With the full support of the practicing and academic dental communities, the financial challenges facing dental education can be resolved.

To address these issues and prepare resolutions for the House, ADA past presidents Dr. Robert Anderton and Dr. Gregory Chadwick convened education summits in 2001 and 2002. The two summit meetings included broad representation from the ADA; American Dental Education Association, or ADEA; the American Student Dental Association; the National Institute of Dental and Craniofacial Research; and ADA-recognized dental specialty organizations. The participants discussed and made recommendations on three interrelated, ADA Board-mandated topics: the cost of dental education, dental student indebtedness and recruitment of dental school faculty. This article presents the major findings from the education summits.

	COST OF DENTAL EDUCATION

TOP ABSTRACT COST OF DENTAL EDUCATION STUDENT DEBT FACULTY POSITIONS OPTIONS FOR ADDRESSING PROBLEMS CONCLUSIONS REFERENCES

 
The table compares all dental school revenues and expenses in 1991 and 1998.^2,3 The 1998 data are adjusted for inflation and are in 1991 dollars. The primary sources of dental school revenues are state government (34.5 percent), tuition and fees (31.4 percent) and clinic income (20.5 percent). While the federal government funds some research, student scholarships and resident stipends, it provides minimal direct operating subsidies to dental schools. From 1991 to 1998, state and local support declined 22 percent. To make up for some of this loss, schools increased tuition fees 38 percent. On the expense side, schools reduced their investment in physical plant maintenance by 24 percent, decreased the number of faculty by 10 percent (data not shown) and kept faculty salary increases below the rate of inflation by 5 percent. They tried to increase net revenues from patient care, but they were unsuccessful, as clinic revenues and expenses rose at about the same rate.

View this table: [in this window] [in a new window]   TABLE COMPARISON OF DENTAL SCHOOL* REVENUES AND EXPENSES, 1991 AND 1998.

One positive development for schools is recent changes in federal legislation that permit schools to obtain graduate medical education, or GME, support for hospital-affiliated dental residents and specialty graduate students. Approximately one-half of dental schools now have agreements with hospitals, and most other schools are moving in this direction. The exact impact of GME funds on dental school budgets is not known.

Financial information from 2001 on dental school finances (data not shown) indicates a modest increase in state support and some reduction in the average annual rate of tuition increases,⁵ but these positive developments are likely to be short-lived. In 2002 and 2003, state governments were expected to experience major budget shortfalls because of a slowing national economy and rapidly rising Medicaid expenditures.⁶ Most states have had to make large cuts in state-supported activities, including higher education. As a result, state resources available to dental schools are expected to decline at an even greater rate than in the previous 10 years.

	STUDENT DEBT

TOP ABSTRACT COST OF DENTAL EDUCATION STUDENT DEBT FACULTY POSITIONS OPTIONS FOR ADDRESSING PROBLEMS CONCLUSIONS REFERENCES

 
To cope with declining state support, schools increased tuition and associated student fees and charges at an annual rate of about seven percent above inflation from 1991 to 1998.^2,3 This rapid increase in tuition is a major factor in high dental student debt levels at graduation. In 2000, the average debt was nearly $68,800 for dental students in publicly supported institutions, $114,400 for those in private schools and $103,560 for those in private state-related schools (Figure 1); 45 percent of students had a debt of more than $100,000 at graduation.⁷ Currently, 96 percent of students take out loans to help pay for their education. Typically, these are government-subsidized or unsubsidized loans. Few students obtain loans from their families.⁷

View larger version (31K): [in this window] [in a new window]   Figure 1. Per-student debt at graduation by type of U.S. dental school, 1980 through 2000. Source: Weaver and colleagues.7

High debt levels appear to have several adverse effects. First, fewer dental students are from lower income families than in the past.⁷ The decline in African-American and Hispanic dental school graduates may be related, in part, to the high cost of education.⁸ Second, debt load also may restrict career choices made by graduates. More students with high debt levels go into associated or employed positions in private practice, and fewer pursue advanced education or academic and government careers.⁷

While student debt is a critical and growing problem, the debt problem has not reduced the number and quality of applicants to dental schools. In fact, the grade point averages for students in entering classes have never been higher,⁹ and the number of applicants to dental schools is rising again.

	FACULTY POSITIONS

TOP ABSTRACT COST OF DENTAL EDUCATION STUDENT DEBT FACULTY POSITIONS OPTIONS FOR ADDRESSING PROBLEMS CONCLUSIONS REFERENCES

 
Another serious consequence of the increasing cost of dental education is that schools are finding it difficult to recruit and retain qualified clinical faculty. As of 2000, about 400 mainly clinical faculty positions were unfilled (Figure 2¹⁰),¹¹ and 50 faculty positions were eliminated during 2001 and 2002.¹¹ This problem is certain to reach crisis proportions in the next 10 years. Nearly 50 percent of faculty members are older than 50 years of age, and 19 percent are 61 years of age or older. Thus, retirement alone will leave from 820 to 1,300 positions open over the next decade.¹¹ The growing disparity between academic and community practitioner incomes will make the recruitment and retention of faculty even more difficult; this problem is especially acute for specialists.

