This article reviews the status of dental, advanced dental and allied dental education programs in the United States as it relates to these programs’ contribution to the dental work force. The primary source of information and data for this review are the surveys of educational programs conducted annually by the ADA Survey Center for the ADA Commission on Dental Accreditation, or CDA. Educational programs must complete the CDA survey each year to maintain their accreditation status. The CDA uses survey information to monitor major changes that may affect the quality of educational programs and to evaluate compliance with standards for accreditation as part of the periodic site visit and program evaluation process. Additional sources of information include surveys and reports by other ADA agencies and the American Dental Education Association, or ADEA. This analysis focuses primarily on data collected over the past decade.

	PREDOCTORAL DENTAL EDUCATION PROGRAMS

TOP ABSTRACT PREDOCTORAL DENTAL EDUCATION... ADVANCED DENTAL EDUCATION... ALLIED DENTAL EDUCATION PROGRAMS CONCLUSION REFERENCES

 
U.S. dental schools play an important role in the dental work force by anticipating needs for dental personnel and managing the supply of dentists. Dental schools, especially public institutions with a land-grant mission, often supply dentists to specific states, thereby influencing the availability of care in areas they supply. As of Aug. 1, 2003, there were 56 accredited dental education programs in the United States, with programs in 34 states, the District of Columbia and Puerto Rico. Many of the 16 states that do not have dental schools have agreements with dental schools in other states to educate their residents and may provide financial subsidies to those schools for this purpose.⁴

The ethnic background of students has remained relatively constant during the past 10 years, with a predominance of white applicants and enrollees.

Within the past six years, three new dental schools have opened: at Nova Southeastern University in Fort Lauderdale, Fla. (in 1997), the University of Nevada, Las Vegas (in 2002) and, most recently, the Arizona School of the Health Sciences in Mesa (in 2003), adding approximately 225 students to the total first-year class enrollment in the United States. The opening of these new schools followed a period of 15 years in which seven dental schools closed, resulting in a nationwide loss of approximately 600 graduates per year. The seven schools that closed all were associated with private educational institutions. In 2002, after a 10-year growth trend, the number of dental graduates reached 4,349.⁵ In 1993, the number of graduates had reached a 30-year low of 3,778; this marked a decline of 34 percent from a peak of 5,756 graduates in 1984.^6,7 The exceptional growth from the 1970s to the early 1980s had been stimulated by federal capitation grants and building subsidies to dental schools that agreed to increase their class sizes.

Figure 1 shows dental school applicant and enrollment trends from 1990 to 2002. Numbers of applicants to dental schools had decreased substantially in the late 1980s and early 1990s in response to a perceived oversupply of dentists, initial public fear of HIV and other infectious diseases, increasing malpractice rates and other economic factors. During that period, dental schools averaged only 1.2 applicants for each available position. Since the 1989–1990 academic year, when 4,964 applicants submitted a total of 22,501 applications to dental schools, the number of applicants has increased by more than 50 percent, with 7,538 applicants submitting 44,522 applications to dental schools for the 2002–2003 academic year.^5,8

View larger version (24K): [in this window] [in a new window]   Figure 1. Dental school applicant and enrollment trends, 1990–2002. Source: American Dental Association.5

View larger version (29K): [in this window] [in a new window]   Figure 2. First-year dental student ethnic profile, 2002. NS: Not specified. Source: American Dental Association.5

In addition to the traditional educational programs leading to the doctor of dental surgery or doctor of dental medicine degree, four dental schools offer two-year supplemental education programs for graduates of foreign dental schools.¹³ With a total nationwide enrollment of approximately 80 students per class,¹³ these programs contribute a modest number of graduates to the work force. In addition, 26 schools accept international graduates with advanced standing, most commonly to the second- or third-year class.¹⁴ The number of these students ranges from only one to just fewer than 150 per school and composes 2 to 3 percent of total U.S. dental school enrollment. These people are awarded a dental degree from the relevant U.S. institution on graduation, whereas graduates of the two-year supplemental education programs receive a certificate of completion.

