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Critical Issues in Dental Education |
Key words: dentists, workforce, dental education, cross-sectional study, dentistry, dental schools, dental students
Submitted for publication 03/07/06; accepted 07/26/06
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Abstract |
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States with public and private/state-related dental schools invest in the education of dentists by funding schools, their infrastructure needs, scholarships, and other programs. All states are involved with regulating dental practice and monitoring access to dental care. In 2000, about $500 million, or 32 percent of all dental school fund revenue, was from state and local support.9 One desired outcome of state funding of health professions education is that, after graduation, the health professionals will stay in the state to practice, thus providing care to the citizens of that state and positively affecting access to oral health services. The dental education pipeline in each state is therefore important as a potential indicator of future supply of dentists and the supply and demand balance for dental care.
One way that states without a dental school try to create a pipeline is through interstate agreements, which are agreements with states to reserve seats ("buy slots") for out-of-state residents. These seats may be set aside for applicants from certain states, or applicants from these states may have priority over other out-of-state applicants. Generally, these agreements allow students to pay in-state tuition, with their home state paying a subsidy, and have varying repayment and service requirements for the students. The Western Interstate Commission on Higher Education (WICHE) is a well-known model of fifteen states that share resources and collaborate on dental education and other matters of higher education.10
Current issues of interest among dental educators and policymakers include whether the presence and size of a dental school in a state, the existence of interstate agreements for states without a dental school, and the percentage of in-state enrollees in dental schools may or may not affect the supply of dentists in that state. This study adds to existing reports4,11 by providing a baseline descriptive assessment in 2000 of state, divisional, and regional data for dental school graduates, in-state enrollment, and interstate agreements.
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Methods |
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The American Dental Education Association (ADEA) publishes descriptive data on the characteristics of dental school applicants and enrollees, nationally as well as by dental school and by state; these data include the number of applicants and enrollees and their state of residence at enrollment.14 ADEA data from 1998 to 2000 were used to describe the state of residence for first-year enrollees, the total number of enrollees (in any dental school) from each state, and the ratio of population to dental school enrollee from each state. These data were also entered into an electronic spreadsheet database for analysis. Information about interstate agreements was obtained from an ADEA handout titled "Dental School Agreements with States to Reserve Seats for Out-of-State Residents, 2001" and from various Internet searches.
The dental schools in U.S. states in 2000 were included in the analyses. The dental school in the District of Columbia (Washington, DC) was included in the national and regional totals only. The dental school in Puerto Rico was not included in the count or the analyses.
School-level data were aggregated to the state level. State data were aggregated to the division and region level based on U.S. Census Bureau designations.15 There are four census regions: Northeast, South, Midwest, and West. The Northeast region has two divisions: New England (six states) and Middle Atlantic (three states). The South has three divisions: South Atlantic (eight states and the District of Columbia), East South Central (four states), and West South Central (four states). The Midwest has two divisions: East North Central (five states) and West North Central (seven states). The West has two divisions: Mountain (eight states) and Pacific (five states).
To calculate the number of graduates per 1,000,000 population by state for each year (1990 through 2000) and for the eleven-year average, yearly state population values were extrapolated from each state’s estimated annual growth rate determined by taking U.S. Census Bureau populations for each state in 1990 and 2000 and assuming constant exponential growth (see Table 1
). Therefore, the graduate production ratio for each state is the sum of the number of graduates for each year 1990 through 2000 divided by the population each year, divided by eleven years. This graduate to population ratio is referred to in this article as the "graduate production ratio" and is used to compare graduate production across regions, divisions, and states. The national graduate production ratio is for all states, not only those with a dental school.
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Table 2 presents data at the region, division, and state levels for in-region, in-division, and in-state enrollment; these figures are three-year averages from 1998 through 2000. Shaded columns show the percentage of enrollees from that state/division/region who enrolled in dental schools in the same state/division/region; white columns show the percentage of enrollees from that state/division/region out of all residents of that state/division/region enrolled in any U.S. dental school. To clarify, consider Connecticut as an example. For Connecticut, 69 percent of the students at the dental school (since there is only one dental school in Connecticut; this number would be an average for the dental schools in the state if there were more than one school) are from the Northeast region (Column 1); 92 percent of the Connecticut residents going to dental school attend a school in the Northeast Region (Column 2); 54 percent of the students at the dental school are from the New England Division (Column 3); 69 percent of the residents going to dental school attend a school in the New England Division; 30 percent of the students at the dental school are from Connecticut; and 50 percent of the state’s residents going to dental school attend the school in Connecticut.
