Demand for Dentists: Forecasting the Future of the Profession
Will there be too many dentists in the future? Few questions elicit as much debate in the dental community.
Forecasting whether a dental shortage or surplus is in store is complex, made no easier by different trends pointing in different directions.
On one hand, factors signaling a potential shortage include the rising U.S. population, expanding dental insurance coverage and the ever-increasing need to provide care for millions living in dental shortage areas.
On the other hand, trends indicating a potential surplus include improved overall oral health, skyrocketing dental school enrollments, and advancing technology that may reduce total dental visits and procedure time — or eliminate the need for the dentist entirely.
Predicting the future of dentistry is by no means an exact science; rather, predictions are guided by several factors and trends. Different dental researchers have different perspectives on the outlook of the profession, including the myriad evolving variables expected in the next several decades that may influence the need for dentists.
A look back can illuminate how previous decades met the shifting perceptions of the dental workforce. How dentistry responded decades ago may help shape the approach to meeting the future needs of the field.
The Dentist Workforce in the 1970s, 1980s and 1990s
The 1970s and 1980s saw a steady increase in the number of dental school graduates, thanks in part to sentiments planted in the 1950s and 1960s that the nation was facing a shortage of dentists and other healthcare providers.1
The U.S. government combatted the perceived lack of providers by unveiling plans aimed at funding school construction projects and providing loan and scholarship dollars to students. The Health Professions Educational Assistance Act of 1963 and The Comprehensive Health Manpower Act of 1971 promoted a major expansion of the national healthcare educational landscape, including enrollment in dental schools.1
In 1970, the Carnegie Commission on Higher Education released a report further supporting the notion that America needed more dentists. Dental school funding (excluding research and postgraduate programs) jumped from $64 million in 1970–71 to $80 million in 1971–72. Six new dental schools opened between 1971 and 1975.1
But by the mid-1970s, the pendulum began to swing the other way as concerns of an oversupply of healthcare providers began. Congress reacted by slashing funding for medical and dental education to $57.8 million in 1974–75.1
It wasn’t long before the whipsaw effect caused by the give-and-take of government funding had detrimental effects on dental schools across the country.
During the 1970s and early 1980s, the number of dental school graduates grew to 6,300 per year. Then came a sharp decline. Seven dental schools closed, and the number of graduating dentists dropped to 3,744 in 1994.2
In the late 1980s and 1990s, most dental schools that remained open saw enrollment cuts. Although only seven dental schools shuttered during this time, the combined enrollment cuts were equivalent to the closure of 20 averaged-sized dental schools.1
The flood of dental school education funding in the 1970s had evaporated as quickly as it came, creating disruption and disagreement among educators and practicing dentists about the appropriate size and number of dental schools and the size and distribution of the national dental workforce.1
The dental field was in a challenging position at end of the 1980s and 1990s, with an oversupply of dentists, several dental school closures, decreased enrollment and rising tuition costs. Plus, the American people had better oral health than in decades past, which begged the question: Were dentists needed as much as they once were?3
The State of the Dentist Workforce Today
Today, approximately 59 million Americans live in dental health professional shortage areas (HPSAs), or parts of the nation where dental care is hard to access.4 The HPSA designation was developed in the 1970s and is defined as an area that has a population-to-provider ratio greater than 5,000 to one, or 4,000 to one in areas with a higher dental need.5
Scott Kodish of the U.S. Health Resources & Services Administration (HRSA) said the agency estimates that approximately 10,000 additional dental practitioners are needed to lift the designation on the more than 6,300 mostly rural communities considered HPSAs.4
The HRSA offers programs, grants and training to eliminate oral health disparities in rural communities and advance dental health nationwide. One of its initiatives — the National Health Service Corps (NHSC) — provides loan repayment and scholarships to dental health professionals and students who commit to serving in HPSAs in underserved, high-need rural, urban and tribal communities throughout the United States.
“Currently, 1,470 dentists provide care to approximately 1.5 million Americans in HPSAs across the United States,” Kodish said. “One third of NHSC dentists work in rural HPSAs, where the need is more significant than other areas of the country.”
With almost 60 million Americans living in an area with dental care in short supply, does that mean we’re experiencing a dental shortage? The answer is complex, said Marko Vujicic, PhD, chief economist and vice president of the American Dental Association (ADA).
“In terms of shortages, the HPSA statistic, while widely cited, is based on seriously flawed methodology,” Vujicic said. “The ADA Health Policy Institute (HPI) developed a practical yet more insightful way of measuring geographic access to dentists, including for Medicaid populations that, in my view, is an important improvement on HPSAs.”
The HPI data paints a bit of a different picture, Vujicic explained, with fewer people living in areas with limited geographic access to dentists. That data can be found at ada.org/en/science-research/health-policy-institute/ geographic-access-to-dental-care.
