The Evolving Demographic Makeup of Dental Graduates

H. Barry Waldman, DDS, MPH, PhD

Copyright 1998 Journal of the California Dental Association.

The gender, racial and ethnic makeup of dental school graduates and advanced dental education program students is undergoing changes that to some extent mirrors the developments in the general population. There have been marked decreases in the ratio of white dental school graduates to the white population, but limited changes in the ratio of minority group graduates to their respective national populations. Compared to their representation in dental schools, women and minority group graduates are under-represented in specialty training programs, with wide variations by specialty fields. There have been marked decreases in the proportion of dental school graduates whose immediate plans include self-employment practice and increases in the proportion anticipating some form of employment.

Most presentations on dental school enrollment emphasize 1) the marked numeric increases during the 1970s, decreases during the 1980s and general leveling off in the 1990s or 2) the evolving numeric gender and racial composition of dental school classes. Limited attention has been directed to: 1) the relationship of the changing demographics in dental schools and the general population, 2) whether these changes are uniform in dental schools throughout the nation, and 3) the evolving demographics of enrollees in advanced dental training programs.

The following presentation will review these developments to provide current practitioners (many of whom have limited contact with dental schools and advanced education programs) with an overview of dramatic demographic changes in the student bodies of dental education programs. The ability of the profession to reach out and provide services to increasingly diverse communities may well be enhanced by a profession that more closely reflects the demographics of the population it serves.*

* Anecdotal commentaries by patients, practitioners and their staffs to this writer often indicate patient preferences for services by practitioners with common language, culture, and race. This ability to " identify" with particular demographic characteristics is not lost on politicians in their selection of candidates for a "balanced slate" that would attract voters of varying backgrounds.

National demographics

General population

In the mid 1990s, the Bureau of the Census estimates that approximately three-quarters (74 percent) of the resident U.S. population is white (non-Hispanic). The Bureau projects that by the middle of the next century the total population of the country will increase by more than 120 million residents and there will be marked changes in the distribution of the various minority and nonminority population groups. The proportion of the resident population that is white (non-Hispanic) will be reduced to slightly more than half (53 percent) of the U.S. residents. The Hispanic population will increase from 10 to 24 percent, the African-American population will increase from 12 to 14 percent, and the Asian-American population will increase from 3 to 8 percent. The American Indian population will continue at approximately 1 percent.1
Dentists

As the general population is undergoing dramatic changes in its composition, so too is the dental profession beginning to reflect to some extent the population environment within which it provides services.2 Among dentists about to enter the labor force, the percentage of white dental students in senior classes decreased substantially -- in 1980 it was 90.1 percent, in 1996 it was 70.1 percent (a 22 percent decline). By contrast, Asian/Pacific Islanders have shown the largest increase in the number of minority senior dental students (from 197 to 693 students) (Table 1).

In 1990, 14,100 female dentists represented 9.5 percent of the number of active dentists. By 2020, the federal government projects more than 41,000 active female dentists (30 percent of all dentists). In the late 1980s, African-Americans dentists comprised 2.6 percent of all active dentists, with female African-American dentists expected to increase at a faster rate than their male counterparts. 2

Numbers and Diversity of Graduates

Between 1980 and 1996, the number of dental school graduates decreased by 29 percent (a decrease of more than 1,500 graduates) (Table 1). It's important to note the decrease in the number of graduates while the general population has continued to increase. During this period, the number of graduates per million population decreased by 35.7 percent (from 22.4 to 14.4 graduates per million population) (Table 2).

As a result of the annual decrease of more than two thousand white graduates between 1980 and 1996, the ratio of white dental school graduates per million white population has decreased by 50 percent. By contrast, the number of Asian-American graduates have more than tripled, resulting in graduate-to-population ratios that have been more than five times the ratios for whites and more than ten times the ratios for African-Americans and Native Americans.

There have been minor changes in the number of African-American graduates, resulting in an increase through 199, and then followed by a decrease through the mid-1990s, in the ratio of African-American graduates to the African-American resident population. The numbers of Native Americans graduating from dental school have been extremely limited (never more than 17 per year), with limited ratios per American Indian population (comparable in most years to African-American ratios).

The number of Hispanic graduates and the ratio of Hispanic graduates to the Hispanic population increased through 1991, followed by a period of limited change in the 1990s and a decrease in 1996 (Tables 1 & 2).

Variations by Dental Schools

In 1996, the overall small number of African-American and Hispanic graduates from dental schools were concentrated in a relatively small number of dental schools. Eight schools had more than five African-American graduates, including two schools (Howard and Meharry) which had more than one third (37.6 percent) of all African-American graduates. Eleven schools had more than five Hispanic graduates, including Puerto Rico, which had 20 percent Hispanic graduates.

Ten dental schools reported more than 25 Asian-American graduates, including four schools in California reporting 27.1 percent of all Asian-American graduates (Table 3).

In 1996, women represented 36 percent of all dental school graduates. Six dental schools reported that more than half of their graduates were women, including Meharry, with women representing 65.8 percent of its graduates (Table 4).

Advanced dental education

Specialty training

Women

In 1995, women represented 36 percent of all dental school graduates, but only 27 percent of the total enrollment in specialty programs. Compared to their representation in the dental school graduating class, they were "over-represented" in pediatric dentistry (55.8 percent) and oral and maxillofacial pathology (44.0 percent) programs and "under-represented" in prosthetic (24 percent), endodontic (20 percent), and oral and maxillofacial surgery (9.4 percent) programs.

African-Americans

Student enrollment was slightly less than the representation in the graduating dental school class, with "over-representation" in dental public health (14 percent) and oral and maxillofacial pathology (7.8 percent) and "under-represented" in periodontic (1.7 percent) programs.

