Future Organization of Oral Health Services Delivery: From 2012 to 2042.

The United States is currently experiencing a vortex of change in both general health and oral health care delivery, the ultimate outcome of which is still not well understood. The specific focus of this article is to examine the future organization of the oral health services delivery system (OHSDS) in the U.S., with special attention given to the role of large group dental practices (LGDPs) in that future. The article describes the various types of LGDPs and their ability to change the economic characteristics of the OHSDS. Large geographically distributed corporate group dental practices (LGDCGDPs) are the type that may expand their market share to the extent that they could change the economic characteristics of the OHSDS. A wide range of scenarios is used to project the expansion of LGDCGDPs into the future. The scenarios modeled are not intended as predictions but rather to present a range of possible OHSDS market structures that may emerge over the next 30 years. The implications of each scenario for the economic competition within the OHSDS are described. Possible implications of these trends for dental education are also discussed. This article was written as part of the project "Advancing Dental Education in the 21st Century."

Expanded function allied dental personnel and dental practice productivity and efficiency.

This study examined the impact of expanded function allied dental personnel on the productivity and efficiency of general dental practices. Detailed practice financial and clinical data were obtained from a convenience sample of 154 general dental practices in Colorado. In this state, expanded function dental assistants can provide a wide range of reversible dental services/procedures, and dental hygienists can give local anesthesia. The survey identified practices that currently use expanded function allied dental personnel and the specific services/procedures delegated. Practice productivity was measured using patient visits, gross billings, and net income. Practice efficiency was assessed using a multivariate linear program, Data Envelopment Analysis. Sixty-four percent of the practices were found to use expanded function allied dental personnel, and on average they delegated 31.4 percent of delegatable services/procedures. Practices that used expanded function allied dental personnel treated more patients and had higher gross billings and net incomes than those practices that did not; the more services they delegated, the higher was the practice's productivity and efficiency. The effective use of expanded function allied dental personnel has the potential to substantially expand the capacity of general dental practices to treat more patients and to generate higher incomes for dental practices.

Introduction to the 75th anniversary issue of the journal of dental education.

This issue of the Journal of Dental Education is a celebration of its seventy-fifth year as the premier journal for intellectual discourse on all aspects of dental education. It is a well-deserved celebration because it is broader than the journal itself. It is a celebration of excellence, success, and, above all, improved oral health for the American people and beyond. You will read wonderful history, powerful analyses, and insightful judgments in this anniversary issue, produced by some of our best and brightest. In this introduction, I add a few words about our journal and the role it has played in this celebration. Then, I will try to provide a little context about why we are celebrating. Finally, I will provide a brief glimpse of the remarkable experience ahead for readers.

Policy implications of assessing the impact of community-based education on dental school finances.

Dental schools are hard pressed to find the resources to adequately fund their mission of education, research, and service. Over the years, schools have tried to make up for the loss in public funds by increasing student tuition, increasing enrollment, and reducing the growth in faculty and staff salaries and program costs. Unfortunately, these strategies have not solved the financial problems. Declining resources are threatening the future of dental education. Data presented in this report attempt to answer the following question: will community-based dental education restore the fiscal health of dental schools and provide students an equal or better education? By reducing the number of chairs per student and developing revenue-sharing relationships with community clinics, community-based dental education offers a realistic option for putting dental schools on a solid financial footing.

The impact of new dental schools on the dental workforce through 2022.

Following a wave of dental school closures from 1986 to 2001 and a perceived shortage of dentists, three new dental schools were established between 1997 and 2003, and eight more are in various stages of planning and development to open over the next decade. Conditions are moving rapidly, and several institutions have stated intentions to open new dental schools since this analysis. This article presents a supply-side analysis of the impact of the new schools on the effective dentist to population ratio, taking into account changes in graduation rates, retirement rate, population growth, productivity, and gender ratio of the profession. Demand-side factors including utilization, per patient expenditures, and case mix are addressed, as well as the implications of these changes on access to care and the future of the profession. Given approximately ten new schools, by 2022, an additional 8,233 graduates will have joined the workforce, or approximately three dentists per 100,000 people. Effective dentist to population ratios vary greatly depending on all of the factors addressed. Changes in productivity influence the effective ratio most significantly. Most probable scenarios for the dental workforce suggest a stable dentist to population ratio at minimum, with an increase likely given recent productivity changes. The increase in dentists will not noticeably improve access to care for low-income and rural populations absent additional public funding to support demand for these populations and concurrent measures to effect even distribution of dentists throughout the country.

