Demographics
Changing Issues and Demographics Affecting Periodontal and Implant Therapy
Roger K. Rempfer, DMD
Copyright 2002 Journal of the California Dental Association.
Author
Roger K. Rempfer, DMD, is a retired periodontist. He is president of Rempfer & Associates Management and Marketing for Dentistry. He is a vice president for Carroll & Co., a practice-transition and brokerage firm. He is a past chairman of the CDA Council on Dental Care and a past president of the California Society of Periodontists.
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While the U.S. population is growing dramatically, the number of practicing dentists is expected to decrease. In addition, people are keeping more teeth and keeping them longer, thus increasing the amount of dental care they require. These trends bode well for the viability and demand for professional dental services. Thoughtful planning, nurturing of professional relationships, and the use of sound business resources will enable practitioners to realize the financial and personal fulfillment these opportunities afford.
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The 32.7 million population increase in the United States from 1990 to 2000 is the largest 10-year increase in U.S. history, taking the population from 248.7 million to 281.4 million.1 Every state showed an increase, with the West being the fastest-growing region. California showed the largest numerical increase of any state, 4.1 million people.1 Estimates of further growth based on 1994 projections show the 2025 population approaching 335 million people.2 Bureau of the Census data from 1998, however, suggest this estimate is too low.3 The Bureau of Census provides three sets of population projections -- highest series, middle series, and lowest series. The high and low series assume extremes in rates of birth, death, legal and illegal immigration. For the purposes of this paper, the middle series, or moderate assumptions, are used.
In the 2000 census, the median age (the age at which half the population is older and half younger) was 35.3 years, up from 32.9 in 1990. The increase reflects a 28 percent growth in the number of 35- to 64-year-olds. The most rapid increase of any group in the Census 2000 profile was the 45 to 54 age group, which showed a 49 percent jump. This increase to 37.7 million in 2000 was fueled mainly by baby boomers (those born from 1946 to 1964). The slower growth of the population group age 65 and older reflects the relatively low number of births in the late 1920s and early 1930s.4
Further changes in the older than 65 population will be reflected by increases in life expectancy. Census bureau data projects increases of two to five years for different racial population groups when comparing data from 1999 and matching it against 2025 projections using middle series data.5
Trends Among Dental Practitioners
In 1990, the number of professionally active dentists in the United States reached a maximum of 59.5 per 100,000 population. The number of professionally active practitioners for that same period was 55 per 100,000. In 1976, the ratio was 51 dentists per 100,000 population with 46 of them per 100,000 population being professionally active practitioners. The ratios since 1990 have been in decline. ADA and the federal Health Resources and Services Administration suggest that this declining ratio will continue throughout the 2020 projection period. It is estimated that this ratio will fall to 53 professionally active dentists per 100,0006 or slightly less than the 1980 ratio. This translates to 48 professionally active practitioners per 100,000.7 It is further estimated by the American Dental Education Association that the number of professionally active dentists will begin to decline about 2014. At that juncture, the assumption is that 81,600 dentists will enter practice while 84,500 will leave.8 This trend is likely to cause modifications in practitioner retirement plans as fewer new dentists will be available to assume practices. Female dentists are a rapidly increasing segment of professionally active dentists. In 1982, female dentists made up 2.6 percent of active private practitioners.9 In 1997, this percentage increased to 12.8 percent.10 Female active private practitioners relative to the total number of active practitioners are estimated to increase to 18.7 percent in 2005, 22 percent in 2010, and 28.3 percent in 2020. As many female practitioners chose different career patterns in order to combine family responsibilities with professional responsibilities, the shortage in the dentist workforce may be further exacerbated.
Patient Trends
With oral health improving and people living longer, the number of teeth to be maintained is increasing at a rate faster than the population is growing. One does not have to look back far to find a generation of adults who believed it was inevitable to lose their teeth and wear dentures.10 A large segment of today’s older adults have maintained a portion or most of their natural dentition. Indeed, 46.3 percent of adults age 70 or older have retained an average of 20.5 teeth.11 A large segment of baby boomers will be entering retirement about 2011 with nearly a full complement of teeth.12 In the period following World War II, children were taught that if they went to the dentist and had their teeth cleaned and filled they would keep them. To a very large degree this succeeded. In the late 1970s and early 1980s, children were taught that with proper home care, the use of fluorides, and the application of sealants, they would not have tooth decay. This succeeded as well.
