Workforce Issues in Pediatric Dentistry: Recommendations of a Recent Conference

A recent conference of the California Society of Pediatric Dentists discussed issues surrounding the shortage of pediatric dentists in the state. Several contributing factors were identified and recommendations made as to ways of working with the dental schools to help increase the number of practitioners. This article frames the problem regarding servicing the state's children and discusses some recommended actions.

In the early 1990s, it became apparent to many practicing pediatric dentists that the number of new colleagues available for practice associations or practice purchase was insufficient to meet the needs. Likewise, dental school administrators experienced a declining supply of pediatric dental educators to meet their current and future needs. This situation was contrary to that of the 1980s, when there seemed to be no need for concern. At the urging of its membership, the California Society of Pediatric Dentists convened a conference in February 1998 to address the workforce issues in pediatric dentistry. This conference was attended by the leadership of the society, the chairpersons of pediatric dentistry departments, and the program directors of all the advanced education postdoctoral programs in pediatric dentistry in California.

The following material is taken from an oral presentation made at the conference.

The Issues

Producing the practitioners and educators necessary to meet the oral health needs of California’s pediatric population in the near future and well into the next century will require a significant increase in pediatric dental training. Changing pediatric demographics and the unmet needs of a growing population will place severe demands on pediatric dental resources.

In his 1995 alert to the profession, Waldman cited U.S. Bureau of the Census figures projecting an increase of 8.1 million people younger than 15 during the following 25 years.^1,2 Of this increase, 3.2 million were expected to reside in California. While the country as a whole will experience a 14 percent growth in its child population, California’s will grow a stunning 43 percent. Two out of every five additional children in this country will be living in California.

According to Waldman’s figures comparing Census Bureau data with survey results from the American Dental Association on the numbers, age, and distribution of pediatric dentists in private practice in 1993, there were 5.6 pediatric dentists in California per 100,000 children. To maintain this current 1:18,000 ratio will require a corresponding 43 percent increase in the number of pediatric dentists. This translates to a statewide need for an expanded workforce of 180 more practicing pediatric dentists. These 180 practitioners are in addition to those pediatric dentists needed to replace some of the current 418 active practitioners who will retire or otherwise withdraw from practice during the next 25 years. When projected growth and projected replacement requirements are considered, at least 511 new pediatric dentists will be needed in California by the year 2020. At the current level of training, California will need to be successful in recruiting one out of every five pediatric dental postdoctoral graduates trained in the United States during the next quarter century.

Seeking to validate these workforce needs projections, in 1997, the California Society of Pediatric Dentists surveyed its active membership on practice patterns, retirement plans and demand for services.³ A 64 percent response rate from the 350 surveys sent to member-practitioners indicated a high interest in workforce issues. Respondents ranged in age from 29 to 76, with an average age of 49 years. Eighty-nine percent reported having ownership interest in their practices, while the remaining 10 percent reported being employees, associates, or independent contractors. In general, pediatric dentists in California reported being busy. Seventy percent of all respondents said they provided patient care at least 32 or more hours a week.

Nearly 30 percent of the practice owners reported that they were currently seeking an associate or partner to increase the number of pediatric dental providers in their offices. Almost 60 percent of the practice owners reported plans to increase the number of pediatric dentists within five years. When these practice owners were asked to estimate the demand for services if an additional provider were available, more than 70 percent responded that they could provide from 2 1/2 to a full five days a week practice opportunity for a new associate.

Plans for retirement among respondents confirmed the need for a significant number of replacement pediatric dentists in the near future. More than 40 percent of practice owners reported planning to reduce the number of hours spent in patient care in the next five years and a majority of practice owners reported similar plans within the next 10 years.

As current practitioners age, reductions in their practice hours will also have a significant impact on availability of patient care since more than 90 percent of them reported plans to reduce their practice time to two to three days a week. Almost 40 percent of practice owners reported having plans for full retirement within 10 years and 20 percent reported having plans to retire from practice within five years, indicating that in each of the next five-year increments, approximately 20 percent of practice principals plan to retire from pediatric dental practice.

As pediatric dentists retire, advanced education postdoctoral programs are not providing adequate numbers for their replacement (Table 1). Since 1980, there has been a decrease in the number of postdoctoral programs in the dental schools and teaching hospitals. The number of new pediatric dental graduates has decreased sharply since the late 1970s. Although this trend has reversed somewhat in the past few years, the most recent figures indicate only about 180 pediatric dental graduates each year complete training programs. The American Academy of Pediatric Dentistry estimates that the number of active pediatric dentists in the country decreased from 3,967 in 1990 to 3,678 in 1997, reducing the available workforce by 7 percent during the past seven years.

