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J Am Dent Assoc, Vol 138, No 7, 1003-1011.
© 2007 American Dental Association
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TRENDS

JADA Continuing Education

The urban and rural distribution of dentists, 2000

Thomas P. Wall, MA, MBA and L. Jackson Brown, DDS, PhD


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Background. The authors examine urban and rural variation in the number of dentists in relation to the U.S. population. They focus on the number and distribution of dentists who practice in rural counties.

Methods. The authors divided U.S. counties into categories based on nine rural-urban continuum codes. They based county-level estimates of population on the 2000 census. They based county-level estimates of dentists on the Distribution of Dentists in the U.S. by Region and State, 2000—a report resulting from the annual census of dentists conducted by the American Dental Association.

Results. Although dentists were found to be more concentrated in urban areas, 84.7 percentage of the population living in the most rural counties lived in a county with one or more private practice dentists.

Conclusions. Private practice dentists are distributed widely across rural areas and are available to a large proportion of the population living in these areas.

Practice Implications. A combination of population and per capita income largely determine the viability of a private dental practice located in a rural area. In areas in which this combination is insufficient, publicly funded or philanthropic programs will be necessary to ensure access to dental services.

Key Words: Dental work force; rural; geographic distribution; urban

Abbreviations: ADA: American Dental Association • DOD: Distribution of Dentists • FIPS: Federal Information Processing Standards • NHSC: National Health Service Corps • USDA: U.S. Department of Agriculture

Assessing the dental work force in the United States requires examining two related issues: the total number of providers and the geographic distribution of these providers. Time is also part of the equation. For example, will the future dental work force be adequate considering the expected population growth and the retirement of the baby boomer dentists?

The author of a 2001 article concluded that although the dental work force at the national level is likely to be adequate for the next several years, regional work force imbalances exist and may get worse.1 Unequal rates of population growth from 1990 to 2000 by region and state were identified as contributing to state and regional dental work force imbalances.

An important aspect of the geographic distribution of dentists is the urban-versus-rural dimension. A 2001 government report stated that "the supply of dentists in relation to population generally decreases as urbanization decreases."2 Articles suggesting that there is a shortage of dentists in small towns and rural areas have appeared in U.S. newspapers.3,4

The economic and social character of rural places varies across the United States. The economy of some rural areas still depends on farming, mining and timber. Many of these communities face declining job opportunities and population losses. In contrast, other rural areas, particularly those rich in natural amenities, have experienced economic transformation and rapid population growth.5 According to a summary of recent research on demographic trends in nonmetropolitan areas, 1,702 of 2,303 nonmetropolitan counties grew between 1990 and 2000, 662 more than during the 1980s.5

From a dentist’s perspective, practice location decisions may appear to be far too complicated and individualistic to have a systematic pattern. A study of the determinants of dentists’ geographic distribution, however, concluded that local economic and demographic factors were strong predictors of the distribution of active dentists in the state of Connecticut.6

In this article, we examine urban and rural variation in the U.S. population and the number of private practice dentists, as well as the role of market forces in the geographic distribution of dentists. Since it has been reported that the concentration of dentists is lower in rural areas than in urban areas,2 in this article we report on the distribution of dentists in rural areas. We also took into account the demographic characteristics of dentists who practice in rural areas and to what extent they are different from dentists practicing in urban areas. We considered four trends that may have an impact on the number and concentration of dentists in rural areas.

While we looked at how supply and demand for dental services are related, we did not examine the issue of access to dental services, which is a complicated subject. The availability of a dentist does not, in and of itself, guarantee access to dental services, nor does the absence of a dentist in a given geographic area mean that people living in that area do not access dental services.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
We based our counts of private practice dentists by county on the Distribution of Dentists in the United States by Region and State, 2000.7 The Distribution of Dentists (DOD) is a report resulting from the annual census of dentists conducted by the American Dental Association. This census is conducted annually using a panel methodology, in which all dentists are assigned randomly to one of three panels. In a three-year cycle, the dentists in each of the panels are contacted and their information is updated. The information collected allows the ADA to maintain and update a comprehensive database containing the number of dentists and their geographic locations, practice statuses and demographic information. We used the dentists’ primary practice address ZIP codes to assign each one to a county.