Hispanics

Student enrollment in specialty programs was comparable to their proportion in dental school graduating classes. They were "over-represented", however, in prosthetic (13.4 percent) and pediatric dentistry (12.2 percent) and "under-represented" in endodontic (3.7 percent) and oral and maxillofacial surgery (3.3 percent) programs.

Asian-Americans

Student enrollment in specialty programs was slightly less than their representation in dental school graduating classes, but with "over-representation" in oral and maxillofacial pathology (28.9 percent) and prosthetic (24.3 percent) programs, and "under-represented" in oral and maxillofacial surgery (10.0 percent) and dental public health (9.2 percent) programs (Table 5).

General Practice

By gender, race and ethnicity, the proportionate representations in the general practice programs were comparable to the representation in the graduating class (Table 5).

Senior Dental Student Plans

In addition to the evolving demographic characteristics of dental classes, the immediate plans of dental school seniors have changed since the late 1970s. In 1978, almost two out of five seniors (39.4 percent) planned to enter some form of private practice ownership, compared to less than one in five seniors (16.9 percent) in 1995. Between the late 1970s and the mid 1990s, there was a 72 percent increase in the percent of seniors planning to be an employee in a private practice, an 85 percent increase in those planning advanced education, and a 55 percent decrease in those planning on government service. (Table 6). The change in plans may be a reflection of any number of factors, including:

* Increased indebtedness. In terms of constant dollars (i.e. removing the effects of inflation) the average senior debt more than doubled between the late 1970s and the mid 1990s. In 1995, in terms of current dollars, the average graduate debt was $99,456 for graduates of private dental schools, $52,817 for graduates from public schools, and $80,839 for graduates from state-related schools.10

* Increased practice start-up costs.

* Availability of positions in the armed services being replaced by increased numbers of general practice residencies.

* Changed delivery modalities, including HMO's, IPA's, POS systems and any number of other third party arrangements.

* Increased interest in combining parenting and professional careers.

Findings

Since 1980, there have been marked decreases in the proportion of white dental student graduates per white population, but limited changes in the ratio of minority group graduates and their respective national populations. The ratio of African-American and American Indian graduates and their respective national populations consistently have remained the lowest of all groups, while Asian-American ratios have remained the highest (at times 10-15 times that of other minority groups).

Minority group dental students are not distributed uniformly in dental schools throughout the nation (more than one-third of African-American graduates were from two schools, 20 percent of Hispanic graduates were from one school, and almost one-third (32.3 percent) of all Asian-Americans graduated from schools in California.

Compared to their proportion in dental school graduating classes, smaller numbers of women and minorities enrolled in specialty training programs.

Commentary

There is no question that all areas of the profession should be open to any and all qualified applicants but, as it has been argued previously,11 it is fallacious reasoning to assume that the demographic distribution of dental personnel must match the population distribution to assure needed care for all segments of our communities, or that particular groups must be recruited to the profession so that "they" will "return" to care for "their people".

On the other hand, we should not overlook the potential willingness of populations to seek care from providers with whom they can more readily identify. If this argument holds some value, then the continued limited numbers of African-Americans, Hispanics and Native Americans entering dentistry (or particular areas within the profession) would tend to indicate that we have a long way to go.

If we are to understand and plan for the future of the profession, then it would be essential to explore interests and expectations of the different populations being attracted to the profession. Note: reports by the American Association of Dental Schools do not distinguish practice plans by gender, race or ethnicity.

The practice of dentistry and the profession itself will be different in the future. It would be "nice" to know more about the potential for these differences than just the fact that the number of dental school graduates had "leveled down" while the general population continues to increase.

Author / H. Barry Waldman, DDS, MPH, PhD, is Professor of Dental Health Services at the School of Dental Medicine at SUNY at Stony Brook, New York.

References

1. Day JC, Bureau of the Census. Population projections of the United States, by Age, Sex, Race and Hispanic Origin: 1992 to 2050. Current Population Reports, Series P25-1092. Washington, D.C., Government Printing Office, 1992.
2. Department of Health and Human Services, Health Resources and Services Administration. Health Personnel in the United States: Eighth Report to Congress: 1991. DHHS Pub. No. HRS-P-OD-92-1. Rockville, MD, Bureau of Health Professions, 1992.
3. Division of Educational Measurements. 1980/81; 1985/86 Annual Report on Dental Education. Chicago, American Dental Association, 1981; 1986.
4. Division of Educational Measurements. 1980/81 Minority Report. Supplement 3 to the Annual Report on Dental Education. Chicago, American Dental Association, 1981.
5. Survey Center. 1995/96; 1996/97 Survey of Predoctoral Dental Education Institutions: Academic Programs, Enrollment, and Graduates, Vol 1. Chicago, American Dental Association, 1996; 1997.
6. Wetrogan, S.I. Bureau of the Census. Projections of the Population of States by Age, Sex, Race: 1998 to 2010. Current Population Reports, Series P25-1017. Washington, D.C., Government Printing Office, 1988.
7. Department of Commerce. Statistical Abstract of the United States: 1990; 1993 Washington, D.C., Government Printing Office, 1990; 1993.
8. Campbell, P.R. Bureau of the Census. Population Projections for States by Age, Sex, Race and Hispanic Origin: 1993 to 2020. Current Population Reports, Series P25-1111. Washington, D.C., Government Printing Office, 1994.
9. Survey Center. 1995/96 Survey of Advanced Dental Education. Chicago, American Dental Association, 1997.
10. Survey of Dental Seniors: 1995 graduating class. Washington, D.C., American Association of Dental Schools, 1996.
11. Waldman, HB, Evolving "faces" of the next generations of pediatric patients. J Dent Child, 64:39-42, 1997.