The effects of insurance carrier market power on dentists and patients.

BACKGROUND: Market power among dental insurance carriers is a carrier's ability to reimburse dentists at rates below what would exist in more competitive areas. Competition among carriers for dentists' participation in their networks protects dentists from highly discounted fees. The authors examined the extent to which dental insurance carriers facing less competition increase fee discounts. METHODS: The authors selected a sample of dentists from listings of general practitioners. They identified 219 metropolitan areas and contacted 11,542 dentists in those areas by mail, telephone or both. A total of 8,017 dentists completed surveys (a response rate of 69.46 percent). The authors' key focus was the possible relationship between carrier market power and the size of the fee discount. The authors compared discounts across metropolitan areas with their differing levels of insurance coverage and carrier market shares. RESULTS: Carrier market power was directly related to the sizes of fee discounts. The larger discounts were found where there was significant dental insurance coverage and few carriers providing this coverage. Dentists' net incomes were significantly less in areas with larger fee discounts. CONCLUSIONS AND PRACTICE IMPLICATIONS: Dental insurance carrier market power leads to increased fee discounts. These higher discounts reduce dentists' earnings. Although the larger discounts may result in lower overall patient costs, this patient benefit is temporary. Ultimately, the number of practicing dentists in these communities will decrease as dentists seek improved practicing conditions elsewhere. This reduction will lead to overall fee increases until the earning potential of dentists is restored.

U.S. dental school applicants and enrollees, 2006 and 2007 entering classes.

The number of applicants to dental schools in the United States continues to rise at a double-digit rate, 12 percent from 2005 to 2006 and 14 percent from 2006 to 2007. The number of applicants to the 2006 and 2007 years' entering classes of U.S. dental schools was 12,500 and 13,700, respectively. The number of first-time enrollees (4,600) in 2007 was the highest recorded since 1989. Men continue to comprise the majority of all applicants, 55 percent in 2006 and 53 percent in 2007. However, the percentage of women applicants to each school ranged from a third to more than half. Underrepresented minority (URM) applicants comprised 12 percent of the applicant pools in both 2006 and 2007. For the 2007 entering class, URM enrollees comprised 13 percent of enrollees. As in previous years, in 2007, the largest number of applicants and enrollees came from states that are among the largest in population in the United States: California, Texas, New York, and Florida. Grade point average and Dental Admission Test scores were the highest in more than a decade. More than three out of four of the 2007 first-time, first-year enrollees earned a baccalaureate degree either in biological/life or physical sciences or in health. Regardless of major field of study, the percent rates of enrollment generally exceeded 30 percent, though there were exceptions (e.g., engineering and education). The majority of enrollees to the 2007 entering classes were twenty-two or twenty-three years of age.

Public dental expenditures and dental visits among children in the U.S., 1996-2004.

OBJECTIVES: Congress created the State Children's Health Insurance Program (SCHIP) in 1997 as an expansion of the Medicaid program to provide health insurance to children whose family income is above the Medicaid eligibility standards-generally up to 200% of the federal poverty level (FPL). This article examines changes in the utilization of dental services during a period of increasing public funding of dental services. METHODS: Public dental expenditure estimates came from the Centers for Medicare & Medicaid Services (CMS), and a breakdown of these expenditures by patient age and income level was based on the Medical Expenditure Panel Survey (MEPS). RESULTS: According to CMS, funding for dental SCHIP and dental SCHIP expansion grew from $0 prior to 1998 to $517 million in 2004. According to the MEPS, between 1996 and 2004 there was an increase in the number and percent of children 2 to 20 years of age who reported a dental visit during the past year. These increases were most notable among children in the 100% to 200% FPL category. Approximately 900,000 more children in this income group visited a dentist in 2003-2004 than in 1996-1997. Children in this income group reported an increase in the amount of mean dental charges paid for by Medicaid and a real increase in mean dental charges per patient from $217 to $310. CONCLUSIONS: Recent increases in the public funding of dental services targeted to children in the 100% to 200% FPL category were related to increased utilization of dental services among these children from 1996 to 2004.

