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J Dent Educ. 70(12): 1320-1327 2006
© 2006 American Dental Education Association
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Critical Issues in Dental Education

In-State Graduate Retention for U.S. Dental Schools

Hsuan L. Lin, D.D.S.; Michael L. Rowland, M.A., Ph.D.; Henry W. Fields, D.D.S., M.S., M.S.D.

Key words: dental workforce, access to care, dental education

Submitted for publication 03/17/06; accepted 08/28/06


   Abstract
Top
 Abstract
Materials and Methods
 Results
 Discussion
 Conclusions
 References
 
Currently, dental school graduates are viewed as a resource by their institutions and those who underwrite their educational costs. The purpose of this study was to determine the percentage of dental school graduates who practiced dentistry in the same state as their dental school. Using the American Dental Association database of approximately 35,000 graduates between 1985 and 1995, the data were analyzed to determine the percentage of graduates who were retained and currently reside in the state of their dental school versus those located outside of that state ("exported"). It was also possible to calculate the number of dentists who moved into each state but were educated elsewhere ("imported"). The ratio of imported to exported graduates was calculated and indicated a positive flow into the state when greater than one and an outflow when less than one. Overall, mean graduate retention was 67.3 percent, 65.4 percent, and 44.3 percent for public, public state-related, and private schools, respectively, while the median graduate retention of 71.1 percent and 71.6 percent for public and public state-related schools made them indistinguishable. The mean import-export ratio for public school graduates was 2.9, indicating that on average nearly three dentists were imported to a state for every public dental school graduate exported. States’ total import-export ratio for all types of graduates was 2.2, indicating that on average a little over two dentists were imported to every one exported by a state with a dental school of any kind. The medians for all these ratios were much more modest (0.95 and 0.80 for public dental schools and states with dental schools), indicating that they sent more students out of the state than they imported. Six public dental schools exported greater than 50 percent of their dental graduates, while five public schools retained more than 85 percent of their graduates. Only one private state-related school retained less than 50 percent of its students. In view of these results, it is apparent there is great variability in graduate retention, and the total yield of new dentists for each state is determined by both the retention rate for graduates and its import-export ratio. Most public and public state-related schools do a good job of retaining graduates. When they do send graduates out of state, the median shows they do not gain quite enough to offset those exported. In most instances, this becomes highly problematic only when a low retention rate is paired with a low import-export ratio. Each state must consider its unique situation carefully and consider its yield, the types of problems that face the state in terms of dental workforce, and possible solutions.

During the last decade there has been a general increase in both the number of dental student seats available and in the number of U.S. dental schools.1 This programmatic expansion has come at a time when dental student educational debt levels have substantially increased.2 State governments and universities that fund these programs are under severe pressure to balance reduced budgets.3 Access to dental care is a state and national problem that focuses attention on the capacity of dental students and graduates to provide a remedy.

States and universities want value for their investment in dental education, and they expect that dental school graduates will establish practices within the state to serve the oral health care needs of their citizens. State residents want admission to educational programs such as dental schools and desire access to safety net dental care programs often associated with these institutions. Alumni want access to dental school for their children, and the rapidly growing cohort of senior practitioners nearing retirement are seeking associates and buyers for their practices. These factors can be competing interests as dental schools also attempt to enroll the most competitive students with high GPAs and Dental Admission Test scores for their institutions. All of these factors, including issues of access to care for the underserved,4,5 demand that both old and new dental education programs provide accountability for their budgets and outcomes.

As a consequence, the students’ state of origin and their ultimate practice location attract great interest from state legislators who have expectations that dental schools will train dentists who will remain within the state to provide oral health care. This expectation poses a substantial challenge for state-supported institutions. Numerous states have implemented strict guidelines, limited nonresident enrollees, and stipulated policies regarding the enrollment of only their state’s residents into the dental school. Luke and Kluender6 noted that 70 percent of all the first-year positions available are reserved for state residents. There are currently fifty-six dental schools located in thirty-four states, leaving sixteen states that do not have a dental education program. These sixteen states must either attract graduates from other domestic areas or other countries based on the appeal of the location’s attributes, opportunities, or liberal state dental practice acts; establish contractual agreements with other states that do have dental schools; or establish their own dental education programs. State-supported and private state-related dental schools are being reminded by state legislators, who control the budgetary purse strings, that a primary mission of their school is to supply dentists for their state. The dental workforce and distribution of dentists by state have been the focus of numerous research studies, and the results underscore the fact that some areas have greater demands and urgency for manpower than others.3,7–16

Bailit and Beazoglou3 postulate that students are more likely to practice dentistry in the state where they were raised, whereas the location of the dental school attended plays less of a role in selecting a practice location. They contend that when in-state students are recruited to their own state dental school, it may enhance the state’s supply of dentists.