Gender changes in pediatric dentistry during the past 20 years have been dramatic as well. In 1980, only 8 percent of the postdoctoral pediatric dental training positions were occupied by women. Today, this population is approximately 60 percent female. While the long-term impact of this gender inversion is not yet measurable, preliminary indications are that the overall productivity of the pediatric dental workforce may decrease.⁴

Furthermore, not every graduate of a postdoctoral pediatric dental program in the United States is available to meet U.S. needs. Only about 70 percent of these students are U.S. citizens. Many are foreign-trained graduates who return to their countries of origin.

The conference identified six specific factors that have contributed to the workforce crisis in pediatric dentistry in California.

Age

The majority of private practicing and/or academic pediatric dentists in California are middle aged and older. Many have impending plans to reduce their work effort.

Number of Programs

Four of the five California Dental Schools (Loma Linda University, the University of California at Los Angles and San Francisco, and the University of Southern California) have postdoctoral training programs. None have dramatically increased their graduate student numbers. Most graduate students are women. Some are residents of other states or foreign countries (Table 1).

Gender

The majority of new pediatric dentists are women. Many have a desire to have a reduced work effort in private practice and/or academic pediatric dentistry as they start or maintain a family.

Geography

The majority of pediatric dentists are still concentrated in the larger metropolitan areas of California, especially in Southern California.

Practice

The majority of practicing pediatric dentists have a traditional fee-for-service practice. Very few are involved in managed care programs and/or indigent care programs. As these programs increase, the shortage of pediatric dentists will become more apparent.

General Dentists/Dental Auxiliaries

The majority of practicing general dentists expect to reduce their work effort in pediatric dentistry as they get more established in their practices. The majority of dental auxiliaries are undertrained and underutilized for providing an expanded work effort in pediatric dentistry in both general dental and pediatric dental practices.

The conference concluded that these six factors are exerting major influence on the workforce crisis in pediatric dentistry. Not only is there an overwhelming need for more new pediatric dentists, but there is also a need for redistribution of the numbers of pediatric dentists throughout California. Likewise, the need to have general dentists treat more children in their practices was apparent as was the more appropriate utilization of better-trained dental auxiliaries.

Conference Recommendations

The conference recommended increasing the number of new pediatric dentists in California. Since more than two-thirds of practicing pediatric dentists in California were educated in advanced education postdoctoral programs in California, the conference identified and analyzed five factors that would influence increasing the number of advanced education postdoctoral students in the four California programs.

Applicant Pool

Although the applicant pool is very good in numbers and qualifications, much can be done at the predoctoral level to increase awareness of a career in pediatric dentistry.

The conference recommended that the California Society of Pediatric Dentists appoint five members to act as liaisons at each of the five California dental schools and that CSPD sponsor a program at each school to include study club membership and a senior student award to increase awareness.

Faculty

There is a shortage in both clinical and career-track faculty in all postdoctoral programs in California. The shortage in clinical faculty is attributed to recruitment. The shortage of career-track faculty is attributed to the low numbers of research-qualified candidates and the compensation at California universities being inadequate for the state’s cost of living. Without adequate clinical and career-track faculty, the postdoctoral programs cannot increase the number of students.

The conference recommended that CSPD appoint five members to act as liaisons to the five dental schools and that CSPD sponsor a reception for all five schools and their faculty at its annual meeting to allow members and faculty an opportunity to interact and members to possibly agree to become predoctoral and/or postdoctoral faculty.

The conference further recommended that CSPD explore the feasibility of establishing a separate nonprofit foundation that could obtain funds from other nonprofit entities for faculty endowments and research.

Facilities

Most of the postdoctoral programs have facility problems. These include outdated equipment, inadequate space, poor patient teaching pool, and inadequate research support. Inadequacies in onsite facilities often lead to offsite utilization with resultant loss of income at the onsite facility. This loss of income contributes to the lack of funds for facility upgrade, faculty, and students.

The conference recommended that CSPD explore the feasibility of establishing a separate nonprofit foundation that could obtain funds from other nonprofit entities to utilize for improvement and expansion of onsite facilities and/or the establishment of new offsite facilities. The conference recommended that CSPD support alumni groups at each of the postdoctoral programs in California that would support facility upgrade projects. The conference recommended that CSPD establish a regional advisory board to each of the postdoctoral programs to assist in innovative alternatives to onsite education, patient care, and research, such as new offsite faculty care affiliation and electronic offsite learning extensions.

Patients

Patient shortages are common at many of the onsite facilities of postdoctoral programs. This often necessitates having students go off site, which results in a loss of revenue for the postdoctoral programs and loss of funding for onsite faculty improvement, increase in faculty and/or faculty compensation, and increase in students.

The conference recommended that CSPD continue to be a strong advocate for dental health care programs for children in California and that CSPD create a clearinghouse and network for new governmental and private insurance information in dental health care for children and that the dental school pediatric departments be involved in this process so that more patients may be procured.

Dean Involvement

The deans of the five dental schools are the fiscal officers of their schools. As such, decisions about increasing postdoctoral students involve them. The conference recommended that CSPD implement a public relations program for each of the deans. This program could be individual as well as collective. It should involve key alumni at each school as well as CSPD leadership.

