality measurement to this system, we would long ago have identified the weaknesses of any of these many constellations of allowable duties. However, there are no such data, and there do not seem to be problems with any parts of the continuum! One can only conclude that dental auxiliaries can function at a very high level with adequate training and supervision, yet we continue to have such wide variation. What is sorely needed is a uniform approach that (1) maximizes the utilization of auxiliaries and (2) constantly pushes the envelope of functions to further refine the "skill mix" of dental practices. This would immediately maximize efficiency and productivity and secondarily encourage the broadening of dental access and productivity without needing more dentists. The Future of Dentistry Clinical Practice Recommendation–9³ speaks directly to what needs to be done—do away with the politics of paranoia about loss of control and recognize that a standardized skill mix of auxiliary procedures benefits everyone!

Dentistry needs to do away with the politics of paranoia about loss of control and recognize that a standardized skill mix of auxiliary procedures benefits everyone.

"Elasticity" also has been applied to nondental professionals, such as physicians, who have a legitimate role in oral health promotion.¹ In fact, some have recommended a marriage of medical and dental education. Those familiar with the medical literature have to conclude that medical practice is becoming less comprehensive rather than more so, and the likelihood that physicians will spend more time doing dentistry is naïve—as is the likelihood that medical schools will absorb higher education’s most expensive family member!²

1 Lewis CW, Grossman DC, Domoto PK, Deyo RA. The role of the pediatrician in the oral health of children: a national survey. Pediatrics 2000;106(6):E84.

2 Graham BS. Commentary on Dr. Michael Cohen’s article. J Dent Educ 2002;66(3):383–4.

3 American Dental Association. Vision and recommendations. In: American Dental Association. Future of dentistry: Today’s vision, tomorrow’s reality. Chicago: American Dental Association Health Policy Resources Center; 2001:11.

Dr. Harms: There are few issues as controversial as the use of allied personnel to meet potential shortfalls in the dental work force. The Future of Dentistry report looked at research from the 1970s, which demonstrated that a number of tasks could be safely and effectively delegated to dental hygienists and assistants. The problem that we seem to run into when discussing this issue on a national level is in determining at what point delegation becomes ineffective and unsafe.

Minnesota has very liberal practice laws. Hygienists can give anesthesia and nitrous oxide, and assistants can polish teeth. This does lead to a great deal of elasticity in our offices. For instance, when a hygienist calls in sick, there is no need to reschedule her patients. We simply team up an assistant with a remaining hygienist and do assisted hygiene. This also is helpful in August, when our requests for children’s prophylaxes exceed our hygiene capability. We schedule an additional room for pediatric prophylaxes with an assistant for that month.

The question that must be answered, however, is at what point does a procedure require that the person performing it go to dental school? My opinion is that a person needs to go to dental school to make a diagnosis and to perform any surgical procedures (which include cutting into hard tissue). Procedures that are reversible can be delegated to an appropriately trained auxiliary under supervision.

Dr. Staubach: In the work force model of the FOD report, there is a section pointing out that creative methods must be developed to ensure an ‘elastic’ work force that adjusts to the changes in a timely and effective manner. I am not certain what the term ‘elastic’ implies; however, should it mean an increased sharing of responsibility chairside, then I am in favor if the term "responsible" is adhered to. The medical profession has engendered such a movement and has become an apparent success. In order to meet the needs of a growing population, we as dentists can no longer assume the role of sole proprietors of dental care delivery. We will need well-trained and professionally responsible staff personnel if we are to successfully accomplish our future mission in dentistry.

Q Much had been said about the faculty shortage in dental education and its impact on the future of the dental profession. How severe is the shortage? What impact will it have on the composition and effectiveness of the dental profession? What steps should be taken?

Dr. Harms: All academic representatives on the Future of Dentistry Oversight Committee agreed that the faculty shortage is a major problem. How can future dentists be appropriately trained if a shortage of educators persists? I don’t have any firsthand knowledge about the severity of the shortage. A shortage of personnel will have a tremendous impact upon the effectiveness of the profession, particularly for those dentists completing their education. It ultimately will have an effect upon the composition and numbers of dentists graduating, as schools will have a difficult time maintaining class size. One of the major problems schools have is competition from the private marketplace when it comes to salaries. Perhaps offering incentives for part-time educators would work, or recruitment efforts within the dental schools (perhaps an educator’s "track" with additional education in education). Another option might be to get involved in new education technology so that schools could "share" faculty.