The purpose of this descriptive study was to determine the sources and destinations of graduates from U.S. dental schools who have had sufficient time to establish a dental practice. This effort will compare results for different types of schools and inform administrators and policymakers so they can review their student recruitment strategies and admissions guidelines.


   Materials and Methods
Top
 Abstract
 Materials and Methods
Results
 Discussion
 Conclusions
 References
 
Sample
The sample for this descriptive study consisted of approximately 35,000 dental graduates between 1985 and 1995 from current U.S. mainland dental schools who are currently full- or part-time practitioners available in the American Dental Association (ADA) data set. The data set contained no personal identifiers for the dental graduates. Likewise, the location of the dentists’ residence prior to attending dental school was not included in the data set. The data set, updated in July 2004, contained information on current location, year of graduation, and school of graduation. Dentists included in this data set had a minimum of nine years after graduation to select an eventual location. This allowed sufficient time for most dentists to complete residency or specialty training and make any other decisions before choosing a permanent location. All dentists located on military bases and outside of the United States (Virgin Islands and Puerto Rico) were excluded.

Data Analysis
These data were sorted by dental school and the state location of each dental school. Each school was designated as public, private, or private state-related according to ADA information. The total number of graduates from 1985 to 1995 was tabulated for each school.

Next, these data were analyzed to determine graduates who currently reside in the state of their dental school versus those located outside of that state. This number represents the dentists who "resided in-state" versus practitioners who were "exported" to practice in a different state. All values were then converted to percentages due to the varying number of students at each school. The overall mean, standard deviations, and median percentages for the student retention rate for public, private, and private state-related dental schools in the United States were calculated as well.

It was also possible to calculate the number of dentists who moved into each state but were educated elsewhere. These were termed "imported" dentists. The number of imported dentists to a state was obtained by subtracting the number of graduates that resided in-state from the total number of new dental graduates in each state. The number of imported practitioners was converted into a percentage for each state by dividing the total number of imported dentists to that state by the total number of new dentists in that state.

Several ratios were calculated to provide a picture of the flow of dentists for a state. First, an import-export ratio was calculated for imported dentists divided by the number exported by the state’s public dental schools. Next the state’s total import-export ratio was calculated by dividing the total number of dentists imported to that state by the total number exported from that state by all its dental schools. By this method, a state ratio quotient of 1 indicates a state that sends as many graduates out of state as it gains through inward migration. Those with values greater than 1 demonstrate a positive flow of dentists into the state, while those with values less than 1 show a negative flow out of the state. The import-export ratio must be combined with the retention of graduates to obtain a full picture of the yield for a state.


   Results
Top
 Abstract
 Materials and Methods
 Results
Discussion
 Conclusions
 References
 
Table 1Go shows the mean, standard deviations, and median percentage of students retained by states as practitioners from public, private, and private state-related dental schools. Public schools had the highest mean percentage for student retention (67.3 percent), followed closely by private state-related schools (65.4 percent) and, at a lower rate, by private schools (44.3 percent). The median values for these same types of schools, which probably are more meaningful given the large standard deviations and ranges of the results, actually showed that private state-related schools retained a higher percentage of residents than did public schools. Table 1Go also shows that the mean import-export public school graduates ratio was 2.9, indicating that on average nearly three dentists were imported to a state for every public dental school graduate exported. The median for that ratio, which was probably more meaningful than the mean due to the large variation, was 0.95, indicating that approximately half the states sent out more graduates than they received (regardless of the graduation retention rate) when considering only public schools. Looking at states’ total import-export ratio for all types of graduates, the ratio was 2.22, indicating that on average a little over two dentists were imported to every one exported by a state with a dental school. Again, the median was much lower and showed that 0.8 dentists were imported for each graduate, either public or private, who left the state for the states with dental schools.