The cost of dental education and its impact on potential applicants and students has become a significant concern for the profession. In the 2002–2003 academic year, first-year tuition reached an average of $17,811 for in-state residents and $28,225 for nonresidents.⁵ All other costs ranged from an average of $3,808 in the fourth year to $7,611 in the first year, with a total of $23,353 for all other costs during four years. The total combined costs for the four years of dental school ranged from $35,537 to $206,139. In many public and private, state-related schools, dwindling state support in recent years has resulted in substantial increases in tuition. Data available on student debt following the 2001–2002 academic year show escalating debt, with the average student debt increasing from less than $60,000 in 1990 to more than $107,500 in 2002.¹⁵ Although there have been modest increases in debt on entering school, debt on graduation has increased significantly since 1992. In 2002, 12 percent of dental school seniors reported having no debt at the time of graduation.¹⁵

	ADVANCED DENTAL EDUCATION PROGRAMS

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In 2002–2003, there were 727 advanced specialty and general dentistry education programs in the United States.⁵ Less than one-half of these programs are sponsored by dental schools; the majority are sponsored by other institutions, such as hospitals and the military. Each year, approximately 36 percent of graduating seniors enter advanced education programs in general dentistry or one of the nine dental specialties.¹⁵ In the past 10 years, first-year enrollment in advanced education programs has increased by approximately 16 percent from 2,447 to 2,838 in 2002.^5,16 With a combined total of 2,731 graduates of both dental school and nondental school institutions, dental residencies represent an important point of entry into the work force.^5,16 In addition, residency programs are an important source of care for the underserved, including economically and socially disadvantaged populations and medically compromised patients.¹⁷ Although approximately 20 to 25 percent of graduates of advanced specialty education programs are non-U.S. citizens who received their dental degrees at nonaccredited international dental schools,¹⁶ no data are available to indicate whether these graduates remain in the U.S. work force or return to their country of origin.

	ALLIED DENTAL EDUCATION PROGRAMS

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Allied dental personnel play important roles as members of the dental team in serving the public’s oral health needs. Accredited formal education programs provide a competent core of allied personnel who enhance the capacity for delivery of quality oral health services.

Most allied dental education programs are housed in community college and technical college settings. Although a small number continue to reside in dental school settings, that number has declined over the years. Table 2 provides a summary of the number of accredited allied dental education programs in the United States in 1990 and 2003.^18,19 The number of both dental hygiene and dental assisting programs has increased since 1990, while the number of dental laboratory technology programs has declined by more than 50 percent. The number of dental hygiene programs has shown the greatest increase (35 percent), with 71 new programs. Significant expansion in the number of programs in some states has resulted from the collaborative efforts of state and local dental society leaders and their local communities. Illinois, for example, has more than doubled the number of programs since 1993. The ADA’s 1999 Workforce Needs Assessment Survey showed that two-thirds of dentists believe that there is a shortage of dental hygienists and dental assistants; in addition, it revealed that the top two reasons for the perceived shortage were a lack of graduates and an insufficient number of educational programs.²⁰ Figure 3 provides an overview of the number of graduates from allied education programs from 1990 through 2002.^18,19

View larger version (29K): [in this window] [in a new window]   Figure 3. Graduates of allied dental education programs, 1989–2002. Sources: American Dental Association18; American Dental Association Council on Dental Education.19

Dental assisting also showed increases in first-year enrollment, from 5,500 in the 1989–1990 academic year to 7,304 in the 2002–2003 academic year.^18,19 The number of applications for dental assisting programs reached 11,954 in 2002–2003, with 8,260 students accepted for admission. The gap between capacity and enrollment for dental assisting, however, was much wider than for dental hygiene. Survey data indicated that 2,421, or almost 25 percent, of first-year class seats were unfilled.¹⁸ For dental laboratory technology, the gap between capacity and enrollment was smaller: 15 percent. However, both capacity and enrollment in dental laboratory technology programs decreased steadily over the past decade, and the number of graduates has declined by more than 50 percent.¹⁸ The minimum educational requirements for enrollment in dental assisting and dental laboratory technology education programs are similar; almost all require a high school diploma or GED. Less than 2 percent of dental assisting programs require some college courses and 4.2 percent of dental laboratory technology programs require some college coursework for admission.¹⁸

Both capacity and enrollment in dental laboratory technology programs decreased steadily over the past decade, and the number of graduates has declined by more than 50 percent.

Annual tuition for first-year dental hygiene students attending a dental hygiene program in their own district averaged $3,345 for the 2002–2003 academic year.¹⁸ Total costs for the first year—including tuition, fees, supplies and instruments, uniforms, textbooks and miscellaneous expenses—ranged from $3,617 to an atypical high of $68,158.¹⁸ Costs for students attending programs out of district, out of state or at private institutions were higher than for students attending a public community or technical college within their district of residence. For dental assisting education programs, average costs for tuition and fees for the 2002–2003 academic year ranged from $4,334 for in-district students to $7,765 for out-of-state students.¹⁸ Tuition and fees for dental laboratory technology education programs were somewhat higher, ranging from $5,237 for in-district students to $12,464 for out-of-state students.¹⁸ For all allied dental education programs, costs for out-of-district students were approximately 10 percent higher than for in-district students.¹⁸