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Results |
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.) Over the eleven-year period, there were 43,289 graduates, with little fluctuation by year. Fifty-six percent of graduates during this time period were from public schools, also with limited variation by year. Men accounted for almost two-thirds of graduates during this time period (data not shown). In 2000, there were nineteen private (five of which were private/state-related) and thirty-five public schools. Eighteen states had no dental schools; twenty states (as well as Washington, DC) had one school; six states had two schools; four states had three schools; one state had four schools; and one state had five schools.
The distribution of schools and graduates differed by geographic region. The South had the largest number of total graduates from 1990 through 2000, followed by the Northeast, Midwest, and West. However, with population adjustment, the Northeast region had the highest graduate production ratio, followed by the Midwest, South, and West. The eight states of the Mountain division had the lowest numbers of graduates and the lowest graduate production ratio, with just one dental school. The Northeast region had a substantially lower proportion of public school graduates (19 percent) than the other regions.
Examination of population, dentists, and new dental graduates shows disparities by census region (Figure 1). For example, the Middle Atlantic division comprises 14 percent of the U.S. population, 21 percent of dental graduates, and 18 percent of professionally active dentists.
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The states with the largest number of graduates (California, New York, Pennsylvania, Massachusetts, and Texas) each had at least three dental schools. Illinois was the only other state at that time with three dental schools and is the next highest in graduates. The top five states alone accounted for 46 percent of the total graduates in 2000, yet only 33 percent of the total U.S. population. The eighteen states without a dental school accounted for 9.5 percent of the total U.S. population.
The national graduate production ratio for the eleven-year period was 16 graduates per 1,000,000 population. The states with the highest graduate production ratios were Nebraska (74 per 1,000,000), Massachusetts (46), Kentucky (27), Iowa (25), Pennsylvania and New York (both 24), and Oregon and Tennessee (both 23). Florida (6) and Georgia (7) had the lowest graduate production ratios, followed by six states (Colorado, Connecticut, Mississippi, New Jersey, North Carolina, and Washington) with a graduate production ratio of 10 per 1,000,000.
Of states with at least one dental school in 2000, there were several that could be considered "underproducers" of dental graduates relative to their population, notably Florida and Georgia. The two largest population states, California and Texas, were about average in terms of graduates adjusted to population (17 and 14 per million, respectively). Figure 2 shows a map of the graduate production ratios by state, with darker shading indicating higher population adjusted graduate counts.
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). The number of first-year dental school enrollees per resident ranged from 1:18,058 in Utah to 1:254,985 in Maine. Four of the five states with the fewest dental school enrollees per population were in New England, and none of these states had dental schools in 2000. California, described as an "average producer" above, had the third-densest ratio (1:46,784).
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.) Nationally, in-state enrollment in dental schools was 67 percent. There was much higher average in-state enrollment for public schools (78 percent) compared to private schools (34 percent). Eight public schools had in-state enrollment greater than 90 percent; half of public schools had in-state enrollment greater than 83 percent. Among the private schools, only six had in-state enrollment above 40 percent (data not shown). Schools in the West region enrolled more students from their own state/division/region (82 percent) than did schools in other regions, while schools in the Northeast enrolled the lowest percentage of students from their own state/division/region (57 percent). The West had the fewest number of dental schools, and it also had the fewest residents enrolled in dental schools in their own state/division/region. The majority of residents in the other regions stayed in their own division or region for dental school (e.g., for region, 52 percent for West compared to 91 percent Northeast, 85 percent South, and 89 percent Midwest).
Of the nine census divisions, schools in the West South Central and Pacific divisions had the highest percentage of enrollees from their own state/division/region, while schools in the Middle Atlantic had the fewest enrollees from their geographic area. Only 11 percent of Mountain residents went to the one dental school in that division, while well over 60 percent of all other divisions’ residents (over 80 percent in five divisions) attended a dental school in the same division.
States with dental schools with the lowest percentage of in-state enrollment in 2000 were Massachusetts (14 percent), Nebraska (23 percent), Connecticut (30 percent), and Wisconsin and Pennsylvania (both 32 percent). States with the highest percentage of in-state enrollment were Mississippi (99 percent), Georgia (96 percent), Texas (92 percent), Alabama (90 percent), Illinois (90 percent), Louisiana (89 percent), Oklahoma (88 percent), and South Carolina (87 percent).
States with low graduate production ratios (Table 1) generally had higher in-state enrollment (Table 2). The seventeen states (of states with a dental school) with graduate production rates below the national average had an average in-state enrollment of 75 percent; only two of these states—Connecticut (one public school) and Wisconsin (one private/state-related school)—had a low in-state enrollment of 30 percent and 32 percent, respectively. Conversely, the fifteen states with graduate production ratios above the national average had an average in-state enrollment of 57 percent. The two highest-producing states—Nebraska (one public and one private school) and Massachusetts (three private schools)—had the lowest percentages of in-state enrollees (23 percent and 14 percent, respectively).