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  		Table 1. Practitioner retention for U.S. dental graduates from 1985 to 1995, a minimum of nine years following graduation
 
Table 2Go describes in detail for each U.S. dental school the percentage of graduates during the study period that resided out-of-state and in-state a minimum of nine years after graduation, the total percentage of imported dentists in a state (as a percentage of retained graduates and imports), the imported dentists to exported graduates ratio for each public school, and the same ratio for all exported graduates from all types of schools for the state. Six public dental schools exported greater than 50 percent of their dental graduates a minimum of nine years after graduation. Five public schools retained more that 85 percent of their graduates. Only one private state-related school retained fewer than 50 percent of its students. Private school retention of practitioners in their states was highly variable, but consistently under half of the graduates (mean and median of 44 percent and 39 percent, respectively) established a practice in the state. Some states exported more graduates than they imported, and others imported more; but with only one exception, states were importers or exporters regardless of how the ratio was figured (i.e., whether only public or all dental schools were considered).


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  		Table 2. Practitioner retention for U.S. dental schools by state for 1985–95 graduates, a minimum of nine years following graduation
 

   Discussion
Top
 Abstract
 Materials and Methods
 Results
 Discussion
Conclusions
 References
 
The data certainly are highly variable depending on the state, but the central tendency indicates that when examining the medians and thereby reducing the influence of the extremes, public and public state-related dental schools generally retain just over 70 percent of their graduates. Although 100 percent would be enviable, that is not realistic. In the main, compared to those graduates not retained in a state, not quite as many migrate into the state. So on the whole, for every 100 students graduated, fewer than 100 are in the state, but not too many fewer. It appears that the venture of public-supported dental education, given migratory give and take, is good for states with dental schools and a responsible overall yield. With the options for employment in numerous states without dental schools as a competing interest, the return is quite impressive.

The return for the state where a private dental school is located is approximately half that of a public or private state-related school, but still at nearly the 40 percent graduate retention level. The lower retention level is not surprising because these institutions generally have more of a regional or national mission, while at the same time having local impact.

On the other hand, the whole story is told only when individual situations are examined. That includes combining the specific information of graduate retention and the import-export ratio. Selected examples are shown in Table 3Go. States can have similar graduate retention and vastly different yield on a per 100 graduate basis. Take Colorado and Indiana, which both have graduate retention rates near the national median for public dental schools. Even though Indiana’s retention rate is 5 percent higher than Colorado’s, given the import-export ratio the calculated yield per 100 graduates shows that Colorado will have 276 dentists and Indiana will have 88. The imports and the apparent attraction of the state are extremely beneficial.


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  		Table 3. Yield of state practitioners for selected states with public dental schools per 100 dental graduates, considering retained graduates and imported and exported graduates
 
Another interesting situation occurred when schools retained fewer than half their graduates, but due to highly different import-export ratios had quite different yields. Maryland and Connecticut do not retain the majority of their graduates, but both states yield at or better than 100 graduates for their state per 100 graduates simply due to the imports. In this case, Connecticut has a two-to-one advantage and is the only state with a graduate retention percentage of less than 50 percent and an import-export ratio greater than one.

The real problems occur when graduate retention is low and there is no inward migration to offset it. Iowa and West Virginia show this problem by retaining approximately a third of their graduates and importing very few. Iowa’s state yield is just over fifty for 100 graduates while West Virginia’s is just over forty.

Funding for dental education has become increasingly more limited across the nation, and access to desirable matriculation positions in dental schools has continued to be competitive. Policymakers, practitioners, and alumni are asking for information regarding both the sources of students, usually in terms of state residency at the time of admission, and their eventual practice location.

Some of these questions revolve around admissions positions. Having high-quality admissions statistics relative to peer institutions is an important input measure for a school: it can be used as a recruiting tool for attracting the most highly qualified applicants and is also used within the university setting to demonstrate academic excellence of dental matriculants. These types of admissions data often are not as valued among state dental constituents or policymakers who want dentists for the state and, if possible, from the state. This has called for more creative and aggressive solutions to attract local students and retain dental graduates. In some rural states, attracting dentists to the state and specifically to dental shortage areas is being addressed by linkage programs between colleges and dental schools that reserve dental school student seats for those from underserved areas if they promise to return to the rural areas to practice. Student loan repayment programs are another method rural states use to attract practitioners.17 Loan forgiveness programs are also being incorporated in more populous states as a method to retain dentists and ensure a better distribution to underserved areas. Another enticement has been modification of the dental practice act to make licensure testing requirements more flexible.18

Some institutions have implemented foreign graduate programs that prepare foreign graduates for a contemporary dental degree and practice in the United States using a truncated curriculum that is generally focused on the clinical years. Such a program provides both tuition and clinical income for the school, but may not ensure that the graduates practice in the school’s state. Possible ways to tether the graduates to the state are through the previously mentioned loan forgiveness programs or alterations of the state’s dental practice act to guarantee maximum flexibility.