Orthodontic dental patients and expenditures--2004.

INTRODUCTION: In this article, we describe recent trends in the age of patients receiving orthodontic services and look at how expenditures for these services are related to patient age and income level. METHODS: These findings are based on 3 national health expenditure surveys sponsored by the Agency for Healthcare Policy and Research conducted in 1987, 1996, and 2004. RESULTS: Recent increases in the number of patients receiving orthodontic services were largely due to an increase in the overall population. There has been a shift in the age distribution of patients receiving such services. Children 8 to 18 made up a greater percentage of all patients receiving orthodontic services, but there were fewer adult patients aged 19 years and older. CONCLUSIONS: Children 8 to 18 years old made up a larger percentage of patients who received orthodontic services in 2004 compared with 1996 and 1987. The percentage of total dental expenditures of children 8 to 18 for orthodontic services might increase in the future because of less need for restorative services among this segment of the population.

U.S. state-supported dental schools: financial projections and implications.

This article examines the impact of financial trends in state-supported dental schools on full-time clinical faculty; the diversity of dental students and their career choices; investments in physical facilities; and the place of dentistry in research universities. The findings of our study are the following: the number of students per full-time clinical faculty member increased; the three schools with the lowest revenue increases lost a third of their full-time clinical faculty; more students are from wealthier families; most schools are not able to adequately invest in their physical plant; and more than half of schools have substantial NIH-funded research programs. If current trends continue, the term "crisis" will describe the situation faced by most dental schools. Now is the time to build the political consensus needed to develop new and more effective strategies to educate the next generation of American dentists and to keep dental education primarily based in research universities. The future of the dental profession and the oral health of the American people depend on it.

Outcomes of root canal treatment and restoration, implant-supported single crowns, fixed partial dentures, and extraction without replacement: a systematic review.

STATEMENT OF PROBLEM: Dentists and patients are regularly confronted by a difficult treatment question: should a tooth be saved through root canal treatment and restoration (RCT), be extracted without any tooth replacement, be replaced with a fixed partial denture (FPD) or an implant-supported single crown (ISC)? PURPOSE: The purpose of this systematic review was to compare the outcomes, benefits, and harms of endodontic care and restoration compared to extraction and placement of ISCs, FPDs, or extraction without tooth replacement. MATERIAL AND METHODS: Searches performed in MEDLINE, Cochrane, and EMBASE databases were enriched by hand searches, citation mining, and expert recommendation. Evidence tables were developed following quality and inclusion criteria assessment. Pooled and weighted mean success and survival rates, with associated confidence intervals, were calculated for single implant crowns, fixed partial dentures, and initial nonsurgical root canal treatments. Data related to extraction without tooth replacement and psychosocial outcomes were evaluated by a narrative review due to literature limitations. RESULTS: The 143 selected studies varied considerably in design, success definition, assessment methods, operator type, and sample size. Direct comparison of treatment types was extremely rare. Limited psychosocial data revealed the traumatic effect of loss of visible teeth. Economic data were largely absent. Success rates for ISCs were higher than for RCTs and FPDs, respectively; however, success criteria differed greatly among treatment types, rendering direct comparison of success rates futile. Long-term survival rates for ISCs and RCTs were similar and superior to those for FPDs. CONCLUSIONS: Lack of comparative studies with similar outcomes criteria with comparable time intervals limited comparison of these treatments. ISC and RCT treatments resulted in superior long-term survival, compared to FPDs. Limited data suggested that extraction without replacement resulted in inferior psychosocial outcomes compared to alternatives. Long-term, prospective clinical trials with large sample sizes and clearly defined outcomes criteria are needed.

Economic impact of regulating the use of amalgam restorations.