We based population counts for each county in the United States on the U.S. 2000 census of population and housing.8 County-level personal income estimates are from the U.S. Department of Commerce, Bureau of Economic Analysis.9

We used the rural-urban continuum codes developed by the U.S. Department of Agriculture (USDA), Economic Research Service, to distinguish metropolitan counties by the population size of their metropolitan area and nonmetropolitan counties by degree of urbanization and adjacency to a metropolitan area or areas (Table 1Go).10 This classification scheme is useful for analyzing trends in nonmetropolitan areas that may be related to degree of ruralism and to metropolitan proximity. Most counties, whether metropolitan or nonmetropolitan, contain a combination of urban and rural populations.


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  		TABLE 1 Rural-urban continuum codes.*

 
We also used USDA county typology codes to classify nonmetropolitan counties according to six nonoverlapping categories of economic dependence (farming, mining, manufacturing, federal/ state government, services and nonspecialized), and seven overlapping categories of policy-relevant themes (that is, housing stress, low level of education, low level of employment, persistent poverty, population loss, nonmetropolitan recreation and retirement destination).10

We constructed a database with one record for each of the 3,142 counties in the United States. Each record contained a county Federal Information Processing Standards (FIPS) code, a rural-urban continuum code, the 2000 population count, the average per capita income in 2000, the number of private practice dentists in 2000, the number of male dentists in 2000, the number of female dentists in 2000, the number of full-time (30 or more hours per week) dentists in 2000, the number of part-time (less than 30 hours per week) dentists in 2000, and the number of dentists in each of the following age groups in 2000: younger than 35 years, 35 to 44 years, 45 to 54 years, 55 to 64 years, 65 years and older. FIPS publication 6–4 provides the names and codes that represent the counties and other entities treated as equivalent legal or statistical subdivisions of the 50 states, the District of Columbia, and the possessions and freely associated areas of the United States.11 The following entities are considered to be equivalent to counties for legal or statistical purposes: the parishes of Louisiana; the boroughs and census areas of Alaska; the District of Columbia; the independent cities of Maryland, Missouri, Nevada and Virginia; the part of Yellow-stone National Park that is in Montana; and various entities in the possessions and associated areas.

The average per capita income for each rural-urban continuum code reported in Table 1Go is a weighted average of the individual county estimates. We calculated a weight for each county by dividing the county population by the sum of the population in counties with the same continuum code.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
The percentage distribution of private practice dentists across nine rural-urban continuum code categories is close to the percentage distribution of the population in 2000 (Figure 1Go). Category 1 counties were the only ones in which the percentage of dentists was greater than the corresponding percentage of the population. The average per capita income was highest in these counties ($33,600) (Table 1Go).


Figure 1
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  		Figure 1. Percentage of population and percentage of dentists by rural-urban categories, 2000. Sources: American Dental Association Survey Center,7 U.S. Census Bureau8 and U.S. Department of Agriculture.10

 
Counties without a private practice dentist. There were 224 counties without a private practice dentist in 2000. Of these counties, 196 were categorized as nonmetropolitan (Table 1Go). For nonmetropolitan counties, level of urbanization also can be measured in terms of adjacency to a metropolitan area; that is, nonmetropolitan counties can be divided into those that are adjacent to a metropolitan county and those that are not. Those that are not adjacent are considered more rural. A total of 134 counties without a private practice dentist fell into continuum code category 9. We focus on these counties in the remainder of this article.

Category 9 counties. In 2000, there were 430 category 9 counties, with a total population of 2.8 million. Most of these people lived either in the Midwest (46.0 percent) or the South (41.7 percent); 10.2 percent lived in the West, and 2.1 percent lived in the Northeast.

The National Health Service Corps (NHSC) of the Health Resources and Services Administration’s Bureau of Health Professions attempts to increase health care access for people who are underserved by placing primary health care clinicians in communities designated as having a shortage area for primary care, mental health or dental health services. In 2000, NHSC dentists were working in 13 category 9 counties. We compared the number of NHSC dentists in these 13 counties with the counts based on the 2000 DOD. We found that in six of these counties, there were other private practice dentists in addition to NHSC dentists. In three counties, the number of NHSC dentists equaled those in the 2000 DOD. We did not include the dentists in these three counties in our analysis. There was an NHSC dentist, but no private practice dentist, in four counties, according to the DOD. We did not include the dentists in these four counties in our analysis.