According to Vujicic, the bigger issue affecting workforce adequacy in dentistry is revealed in the research on why people do not go to the dentist. For adults, irrespective of income level, cost — or, more accurately, the “perceived” cost — is the deterrent.
“For children, the best studies I have seen show the top barrier to access is that dental care is not a priority. This includes publicly insured children for whom access to providers is generally more limited than for privately insured children,” Vujicic said. “I know this goes against a lot of the conventional wisdom in health policy circles, which argues that lack of providers is the key barrier.”
To solve the perceived affordability issue for adults, Vujicic explains there are two types of solutions — reduce the cost of care or change people’s perceived benefit of the care.
“Expanding dental insurance coverage is one way to reduce the cost to consumers, but let me caveat that by saying it’s not necessarily possible under the current private dental insurance paradigm,” Vujicic said. “The expansion would be something more akin to how dental coverage for children is designed in Medicaid and [the Children’s Health Insurance Program], which serves as a model for how a wide basket of services can be covered — not necessarily reimbursed well, but covered.”
Another way to reduce the cost of care is to move to different payment models that are outcome based and incentivize prevention rather than treatment.
“Part of why we are seeing more states expand dental coverage to adults in Medicaid and an intensified policy debate over Medicare is that policymakers want to do something about the affordability issue for adults and seniors,” Vujicic said.
The other potential solution to the affordability problem is to raise the perceived benefit of visiting the dentist and then convince consumers to pay out of pocket for dental care, which Vujicic admitted seems much harder.
“Dentists need to understand that the self-pay patient base is shrinking, and the only thing keeping it from disappearing entirely is that we have an expanding senior population,” Vujicic said. “Our research shows that in the past 10 years, there has been a 37% reduction in the number of self-pay patients who are 19–64 years old. Not per dentist. Not per capita. In total.”
Vujicic noted that seniors have fueled an expansion in self-paying, but that expansion will not last much longer. Population demographics will start to change considerably in the next five to 10 years, Vujicic said. Millennials will gain prominence, and baby boomers will decline.
“This is only going to dampen demand for dental care, at least in the traditional private practice,” Vujicic said. “Dentists who can cater to what millennial patients want — convenience, price and quality transparency, user experience — are going to gain market share.”
Another crucial factor affecting today’s dental workforce is the growth in dental school openings and enrollment. In sharp contrast to the school closures and enrollment cuts of the late 1980s and 1990s, dental schools are opening at a greater rate than closing. In 2000, the United States had 54 dental schools.6 Today, there are 67.7
Dental school enrollment is surging, too; in fact, the 25,381 predoctoral students enrolled in the 2018–19 academic year represent the highest enrollment numbers ever. The next highest enrollment was in 1980–81, when 22,842 students were enrolled in American dental schools.7
Have dental schools reached their peak in terms of enrollment and graduation numbers? Vujicic said that’s likely the case, but, again, the answer isn’t so simple.
“If you ask me whether we need more dentists, I would say if more are going to practice in rural areas and inner cities, treat large numbers of Medicaid patients, and collaborate meaningfully with medical practices, then yes,” he said. “But if they want to locate in saturated markets or middle- to upper-income urban areas and want a significant self-pay patient base, I would say no.”
The maldistribution of the current dental workforce poses a significant challenge for the future, so the HRSA has invested in programs to highlight the issue now, Kodish added.
“The HRSA funds postdoctoral dental programs in rural areas to bring more oral health providers to HPSA communities,” Kodish said. “These programs increase access to comprehensive dental care while encouraging oral health professionals to ultimately practice in rural communities. HRSA programs are also making investments in dental training opportunities located in rural and other underserved communities. In the future, general dentists in rural communities may have to acquire a broader range of clinical skills to meet the unique needs of underserved people.”
Shifts in patient demographics, payer complexities and uneven provider distribution are important pieces to the puzzle that impacts today’s dental workforce. How these trends evolve, along with other factors — such as emerging technologies and improving patient health status — offer a glimpse into future workforce challenges and opportunities.
Predicting the Future of the Dentist Workforce
Several research studies have endeavored to estimate the demand for dentistry as far out as 2040. An overview of some findings includes:
- In 2017, “Estimating the Number of Dentists Needed in 2040,” co-authors Stephen A. Eklund, DDS, MHSA, DrPH, and Howard L. Bailit, DMD, PhD, predicted a surplus of dentists in 2040 based on future U.S. population projections of 380,000,000 and assumptions that dentists, on average, treat 2,000 patients per year:
- 80,000 full-time dentists will be needed if 42% of the population seeks dental care.
- 127,000 full-time dentists will be needed if 67% of the population seeks dental care.
