Dental Student Debt Looms Large

It’s a problem looming large for dentistry, and it permeates virtually every area of the profession. The problem -- the large educational debt that many dental school students accrue -- is rippling outward, from dental schools, to individual dentists, and to the profession itself.

The problem is getting worse. According to the American Association of Dental School’s Survey of Dental School Seniors, 1998 Graduating Class, dental education debt has climbed from a national average of $18,500 in 1980, to $54,550 in 1990, to $84,000 in 1998. And in California, student debt levels have now reached an average of more than $123,000.

Dental school debt has long been an issue with dentists who struggle to pay off the debt while trying to build a practice. Harold S. Harada, DDS, who in 1985 was CDA president, graduated from the College of Physicians and Surgeons, now the University of the Pacific, in 1956. Even though his debt, as he remembers it, was only a few thousand dollars, it required some hard work to pay it off.

"I was married with a child when I started dental school, so I had a lot of expenses," he said. "I was able to get it paid off pretty quickly, but I had to work evenings and Saturdays six days a week for a couple of years to complete the payoff."

For Nava Fathi, DDS, the debt from dental school and a two-year endodontic program totaled about $250,000.

"I couldn’t get additional loans for the specialty training, so I got private loans, but the downside is higher interest rates," said the 1995 UOP graduate, who completed her endodontic training at the University of Southern California in 1998. "Generally, I think those starting out as specialists have a higher earning potential. Finding a job as a general dentist with an income high enough to pay off student debt is more difficult."

Fathi bought a practice in the Central Valley town of Gilroy last June. To help pay off her loans, she works as an associate in San Francisco, and teaches part-time at UOP. She said she enjoys teaching very much but realizes that being a full-time faculty member doesn’t pay enough to afford monthly payments to retire her debt load.

"To teach full time, I would have to be debt free," she said.

No-Hee Park, DMD, PhD, dean of the University of California at Los Angeles School of Dentistry, said that student debt directly affects the quality of dental education.

"Nationwide, we have a crisis in recruitment and retention of faculty in dental schools, because of indebtedness," Park said. "New graduates have to make money and many can’t afford to be further trained. This will undermine our educational quality, the quality of future academicians, and it will very seriously threaten our profession itself."

Arthur A. Dugoni, DDS, dean of the University of the Pacific School of Dentistry, said for the long term, dentistry should embark on a national endowment. He envisions a large dental education endowment over the next 25 years, to be funded through dental-related, government, and private industry resources.

Dugoni also said that because of student debt, many specialists don’t locate in underserved or economically disadvantaged regions, and general practitioners are more likely to practice in metropolitan areas where there is the potential of higher income.

"Graduates who are deeply in debt will also be less prone to provide unreimbursed dental care or to establish practices in economically deprived regions of the country," Dugoni warned. "And because young graduates will need to establish a substantial cash flow immediately upon graduation, some have raised the concern that economic survival, rather than decisions based solely on what is best for each patient, will color decisions related to patient care, which could affect the quality of care."

CDA annually provides $6,000 in scholarship funds to each school to help selected sophomore students pay for their education. Park said that while the funds help, they are not sufficient to help solve the problem.

"When dentists don’t care about the future of the profession or quality of care, who else will take care of it? I think CDA should take a stronger leadership role."

CDA President Kent Farnsworth, DDS, said that the association is restructuring its CDA Charitable Fund to direct more resources to scholarships in general, and the method of choosing the sophomore scholarship recipients is being re-evaluated.

"The money in the Charitable Fund has been growing, so we’re looking at how we can best distribute it in scholarships," he said.

Farnsworth acknowledged that this is a short-term solution and said that there is a longer-term solution that hinges on the successful establishment of a CDA credit union.

"Once that’s established, I’m going to personally head an appeal to our established members to contribute to a new professional loan fund, which would grant low-income loans to recent graduates, because they are the ones that have the most difficulty in obtaining relief while they get their practices started. And if they can’t get additional funding, they can be forced into less desirable practice modes simply to keep their heads above water financially, as opposed to developing a practice mode that would be kept in keeping with their education."

Farnsworth said that this is a win-win situation that would also serve as a recruitment and retention tool, because loan applicants would have to be members of the credit union, and to do that they would have to be CDA members.

"We have to break the downward spiral that dental educational debt creates."

