A call to action: Time for dental education to revisit advances in the 21st century

Dental education is undergoing profound change today, not unlike the early decades after release of the Gies Report in 1926. We are approaching the 100th anniversary of the Gies Report, with what has been nearly unparallel recognition of its impact on dental education, research, and oral health professions. Based on a 3-year strategic planning process, the 21st Century Study (Advancing Dental Education in the 21st Century Project), completed in 2018, provides a similarly transformative framework to address our contemporary challenges. This paper is a follow-up of the original study. The 21st Century Study1 is the present-day counterpart of the1926 Report on Dental Education in the United States and Canada.2 The critical changes needed today—for implementation—are the focus of the 21st Century Study (2015–2018).4 It was designed to explore the emerging climate in dental education at the time, to make recommendations over a 25-year period to 2040, and to adapt to the future.* The Study resulted in 38 background papers and publication in electronic issues of the Journal of Dental Education in 2017 and 2018. When this study was envisioned in 2015, the project directors recognized that dental education was already entering into an active period of change. The study was designed in two phases to assess the challenging environment. In Phase 1, background data were collected. The 38 papers prepared by over 50 authors in six categories contained the background information: (the six categories were: the current state of dental education; how many dentists are needed in 2040; what should oral health professionals know in 2040; the dental delivery system in 2040; the allied dental profession in 2040, and dental research and scholarship in 2040). The authors of the papers were urged to think ahead to 2040 as they analyzed the results of the information they collected. It was recognized that changes happen slowly. We believed that the study's in-depth analyses recommended changes that would take time. In Phase 2, the information from the 38 background papers was formulated into strategic recommendations in each of the six categories listed above. The recommendations along with a summary of the discussion from a national conference were published in an electronic version of the Journal of Dental Education (see references32, 33). Taking a broad view of dental education today, it is apparent that some of the many recommendations from the study appear to be moving along in some places but not so in others. Therefore, we believed it was time to take stock of current trends to determine where more attention is needed. The purpose of this paper is a call to action—a call to revisit a portion of the 21st Century Study, now 5 years after its publication, and to reconsider three of its significant findings within the context of current trends in dental education, treatment, and practice. In so doing, we provide an analysis of the original findings within the following environment: (1) the addition of 11 new dental schools over the past 15 years, (2) the financing of clinical dental education as it relates to student indebtedness, and (3) realignment of the curriculum in the face of changing structures for clinical practice, where practice consolidation into dental service networks is becoming the norm. A future paper will revisit work from the 21st Century Study on two additional topics of equal importance and value to advancing oral health and dental education; the allied health professions and work done to advance commitments to research and scholarship serving the oral health professions and the health of the public over the next two decades. These areas are our commitments for increased emphasis to research and scholarship and to practice and education in the allied health professions. Taken together these three areas, the first addressed paper, and the next two areas to be addressed in a follow-up piece, are current day, 21st century parallels to the findings and recommendations of the foundational Gies Report.‡ We begin with a description of the rationale for the founding of new dental schools. The federal government (Health Resources and Services Administration [HRSA]) projects 9932 dental practitioners will be needed to fill the oral care services gap for underserved and unserved populations living in 6860 dental health professional shortage areas (HPSA, population 58.5 million in 2024).3 The 2024 data from HRSA conflict with the data provided for 2023 in which projected 13,000 dental practitioner were needed in 7399 dental HPSA with 75 million people living in those areas.4 While the shortages of practitioners projected in both 2023 and 2024 are great, this discrepancy needs to be explained. While some state governments are responding, the public expects fully functional new dental schools and those in the current pipeline to alleviate the shortage areas of dental practitioners. Thus, many or most of the new dental schools have been started in the states with HRSA designated oral HPSA. It is difficult to imagine that simply adding new dentists, however, will by itself solve this shortage problem. It is a more complex calculus. Special programs are necessary to enroll students showing a strong inclination to practice in shortage areas.5, 6 Without such programs, even when or if dental schools achieve the number of projected practitioners needed to close that gap, those shortage areas will still be without the needed practitioners, pending commitments made by these new graduates. The high debt level of new graduates, even for those that have