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Challenges Facing the U.S. Dental Profession by Gordon J. Christensen, DDS, MSD, PhD

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by Gordon J. Christensen, DDS, MSD, PhD

The genesis of this article was stimulated as a result of my experiences while speaking on the dental lecture circuit and constantly hearing from dentists their challenges and frustrations about the current state of the profession in the United States. Although there are many easily observable, great characteristics of the dental profession in the United States, there are also some clearly disturbing and growing concerns. I decided to see if my interpretations of the challenges in the profession were just my opinions or if they were truly shared by the majority of practitioners.

Representative groups of dentists in the profession that appear to represent the various different ages and beliefs of dentists were polled. The survey was conducted and the results compiled. Some of the challenges discussed in this article appear to be insoluble, while others have the potential to be overcome by the action of leaders and organizations in the profession. The purpose of the article is to motivate readers to communicate with leaders in the profession and influence them to devise courses of action to overcome these well-identified challenges.

Survey of the Profession
A survey to determine if my perceptions of the challenges facing the dental profession were valid was developed and provided electronically to a representative membership from the databases of three diverse groups of U.S. dentists.

These groups were considered to have significantly different characteristics. Our goal was to validate which topics were considered by respondents to be challenges for the profession. The seriousness of each challenge was ranked by the participants and prioritized from one to three; one being of utmost importance. Details of the data gathering and dissemination on the information concluded from the data follows:

The groups were: Clinicians Report (previously named Clinical Research Associates), Dentaltown and Madow Group; 1,500 dentists responded to the 24-question survey used (see survey on page 30).

Between 73 and 93 percent of the group was American Dental Association members. Years out of dental school were markedly different among the three groups. The combined ranges of the three groups were:

1-5 years          3-25 percent
6-10 years        4-16 percent
11-15 years      7-14 percent
16-20 years      6-9 percent
21-30 years      23-36 percent
+31 years         14-45 percent

The rankings of the severity of the challenges were similar in all three groups, regardless of the perceived characteristic differences of the groups, and regardless of ADA membership. The results from the three groups were nearly identical. Many additional comments and opinions were presented by the respondents, too numerous to include in this brief article. The results of survey were presented to the Board of Trustees of the American Dental Association by Dr. Christensen on August 1, 2011.

The importance of each individual challenge as indicated by the survey was ranked by participants as priority 1= highest priority; priority 2 = medium priority; and priority 3 = lowest priority. Each potential challenge is briefly discussed below in approximate decreasing order of their perceived seriousness as ranked by the respondents. The data speaks for itself, although some readers might disagree with my personal interpretation of the potential reasons for the specific results.

Priority 1

Third-party Dictation of Treatment Plans and Setting Fees
This topic received the highest ranking of importance of all 24 items. The limitations for fee setting determined by thirdparty payment companies create frustration for dentists. Numerous respondents noted that they do not have concern about third-party companies providing benefits for services. Their disagreement is related to companies setting fees and attempting to dictate fees for services for which they do not offer benefits. It is apparent that this issue is paramount and needs immediate discussion and negotiation between representative payment groups and leaders in the profession. It is clear that this problem is now beyond quiet desperation on the part of practitioners, and is nearing the revolution stage by the profession at large.

Mid-level Dental Practitioners
This was one of the highest areas of concern expressed in the survey. The concept of expanded functions for staff has always upset some dentists, dating back to the creation of the dental hygiene profession or denturists or expanded function dental assistants and hygienists. Their concern is understandable, since it can be construed to threaten the livelihood of some dentists. However, in areas of true need, where typical dentists do not choose to practice, the concept can also have merit. Ongoing study of mid-level practitioners accomplished by all involved components of the profession is needed to make the right decisions for the profession at large.

Growth and Influence of Corporate Dentistry Companies that Hire Dentists
Respondents ranked the priority for action of this topic very high. I have observed a considerable amount of “ill will” as some of these firms have moved into geographic areas already saturated with dentists. This appears to be a topic without a clear solution. Entrepreneurs can and will start up where and when they see opportunity. A classic similar situation is the wellknown “Wal-Mart phenomenon” with its good and bad characteristics. Some young dentists join these large corporate groups of dentists as their only hope to pay off student loans and gain clinical competency and speed. We hope the law of supply and demand for dental services will somewhat dictate the continued growth of this concept. In my opinion I see both good and potentially bad characteristics of such companies.