Information for graphic:

Most problems between dentists and children can be handled through better communication, according to Greg Johnson, director of professional services for the Illinois State Dental Society, and staff liaison to the ISDS’s Peer Review Committee.

In an article in the August 1999 Illinois Dental News, Johnson writes that of the 500 peer review cases handled by the committee each year, about 10 percent involve children. He writes that complaints involving children frequently include three issues: parents who are not allowed into the operatory with their child; "hand-over-mouth" behavior control techniques; and continuing a procedure even after a child indicates the dentist should stop. Johnson says that dentists can frequently eliminate these problems by addressing them ahead of time with the child and parent.

Dentists who prefer not to have parents in the operatory should make that office policy clear to the parent ahead of time. "I think at times if a parent objects to a particular policy, maybe it's best the dentist refer them to a colleague who will allow the parent in," says Dr. Richard Kirchoff, a past president of the Illinois Society of Pediatric Dentists. If the parent is to be allowed, ground rules need to be established, Kirchoff notes. The dentist should make it clear that a parent is to be a "quiet observer," sitting in front of the patient, and perhaps holding a child's hand for comfort.

The "hand-over-mouth" technique of controlling a child patient, while approved by the American Academy of Pediatric Dentistry, doesn't always please parents. For those who do use the hand-over-mouth technique, it should be done in a non-angry, non-aggressive manner, without reducing the airway.

Johnson’s article notes many dentists find the hand-over-mouth technique ineffective, noting that if a child's behavior is out of control to the point where the dentist considers using it, it may be best to stop the procedure. According to the article, a parent should be informed prior to its use, and preferably a signed consent form should be obtained from the parent. Johnson notes other methods of control tend to work better, such as voice control.

For children in or near hysterics, another recommended method is the T.O.T.S., or Take Off The Shoe method, based on the theory that four-year-olds don't like to have their shoes taken off. Dentists can promise to replace the shoe if the child cooperates.

As for complaints about dentists continuing treatment after the child indicates he or she wants it stopped, it’s important for the dentist to give the child a signal, such as raising a hand, when they want the dentist to stop. The dentist should stop, give more anesthetic, or take other measures to make the child more comfortable. Letting the child and parent know what the procedure involves ahead of time can alleviate problems. Better communication helps all the way around, Johnson notes.

CDC Presents More Fluoride Support

Dental treatment costs for low-income children can be twice as high and crisis intervention more frequent in nonfluoridated communities than in those with fluoridated water, according to a Sept. 3, 1999, report from the Centers for Disease Control and Prevention, published in the CDC Morbidity and Mortality Weekly Report.

Findings of the study, which was conducted in 19 Louisiana parishes (counties), suggest that very young children lacking access to fluoridated water were three times more likely to receive dental treatment in a hospital operating room than children in communities with optimal levels of fluoridated water.

"CDC’s data are useful for community decision makers as they consider implementing water fluoridation," says Dr. Kimberly McFarland, vice chair of the ADA Council on Access, Prevention and Interprofessional Relations and chair of the council's National Fluoridation Advisory Committee. "From public health experience across the country, we have always known that fluoridation saves money. These data document that water fluoridation is beneficial especially for low-income populations."

The study reports that more Medicaid-eligible children in nonfluoridated parishes received caries-related dental treatment and operating-room-based care at greater cost than did Medicaid-eligible children in fluoridated parishes. The expected annual reduction in dental treatment costs for at least 39,000 preschoolers in Louisiana, as a result of potential benefits from water fluoridation, would be $1.4 million.

Other studies have found that caries in the primary dentition disproportionately affect children from low-income households, including a study reported in the September 1998 Journal of the American Dental Association.

The authors of the CDC-reported study say they did not measure the length or magnitude of the children's exposure to fluoride and said the findings are subject to other limitations. Lower treatment costs associated with water fluoridation should not be generalized to preschool children from middle and high income families because of their lower prevalence of dental decay, the authors say.

Dental Inroads Harder to Find for Managed Care

Managed care organizations are unlikely to penetrate dental markets to the extent that they have medical markets, according to an article by a team of dentists in the Winter 1999 issue of the Journal of Public Health Dentistry.

In the article, the authors examine data collected by the National Association of Dental Plans, the Interstudy Competitive Edge HMO Census, and the Area Resource File from 1987 to 1995 to study the economics of dental and medical markets. The researchers found that the growth of managed care in dentistry is predictable by the same factors as in medicine and closely follows the pattern found in medical markets.