a desire to practice in shortage areas, makes it unable for them to commit to practice in these areas of high need given their loan repayment costs. The newer dental schools and those well-established ones must have resources to provide significant scholarships or grant funds for creating a cadre of a new type of public health dentist or shortage areas will remain and in fact, expand. Unless there is adequate required coverage for oral health care in Medicare and Medicaid either with federal or state resources, shortage areas will not have the resources to support dental practitioners. Unless every Federally Qualified Health Center (FQHC) includes dental care operating with a team approach that includes dentistry, the gap in dental shortage areas will never be closed. The newly formed dental schools have an opportunity to create the environment and programs to address care shortages and can show, perhaps even lead, the way to much needed care. Some of the new schools have stated missions to address care shortages, but in general their strategy has not been widely understood nor adequately evaluated to show progress toward this critical mission for the profession, overall. Taking a snapshot of where we are today, we ask this general question: what does the landscape for educating enough graduates to satisfy the need for practitioners really look like? Let us start with the number of graduates in the latter quarter of the 20th century. The number has fluctuated, in fact, from 5756 in 1978 to a low of 3979 in 1999 to a high of 6745 in 2022.7 The fluctuation is due to the closure of eight dental schools in the 1970s and 1980s and the formation and opening of new schools in the first quarter of the 21st century. The dental shortage of 9932 dentists projected as of June 30, 2024, by HRSA is based on a ratio of dentists to population, that is, one dentist to 4000–5000 population. With this in mind, the 21st Century Study projected the demand for dentists to be dependent on several additional factors including: the growing efficiency of dentists to treat more patients each year, preventive measures leading to less oral disease in the cohorts younger than the 71 million people in the Boomer generation, technological advances in treatment approaches, and percentage of the population seeking oral health care. Taking these factors into account, the 21st Century Study projected that by 2040, graduating approximately 6000 dentists each year would lead to an oversupply of dentists in a status quo treatment environment, and with status quo educational preparation and distribution, all remaining as is. It must be clearly noted, however, that this projection “does not account for the unmet need from a long-standing maldistribution of dentists” [italics added].8, 9 The 21st Century Study concluded that expanded public insurance coverage, that is, required oral health care in Medicaid and Medicare, and loan repayment programs designed to encourage dentists to practice in shortage areas would lead to a greater percent of the population seeking care and a need for the oral healthcare professionals to provide that care. The profession of dentistry, through its academic role and its related organizations, needs to continue to advocate for expanding dental care to populations in need, the elderly and low income, if a fuller public is to receive oral health care on par with those who presently can afford care. With renewed commitments to understanding the fuller structural connections to address change, these conditions clearly set an agenda for vigorous, sustained action for dental educators. New schools chartered in states with oral HPSA need to pay particular attention to advocating for their states to move from optional oral healthcare benefits to required oral healthcare benefits in their Medicaid programs. National, state, and local dental organizations, and all schools, need to continue to advocate for Medicare to cover oral health care for the elderly. The founding of new schools has not begun to address more substantially the structure, financing, and overall cost of dental education. With this realization in mind, the cost of dental education to students and school finances was one of the central issues of concern at the time of the 21st Century Study. That portion of the study examined in this paper looks at several important measures to determine the overall “health” of the dental education financial system in the United States. Included was an in-depth examination of school finances in both public and private schools, tuition costs, return on investment and debt to income ratio, and the applicant pool. The financial outlook (2000–2011) as documented in the 21st Century Study10 showed the drop in state/local government support by 17.20% in publicly supported schools, and an increase in patient care revenue of 25.5%, with a 16.21% increase of patient care expenses. Private schools increased revenue by 15.31% from patient care with a 17.1% increase for those expenses. Overall, dental schools experienced an increase in total expenses of 11.82% versus an increased revenue of only 1.05% during that period. The 21st Century Study suggested a combination of community-based education and a team-based approaches to care in dental school clinics, that is, faculty/predoctoral/postdoctoral arrangements, could provide schools with greater income from patient care. Greater income from patient care would become a lever to reduce approaches that historically and automatically relied on heavy use of tuition increases to balance budgets.11 The 21st Century Study reported that during 2000–2011, schools managed their budgets with a 