There is a growing chasm between the practice of dentistry in the U.S. and the oral health needs of the nation, according to a recent study "The Growing Challenge of Health Care in America" published in the September 5 issue of Health Affairs.

The researchers report that, while the dental professions have flourished, there is "abundant evidence that a sizable segment of the population does not have access to oral health care" and that the dental safety net is "poorly defined and underdeveloped." The article examines the oral health workforce and trends in dental care delivery in relation to the physician workforce and trends in medicine.

"The practice of dentistry has improved, becoming more lucrative and less time-consuming," said Elizabeth Mertz, MPA, lead author and project director at the UCSF Center for Health Professions.

"In comparison to physicians, dentists work more independently, have a higher rate of solo practice, and in some cases their earnings have surpassed the net income of physicians," Mertz explained.

"But, while dentistry appears to remain a "cottage industry" fighting incorporation into larger systems of managed care and capitated payments that have permeated medical groups," she said, "our study found that both the dentist-to-population ratio and the average number patient care hours of dentists have been declining," Mertz said.

There are approximately 150,000 clinically active dentists in the United States. Although the number of dentists has been increasing for the past 20 years, the growth has leveled off in comparison to the growth in the U.S. population, resulting in a decreasing dentist-to-population ratio: 58.41 per 100,000 in 1996. (In 1990, there were nearly 60 dentists per 100,000 population.)

The physician-to-patient ratio currently stands at 286 per 100,000, and between 1960 and 1998, the physician population grew by 198.6 percent. In addition, the dentist workforce is aging, and a good portion of them will reach retirement age in the next decade. There are fewer young dentists in practice, and few dentists working past the age of 65.

In addition, the study found that gender, age and racial composition of the dental workforce does not match that of the general population, and is even more misaligned than the physician workforce. For instance, in a contrast of the racial composition of the U.S. population in 2000 with the dental and physician practice community and the entering dental and medical student population in 1999, the racial/ethnic distribution of the dental workforce is among the least diverse of health professions. Approximately 13 percent of dentists are non-white, compared to 22 percent of physicians and 28 percent of the population. African Americans, Hispanics and Native Americans are generally considered to be underrepresented minorities (URM) in the health professions. Dentistry has a 6.8 percent URM compared to 8.5 percent of physicians and 24.8 percent of the population. First year dental students in 1999 were 34 percent non-white. However, just 10.2 percent of the students in the entering class were URMs. In medicine, 36 percent of the first year students in 1998 were non-white and 14 percent were URMs.

The study found that on average, 63.7 percent of patients are covered by private insurance, 5.7 percent by public insurance and 30.6 percent are uninsured. In 1998, 53.8 billion private dollars were spent on dental services, nearly 50 percent as out of pocket payments.

"Despite much recent activity at the federal level documenting disparities in oral health and access to care, we have found that the dental public health system provides little funding for prevention or oral health care of the underserved," said co-author Edward O'Neil, MPA, PhD, director of the UCSF Center for the Health Professions and professor of family and community medicine and dental public health.

The authors conclude that only by moving beyond the existing systems of finance, reorganizing systems of dental practice, and utilizing dental professionals in new and innovative ways will the system be able to address the unmet health needs of underserved populations. The USCF study recommends the following alternatives:

• Expand alternative organization structures for providing care such as public dental clinics or through the use of dental vans and mobile dental services;
• Educate the underserved populations about new programs in oral health to boost participation in existing and new programs;
• Expand and integrate oral health care services within primary health care facilities to reach a broader population base;
• Develop a multidisciplinary approach to oral health through the use of the public health system professionals and social workers;
• Expand independent practice for hygienists and assistants;
• Develop new dental school strategies for recruitment and retention of professionals from the underserved communities;
• Focus more effort on program evaluation, concentrating on cost-effectiveness and patient outcomes.

Funding for the study was provided by the California HealthCare Foundation and the Bureau of Health Professions. For more information, contact Twink Stern at UCSF News Services: (415) 476-2557 or visit the website for the UCSF Center for Health Professions at http://futurehealth.ucsf.edu.