OBJECTIVE: This article estimates the financial impact of a ban on amalgam restorations for selected population groups: the entire population, children, and children and women of childbearing age. METHODS: Using claim and enrollment data from Delta Dental of Michigan, Ohio, and Indiana and the American Dental Association Survey of Dental Services Rendered, we estimated the per capita use and annual rate of change in amalgam restorations for each age, gender, and socioeconomic subgroup. We used population projections to obtain national estimates of amalgam use, and the dental component of the Consumer Price Index to estimate the annual rate of change in fees. We then calculated the number of dental amalgams affected by the regulation, and the fees for each of the years 2005 to 2020. RESULTS: If amalgam restorations are banned for the entire population, the average price of restorations before 2005 and after the ban would increase $52 from $278 to $330, and total expenditures for restorations would increase from $46.2 billion to $49.7 billion. As the price of restorations increases, there would be 15,444,021 fewer restorations inserted per year. The estimated first-year impact of banning dental amalgams in the entire population is an increase in expenditures of $8.2 billion. CONCLUSIONS: An amalgam ban would have a substantial short- and long-term impact on increasing expenditures for dental care, decreasing utilization, and increasing untreated disease. Based on the available evidence, we believe that state legislatures should seriously consider these effects when contemplating possible restrictions on the use of amalgam restorations.

The urban and rural distribution of dentists, 2000.

BACKGROUND: The authors examine urban and rural variation in the number of dentists in relation to the U.S. population. They focus on the number and distribution of dentists who practice in rural counties. METHODS: The authors divided U.S. counties into categories based on nine rural-urban continuum codes. They based county-level estimates of population on the 2000 census. They based county-level estimates of dentists on the Distribution of Dentists in the U.S. by Region and State, 2000--a report resulting from the annual census of dentists conducted by the American Dental Association. RESULTS: Although dentists were found to be more concentrated in urban areas, 84.7 percentage of the population living in the most rural counties lived in a county with one or more private practice dentists. CONCLUSIONS: Private practice dentists are distributed widely across rural areas and are available to a large proportion of the population living in these areas. PRACTICE IMPLICATIONS: A combination of population and per capita income largely determine the viability of a private dental practice located in a rural area. In areas in which this combination is insufficient, publicly funded or philanthropic programs will be necessary to ensure access to dental services.

Dentist-prescribed drugs and the patients receiving them.

BACKGROUND: Outpatient prescription drugs continue to play an ever-increasing role in health care delivery in the United States. This paper focuses on the drugs prescribed by dentists and the patients who receive those drugs. METHODS: The authors analyzed data from the 2001 Medical Expenditure Panel Survey (MEPS) for the U.S. community-based population. They developed estimates of the total market for prescription drugs related to a dental visit in terms of total number of prescriptions, total expenditures, and sources of payment. Also included are breakdowns by the type of dentist and the therapeutic class of drug prescribed. They also present a model that identifies the patient characteristics that best predict the likelihood of receiving a dental visit related prescription drug. RESULTS: Dental patients who were 18 years and older, African American patients, patients whose education level was less than a college degree, patients whose dental visit frequency was less than twice a year, and patients without medical insurance were most likely to report a prescription drug. CONCLUSION: Respondents' socioeconomic background and other demographic factors were related to the likelihood of receiving a prescription drug related to a dental visit. Patient age was related to the therapeutic class of the drug prescribed. PRACTICE IMPLICATIONS: Patients with fewer than two dental visits per year were more likely to report a dental prescription than patients with at least two visits per year.

The endodontic workforce.

The amount of endodontic care provided in the US requires an understanding of the supply and demand for such care. The supply side includes the number and location of endodontists, type of provider, and productivity. The demand side consists of the changing demographics of the age groups that endodontists predominantly treat along with changes in their dental health. To address these issues, we have compiled and analyzed data from American Dental Association (ADA) with other sources such as US government census data and the National Health and Nutrition Examination Surveys (NHANES). From 1982 to 2002, the supply of endodontists increased at a rate greater than that observed with general practitioners or the other specialty areas. The growth of endodontists in relation to general practitioners is important. The latter are co-providers of endodontic care as well as a primary source for referral of patients to endodontists. Demographic and disease changes are likely to impact the need and demand for endodontic services. Endodontists' patients are generally between the ages of 25 and 64 yrs. Currently, the majority of endodontists' patients are members of the large baby boom generation who in 2000 ranged in age from their late 30s to their late 50s. During the next 20 yrs the Baby Boom generation will be replaced by the numerically smaller Generation-X cohort. This generation has experienced substantially less total caries than baby-boomers and they most likely will have fewer endodontic sequela as they age. A moderating factor that could partially offset the predicted decline in numbers of patients is the increased number of teeth that Generation-Xers are likely to retain. A flexible endodontic workforce strategy must assess the impending demographic and disease trends in relation to future growth rates of both endodontists and general practitioners.