Dr. Casamassimo: I am sorry to say, but I believe it is already too late for dental education as we know it! There are already hundreds of empty positions in dental schools and the millions of dollars needed to fund these positions have been dispersed for other needs. There is no going back. The baby boomer generation will leave education in droves over the next five to 10 years,¹ crippling the system’s ability to perform its function and nurture its young faculty. The educational establishment will turn to overseas educational systems for labor, much like U.S. industry capitalized on the North American Free Trade Agreement. The difference will be that we will import the labor force rather than export the industry. This will cause culture shocks in both American dentistry and these culturally and educationally different dental educators.

The effect of the faculty shortage will be like a row of dominoes falling. Using pediatric dentistry as an example, we will see an immediate decrease in the range of educational experiences as specialists retire. The lack of pediatric dentists interested or able to afford an academic career due to debt will lead to further curtailing of the types of patients seen during the educational process, so the lack of access for preschool-aged children and the disabled will magnify. General dentists will assume the pediatric dentistry teaching load and further simplify the type of student experience. The effect will trickle down to postdoctoral training and continue the downward cycle because there will be no specialist to teach the specialty. Foreign-trained dental educators will be ill-prepared for what they will find in terms of dental caries, the existing infrastructure and the behavior management realities of American life. The dental safety net for poor, minority and disabled children finally will burst. This scenario can be repeated in other specialties as well.

What can be done? First, we all need to recognize that educators need a comparable wage to that of our practicing colleagues. There is a model that combines practice with teaching to provide a livable wage to faculty and provides world class education and quality care—we call it medical education! We need to move away from the parochial approaches to dental education and look at attending-dentist models² and service-learning.³ Second, in the meantime, we need to capitalize on ways to compensate faculty, such as reasonable faculty practice or release time. Too often, these opportunities are limited or the compensation small. Third, we need to look carefully at the seductiveness of looking overseas for faculty. This option may seem attractive, but if states continue to ease licensing as they have recently to address access, then dental education will simply be a short stopover to lucrative dental practice for these transplants. Finally, we need to revisit preceptor education or some hybrid version of dental education. It seems paradoxical that we entrust the care of our families to the dental practice community yet won’t place students in that same system! As one of my early medical mentors said to me years ago, "Good service is good teaching."

The Future of Dentistry report is encouraging in that it clearly addresses the symptoms of what I consider the profession’s greatest challenge, and I am both encouraged and chagrined that the practicing profession has taken the lead in solving it. It may be that the most serious problems facing dental education are the lack of vision and of the willingness to change. I hope I am wrong, and we still can save this vital institution.

1 Valachovic RW. Dental workforce trends and children. Ambul Pediatr 2002;2(2 supplement):154–61.

2 Graham BS. Commentary on Dr. Michael Cohen’s article. J Dent Educ 2002;66(3):383–4.

3 Robert Wood Johnson Foundation. Pipeline, profession and practice: Community-based dental education. Princeton, N.J.: Robert Wood Johnson Foundation; 2001.

Dr. Staubach: The FOD report goes on to state, "There is a shortage of faculty members in the educational institutions and researchers who are so vital to the advancement of dental science." I am not accurately cognizant of how severe the faculty shortage may be at this time (possibly 400 vacancies); however, should this become an increasing problem, there is no doubt that there will be a disastrous and negative impact on the dental profession. As with the question of attracting qualified individuals to become researchers, so it is with faculty. The obvious answer is commensurate compensation and benefits. How this can be accomplished is perhaps the most difficult question of all. Do we expand the duties of each individual faculty member in order to reduce the overall faculty count so each educator can be compensated adequately? Does the increased responsibility then become too burdensome? If surveyed, what do today’s faculty members see as an incentive for future individuals to become teachers and mentors?

There is one issue for which I have some reservations. In my opinion, importation of foreign dentists to supplement our faculty is of questionable value. Oft times, as in the past, there can be a communication barrier. It is difficult for students, new to dental terminology, to easily understand the lecture if the instructor does not have a command of the English language.

We are willing to spend vast sums of money for entertainment, but we are reluctant to set priorities when it comes to funding our vital educational task force, which is the true foundation of all health care. Let’s find a way to adequately compensate them and bring their reward parallel to what they may find available in the marketplace. As with any other facet of life—you only get what you pay for.

Coming in October: A look at the future of access to dental care.