The conference further recommended that CSPD become involved with the California Dental Association’s Council on Education and Professional Relations so that it understands the workforce crisis in pediatric dentistry.

The conference also suggested that CSPD host an annual meeting of all dental school pediatric dental department leadership to further communicate and perpetuate CSPD support for postdoctoral programs. The conference recommended that CSPD establish a new pediatric dental support system to include a mentor program, practice match program, and annual meeting reception. CSPD has already established a conference for new pediatric dentists that will alternate between Northern and Southern California. The first conference was held Aug. 20, 1999, in Los Angeles. The next will be in San Francisco in the spring of 2000.

More than one-third of practicing pediatric dentists in California are educated in postdoctoral programs outside of California. They may have been born or raised in California, or have gone to college or dental school in California. The conference did not cover this issue but attendees realized its importance. More information is needed as well as specific strategic management of this potential resource. A program should be designed and implemented by CSPD to attract more pediatric dentists to California that are educated out of state.

California has no specialty licensure laws. All pediatric dentists desiring to be licensed in California must pass a general dentistry licensure examination. This is often difficult and burdensome to practicing pediatric dentists from out of state. California does not have state board licensure reciprocity with other states, whereby a practicing pediatric dentist in another state can obtain licensure in California by credentials and reciprocity. While the conference did not cover either of these issues, attendees realize their importance. More discussion is needed as well as specific strategic management of this potential resource.

Conclusion

The urgency to have more pediatric dentists in California is very apparent. California’s pediatric population is increasing at a rate faster than any other state’s. Yet, its number of practicing pediatric dentists is not keeping pace with this population explosion. More pediatric dentists must be trained in California dental schools. The applicant pool is sufficient, but the number of postdoctoral program opportunities is insufficient to meet the demand. Too many recent graduates and practicing general dentists applying to postdoctoral programs in California are being turned away not due to poor qualifications, but due to lack of sufficient positions in these postdoctoral programs. California must increase the numbers of positions available in its postdoctoral programs.

Likewise, the postdoctoral programs in California must consider preferential admission to qualified applicants that express an interest in practicing full-time in California. Often, California loses postdoctoral students after completion of their program because they return to their state or country of origin. Also, many female postdoctoral students after completion of their program wish only to practice part time as they consider family goals. Some move to other states based upon the career goals of their husbands who may relocate outside California. The admission process to postdoctoral programs in California must consider the practice goals of the applicant and make every effort to offer preferential admission to those applicants expressing an interest in full-time practice in California.

To increase postdoctoral students in many of our California programs, they need more full-time faculty and alternative training sites. With the high cost of living and relatively average academic salaries in California, the state’s programs have difficulty recruiting and retaining competent faculty. Furthermore, many postdoctoral programs that are in large metropolitan areas are experiencing declining patient numbers. California postdoctoral programs must revise their academic salary offerings to keep pace with its high cost of living so as to attract competent full time academic faculty. California postdoctoral programs must expand their off site, alternative training concepts to offer their postdoctoral students sufficient experiences in pediatric dentistry.

California dental schools must better prepare their graduates for the ever-increasing numbers of children in their practice career. California dental schools must also expand their continuing education programs to better prepare the practicing general dentist to treat this increasing pediatric population. Even with more pediatric dentists, the general dentists and their dental auxiliaries will be required to treat more children in the next century. All too frequently, as a general dentist gets established he or she raises the age level of admitted new patients to his/her practice often to the point of not accepting children at all. This trend must be reversed.

Finally, governmental funding programs for dental care for infants, children, and teenagers from low-income families must raise their reimbursement rates to keep pace with rising dental office expenses. Even if pediatric dentists and general dentists were available to treat indigent children with no dental insurance, they often decline to do so because of low reimbursement rates and lack of profitability in treating this large segment of California’s pediatric population.

Authors/

Roger G. Sanger, DDS, MSEd, is in private practice in Salinas, Calif. He was board director and conference chairperson (1996-1998) of the California Society of Pediatric Dentists (manpower issues).

Paul A. Reggiardo, DDS, is District VI trustee of the American Academy of Pediatric Dentistry and a past president of the California Society of Pediatric Dentists. He is in private practice in Huntington Beach, Calif.

References/

1. Waldman HB, Manpower planning: Planning for the children of your current pediatric dental patients. J Dent Child 62:418-25, 1995.

2. US Bureau of the Census, Population projections for states by age, sex, race and Hispanic origin: 1993 to 2020. Current Population Reports 1994, pp 25-111.

3. California Society of Pediatric Dentists, 1997. Unpublished data.

4. Council on Dental Practice, A Comparative Study of Male and Female Dental Practice Patterns. American Dental Association, Chicago, 1989.

To request a printed copy of this article, please contact/ Roger G. Sanger, DDS, MSEd, 633 Alvin Drive, Salinas, CA 93906.