Approximately 55 percent of children age 5 to 17 have had no tooth decay. In 1986-87 it was 50 percent. In 1979-80 it was 37 percent. About 25 percent of the children have 75 percent of the involved teeth.13 The decline in the number of edentulous adults has fallen dramatically from 14.7 to 7.7 percent between 1971 and 1994.13 In the 65 to 74 age group, edentulism fell from 45.6 to 28.6 percent.14 It is evident that the number of teeth that will be retained and require care will steadily increase. Compounding this further are the U.S. Bureau of Labor Statistics numbers that describe the civilian workforce retiring at a later age. It is estimated that the number of people in the workforce age 55 and older will increase from 17.1 million to 23 million by 2006.
Dental service expenditures have increased 70 percent since 1990. Estimates for 2000 place 56 percent of the U.S. population in dental benefit/insurance plans. Of these, 43 percent are enrolled in indemnity plans. Approximately 18 percent are in health maintenance organizations and 31 percent are in preferred provider organizations. Referral-type PPO programs make up 7.5 percent. Almost 31 percent of patients pay for care themselves, while 63 percent of patients are enrolled in some type of benefit plan.15 It is of significance to note that while more than half of dental plan enrollment is in PPOs and HMOs, only 50 percent of practicing dentists participate in them.
Disease Trends
With the retention of teeth for longer periods and in greater numbers, there comes a shift in dental disease patterns and treatment demands. It was thought in the 1980s that the progressive decline in dental caries, particularly in children, would produce significant changes in terms of treatment needs of the population and possibly a reduced demand for dental practitioners. Instead what has happened is the fulfillment of the counter argument that purported that the increasing retention and maintenance of teeth would create new needs and greater demand for treatment. There has been a progressive shift in severity of caries treatment in children to a greater need for care in the middle aged and older adult population. This trend, however, is not applicable to individuals with low socioeconomic status. Not surprisingly, periodontal disease has been found to be greater in individuals who have retained their teeth.16 By retaining greater numbers of teeth, adults experience greater severity of periodontal involvement.15 This translates into increased treatment needs and complexity of treatment with a growing population. It has been demonstrated that adults with 25 or more natural teeth also made twice as many dental treatment visits as those with 10 teeth.16
Trends in Services
It is understood that the issues that have been described will be significant factors in an increasing demand for periodontal and restorative services. What must also be considered are the specific demands consumers will place on these services as a result of the expectations of the baby boom generation and the growing affluence of dental consumers. Expectations have grown beyond the concept of oral health to having a cosmetically acceptable smile and comfortable functioning teeth. Dentists and patients alike are realizing that single-tooth implants are a more conservative approach to replacing missing teeth than are classic tooth preparations. To deliver on these demands, periodontists will have to invest, utilize, and leverage all the available hard and soft tissue reconstructive procedures to retain teeth, enhance cosmetics, and address the rapidly increasing patient demand for implants. Restorative practitioners will need to maximize their skills as well and will have to invest significantly in products and equipment that are rapidly changing and obsolete all too soon if they are to satisfy both consumer and competitive demands.
A random ADA survey of dentists regarding implants noted nearly a tripling in implant placement during a 10-year period. Periodontists were also noted as placing the largest number of implant fixtures, followed by oral surgeons.17 This same report described a small number of restorative dentists also placing implant fixtures. Considering the characteristc operational costs of restorative practice, adding the additional equipment, inventory, and training costs associated with a surgical implant placement produces concerns regarding a reasonable return on investment. Indeed, many periodontists and oral surgeons do not provide implant services for this same reason. Implant companies are seeking to exploit the restorative dentist market by encouraging them to surgically place implant fixtures. Their approach appears driven by their concerns to capture more market share in an already highly competitive manufacturer marketplace. It does not appear that manufacturers have fully considered or understand the cost and operational ramifications this creates for the nonsurgical practice. More importantly, because they use this approach, it appears that manufacturers do not understand the compromise it brings to the benefits of the shared risk relationships that have been enjoyed by the restorative/surgical team in dealing with compromised as well as successful cases. All disciplines of dentistry have benefited more by leveraging their relationships with each other as opposed succumbing to outside market entities who may offer only their proprietary agendas.
The issues of economy of scale for practice procedures will not disappear regardless of positive changes in demographics. It has been suggested that with current and projected demographic changes combined with the need for operational efficiencies, restorative practitioners will focus their practices on specific areas of emphasis.18 These will include practices limited to esthetic dentistry, geriatric dentistry, diagnostic services, group practices, and HMOs. There may also be opportunities for boutique (single doctor, small staff, fee for service only) practices if executed properly.