The authors conclude that despite the similarities in penetration rates, potential barriers to managed care exist in dentistry that may explain the slower growth to date. Those barriers may ultimately decide the extent of managed care penetration into the dental market. Potential barriers include a lower proportion of the population covered by dental insurance than by medical insurance, the relative infrequency of acute care in dentistry as compared to medicine, and the relative stability of dental expenditures compared to the sharp increase in medical expenditures in the past three decades.

The majority of cost savings by HMOs in medicine have been in the area of acute, inpatient services (e.g., the length of hospital stays and the lowering of rates of expensive hospital procedures), rather than in the area of preventive and wellness-oriented services that characterize most dental services.

"This source of savings in medicine suggests that dental HMOs may find savings to be more elusive than medical HMOs," the authors write.

Dentists Still Rank High in Honesty Poll

Dentists ranked ninth in Gallup’s annual poll of American’s views on the honesty and ethics of various occupations. Nurses, included in the poll for the first time, ranked first.

The poll was changed for 1999 to include 20 additional occupations. In addition to nurses, three newly included occupations ranked in the top 10: veterinarians, grade and high school teachers, and judges. In 1998, dentists tied for fourth.

Health care providers fared well on the list, with five in the top 10. HMO managers, however, ranked 42nd out of 45 occupations.

Trigeminal Neuralgia Can Masquerade as Dental Pain

A patient who complains of toothache or sinusitis-like pain with no apparent dental cause may be suffering from a neurological condition known as trigeminal neuralgia, according to an article in the May/June 1999 issue of Northwest Dentistry.

The article by Claire W. Patterson, president of the Trigeminal Neuralgia Association, and Dr. Judd S. Copeland, DDS, surveys the causes, symptoms, and treatment of the disorder. They write that the patient usually complains of a sharp, stabbing pain that is aggravated by chewing, drinking hot or cold liquids, brushing the teeth, or talking.

Misdiagnosis of the condition can result in unnecessary dental therapies such as multiple extractions, endodontic procedures and TMJ surgery -- frequently with no effect on the patient's discomfort, write the authors.

Trigeminal neuralgia is usually caused by compression of a blood vessel at the trigeminal nerve root entry-exit zone, according to the article. It produces what many physicians consider to be the most excruciating of all types of pain. The symptoms may be mild in the early stages, but develop into recurring episodes of intense, electric shock-like pain in the distribution of one or more branches of the trigeminal nerve.

The article notes that the major diagnostic criterion is the presence of trigger points on the face. The slightest stimulation of any of these points results in an agonizing attack for the patient. About 25 percent of patients will respond to treatment with anticonvulsant drugs, but surgery is required for most.

Classic trigeminal neuralgia has distinct symptoms, which clearly separate it from other forms of facial pain:

* Pain is short, acute bursts rather than a dull, constant ache. Often described as electric shock-like in nature.

* Pain is usually triggered by light touch or sensitivity to vibrations, such as brushing one's teeth, a light breeze, shaving, or talking.

* The pain has a tendency to come and go with periods of intense, sometimes totally debilitating pain, followed by completely pain-free periods of remission lasting from weeks to months or possibly longer.

* Most patients experience pain during the day while they are up and about. Generally, they are free of pain while asleep unless it is triggered by the touch of bed linens or changes in position.

The patient history and description of symptoms are the major aids in confirming the diagnosis, the authors write. Most doctors will recommend a CAT scan or MRI along with other laboratory tests. These are intended mostly to rule out other causes of pain such as tumors or multiple sclerosis. There is no specific test to confirm the diagnosis, according to the authors.

Bacteria by the Mouthful

Stanford researchers have shown that the human mouth is awash with far more bacteria than previously thought.

Using a combination of old and new scientific methods to study a scraping of plaque from a healthy human mouth, the researchers found evidence of 37 unique bacteria that microbiologists had never before recorded. Some were closely related to bacteria that scientists are familiar with, but others were very different.

Knowing more about the bacteria that reside in a normal, healthy mouth may help dentists understand changes in the bacterial population that can lead to gingivitis, periodontitis, and tooth decay.