Alumni with children seeking admission positions feel that the institution has a commitment to provide a measure of competitive advantage for their legacies. They argue that a state resident applicant with a parent alumni should have a clear advantage in the admissions process, especially over an out-of-state applicant. Further, many alumni argue that only graduates who remain in the state are a valued outcome of the educational process, regardless of the contributions of high-quality out-of-state students to the educational environment. State officials may hold similar opinions and may express these perceptions in public forums including budget hearings when university administrators are seeking to secure appropriations for their institutions. Information documenting a school’s history of admissions and graduation outcomes in terms of contributing to the state’s dental resources can defuse highly charged, emotional, and personal discussions.

The information regarding retention rates and practitioner yields for U.S. public and private state-related dental schools may be important for policymakers in determining the allocation of state funding a dental school should receive. These data also could enhance legislators’ desire to act favorably on an institution’s behalf if the school appears to be doing a good job of providing dentists who choose to remain in the state.1 Retention of practitioners constitutes an important criteria used by state legislators when evaluating a dental school’s value to the public. Public schools that export large proportions of graduates may want to reevaluate policies that could affect these outcomes. Some states with lower retention percentages are offset by high percentages of imported dentists, which in the context of net practitioners reflect little problem. Clearly, some private state-related schools benefit their states by leveraging state funds with good yield. In some instances, these institutions are true state resources.

When considering the creation of a new dental school, expanding a program, or maintaining a program, policymakers could examine these provider yield data and be better informed regarding the probability of a positive practitioner yield given the characteristics of the state (state complexion as urban or rural, experience of adjacent states, population base, desirability as a living destination, etc.). These data could suggest whether a state or private state-related entity is recommendable or feasible.

As a further policy matter, a decision could balance the yield of practitioners and benefit of educationally related dental care versus a cooperative purchasing agreement with a state that could educate nonresidents on a per capita basis. A state considering a new dental school might seek a state with a low yield on its graduates as a partner. The existing school could recoup some of its investment in students through out-of-state tuition and a supporting subsidy from the new partner, which could make it feasible to continue in the business of dental education, while the other state could forgo the capitalization of a new dental school. This might be a more economical alternative than a new dental school.

Many variables affect professional location decisions of dental graduates such as personal characteristics and lifestyle choices.19 Desirability of a living destination may be a factor. Studies show that geographic preferences, employment opportunities, location of training programs, peers, and family, and recreational activities are important factors that influence the selection of practice locations.4 Policymakers may use this information to implement proposals designed to increase the retention of dental graduates from that state.1,4 This is an especially important consideration for states where access to dental care is lacking due to a real or perceived shortage of dentists.1,2 Again, methods to enhance retention and knowing the appeal of a location could translate into decisions to develop loan repayment/public service program options as an incentive to retain dentists.

Furthermore, alumni may use this type of information to weigh decisions regarding gift contributions. Their eagerness to contribute may be influenced by their probability of gaining an associate or buyer for the practice who was willing to remain in the state. Although benefactors are encouraged to make contributions based on other than a quid pro quo basis, long-term trends are hard to overlook.

Graduate retention information also may be used by dental schools for the application process to assess where applicants are likely to practice based on their region of origin.3 This ultimately may serve to improve the applicant selection process and better meet the goals of the school.


   Conclusions
Top
 Abstract
 Materials and Methods
 Results
 Discussion
 Conclusions
References
 
Generally, public and public state-related dental schools provided the largest in-state retention of dental school graduates (approximately 70 percent), but there was great variability among the states. Given the many opportunities for dentists and the substantial number of states without dental schools, this record is highly responsible. Private dental schools provided local impact, but to a more limited degree (approximately 40 percent), which is understandable given their more regional and national missions. The total picture of the dental graduate yield for a state is better understood by considering both the graduate in-state retention and the imported and exported new graduates associated with each state. For states with dental schools, the most typical flow is nearly evenly balanced between inflow and outflow, but again there is great variability. Some states with average or lesser graduate retention benefit from great inflow that helps the state. The most problematic combination is low retention combined with low import numbers. The data obtained from this study may be useful in understanding the unique situation for each state, especially those with access issues. This information allows comparisons with other states, so that it can be used to help shape strategic planning discussions and decisions.