Overpopulation of Dentists and Hygienists
This frustration was ranked high by respondents as they see it actually happening in their respective geographic communities. Some dentists are facing bankruptcy and others have gone bankrupt in recent months. DHs in some locations cannot find employment. Practitioners in both areas feel helpless to overcome the looming problem of overpopulation. Dental leaders need to study the overpopulation situation immediately and make corrections to avoid the problems seen historically with overpopulation. Stiffer standards for school accreditation and more leadership interaction and guidance with new schools planning to start are in order.

High Dental School Tuition
The cost of a dental education is far beyond that of dentists educated only a few years ago. New dentists graduating with a debt of 200- to 300-thousand dollars are the average. Respondents were concerned that dentistry is becoming a “rich kid” profession with new dentists financially stressed and often unable to pay back loans. Another result of high tuition and large student loans is potentially lower-quality service. These inexperienced new graduates are slow because of their lack of time in practice. Additionally, their inexperience and slow speed might force them to be less thorough in their clinical efforts due to the fast production pace they must keep to pay back their loans. The solution to this problem is not clear. Lobbying by profession leaders for additional federal and state funds to reduce the tuition challenge and provision of scholarships to low-income potential students seems appropriate.

Offshore Dental Laboratory Proliferation and Questionable Observation of Products
The quantity of laboratory products being produced outside of the United States is well known. Low-cost laboratory services obtainable out of the country caused the closing of 2,000 dental laboratories in the U.S. last year, as reported to me by Bennett Napier, executive director of the National Association of Dental Laboratories. This situation needs immediate attention by dental leaders. I suggest that dental society provides motivation for laboratories to indicate the source of origin of dental laboratory products is necessary. Official government agencies, such as the FDA, should have more observation and control of the quality of laboratory products coming into the United States.

Need for More Dental Research on Clinically Important Subjects
Respondents noted that many reported research projects in the dental literature have little or nothing to do with the mission of the dental profession to prevent and/or treat oral disease. Practitioners desire more pragmatic research on topics that influence patient care.

Lack of ADA-accredited Dental Laboratory Schools
At this time, there are 20 dental laboratory schools accredited by the ADA. Many more are needed to upgrade the American dental laboratory profession, especially in light of the ongoing reduction in dental laboratories and the increase in offshore laboratory products coming into the U.S.

Observed Minimal Clinical Preparation of New Graduates
Participants ranked this challenge between priority 1 and 2. Some respondents lamented the fact that upon hiring new graduates, they were disappointed with their clinical competency. However, it is apparent that because of the increase in dental knowledge and subjects, the dental student of today has far more to learn than in the past, and that the depth of their education in each of many areas is superficial of necessity. Also, patients for dental students are not as plentiful as in the past, due to the competition of some low-cost dentist groups and third-party payment plans having fees comparable to dental school fees. A possible solution for this challenge is the requirement for an internship upon leaving dental school to provide additional experience. In the past, dentists rapidly gained clinical experience by the requirement for military service as a dentist, which is not done by most graduates now. An internship requirement, appropriately funded, could help solve the access-to-care challenge constantly discussed by dental leaders.

Priority 2

Proliferation of Proprietary Dental Schools
Some of these new schools are just private schools classified as non-profit, and they might not consider themselves to be designated as proprietary. However, when observing the tuition charged by some of them, the perception among the majority of practitioners is that they have a major financial motive. The frustration of practitioners is that some of these schools, which are starting throughout the country, have established themselves in geographic areas clearly not needing an increase in dental graduates. This subject is highly controversial, even to dental leaders. However, many dentists have expressed the opinion that the result of a potential overpopulation of dentists by these schools is threatening to the profession and needs immediate observation, study and solution by dental leaders.

Continuing Growth of Foreign-educated Dentists Being Re-educated in U.S. Schools
Dental schools in the U.S. need financial resources, and the high tuition from foreign dentists seeking to obtain a U.S. degree is providing additional operating funds. Again, the threat of dentist overpopulation is apparent to practitioners. There also exists a concern regarding the clinical competency of some of the incoming dentists.

Lack of Dental Assistant Utilization Programs in Dental Schools
Several decades ago, federally funded programs allowed dental assistants to work in dental schools with dental students to provide at least some experience for dental students concerning proper use of dental assistants. The programs have vanished due to lack of federal funding. Dentists have moderate concern about their demise. Personally, I feel this is an important item that is directly related to the observed slow start of most new dentists. Because of lack of education, they do not know how to properly and productively use dental assistants. Again, lobbying for funding for these programs could be one solution.

Need for More Help from the Profession for New Dentists to Start Practicing
The discussed minimal preparation of new dentists could be somewhat reduced if the large leadership academies in the profession assumed the mentoring of new graduates on an organized basis. If each member of the prestigious American and International Colleges of Dentists or the Pierre Fauchard Academy were assigned a new dentist in their respective communities, and they mentored the new dentist and provided some patients for him or her, the result for new dentists could be significantly positive.