A tally of calls to the Academy of General Dentistry smile line during an August 2001 meeting, showed that baby boomers and consumers older than 65 topped the list of callers. Their top dental concerns were periodontal questions and tooth loss. Questions regarding cosmetics, implants, and dry mouth were also issues for this group.19
For 2000, the estimate of the number of dental implants placed in the United States was 910,000.20 This number is expected to increase with a compound annual growth rate of 18.6 percent through 2005. By comparison, the growth rate during the mid 1990s was 7 to 10 percent. AGD statistics suggest that to satisfy current implant needs, every U.S. dentist would need 20 appointments per month for the next 20 years to place and restore fixtures for the current level of missing teeth.21
The Collective Picture
The developing picture discussed is one of growing demand for periodontal and restorative services as a function of increasing scarcity created by:
* Growing population;
* Aging population;
* Progressing decrease in practitioner/population ratio;
* Retained dentitions;
* Increased longevity;
* Deferred retirement;
* Increased consumer sophistication; and
* Increased discretionary income.
Further compounding the issue of demand will be the impact of new technologies that will create new and better treatment options for consumers. Increased information dissemination via the Internet will also fuel demand as consumer awareness and understanding increases.
Successful practitioners will need to qualify and implement efficiencies in the delivery and business of patient care. They will also need to invest significant sums on an ongoing basis into technology and training for themselves as well as their staffs. Patient expectations on quality of service and care will only be increasing. Failure to address any of these may significantly impede practitioners’ abilities to effectively meet patient demand, sustain market share, and remain profitable.
Conclusion
The information discussed here bodes well for the viability and demand for professional services. It is also positive in terms of improving the dental health of the public. What was not seen or predicted a decade ago now creates a new paradigm for the profession. Thoughtful planning, nurturing of professional relationships, and the use of sound business resources will enable practitioners to realize the financial and personal fulfillment this opportunity affords.
References
1. US Department of Commerce News, April 2, 2001.
2. Cheeseman Day J, US Bureau of the Census, Population projections of the United States by age, Sex, Race, and Hispanic Origin: 1995 to 2050, Current Population Reports. US Government Printing Office, Washington DC, 1996, pp 25-1130.
3. US National Projections. US Census Bureau Web site, January 2000.
4. US Department of Commerce News, May 15, 2001.
5. US Census Bureau, Projected Life Expectancy at birth by Race and Hispanic Origin, 1999-2100.
6. J Dent Educ 65(6), June 2001.
7. Brown JL, Lazar V, Dentist work force and educational pipeline. J Am Dent Assoc 129(12):1700-7.
8. J Dent Educ 65(6), June 2001.
9. American Dental Association Survey Center. Distribution of Dentists in the United States by Region and State: 1982. ADA, Chicago, 1984
10. American Dental Association Survey Center, Distribution of dentists in the United States by region and state: 1997. American Dental Association, Chicago, 1997.
11. Douglass CW, Jette AM, et al, Oral Health Status of the Elderly in New England. J Gerontolog 48(2):M39-46, 1993.
12. Watson SJ, Douglass CW, The Projected Unmet Need for Fixed and Removable Partial Dentures for 2005, 2010, and 2020 (senior thesis). Harvard University School of Dental Medicine, 1999.
13. Valachovic RW, et al, Trends in Dentistry and Dental Education. J Dent Educ 65(6):539-45.
14. US Department of Health Services, National Center for Health Statistics and National Institute of Dental Research.
15. National Association of Dental Plans, 2000.
16. Joshi A, et al, The distribution of root caries in community dwelling elders in New England. J Public Health Dent 54(1):15-23, 1994.
17. ADA The Public: News and Media: May 1999: Dental implants Nearly Triple Over 10 Year Period.
18. Douglass CW, Sheets CG, Patient’s Expectations for Oral Health Care in the 21st Century. J Am Dent Assoc Vol. 131, June 2000.
19. AGD news release. Baby Boomers Top Callers to Dental Hotline. Aug 8, 2001.
20. Annual Industry Report. Implant Dentistry 9(3):192-4, 2000.
21. Academy of General Dentistry, Missing Molars? Avoid Jawbone Loss, Anchor an Implant. Press release, Oct 15, 2001.
To request a printed copy of this article, please contact/Roger K. Rempfer, DMD, Rempfer & Associates, Inc., P.O. Box 849, Truckee, CA 96160 or at roger@rempfer-associates.com.