Relationship Among State Population, In-State Enrollment, Dental Graduates, and Dentist Density
An inconsistent relationship exists concerning in-state enrollment, graduate production, and dentist density (dentist to population ratio). Massachusetts and Nebraska had the lowest percentages of in-state enrollment and the highest graduate production ratios; Massachusetts also had the second highest dentist to population ratio. Connecticut had the next lowest in-state enrollment, but had the lowest graduate production ratio and a high dentist to population ratio. States with the highest in-state enrollment (Mississippi, Georgia, Texas, Alabama, and Louisiana) had dentist to population ratios and graduate production ratios below the national average. While the states with the highest graduate production ratios all had dentist to population ratios above the national average, the dentist to population ratios were mixed for the states with the lowest graduate production ratios. The two states (Utah and Idaho) sending the most residents per population to dental school did not have in-state dental schools, and the five states (Maine, Vermont, New Hampshire, Rhode Island, and Delaware) sending the fewest residents per population to dental school also did not have their own dental schools.
Interstate Agreements
Table 3 shows the eighteen dental schools, from thirteen states, that participated in some form of interstate agreements. The formality of interstate agreements varies considerably among schools and states. Twenty-one percent of the year 2000 seats in these schools went to interstate agreement enrollees. For nine of these schools, in-state and interstate agreement enrollment combined accounted for more than 90 percent of the dental school class. One of the schools, the University of Connecticut School of Dental Medicine, participates in the New England Board of Higher Education (NEBHE; nebhe.org), which allows students from the other five NEBHE states to enroll and receive a tuition break of approximately 1.75 times the in-state rate, but significantly lower than out-of-region tuition. The differences are mainly only applicable to the first-year student as, after the first year of school, most out-of-state students apply for in-state residency (Edward A. Thibodeau, D.M.D., Ph.D., personal communication, October 5, 2005).
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). Overall, among enrollees from states without a dental school, 53 percent enrolled in schools that had interstate agreements with their home state.
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Discussion |
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The exploration of the relationship among the state population, in-state enrollment, number of dental graduates, and dentist density is limited given the constraints of currently available data. Understanding these relationships would be strengthened with further insight into where dentists and dental students come from, whether they stay, and the return on the state’s investment in dental education.
Consideration should be given to the sustainability of the dental workforce. Where dentists go and with what fluidity merits further thought on the roles of states as under- and overproducers of dentists. The dynamics of the state’s population must be taken into account as well. Population growth could exceed the capacity of a state to produce or attract dentists. The exploitation of resources within the division and region appears to be at least somewhat actualized by individuals enrolling in dental schools during the 1990s.
Two U.S. dental schools have opened since 2000. One of the dental schools in existence in 2000 has closed. Reviewing the relationships of these three dental schools with their states, divisions, and regions may help provide insight into the utility of the data in this article as well as other issues not measured in this study.
Review of the Opening of Two Dental Schools Post-2000
The two new schools are both in states (Arizona and Nevada) previously without dental schools (Table 1). Furthermore, they are both in the Mountain Division, where Colorado had previously been the only one of eight states with a dental school. Both Arizona and Nevada had lower dentist to population ratios than the national, regional, and divisional averages. For the entire region, only New Mexico has a lower state dentist to population ratio.
The Mountain Division is the lowest of any census division regarding having residents attend dental school in the division or region (Table 2), but it appears that the one dental school (University of Colorado) in this census division yields in-division and in-region enrollments similar to other divisions. The University of Colorado Dental School is public, so monitoring the long-term influences of the addition of a public dental school (Nevada) and the introduction of a private dental school (Arizona) will be important.
The one dental school (Colorado) in the Mountain Division did participate in formal agreements to place out-of-state dental students. Yet the school had the smallest class size of the dental schools with agreement seats in 2000 (Table 3) and the lowest percentage of in-state enrollees among the WICHE schools. Arizona and Nevada also had agreements to place their residents in dental schools located in other states, with 65–71 percent being placed under such arrangements (Table 4).
The contrasts in dental student enrollment per state population (Figure 3), with Nevada having a denser student to population ratio than Arizona, may support the differences in state versus private funding for the respective schools. Another state in the division, Utah, is unique due to high numbers of dental students relative to the state population (Figure 3), yet a small percentage going to schools with seat agreements (Table 4). Looking only at cross-sectional data and based on high dentist to population ratios, it appears that Utah, Alaska, and Hawaii (in the same region) all have graduates who return or were attracted to the state. Utah borders the three states now with dental schools in the Mountain Division (Figure 4); hence, there is another interesting relationship to study as the new schools mature.