"Our data suggest that a significant proportion of the resident human bacterial flora remain poorly characterized, even within this well-studied and familiar microbial environment," said David Relman, MD, assistant professor of medicine and of microbiology and immunology at Stanford, and lead author of the study published in the Dec. 7 issue of the Proceedings of the National Academy of Sciences. Relman and colleagues conducted the research in his lab at the Veterans Affairs Palo Alto Health Care System.

Relman said the subgingival crevice has been repeatedly scrutinized in the search for microbes. Even though almost 500 bacterial strains have been identified already, Relman believes this may be only a fraction of the bacteria in the crevice.

Oral bacteria have traditionally been studied by taking a scraping or sample from inside the mouth, growing the bacteria in the laboratory and then identifying different species according to biochemical tests and the type of food source that each bacteria prefers. Using this method, the Relman team identified bacteria found in a sample of plaque taken from the subgingival crevice.

They also searched the same sample using molecular techniques. Instead of nurturing the bacteria in the lab, they prepared DNA directly from the plaque and studied each genetic sequence that had a bacterial signature. Comparing the results, they found that the molecular method yielded many new bacteria. Not only did the method reveal bacteria that had never before been found in the mouth, many were bugs that had not yet been documented by microbiologists.

The team discovered 31 bacteria using the molecular method. In contrast, the traditional approach, which only identifies bacteria that can be cultivated in the lab, uncovered only six new ones.

Honors

Harold C. Slavkin, DDS, PhD, has been named dean of the University of Southern California School of Dentistry. He will assume his new duties in August. Slavkin is currently director of the National Institute of Dental and Craniofacial Research.

Arthur A. Dugoni, DDS, dean of the University of the Pacific School of Dentistry, has received the 1999 Callahan Memorial Award. The award is presented each year at the Ohio Dental Association’s Annual Session.

Eri Hatta, a dental student at the University of California at San Francisco, won third place in the category of basic science and research at the 1999 ADA/Dentsply Student Clinician Program. The program was held at the American Dental Association Annual Session in Honolulu in October.

Web Watch: General Reference

Pages for general reference information.

http://www.brittanica.com

The complete Encyclopædia Britannica, plus links to Web sites, magazines, and books.

http://www.w-m.com/home.htm

Contents of Merriam-Webster’s Collegiate Dictionary, Tenth Edition

http://www.thesaurus.com

An online version of Roget’s Thesaurus

http://www.almanac.com

The Farmer’s Almanac online, including weather, tides, and moon phases.

http://www.bartleby.com/99

An online version of Bartlett’s Familiar Quotations

A listing here does not constitute endorsement by the California Dental Association. As is the case with all web sites, content is subject to frequent change.

Upcoming Meetings

2000

March 1-4 Academy of Laser Dentistry Conference and Exposition, Panama City Beach, Fla., (954) 346-3776

March 2-4 Utah Dental Association annual convention, Salt Lake City, (801) 261-5315

April 5-9 American Society for Laser Medicine and Surgery annual meeting, Reno, Nev., (715) 845-9283

April 6-8 Dentistry 2000 -- British Dental Association Annual Conference and British Dental Trade Association Dental Showcase Exhibition, Birmingham, England, 01934 844408

April 11-15 American Academy of Oral Medicine Annual Scientific Session, Las Vegas, (410) 602-8585

April 13-16 CDA Scientific Session, Anaheim, Calif., (916) 443-3382, Ext. 4470

May 15-20, World Biomaterials Congress and Exposition, Kamuela, Hawaii, (612) 543-0908

June 12-13 "The Face of a Child" -- Surgeon General’s Conference on Children and Oral Health, Washington, D.C., (301) 588-6000

July 30-Aug. 2 Congress of the International Society for Lasers in Dentistry, Brussels, Belgium, +32 2 648 80 59.

Sept. 15-17 CDA Scientific Session, San Francisco, (916) 443-3382, Ext. 4470

Sept. 17-20 American Academy of Periodontology Annual Meeting, Honolulu, www.perio.org

Oct. 14-18 ADA Annual Session, Chicago, (312) 440-2500

Nov. 29-Dec. 2 Le Mondial du Dentaire, Paris, http://www.fdi.org.uk/calender/index.htm

2001

May 4-8 Australian Dental Congress, Brisbane, +61 (0) 7 3369 0477

To have a meeting included on this list, please send the information to Upcoming Meetings, CDA Journal, P.O. Box 13749, Sacramento, CA 95853 or fax the information to (916) 443-2943.