- ADA estimates 168,000 full-time dentists in 2040, indicating a dental surplus between 32% and 110%.8
- In order to sustain 168,000 full-time dentists, approximately 88% of the projected U.S. population would need to seek dental care.
- The HRSA’s “Oral Health Workforce Projections, 2017– 2030” projects an “adequate” supply of dentists across the entire profession in 2030, although the report forecasts a shortage of about 4,000 general dentists. Balancing the general dentist shortage, the report predicts a surplus of certain dental specialists, including pediatric dentists.9
- Analysis in “Projecting the Demand for Dental Care in 2040” by co-authors Richard J. Manski, DDS, MBA, PhD, and Chad D. Meyerhoefer, PhD, provides a more mixed prediction. The authors surmise that:
- Total dental visits will increase from 294 million in 2017 to 319 million in 2040.
- Dental visits per person will decrease from 0.92 in 2017 to 0.84 in 2040.
- The percentage of the population with a dental visit will rise from 41.9% in 2015 to 44.2% in 2040.10
Population Changes Influencing the Future Workforce
The U.S. population is growing, and it’s expected to grow to about 380 million by 2040 — up 19% from 2015.10 But a growing projected population alone doesn’t equate to a need for more dentists, said Manski.
“The future demand for dentists will be a function of an increased total population and increased likelihood that people will retain their teeth and need more care later in life,” Manski said. “It’s still undetermined if success with fluoride leads to later life decay prevention, or if population taste and preference for age-defying treatment, such as esthetic dental care, will increase with time.”
Manski said that he sees a bifurcated need for dental providers as a possible trend in the future workforce.
On one side, a need for providers to care for those who are at risk and underserved, and then a separate market for those with the resources to pay for needed care or desired esthetic care,” Manski said. Aside from population growth, population demographics will change, skewing younger as baby boomers die. The younger population — which has enjoyed water fluoridation, preventive dental education and expanded dental insurance coverage — points toward a future decrease in the number of dental visits per person and increased efficiencies during visits.
Preventive measures that have been commonplace for decades — such as the wide availability of fluoride — along with increasing expectations for oral health have had considerable effects on the oral health improvements over the past 50 years and will help shape the future of the field, said Eklund.
“These oral health improvements are important factors in the reduction of treatment time required to maintain the oral health of the average patient,” Eklund said.
Different dental health experiences between birth cohorts will result in major aggregate differences between 2015 and 2040. These differences will be further reinforced by the difference in the size of the birth cohorts, Eklund said. Those born between the end of World War II and 1964 — the baby-boom generation — experienced far higher levels of decay as children than every birth group that has come since, Eklund explained.
“These large numbers of heavily restored teeth have placed tremendous demands on the dental profession over the past several decades to maintain and repair,” Eklund said. “The birth groups since that time have experienced far less damage to their dentitions as children and young adults, and, therefore, per capita and in the aggregate, they do and will require less intensive care.”
Looking ahead to 2040, Eklund said each dentist will be able to maintain the oral health of more of these healthier individuals in less time.
“As the younger, healthier cohorts replace the older cohorts who had more demanding care needs, dentists will need to spend less time per patient on the average American adult in 2040,” Eklund said.
Another trend affecting the future of the dental workforce is mandated pediatric dental coverage in private health insurance plans. Manski noted that although expanded pediatric dental coverage has driven a current demand for pediatric providers, it will continue to flatten as more and more children are covered. Opportunities will still exist for pediatric dentists to care for at-risk and underserved populations, but Manski pondered whether an updated payer model would be helpful to better support these populations.
“Will there be efforts to revise the plans to cover care that is most needed by patients with the highest need and at the highest risk?” he said. “There is a finite amount of funds to provide this needed care. Will efforts to best allocate these funds be successful?”
Dental Practice Changes Influencing the Future Workforce
A 2015 ADA survey reported that nearly 40% of private practice dentist owners said they were not as busy as they would like to be.8 Looking ahead to 2040, how will group practice models, rising dental school debt and technological advances affect dentists’ practices in the future?
The rise of group practices allows associate dentists and owners to increase their patient loads compared with individual practice owners, but the impact of group practices on the future of the field is not fully understood, Manski said. However, he noted that group practices can improve dentistry’s outlook by harnessing their ability to achieve efficiencies not possible in small practice settings, all while maintaining the patient-driven mindset of a private practice.
“If large group practices can find a harmonious balance between profit and service, the dental profession, dentists and society will benefit,” Manski said.
Two other influences on practice changes are graduate debt and technological advances, which — while they may not seem interconnected — may have big impacts on the future of the workforce, Manski said.
Rising dental school tuition will continue to lead to greater graduate debt, which will lead to dentists exploring ways to cut practice costs to pay off that debt, Manski said.
