Dr. Meskin suggests in "Back to the Future" (April JADA) that the answer to the pending shortage of dentists is not to increase the size of dental schools, as government grants promoted in the 1960s, but to increase the number of auxiliaries who can handle an increasing number of legalized duties. However, the realistic solution is a little bit of both.
The available demographics show that the number of dental school graduates has remained static for many years (at approximately 4,000 per year) after the precipitous downsizing and closing of schools in the 1980s. The number of dentists who are retiring, dying, working part time or going into other careers (because they can afford to) exceeds this number.
So the supply side is decreasing while the demand side is increasing; the general population is growing, as is the number of employees covered by dental benefits plans. Add to that the emphasis from all quarters on increasing access, and there is no way the supply can meet demand.
But relying on expanding the duties of dental assistants alone is overly optimistic. Why? There are too many of our own member dentists who oppose it. Thankfully, one-auxiliary offices are no longer the norm, but there are too many dentists whose assistants lovingly refer to them as "control freaks" behind their backs.
These dentists doubt that auxiliaries could ever develop the hand-eye coordination to take impressions or X-rays, make temporaries, scale teeth or place simple restorations, let alone pass the didactic courses. Despite the military and many pilot programs over the years (remember Expanded-Functions Dental Assistants?), which proved otherwise, they have a right to their opinion. Furthermore, there is a limit on how many auxiliaries a dentist can reasonably supervise before quality of care suffers.
The ADA needs to change its policy approach to effect change (perhaps the "Future of Dentistry" report will be a start). For example, even though over half the states allow dental hygienists to administer local anesthetic, the majority of delegates in the ADA House recently voted to affirm ADA policy opposing such delegation.
Some argued that allowing hygienists to give shots motivates them to seek independent practice. But in every other industry, just the opposite is true: the more responsibilities employees are given, the more rewarding they find their jobs and the longer they stay.
There will always be an activist minority within the dental hygiene lobby who will push an independent practice bill in every state capital. Opposing it is just an inevitable core tenet of our legislative program, as is our commitment to protect the public’s health. Let’s accept that and not allow it to be an impediment to helping our members who need help in their offices.
But reasonable restrictions must be part of any enabling legislation expanding delegation of duties because the public must be protected from those few dentists whose entrepreneurial urges are out of balance with their professional ethics. Hygienists are often testifying anecdotally in legislative hearings that they "work weeks at a time while their boss is in Hawaii." Although this is as much of an exaggeration as patients who claim, "I never saw the periodontist/orthodontist during my entire treatment," we still have to guard against the potential for abuse.
There should be no debate that the basic demographics demand an increase in the number of dental school graduates. Not by double perhaps, but by how many is certainly still in doubt, as Dr. Meskin so clearly explains. And as the premier dental organization in the world, the ADA should be the premier prognosticator of dental work-force needs.
To do so, it must commit significant budget dollars to assembling and analyzing the best demographic data available—a huge challenge indeed. The data must answer complex interdependent questions. A sampling:
- – How widespread will fluoridation become and how much will it impact restorative care in all populations?
- – How will technology improve the efficiency of the average practice?
- – Will legislation expanding access and delegation of duties become successful nationally?
- – How will early retirement and part-time practice patterns affect overall productivity?
- – Will the shortage of hygienists, assistants and lab techs be resolved?
- – Will demand for elective and cosmetic procedures continue to increase?
- – Will managed care plans and nonindexed annual caps continue to erode benefits?
- – Will the tax-exempt status of dental benefits be preserved?
With the best data and the best analysts, the ADA can influence the properly controlled growth of dentists and their multifaceted auxiliaries to meet the public’s oral health needs. Consistent with human nature, there will be no groundswell demand from grassroots members to increase class sizes as long as their practices are thriving.
So improving our profession’s future with responsible solutions requires leadership. Obviously, there are many questions to be answered. Let’s start with the most important: if the ADA doesn’t develop the ideal practice model and growth patterns, who will?
