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
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.
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
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
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
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
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
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
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.
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
Continuing Proliferation of Proprietary Dental
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 Company Sponsorship of Continuing
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.
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.