Of 430 category 9 counties, 163 (37.9 percent) had two or more private practice dentists and 133 (30.9 percent) had one private practice dentist in 2000 (Table 2Go). We found that 59.7 percent of the population was located in counties with two or more private practice dentists and 25.0 percent was located in counties with one private practice dentist. We found that 426,453 (15.3 percent) people lived in one of 134 category 9 counties without a private practice dentist (Table 2Go). Almost three-fifths of this population (57.5 percent) located in 85 category 9 counties, lived in seven states: Texas, Nebraska, Kansas, South Dakota, Missouri, Georgia and North Dakota (Table 3Go).


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  		TABLE 2 Distribution of category 9 counties by number of private practice dentists in 2000.*

 

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  		TABLE 3 States with large numbers of people living in category 9 counties without a dentist, 2000.*

 
We used the USDA county typology codes to further classify the 134 category 9 counties without a private practice dentist.10 We found that 97 (72.4 percent) were farming-dependent; that is, either 15 percent or more of average annual labor and proprietors’ earnings derived from farming during the period of 1998 through 2000 or 15 percent or more of employed residents worked in farm occupations in 2000. Of these 97 farming-dependent counties, more than two-thirds (71.1 percent) were characterized by population loss; that is, the number of residents declined both between the 1980 and 1990 censuses and between the 1990 and 2000 censuses.

We categorized 23 category 9 counties without a private practice dentist as nonmetropolitan recreation on the basis of a number of factors, including share of employment or share of earnings in recreation-related industries in 1999, share of seasonal- or occasional-use housing units in 2000, and per capita receipts from motels and hotels in 1997.

Figure 2Go is a scatterplot of all category 9 counties. We color-coded the counties; the green dots represent counties with one or more private practice dentists in 2000, and the red dots represent counties without a private practice dentist or with only an NHCS dentist. Figure 2Go shows the fundamental importance of population in determining whether a county has a private practice dentist. All counties on the right side of the scatterplot (with a relatively large population) had a dentist, irrespective of income level. Counties on the far left (with a relatively small population) had a wide variation in income. Few of these counties had a private practice dentist, and a high per capita income did not appear to increase the likelihood of the counties’ having one. The counties in between appeared to have relatively high population and income and were more likely to be represented by a green dot.


Figure 2
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  		Figure 2. Scatterplot of continuum code category 9 counties by average per capita income and population, 2000. Green dots represent counties with one or more dentists. Red dots represent counties without a private practice dentist or only a National Health Service Corps dentist. Sources: American Dental Association Survey Center,7 U.S. Census Bureau,8 U.S. Department of Commerce, Bureau of Economic Analysis9 and U.S. Department of Agriculture.10

 
We calculated a county’s market power by multiplying the population size by the average per capita income. We sorted counties by market power from high to low and color-coded them the same as we did for Figure 2Go (Figure 3Go). The numbers on the horizontal axis correspond to the numbers that were assigned to each county after we sorted them (range, 1 to 430). Counties with high market power are on the left side, and counties with low market power are on the right side. When we further analyzed 26 category 9 counties with relatively high market power but no dentist in 2000, we found that in 1995, 12 had had a dentist and 14 had not.


Figure 3
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  		Figure 3. Graph of continuum code category 9 counties by market power, 2000. Green lines represent counties with one or more dentists. Red lines represent counties without a private practice dentist. Sources: American Dental Association Survey Center,7 U.S. Census Bureau8 and U.S. Department of Agriculture.10

 
Characteristics of dentists practicing in category 9 counties. We examined whether dentists practicing in category 9 counties are older than all dentists (Figure 4Go, page 1009). We found that, overall, the distributions by age were similar. However, dentists practicing in category 9 counties were somewhat less likely to be younger than 44 years, more likely to be 45 to 55 years of age, less likely to be 55 to 64 years of age and more likely to be 65 years and older.


Figure 4
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  		Figure 4. Percentage distribution of continuum code category 9 private practice dentists, by age, sex and employment status versus all U.S. private practice dentists, 2000. Sources: American Dental Association Survey Center7 and U.S. Department of Agriculture.10

 
We found that the percentage of dentists practicing part-time (less than 30 hours per week) was somewhat lower among category 9 dentists than among all dentists (11.7 percent versus 12.7 percent). We found that 14.5 percent of all private practice dentists in 2000 were female. The percentage of female dentists practicing in category 9 counties was 11.1 percent.