“Graduates with significant debt must service that debt after graduation,” Manski said. “This is, in part, what leads to the discussion about nondentist providers as an attempt to lower the cost to provide dental care. Unfortunately, nondentist providers may actually distort the overall dental market — as providers like dental therapists do more procedures that general dentists also do, general dentists will have to increase the prices of other procedures to maintain their overall revenue, causing an unintended increase in the cost of more complex care. Perhaps, a better approach would be to lower or subsidize the cost of dental education.”
Thanks to advances in technology, more general dentists in decades to come may be positioned to offer treatments currently provided by specialists. Manski pointed to two unknowns with respect to cost-cutting technologies: advances in technologies to simplify implant placement and lowering the costs of in-office lab fabrication.
“If technology gets to the point where implant placement becomes routinely provided by general practitioners, then the cost reductions will likely follow our colleagues in ophthalmology with laser eye surgery,” Manski said. “Technology could be the driver that lowers the cost enough to be in the range of most patients’ budgets. Then, we need to consider changes that will be dependent upon new science that could change the course of disease or treatment completely, but, for now, that is difficult to predict.”
Drawing Conclusions: Preventing a Dentist Surplus
With all the evolving variables expected over the next several decades, it’s not possible to say whether dentistry is facing a workforce shortage or surplus. Available research findings share mixed results, but one certainty is that the profession needs more research on the subject so dentists can be prepared for future workforce demands. What information needs to be obtained to determine whether there will once again be a surplus of dentists? A good place to start is tracking the average treatment patterns of patients by age, Eklund said. Monitoring how these patterns change over time should give signals as to whether important workforce changes could be needed.
“If the per capita need for major restorative care is declining and the proportion of preventive care rises, for example, this suggests that personnel needs may have to shift to a higher proportion of auxiliary personnel with a proportional decline of dentists,” Eklund said.
Equally important is carefully monitoring the size of the population by birth cohorts to measure the various levels of need among different cohorts relative to the supply and age of dentists, Eklund added.
Dental schools are also crucial to understanding supply and demand concerns. Today’s dental school enrollment is at its highest levels historically. Will the demand for dental school spots continue in the future? The market suggests yes, Manski said.
“As long as there are more applicants than spots and tuition is high enough that schools project adding a program to be profitable, there will be more schools opening,” Manski said. “Also, as long as there are potential applicants that believe that dentistry is a lucrative profession, the overall number of applicants will likely not decrease. Schools may have to be less choosy, but the number will remain steady.”
As school enrollments rise, concern of a future surplus begins. When it comes to taking action to prevent a surplus, dental schools are in a difficult position. Dental education funding has become more dependent on tuition and clinical income, Eklund explained, which are both tied to enrollment numbers.
“Because decisions on enrollments are made at the individual school level, dental schools are in a position of conflict between their current income needs and the longer-term potential need for dentists in the more distant future,” Eklund said. “As long as there are qualified candidates available, the incentive at the moment is to maintain or increase enrollment.”
What happens if there is a dental workforce surplus? Eklund explained that an extreme surplus will likely create financial problems for some dentists.
“If there are not enough patients available per dentist, it may become increasingly difficult to meet the economic demands of supporting a dental practice,” he said.
Manski said that in an event of a surplus, the market would adjust with more demand for esthetic dentistry, decreased cost of care, decreased dentist salaries, fewer dental school applicants and increased dental school closures.
And an entirely new question has emerged: How will COVID-19 alter the future of the dental workforce? Will it influence a potential medical school applicant to choose dentistry instead? Will it encourage a potential dental school applicant to adopt a nonhealth-related career? Will the pandemic create longstanding changes to practice operations?
“Even in a post-COVID environment, the future for the dental profession is bright and will remain so,” said Manski. “However, for the next year or two, there will be challenges and troubled waters ahead that we must navigate. While it will be our responsibility to adopt new best practices to ensure the safety of patients, staff and ourselves, we will also need to adapt to changing patient perceptions and concerns. While the need for dentistry has not changed, we will experience a new equilibrium resulting from pent-up demand offset by patient apprehension. Additional attention to best practice management processes will be needed to optimize each patient encounter and to reassure patients.”
Researchers will need to continue considering future supply and demand of dental services. But for now, general dentists — both practicing and aspiring — have plenty of challenges and opportunities to keep furthering the profession.
Manski is optimistic. “Even with the difficulties that we currently face, dentistry is a wonderful profession in which our colleagues are able to provide an important needed service, contribute to society in a meaningful way and live a very nice life,” he said.
Kelly Rehan is a freelance journalist based in Omaha, Nebraska. To comment on this article, email firstname.lastname@example.org.
Note: This article was developed with the assistance of Allan J. Formicola, DDS, MS, dean emeritus and professor emeritus of the Columbia University College of Dental Medicine.
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