The Loan Arrangers Dr. Jarod Johnson, DDS

Editor's note:
Dr. Jarod Johnson, a pediatric dentist practicing in Muscatine, Iowa, was awarded $80,000 in educational loan repayment through the Fulfilling Iowa's Need for Dentists (FIND) Project. Through this program, more than one-third of Johnson's practice is devoted to serve patients who are Medicaid-eligible, at-risk children, disabled or otherwise underserved. Johnson's award comprises funding from the Delta Dental of Iowa Loan Repayment Program, matching funds from the Muscatine Health Support Foundation and a state appropriation for the FIND Project.

With the increasing costs of dental education, student debt is a concern for recent graduates. In 2016 it was estimated that the average dental student graduates with $261,149 in student debt.¹ While there are many programs available for student loan forgiveness through government programs at federally qualified health centers,² there are limited opportunities for new graduates to establish a career in private practice.

One state's situation—and solution
Iowa, for example, has a dental health care shortage because of its aging population of dentists. Most dentists who practice in the state are near retirement age; a 2016 survey showed that half were over age 50, and 29 percent were over 60.³ As those dentists retire, the state could face a shortage to serve rural communities—which is even more problematic considering 89 of Iowa's 99 counties already have been identified as "high-priority counties," meaning they're short in dental health professionals.⁴ In 2008, the state of Iowa introduced a plan to attract and retain dentists to rural communities. The Iowa FIND Project will pay up to $100,000 of educational debt for dentists who:

• agree to allocate 35 percent of their patient load to "underserved" patients
• have at least $50,000 in educational debt
• and are fully trained and licensed, and in good standing with the dental board.⁵

Since its inception, 32 private-practice dentists have been chosen for the program and provided more than 354,000 services to the 115,000-plus patients in Iowa who qualify as underserved.⁶ (The category includes the elderly; children under age 3; nursing home residents; noninsured patients; and patients receiving health insurance through state-funded dental care insurance programs.⁷)

Perhaps the largest incentive for young dentists is the repayment of their school loans, but the FIND Project also has partnered with the Iowa Area Development Group to help dentists secure no- or low-interest loans to support a practice purchase or startup.

The program was established in conjunction with current partners Delta Dental of Iowa, the University of Iowa College of Dentistry and Dental Clinics, the IADG, the Iowa Department of Public Health, Aureon and the Community Foundation of Greater Des Moines.

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  A mural overlooking downtown by local artist Chris Anderson depicting the history and the future of Muscatine. The mural represents the city from the river to the industry present.

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  A lion at Muscatine's Zoo Garden overlooking the Mississippi River in historic Weed Park. The Zoo Garden has multiple animals that celebrate the zoo that was once present at the site.

The program's benefits to the communities

• Growth factor. Without quality health care providers and systems, communities can find it difficult to attract and retain the businesses and professionals that lead to growth. Knowing this, Community Foundation of Greater Muscatine and the Muscatine Health Support Foundation collaborated with the FIND Project to support the initiative that funded my participation.
• Stanching "retail leakage." Retail leakage occurs when residents spend money outside of the community they live in. If consumers travel to a different city or town to see a dentist, they'll likely also visit restaurants and stores on their trip, which is income not spent in their community. That "dental visit" will likely have a larger impact than just the dollars spent at the dentist.
• Community dental health. Eighty percent of tooth decay occurs in only 25 percent of the child population,⁸ and a large majority of cavities are in children who are underserved.

The American Association of Dentists, the American Academy of Pediatric Dentists and the American Academy of Pediatrics recommend that a child's first dental visit occur by age 1 or when the first tooth erupts,^9,10,11 because early dental screenings have been shown to reduce the cost of future dental treatment.¹² If children can be evaluated for decay before any cavities have the chance to develop, it provides an opportunity to educate parents on the risk factors for the development of future decay.^13,14 Cavities are for the most part preventable, but the most predictable indicator of future decay in children is the presence of decay early on.¹⁴

My history with the project
I first heard about the Iowa FIND Project while I was a student at the University of Iowa College of Dentistry and Dental Clinics, which organizes many events related to mentorship and career development for students. The FIND Project had only been around a few years but already was a success; the previous recipients who spoke at the university praised the program and discussed their love for the communities they served.

Toward the end of my final pediatric dental residency program at the University of Nevada, Las Vegas School of Dental Medicine, it became time to plan. There were many opportunities to become an associate in private practices and corporate offices. But while the initial salary and sign-on bonuses were impressive, I knew I wasn't ready to produce the amount of dentistry required, at a high level of care, to maintain the level of production required to make the salary sustainable in a corporate environment.