In 2000, 11.8 percent of all male dentists in the United States practiced in any of the nonmetropolitan counties. The corresponding percentage of female dentists was 6.5 percent. Since female dentists were younger, on average, than were male dentists, this could explain why female dentists were less likely to practice in a nonmetropolitan county. However, we also found that in each age group, female dentists were less likely than male dentists to practice in a nonmetropolitan county.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
We found the highest concentration of dentists in metropolitan areas of 1 million or more (category 1). This was the only rural-urban continuum code in which the percentage of dentists practicing in these areas was higher than the percentage of the population living in these areas. Per capita income was highest in these counties, and higher income has been shown to be related to higher demand for dental services.12,13

In 2000, 2.8 million people (about 1 percent of the U.S. population) lived in a county described as completely rural or less than 2,500 urban population, and not adjacent to a metropolitan area. Almost 90 percent of these people lived in the Midwest or Southern regions of the United States. Of the 2.8 million people living in the most rural counties in the United States, 59.7 percent were living in a county with at least two dentists, and 25.0 percent were living in a county with one dentist. This should not be considered a measure of access, since access to dental services involves both supply and demand. It is, however, a measure of the wide geographic distribution of private practice dentists.

On the other hand, 426,453 people (15.3 percent) lived in a category 9 county without a private practice dentist. More than two-thirds of these counties were found to be farming-dependent, and more than two-thirds of the farming-dependent category 9 counties without a private practice dentist were characterized by recent population loss. However, category 9 counties without a private practice dentist can be distinguished on a number of dimensions.

The seven states with the largest number of people living in category 9 counties were located in the Midwest and Southern regions of the United States. These states varied in terms of recent population growth. Population growth was above the U.S. average in the two Southern states (Georgia and Texas), but below the national average in the five Midwestern states (Nebraska, Kansas, Missouri, South Dakota and North Dakota). Population growth probably was not distributed evenly across the metropolitan and nonmetropolitan counties of the two Southern states, but states with above-average population growth could be expected to have a growing tax base (for example, state income tax or sales tax receipts) to address potential access problems related to the uneven distribution of dentists in their state.

Four of the seven states have one or more dental schools; Texas has three, Nebraska has two, Missouri has one, and Georgia has one. If these schools could recruit more students from rural areas within their respective states, the uneven geographical distribution of dentists could possibly be alleviated. There is no guarantee that these students will return to these rural areas to practice, but they are more likely to practice in the community from which they came than would dentists with no ties to the community.14

A combination of population size and income is required to support a private dental practice. If either is too small, an abundance of the other will not support a private dental practice. For example, the category 9 county with the highest per capita income ($60,292) had a total population of only 67 people. However, some of the category 9 counties without a private practice dentist arguably could support a dental practice because they appear to have sufficient population and income. In fact, according to our market power analyses, we found that 12 of the 26 category 9 counties with relatively high market power but no dentist in 2000 had had a dentist in 1995. This suggests that the condition of not having a dentist for some of these counties may have been temporary.

These counties or large municipalities within these counties should use information such as population size, expected population growth, per capita income and any other amenities they may possess (for example, climate, natural amenities, schools, quality of life) to more effectively present their communities to dentists as attractive practice locations. In this light, it should be noted that 23 of the category 9 counties without a private practice dentist were designated as "nonmetro recreation." If these efforts are successful, the payoff could be substantial and not limited to the increased availability of dental services. A 2003 study determined that the total economic impact of one additional dentist office on the nation’s economy in 2000 was $1,278,253, and that most of the benefits accrue to the local economy.15

On the other hand, the combination of population and income in many category 9 counties will not be sufficient to support a private dental practice. To facilitate the provision of dental services to the people living in these areas, nonmarket programs (that is, publicly funded or philanthropic programs) probably will be necessary to supplement market forces. Possible solutions include facilitating the travel of these patients to dentists in other counties, facilitating and subsidizing the travel of dentists to counties without a private practice dentist, or subsidizing the incomes of dentists so that their total income is competitive with dentists in other areas.

NHSC recruits dentists to practice in areas with a dental professional shortage by offering a loan repayment program coupled with a competitive salary. A shortage area may be defined in terms of a geographic area or population group.16 A dentist must agree to work in the shortage area for a minimum of two years. This is an example of a nonmarket program that can be used to encourage dentists to work in rural counties. However, because much of the incentive is tied to loan repayment, the long-term impact on improving access for the underserved must be monitored carefully.

In 2000, there were NHSC dentists working in 13 category 9 counties. In seven of these counties, the NHSC dentist was the only dentist. Although this represents a small percentage of the dentists practicing in category 9 counties, it is not known how many category 9 dentists started out as NHSC dentists and then decided to stay after their NHSC service agreement ended.