Most dental hygiene students complete their educational programs in two years and receive an associate’s degree. Only 11 percent of dental hygiene programs grant a baccalaureate degree, and 3 percent grant a certificate. Eight programs offer a master’s degree in dental hygiene to prepare students for teaching, research and related careers.²¹ Most dental assisting programs are one year in length and award certificates or diplomas to graduates. Almost two-thirds of dental laboratory technology programs award associate degrees. The curriculum for dental laboratory technology requires the equivalent of two years of study.²² On-the-job training and other nonaccredited educational options are available for both dental assisting and dental laboratory technology. Because most states do not license these allied personnel or regulate educational requirements for employment, it is difficult to assess the impact of these options on the work force relative to the patterns of enrollment and graduation from accredited programs. A 1995 survey of dental assisting programs not accredited by the CDA found that many of those programs were located in public secondary educational institutions—that is, high schools.²³ For the two years studied, enrollment levels for non–CDA-accredited dental assisting programs were 3 to 5 percent higher than for accredited programs, and the number of graduates from non–CDA-accredited programs was approximately 15 percent higher than the number of graduates of accredited programs.

The demographic characteristics of enrollees and graduates of allied dental education programs provide useful information regarding the adequacy of the allied dental work force and potential opportunities for recruitment. Historically, women have composed the greatest proportion of allied dental personnel. Dental hygiene continues to remain a predominantly female profession, with men representing only approximately 2.5 percent of enrollees and graduates in 2002 and the three preceding years.¹⁸ Although small, the proportion of men has increased; it was less than one percent before the mid-1990s. The proportion of male graduates of dental assisting education programs was slightly higher than that of male graduates of dental hygiene programs in 2002, at 4.4 percent. In dental laboratory technology, slightly more than one-half (52.5 percent) of 2002 graduates were male.

Data on the age of graduates of allied education programs have been collected through ADA surveys since the early 1990s. In 2002, almost two-thirds of graduates of dental assisting programs were aged 23 years and younger, and almost 85 percent were younger than 30 years of age.¹⁸ By contrast, the proportion of dental hygiene graduates who are aged 23 years and younger has decreased, from 45 percent in 1993 to 37.9 percent in 2002, and the proportion of graduates aged 35 years and older has increased, to 13.6 percent.¹⁸ These data would seem to indicate that the increasing flexibility of program curricula and the use of distance education have made dental hygiene education a more feasible and attractive option for people beyond the traditional college-age population. Dental laboratory technology graduates generally have shown greater diversity in age. In 2002, 43.4 percent were aged 23 years and younger, and 18.5 percent were aged 35 years or older.

As in dental schools, people of white ethnic backgrounds predominate in allied dental education programs. Dental hygiene exhibits the least diversity, with more than 80 percent white graduates. Both dental assisting and dental laboratory technology have higher proportions of graduates who identify themselves as black, Hispanic or American Indian, and these disciplines come closer to reaching a level of diversity that is comparable with that of the U.S. population. Although approximately 14 percent of graduates of dental laboratory education programs were of Asian background, the percentage of Asian graduates of both dental hygiene and dental assisting programs was relatively small, at 4.3 percent and 3.5 percent, respectively. A recent report by the ADEA²¹ indicates that there are no data on the number of underrepresented minority applicants to allied dental education programs, making it difficult to understand their potential interest in and acceptance into allied education programs.

The ADA’s Council on Dental Education and Licensure has developed recruitment materials and career guidance programs aimed at enhancing the interest, number and diversity of applicants to allied dental education programs, as well as to dental education programs.^24,25

With respect to citizenship, graduates of both dental assisting and dental hygiene tended to be U.S. citizens, with levels approaching 95 percent.¹⁸ In dental laboratory technology, however, only approximately two-thirds of graduates were U.S. citizens.¹⁸ Anecdotal reports indicate that a significant number of foreign-trained people contribute to the dental laboratory work force, in addition to the number trained in the United States either on the job or in accredited educational programs.

	CONCLUSION

TOP ABSTRACT PREDOCTORAL DENTAL EDUCATION... ADVANCED DENTAL EDUCATION... ALLIED DENTAL EDUCATION PROGRAMS CONCLUSION REFERENCES

 
Trends for the past decade show an overall increase in the number of applicants to, enrollees in and graduates of educational programs in dentistry, dental hygiene and dental assisting. In dental laboratory technology, the numbers of both educational programs and graduates have declined significantly. Patterns in applications, enrollment and graduation are important determinants of the dental and allied dental work force. The cost of education and the levels and sources of funding significantly affect the attractiveness of dental careers and the sustainability of educational programs and should be carefully monitored by the profession.