68.6% tuition increase for public schools and 38.9% for private schools. The steep increase in tuition became a concern for both perspective students and graduates who accumulated even larger debt, on average $200,000 per graduate, at that time and increasing through today. It was pointed out at the time, the applicant pool was robust, approximately 12,000 applicants and a ratio of 2.12 applicants for each position in the 62 dental schools existing at that time. The return on investment for dental education was calculated at a robust 29.4%. Still, a decrease in income of general practitioners, at the time, caused concern that the debt-to-income ratio at graduation required attention to keep dentistry a viable and attractive profession for future generations.12, 13 Clearly, tuition, which increased at the rate of 7%–10% per year during the 2000–2011, could not be increased at that rate going forward. The overall financial picture of US dental schools has not changed much from that reported in the 21st Century Study. Dental schools have continued to rely on three sources of major revenue over the past decade: (1) tuition, (2) government funding, and (3) patient care revenue. In the 10-year period from 2010 to 2020, revenue from tuition and fees of all schools more than doubled from 31.4% to 68.5%. State/local government support was reduced from 14.0% to 0.5% while overall patient care revenue dropped from 22% to 13.9% of schools’ revenue. Additionally, there is a wide range of government support for the public schools. One school, for example, reported 44% of its revenue from state and local government (Table 1).14 The drop in revenue for all schools from patient care from 22% of revenue to 13.9% over the 10-year time is disappointing as well as the overall patient care expenses of 25.7%, which exceeded revenue. Added to this picture of variability, is the wide range of revenue from patient care, from a low of 5.6% to a high of 35.6%. Some schools reported substantial income from community-based care. It is our observation that the schools with a significant percentage of revenue from patient care have learned how to operate their patient care programs so that they are a positive contributor to the schools’ budget. Patient care revenue, as we projected in the 21st Century Study, is the most likely source of new income for the overall financial picture, systemically, for dental education. With this precarious view of finances today, a detailed national study of schools leading with revenue positive changes on the clinical side, would assist all schools. Learning how to use their clinical care delivery model to produce more revenue where patient care expenses do not exceed revenue and become a net positive contributor to schools’ resources is the clear goal, here. A fresh look at tuition is needed as well. Tuition can vary from a high of approximately $100,000 per year to a low of $30,000.14, 15 the by dental schools by three percent of total revenue with tuition at is the ratio of revenue from for all dental The schools in with in the are out of range when schools and two reported and of their overall revenue was from These tuition schools should be their financial model to this on in 2023 students reported average debt of approximately The of such high of debt to the of dentistry will at some future students from to dental schools. This view of and tuition and clinical structures a and view of the and for revenue here. practice and and revenue are important from income and and practice In to schools, to operate the for clinical education a major for dental schools, expenses that are not by health professions schools. health profession schools rely on to provide patient care In an we projected of school finances and student when to community-based and private In this way student would in structures designed to be and dental school could be to school finances with are to and have pointed out to dental school into a more positive revenue to could reduce the and of operating dental With the of or dental service organizations, dental schools could create to those as educational for are for student education while to more Some newer dental schools have of these from these need to be now and widely dental education. patient care revenue and expenses over three decades clearly that dental schools continue to operate when their patient care expenses exceed the This places greater on tuition as a revenue clearly the in revenue and from patient in the year, schools reported that the percent of revenue from patient care was and of total revenue, while schools reported their total patient care were and It is difficult to determine from the data patient care revenue is a positive or contributor to the of schools’ example, one school reported patient care revenue of million expenses of which should make patient care revenue a net positive contributor to that budget. for example, school reported patient care revenue of million with of the data are a study of these two schools to determine one was to operate their patient care to to support the schools operating expenses while the school its revenue. school number was to of its revenue from tuition, a balance in its sources of revenue. The of Dental a study published in 2024, was an of the cost of dental school much of which is still and efficiency of dental schools are to their was a stated for that study. to financial are the study. One of the suggested was to efficiency and three decades patient care revenue as reported in of the of Dental Education that patient care revenue still well tuition revenue in financing dental schools, it is on the to its attention on the overall to