In 2005, 23 states offered loan forgiveness programs designed to encourage dentists to practice in underserved areas (American Dental Association Department of State Government Affairs, written communication, Feb. 24, 2006). Many of these states, however, either did not have a means to measure the success of the program accurately or found that the program was too new to have completed an assessment.

We found the age distribution of dentists practicing in nonmetropolitan counties to be similar to the age distribution of dentists practicing in metropolitan counties. However, younger dentists were somewhat more likely to practice in metropolitan areas. As dentists age, they may be more likely to move to nonmetropolitan areas. This could account for the fact that nonmetropolitan counties had somewhat higher percentages of older dentists than did metropolitan counties. There also could be a cohort effect (the particular impact of a group connected by time or common life experience), with the younger dentists’ preferring to practice in metropolitan areas. The cross-sectional data from our study did not allow us to determine which of these scenarios is more likely. Further study is needed.

In addition to the number of dentists in a given county, the number of hours worked per week by dentists determines the supply of dental services available in that county. It has been reported that young female and older male dentists are more likely to work part-time.17 We found that 12.7 percent of all private practice dentists reported that they worked part-time in 2000. We found that the percentage of private practice dentists working part-time was similar across all of types of counties we examined. Since part-time employment was defined as working less than 30 hours per week and the number of hours worked could range from one to 29 hours per week, it was difficult for us to measure accurately the short-term impact of part-time practice on the supply of dental services in a given county. It also was difficult for us to estimate the long-term effect, since the reasons and duration dentists practiced part-time varied (for example, starting or building a practice, acute or chronic illness, family responsibilities, semiretirement, lack of busyness). A more accurate characterization of part-time employment would be valuable, since the impact of practicing part-time on the supply of dental services could be substantial in a county with a small number of dentists.

We examined the distribution of dentists in the United States relative to demand for dental services. Data for the 134 category 9 counties without a private practice dentist showed that where demand is insufficient, dentists are scarce. This could indicate that the people living in these counties have problems with access to dental services. As we stated previously, access to care is a complex issue. We are undertaking a study of commuting patterns, driving times and the role of micropolitan "market centers" to further clarify access to care in rural areas.

Limitations. The county-level analysis of dentists and rural populations we present in this article is subject to two limitations in addition to those we mentioned previously: measuring part-time employment accurately and addressing the issue of access to dental care in more detail. The first limitation is that some counties that are large in terms of land area (typically located in the Western region of the United States) are categorized as metropolitan because they have large population centers. However, large parts of these metropolitan counties can be considered rural. We did not include these counties in our analysis.

A second limitation is that rural counties also vary in terms of land area. Depending on how the population is distributed within the county, a small rural county with one dentist may not be equivalent to a large rural county with one dentist. Further analysis could look at counties in each of these categories and examine the distribution of the population relative to existing dental practice locations.

Four trends. The results of our study should be considered in the context of four trends. Three of these trends suggest that the number of people living in a rural county without a private practice dentist may increase in the future.

The first trend is that, although the nonmetropolitan population as a percentage of the total U.S. population fell from 21.6 percent in 1980 to 19.7 percent in 2000, in absolute numbers this population increased from 49 million in 1980 to 55.5 million in 2000.18 Most of the growth between 1990 and 2000 came from net migration rather than from natural increase (births and deaths) that traditionally has fueled nonmetropolitan growth.5 Even some rural areas far removed from metropolitan areas had significant population gains in the 1990s, but these tended to be counties that attracted retirees and counties with recreational amenities.

The second trend is the projected decline in the dentist-to-population ratio from .54 active private practitioners per 1,000 U.S. resident population in 2000 to .50 in 2025.19 Expected increases in productivity will offset a large portion of this decrease in the per capita number of dentists. However, an increase in productivity will not help in a nonadjacent, nonmetropolitan county that loses its only dentist.

The third trend is the dramatic increase in the projected number and percentage of female dentists, from 9 percent of all dentists in 1991 to 29 percent in 2025.19 We found that female dentists were less likely to practice in nonmetropolitan areas. If this difference between female and male dentists continues to increase in the future, metropolitan and nonmetropolitan differences in the concentration of dentists are likely to increase.