   Footnotes
 
Dr. Lin is a 2006 graduate; Dr. Rowland is Assistant Professor, Section of Primary Care; and Dr. Fields is Professor, Section of Orthodontics—all at The Ohio State University College of Dentistry. Direct correspondence and requests for reprints to Dr. Henry W. Fields, 4088 F Postle Hall, The Ohio State University College of Dentistry, 305 W. 12th Ave., P.O. Box 182357, Columbus, OH 43218-2357; 614-292-1120 phone; 614-688-3077 fax; fields.31{at}osu.edu.


   REFERENCES
Top
 Abstract
 Materials and Methods
 Results
 Discussion
 Conclusions
 References
 

  1. Weaver RG, Ramanna S, Haden NK, Valachovic RW. Dental school applicants and enrollees: 2003 and 2004. J Dent Educ 2005; 69(9):1064–72.[Abstract/Free Full Text]
  2. Bailit H, Weaver R, Haden K, Kotowicz W, Hovland E. Dental education summits: the challenges ahead. J Am Dent Assoc 2003; 134(8):1109–13.[Abstract/Free Full Text]
  3. Bailit H, Beazoglou T. State financing of dental education: impact on supply of dentists. J Dent Educ 2003; 67(12):1278–85.[Abstract]
  4. Altieri JP, Bruce SM, Crall JJ, Eklund SA, Parrish JL, Schneider DA, et al. Future of dentistry: access to care—today’s vision, tomorrow’s reality. J Am Dent Assoc 2002; 133(10):1408–24.[Free Full Text]
  5. U.S. Department of Health and Human Services. Oral health in America: a report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.
  6. Luke G, Kluender R. Dental schools raise tuition as a result of declining state support. Bull Dent Educ 2002; 35(12): 4–5.
  7. Casamassimo PS, Harms KA, Parrish JL, Staubach JW. Future of dentistry: the dental work force—today’s vision, tomorrow’s reality. J Am Dent Assoc 2002; 133(9): 1226–35.[Free Full Text]
  8. Neumann LM. Trends in dental education and allied dental education. J Am Dent Assoc 2004; 135(9):1253–9.[Abstract/Free Full Text]
  9. Beazoglou T, Bailit H, Heffley D. The dental workforce in Wisconsin: ten-year projections. J Am Dent Assoc 2002; 133(8):1097–104.[Abstract/Free Full Text]
  10. Tira DE, Peters RJ, Reed MJ, Killip JW. Addressing dental workforce issues in Missouri and Kansas: one school’s initiative. J Dent Educ 2003; 67(8):902–8.[Medline]
  11. Brown LJ, Lazar V. Workforce trends that influence dental services capacity. J Am Dent Assoc 1998; 129(5):619–22.[Abstract/Free Full Text]
  12. Brown LJ, Lazar V. Trends in dental health workforce. J Am Dent Assoc 1999; 130(12):1743–9.[Abstract/Free Full Text]
  13. Susi L, Mascarenhas AK. Using a geographical information system to map the distribution of dentists in Ohio. J Am Dent Assoc 2002; 133(5):636–42.[Abstract/Free Full Text]
  14. Waldman HB. Distributing dentists throughout the nation. Ann Dent 1994; 53(2):26–9.[Medline]
  15. Douglass CW, Cole KO. The supply of dental manpower in the United States. J Dent Educ 1979; 43(5):287–302.[Abstract]
  16. McDonald RE, Barton P. Activities by the schools to improve the distribution of dentists: an AADS report. J Dent Educ 1980; 44(5):246–7.[Abstract]
  17. McCord J. Rural folks aren’t smiling over shortage of dentists: number of dentists in Nebraska counties. Omaha World Herald, December 11, 2002, Sunrise ed:1A.
  18. Smyth JC. The week at the statehouse. Cleveland Plain Dealer, June 2, 2003, Final ed:B3.
  19. Beazoglou TJ, Crakes GM, Doherty NJ, Heffley DR. Determinants of dentists’ geographic distribution. J Dent Educ 1992; 56(11):735–40.[Abstract]



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