the high tuition and reduce the debt level of A close study of the data from the of Dental Education by the Health that some schools are following to keep their tuition it clearly that many are The 21st Century Study was designed to move dental education to reconsider its future Study, and change have to the with the Gies Report, recommendations were made for dental schools to be as 3-year programs with additional time for The dental curriculum into years of with during when dentists were needed for the and in the 1970s when dental schools to 3-year programs. When the and after a period in the 1970s and 1980s so the 3-year but one of the 3-year schools from that period to research and have for the dental school curriculum to reduce the cost of dental education, for those who to practice in shortage the curriculum has already significant attention for more than a century. It has from the years of and in and with in to from and clinical to that the and dental school for service in community-based have in most schools. however, there is a move to reconsider the years necessary for and dental education based on the cost of dental education for One of the newer schools has already its of Dental to be completed in years of Dental are showing that graduates in their for clinical and of conditions with the current and new in clinical dental have made areas of care less complex to With and advances and to clinical care and disease changes in what is over time in dental school will continue to and address new for clinical practice. A of the of education dental and education and the cost for each could be to future graduates the perhaps even the and clinical be the balance and clinical and the need to new areas of study in the curriculum as well as the way students clinical care in have all major In the 21st Century Study papers on what oral health professionals need to know in 2040 provide to what is most for the These (1) dental education required for the changing healthcare (2) trends in and advance dental education, (3) the future of oral health care provided by and allied the role of oral healthcare professionals in and the future of education and practice for dentists and dental The of these papers to the for education of the next of oral healthcare the it is that in population disease and treatment needs curriculum changes to address more patient patients with and dental younger patients with and and populations with unmet Additionally, the 21st Century Study that oral health professionals can to address of the population and the increasing of complex new the benefits of early and and the maldistribution and shortages of care in some areas are all factors that provide a strong rationale for in dental Taking the view of these two latter important what is in dental school, it is time for for and education to work toward and dental education in a educational of the the and education is required to move ahead and with attention this can be by In the role of and allied a strong is made for their role in practice with dentists in two of the In one two of practice are as In one Dental is through the electronic health and a patient support which for care and and for In Dental an model is emerging and in paper prepared by a care the to the what will be needed to achieve oral health the of as of the will moving from the This paper that will have to be Health both and will need new will change healthcare and to overall health and in to the profession of dentistry in the for the health of the public and to to the need not be to think moving in these and these for change as of the role the must to oral overall the United States. important of the growing and changing trends in dental education is the consolidation of dental into This is and even the landscape of practice in many areas of the are to by dental service of the health profession, these dentists to practice in and are education for new graduates. of practice are of dental are growing along with The dental curriculum should information on the of and to assess and the role of the and the to the practitioners. Dental education would from understanding this environment as the practice environment education and In as for clinical for students and for graduating students to their education in in provide for new and now in the consolidation of is for newly students to receive for the important first years in practice. is for dentistry to remain an in this for trends to be addressed through change in curriculum and clinical structures is in the 38 papers and analysis of in the 21st Century Study. These changes and were at the June at of Dental While each of these papers can as topics they were into six for analysis and some 5 years we are and adding to the critical analyses of the 21st Century Study. We are to that two critical issues of tuition as the major source of revenue in both public and private schools is and there is, a need to the of the curriculum all of the educational years, from and dental to education. The strategy for moving to adapt to the changes in dental education and practice, should be through approaches designed to the cost of dental education with a understanding for an action agenda for how the United States will resources to care to those in oral healthcare shortage We in that the 21st Century Study six background papers on allied dental professions and background papers on for oral health research and scholarship in A future publication will revisit these two areas with a to how those papers from the 21st Century Study continue to future needs that advance the importance and value of research and health professions education. The authors have to