Figure 1 provides a visual contrasting the percentages for the divisions by U.S. population, U.S. dental school graduates, and U.S. professionally active dentists. This figure demonstrates the current inconsistencies among dental graduates and state populations, but does not enable the dynamic nature of the changing populations to be explored. Data on dentist characteristics (e.g., age) would help illuminate the trends and workforce needs. The graying of the dentist workforce is a major concern—and would be expected to be particularly burdensome for states like Nevada and Arizona with rapidly increasing populations.
Review of the Closing of a Dental School Post-2000
A private dental school (Northwestern) in Illinois closed in 2001. The 2000 data suggest a significant impact would be felt by the state with this closure. Based on the ADA data used, from the time that Loyola closed through 2000, Northwestern accounted for 40 percent of Illinois’ graduating dentists. During the time period we studied, Illinois had the highest dentist to population ratio in the region and was the only state in the region to have three dental schools. Every state in the East North Central Division had at least one dental school, and recognizing Wisconsin’s substantial financial support to the private dental school in its state, all states in the division had at least one publicly supported school. Interestingly, with three dental schools in Illinois, including the one private school, the vast majority of Illinois residents going to dental school went to an in-state school. Relatively little added value appears for Illinois residents by having in-division or in-region schools (Table 2). Given that the two state schools had policies to admit an in-state student body, these figures suggest an interesting dilemma for the private school. Should a private school be thinking of support to the state in which it is located, or should it recruit solely on who is best from the applicant pool? Indeed, what might be incentives to private schools to recruit from out of state?
No schools in Illinois participated in formal agreement seats for dental students (Table 3). Marquette in Wisconsin was the only dental school in the division doing so. However, four out of the five dental schools in the West North Central Division, the other division in the Midwest Region, did have agreements to reserve seats for out-of-state students. This raises a question of whether there was spare capacity within the region and whether it is an indication of distribution issues within the region. Contrasting further, North Dakota and South Dakota placed nearly all of their residents interested in attending dental school in an agreement school (Table 4), whereas just over a third of Kansas residents went to agreement schools. It is of interest to note that the number of students from the Dakotas equals the number of students from Kansas. The enrollment patterns beg for further exploration and explanation of effectiveness of agreement seats.
The percentages of population, graduates, and dentists appear the most aligned for the East North Central Division for any of the U.S. divisions (Figure 1). Yet, at the state level, even including the now closed dental school, Illinois appears low on graduate and enrollment levels (Figures 2 and 3).
Future Studies
The ability to fully track individuals as they prepare to go to dental school, attend dental school and other training, and establish dental practice would be very useful. The current datasets only allow for ecological comparisons of state-level data. Further assessment is also needed regarding the influence of licensure processes on dentist mobility.
With many states facing dentist shortages in many counties and an aging dentist workforce, the importance of having an in-state dental school and/or interstate agreements on the future supply of dentists for a state is an area of interest. Currently available data do not allow us to link a dentist’s hometown (where he or she graduated from high school), dental school he or she graduated from, location of any postdoctoral study, and current practice location. These data would inform states about the "return on investment" (future supply of dentists) they receive from funding dental schools and pre- and postdoctoral training experiences. Studies in Illinois and Wisconsin show that 79 percent and 67 percent, respectively, of dentists currently practicing in those states attended dental school there,5,6,19 which is consistent with research on practice location from the 1970s.20 Historically, the rates of graduates’ retention in state from dental schools seem not to have changed. A national study of physicians found that 51 percent began practice in the state where they took their graduate medical education (range of 6 to 71 percent among states) and 63 percent practiced in the same region.21 What can dentistry learn from these types of data about physicians and other health professionals?
A number of initiatives are currently under way that may impact distributions. These include projects by the Robert Wood Johnson Foundation and the California Endowment, which include a number of areas of focus such as adding to the diversity of the student body and increasing dental student awareness of access to care issues. Assessment of their impact is needed beyond the current grant support, which is to end in 2007. Other federal, state, and local efforts may contribute to and provide documentation of programming directed at community needs.22 Interestingly, declarations have been made recently for the creation of two new schools with proposed locations in Arizona and North Carolina, states with existing dental schools. Assessment of the impact of these schools will add further to the understanding of the balances of enrollees, populations, funding mechanisms, and existing dentists in the workforce.
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Conclusions |
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Acknowledgments |
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Footnotes |
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This project was funded by the U.S. Health Resources and Services Administration, Bureau of Health Professions, Office of Workforce Analysis (U79 HP0002-04).
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Indicates state had a dental school open since 2000.