The fourth trend is an expected increase in the percentage of dentists practicing part-time (from 14.0 percent in 2005 to 17.9 percent in 2025).19 This increase will be driven mainly by the increase in female dentists. However, since we found that female dentists were less likely to practice in nonmetropolitan areas, the expected increase in part-time practice may be most prominent in metropolitan areas.


   CONCLUSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
Although there is a higher concentration of dentists in metropolitan areas than in nonmetropolitan areas, dentists are distributed widely across metropolitan and nonmetropolitan counties in the United States. Dental work force markets have functioned effectively to distribute dentists according to the demand for dental services. Dentists are available to a huge proportion of the U.S. population. Dental practice location decisions are related to demand that, in turn, is driven by population size and income.

In 2000, 426,453 people lived in 134 rural counties without a private practice dentist. Most of these counties had an insufficient combination of population and income to support a private dental practice. Nonmarket solutions for increasing the availability of dental services to the population living in these areas have been suggested.


   FOOTNOTES
 

Mr. Wall is the manager, Statistical Research, Health Policy Resources Center, American Dental Association, 211 E. Chicago Ave., Chicago, Ill. 60611, e-mail "wallt{at}ada.org". Address reprint requests to Mr. Wall.


Dr. Brown is the managing vice president, Health Policy Resources Center, American Dental Association, Chicago.


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

  1. Brown LJ. Dental work force strategies during a period of change and uncertainty. J Dent Educ 2001;65(12):1404–16.[Abstract]

  2. National Center for Health Statistics. Health, United States, 2001 with urban and rural health chartbook. Hyattsville, Md.: 2001. HHS publication (PHS) 2001–1232.

  3. Crary D. Small towns across America facing dentist shortage. Chicago Tribune Sept. 21, 2003; Business section.

  4. What the tooth fairy forgot: dentists for rural America. The New York Times August 7, 2002:1.

  5. Johnson KM. The rural rebound: Recent nonmetropolitan demographic trends in the United States. Available at: "www.luc.edu/depts/sociology/johnson/p99webn.html". Accessed April 24, 2007.

  6. Beazoglou TJ, Crakes GM, Doherty NJ, Heffley DR. Determinants of dentists’ geographic distribution. J Dent Educ 1992;56(11):735–40.[Abstract]

  7. ADA Survey Center. Distribution of dentists in the United States by region and state, 2000. Chicago: American Dental Association; 2001.

  8. U.S. Census Bureau. 2000 census summary file (SF 1) 100 percent data (DVD). Washington: U.S. Census Bureau; 2001.

  9. U.S. Department of Commerce, Bureau of Economic Analysis, Regional Economic Measurement Division. Regional economic information system (REIS) CD-ROM 1969–2002. Washington: U.S. Department of Commerce, Bureau of Economic Analysis.

  10. U.S. Department of Agriculture, Economic Research Service. Measuring rurality: Rural-urban continuum codes. Available at: "www.ers.usda.gov/Briefing/Rurality". Accessed April 12, 2007.

  11. National Institute of Standards and Technology, Information Technology Laboratory. Federal Information Processing Standards publication 6-4. Aug. 31, 1990. Available at: "www.itl.nist.gov/fipspubs/fip6-4.htm". Accessed April 12, 2007.

  12. Upton C, Silverman W. The demand for dental services. J Human Resources 1972;7(2):250–61.

  13. Brown LJ, Lazar V. The economic state of dentistry. Demand-side trends. JADA 1998;129(12):1685–91.

  14. Webster DB Jr, Packer MW. Effects of two rural scholarship programs on practice location decision of dental graduates: Kentucky’s experience part one. Evaluation of the Southeastern Kentucky Health Professions Scholarship. J Ky Dent Assoc 1981;33(3):21–4.[Medline]

  15. ADA Health Policy Resources Center. Economic impact of dentists. Chicago: ADA; 2003.

  16. Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services. Criteria for designation of areas having shortages of dental professionals. Available at: "http://bhpr.hrsa.gov/shortage/hpsacritdental.htm". Accessed April 12, 2007.

  17. Brown LJ. Adequacy of current and future dental workforce: Theory and analysis. Chicago: ADA Health Policy Resources Center; 2005.

  18. U.S. Census Bureau. Statistical abstract of the United States, 2001: The national data book. 121st ed. Table no. 30. Washington: U.S. Government Printing Office; 2001.

  19. American Dental Association Health Policy Resources Center. American Dental Association dental workforce model: 2003–2025. Chicago: American Dental Association Health Policy Resources Center; 2005.





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