Lack of Qualified Dental Educators
This is one of the challenges that appear to have minimal possibility to be overcome. It is apparent to respondents, despite most of them not being in academic dentistry, that the shortage of dental educators is a challenge. It is no mystery that salary limitations are one of the reasons, combined with the fact that most dentists really want to practice and not teach. This challenge has always been present. It appears that an overt expansion into use of more part-time faculty, who do not demand significant salaries and who are always reported to be highly valuable by students, is one of the solutions.

Lack of Dental Laboratory and Hygiene Educational Programs Located in Dental Schools
Participants marked this between priorities 2 and 3. Most of these programs are now located outside of dental schools. Although, it seems logical to have them located in dental schools, this topic was of only moderate concern to respondents.

Priority 3

Young Dentists’ Lack of Interest in Attending Continuing Education Courses
As is evidenced by a low priority assigned to this topic, some dentists may not recognize the severity of this challenge. Young dentists are not attending CE courses as frequently as previous generations of dentists have attended. They are more interested in online presentations. The result is a diminished amount of social/professional interaction between young and older dentists. One of the topics described above, helping young dentists get started in practice, should include this point. Older dentists should encourage young dentists to go to CE courses with them to assist the young dentists in furthering their education. Equally important, such interaction will show young dentists the value of live CE and interaction with peers.

Continuing Proliferation of Proprietary Dental Hygiene Schools
The responses to this question undoubtedly had mixed messages. It is a general opinion of dentists that DHs have had inappropriately high salaries when compared to other professions requiring similar education. However, overpopulation of DHs could lower entrance standards and the overall competency of the DH profession. Undoubtedly this challenge would have a higher priority if answered solely by dental hygienists.

High Dental Hygiene Tuition
The challenges here are similar to high dental school tuition, and a survey of solely dental hygienists would probably yield a higher priority ranking.

Lack of Dental Student and Dental Laboratory Student Interaction While in Dental School
Although the desirability of having these two groups interact while in school seems to be logical, the respondents rated this topic to be in the lowest priority category.

Lack of Dental Laboratory Knowledge and Laboratory Experiences for Dental Students
There is no question that dental students do not receive as much technical knowledge and experience as they did in the past. The proliferation of new information in the profession, which has congested dental school curricula, and the changing and expanding of knowledge in the profession into other areas, have undoubtedly influenced respondents to feel that this topic is not as important as in the past. I feel that at least some introduction to the technical phases of dental laboratory work is essential for students to allow them to understand this aspect of dentistry and to communicate with dental technicians.

Dental Company Sponsorship of Continuing Education Courses
This item received relatively low priority for action. Apparently respondents recognize and expect dentists to be intelligent enough to realize that the majority of dental continuing education speakers express factual information in spite of who paid for the program. Further, when a dentist enrolls in a program funded by a specific company they should expect to hear about the products and biases of that company.

Dental Company Sponsorship of Dental Magazines
As in the preceding topic, this subject does not seem to concern dentists for the same reasons expressed in that item.

Need for Stimulation by Profession Leadership for Programs Supporting Access to Care
The responses indicate that dentists feel this is not as large of a problem as some leaders feel it is. Some respondents indicated that lack of funding is the major problem most causative for lack of access to care, not the availability of practitioners. The items indicating challenges with overpopulation of dentists and dental hygienists seem to substantiate this belief.

Conclusions
In spite of the many laudatory characteristics of the U.S. dental profession, there are many serious challenges present. Some of these problems seem unsolvable, while others could probably be solved by immediate action by the appropriate organizations to overcome them. This survey ranked the various potential problems facing the profession. It is the intent of this article to motivate those involved individuals, organizations and the American Dental Association to place effort on overcoming the identified problems.

*Special thanks are given to the staffs of Clinicians Report, Dentaltown and the Madow Group for surveying their client groups to obtain the data used in this article.
Author’s Bio
Dr. Gordon J. Christensen is founder and director of Practical Clinical Courses (PCC) in Utah. This group is an international continuing education organization providing courses and videos for all dental professionals. He is also co-founder of the nonprofit Gordon J. Christensen Clinicians Report (previously CRA), as well as an adjunct professor for Brigham Young University and University of Utah. He is a diplomate with the American Board of Prosthodontics. Dr. Christensen has presented more than 45,000 hours of continuing education throughout the world and has published many articles and books. Further information is available at www.pccdental.com.
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