After much thought, I decided to consider underserved communities in Iowa that could sustain a pediatric dentist because of the Iowa FIND Project. After speaking with faculty at the University of Iowa and the Office of Practice Opportunities, my wife and I selected Muscatine, a town of about 23,000 people that was close to our families but had no full-time pediatric dentist.

The town has a large portion of underserved children—more than 50 percent of children receive free or reduced-price lunch programs—and a history of supporting the FIND Project. After establishing community connections through the Chamber of Commerce and the Greater Foundation of Muscatine, the community provided the matching funds to secure my grant.

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  The Muscatine County Courthouse, built in 1909, is listed on the National Register of Historic Places.

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  A view of the Mississippi River from Mark Twain Overlook. Twain, who spent time in Muscatine, had fond memories of the city and its summer sunsets.

Benefits go both ways
Muscatine has provided me a great opportunity—I've been able to provide for my family, to purchase and sustain my building from the inception of my private practice and of course, to receive student loan forgiveness through the Iowa FIND Project.

In return, I've committed to establishing care for underserved patients, which is one of the most enjoyable parts of my job. During the first six months of the program I provided more than 4,900 services to 900-plus at-risk children. I've seen most parents follow through with completing the recommended treatment for their children, and are happy to have specialty services such as oral sedation and general anesthesia for their children.

In addition to providing dental care to children within the community, my practice has helped benefit the local economy; my business has created seven jobs, reduced retail leakage by keeping residents in town for children's specialty dental services, and even attracted patients to travel to our community for care.

I still have a substantial amount of practice debt and student loan debt, but I couldn't be more pleased with my decision to practice in this community. The Iowa FIND Project, the Community Foundation of Greater Muscatine and the Muscatine Health Support Foundation have had a huge impact on my life and the lives of the children I treat.

I would strongly encourage states and dental colleges and universities to consider establishing federal loan-forgiveness programs modeled after the Iowa FIND Project. When we are all invested together, we can provide a solution to dental student debt, improve access to care for underserved patients, and grow our local communities.

References
1. American Student Dental Association. Dental Student Debt. American Student Dental Association. 2016. Available at: https://www.asdanet.org/index/get-involved/advocate/issues-and-legislative-priorities/Dental-Student-Debt. Accessed September 4, 2017.
2. American Dental Education Association. Summary of State Loan Forgivness Programs. American Dental Education Association. November 8, 2016. Available at: http://www.adea.org/advocacy/state/loan-forgiveness-programs.aspx. Accessed September 4, 2017.
3. Iowa FIND Project. Community Partners. Iowa FIND Project. 2017. Available at: http://www.iowafindproject.com/community.php. Accessed September 4, 2017.
4. Delta Dental of Iowa Foundation. Delta Dental of Iowa FIND 2016-2017 Loan Repayment Program High Priority Counties. Delta Dental of Iowa Foundation. June 2017. Available at: https://www.deltadentalia.com/webres/File/foundation/2016-2017%20Priority%20Counties%20Map-%20FIND%2020JUN2017.pdf. Accessed September 4, 2017.
5. Delta Dental of Iowa Foundation. Loan Repayment. Delta Dental of Iowa Foundation. 2017. Available at: https://www.deltadentalia.com/foundation/find/. Accessed September 4, 2017.
6. Delta Dental of Iowa Foundation. 2016 Foundation Annual Report. Johnston: Delta Dental of Iowa Foundation; 2016.
7. Dental Education Loan Repayment Program. Delta dental of Iowa Foundation. June 2017. https://www.deltadentalia.com/webres/File/foundation/LRP%20%20FIND%20application%20PDF%20Update%2028JUN2017.pdf. Accessed September 4, 2017.
8. Fast Facts: American Academy of Pediatric Dentistry 2014. American Academy of Pediatric Dentistry. 2013. http://www.aapd.org/assets/1/7/fastfacts.pdf. Accessed September 4, 2017.
9. American Dental Association. Statement on Early Childhood Caries. American Dental Association. 2000. Available at: http://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/statement-on-early-childhood-caries. Accessed September 4, 2017.
10. Council on Clinical Affairs. Definition of Dental Home. Pediatr Dent. 2017;38(6):12.
11. Hale K. American Academy of Pediatrics, Section on Pediatric Dentistry. Oral health risk assessment timing and establishment of the dental home. Pediatrics. 2003;111(5):1113-1116.
12. Savage M, Lee J, Kotch J, Vann W. Early Preventive Dental Visits: Effects on Subsequent Utilization and Costs. Pediatrics. 2004;114(4):418-23.
13. ibid.
14. Council on Clinical Affairs. Policy on Early Childhood Caries (ECC): Unique Challenges and Treatment Options. Pediatr Dent. 2017;38(6):55-56.

Which states are looking for dentists?
To find a complete list of Loan Forgiveness programs, organized by state, click here.