View larger version (31K): [in this window] [in a new window]   Figure 2. Number of vacant budgeted faculty positions in U.S. dental schools, 1992 through 2000. Source: Valachovic and colleagues.10

	OPTIONS FOR ADDRESSING PROBLEMS

TOP ABSTRACT COST OF DENTAL EDUCATION STUDENT DEBT FACULTY POSITIONS OPTIONS FOR ADDRESSING PROBLEMS CONCLUSIONS REFERENCES

 
Two general strategies were explored at the education summits for dealing with dental schools’ financial problems: reduce expenses and increase revenues. Many options were discussed, but we present only the more important ones.

Expenses. Dental schools have been trying to operate more efficiently, so there are no easy options for reducing expenses. Since most dental school expenses are related to clinic operations and these clinics require substantial subsidies, most savings must come from this area. One option that has considerable promise is having senior students and residents spend more time in community clinics and practices that care for underserved populations. The expected savings from community-based education come from reductions in the funds needed to operate school-based clinics and from alternative uses of clinic space and staff.¹⁵ Another potential advantage of this model is giving students and residents clinical experiences in delivery systems in which high-quality, efficient patient care is the primary goal. Several schools (that is, University of Colorado, School of Dentistry; University of Michigan, School of Dentistry; West Virginia University, School of Dentistry; Boston University, School of Dental Medicine; and University of Connecticut, School of Dental Medicine) already are moving rapidly in this direction, and a recently awarded Robert Wood Johnson Foundation grant is helping 10 schools financially and technically develop this new model of dental education.

Other long-term options for reducing expenses include establishing fewer, but larger, regional dental schools and using new communications technology to share faculty and other resources among schools.

Revenues. The primary source of revenues for public dental schools is state governments. Thus, a major effort needs to be made to have states adequately support dental education. The ADA needs to make the leadership of constituent dental societies aware of the financial problems facing dental education and provide them with technical support in seeking funds from state legislatures. Likewise, dental schools need to work closely with their constituent and component dental organizations in seeking state support.

The federal government support for dental education is mainly in the form of student scholarships and loans, research grants, facility and equipment awards and special initiatives aimed at providing care to low-income populations. The ADA has a very effective Washington office. Working with the ADEA and other national organizations with an interest in dental or health professional education, the ADA needs to continue to make every effort to obtain additional federal government support for dental education.

The dental profession needs to establish an endowment that can be used to support dental education. These funds can be used to meet financial emergencies and to take advantage of special opportunities for innovative programs such as scholarships, fellowships, loan forgiveness and those that will advance dental education and the profession. Over the next 10 years, the ADA needs to take the lead in establishing significant endowments that can be used to support dental education.

	CONCLUSIONS

TOP ABSTRACT COST OF DENTAL EDUCATION STUDENT DEBT FACULTY POSITIONS OPTIONS FOR ADDRESSING PROBLEMS CONCLUSIONS REFERENCES

 
Dental education is a national resource that plays an essential role in educating the professionals needed to care for the oral health of the American population, as well as in generating new knowledge and methods for the prevention and treatment of dental diseases. A strong dental education system also is a critical element in keeping dentistry a learned and prestigious profession. The dental education system has major financial problems that most likely will get worse if current trends continue. The word "crisis" seems appropriate to describe the seriousness of the situation.

There are no easy solutions for these financial problems. Schools need to make greater efforts to reduce their operating expenses through innovative and more effective models of educating students and residents. Equally important, the practice and academic communities must come together and seek more state and federal government support for dental education. With this support, dental schools can reduce the rate of tuition increases—a major source of student debt—and provide current and future faculty members with more competitive salaries, a primary factor contributing to the large number of open positions in dental schools. Without this support, more schools may close, and those that remain open will have to reduce the quality of their education and research programs.

The ADA Board reviewed and accepted the report from the first education summit in 2001 and concurred that the ADA should provide leadership in addressing these issues. The 2001 ADA House adopted six resolutions that called for increasing members’ awareness of these issues, seeking more federal and state funds for dental schools, developing an educational endowment fund and establishing debt consolidation services for members. (See the Box, page 1110, for the full list of resolutions.)

With these strategic initiatives under way and with the full support of the practicing and academic dental communities, the financial challenges facing dental education can be resolved.