8 The Dental Workforce

The vision of the dental team is one of various people in dentistry with different roles, functions, and periods of training, all working together to treat patients.¹⁰⁶ Dental team is more a concept than a precise term, although the dental profession in the United States has long recognized that several different categories of personnel are fundamental to the efficient provision of care. Virtually all dentists employ at least one nondentist staff person, more than 94% of general practitioners employ at least one full- or part-time chairside assistant, and more than 63% employ at least one full- or part-time hygienist.²⁹

This chapter defines the various types of personnel involved in the provision of dental services and assesses the factors that influence their supply and distribution.

TYPES OF DENTAL PERSONNEL

Dentists

A dentist is a person who is permitted to practice dentistry under the laws of the relevant state, province, territory, or nation. These laws are intended to ensure that a prospective dentist has satisfied certain requirements such as (1) completion of a specified period of professional education in an approved institution, (2) demonstration of competence, and (3) evidence of satisfactory personal qualities. Dentists are concerned with the prevention and control of the diseases of the oral cavity and the treatment of unfavorable conditions resulting from these diseases or from trauma or inherent malformations. A dentist is legally entitled to diagnose and treat patients independently, to prescribe certain drugs, and to employ and supervise auxiliary personnel. The mechanisms for fulfilling these requirements differ among nations. In the United States and Canada, for example, professional education is separate from the additional testing required for licensure. In many other countries, these two functions are combined under the authority of the educational institutions.

Dental Auxiliaries

Dental auxiliary is a generic term for all persons who assist the dentist in treating patients. It includes the categories of dental hygienist, dental assistant, hygienist or assistant with expanded functions, dental laboratory technician, receptionist, and secretary. Auxiliaries can be classified as operating and nonoperating,¹⁰⁷ depending on whether they carry out any intraoral procedures in the direct treatment of patients.

With rare exceptions, auxiliaries of all types operate under varying degrees of supervision by dentists. Even those auxiliaries who appear to operate more or less independently, such as the school dental therapist of New Zealand (see Chapter 6), work under some degree of supervision. Defining the extent of supervision required for various types of dental auxiliary can be confusing, because bodies concerned with supervision continue to modify their stance and definitions. As of 2002, the American Dental Association (ADA) acknowledged four levels of supervision of allied dental personnel as shown in Box 8-1.

BOX 8-1 Levels of Supervision of Allied Dental Personnel As Defined by the American Dental Association in 2002 ⁸

American Dental Association

1. Personal supervision: The dentist is personally operating on a patient and authorizes the allied dental personnel to aid treatment by concurrently performing a supportive procedure.

2. Direct supervision: The dentist is in the dental office or treatment facility, personally diagnoses the condition to be treated, personally authorizes the procedures and remains in the dental office or treatment facility while procedures are being performed by the allied dental personnel and, before dismissal of the patient, evaluates the performance of the allied dental personnel.

3. Indirect supervision: The dentist is in the dental office or treatment facility, has personally diagnosed the condition to be treated, authorizes the procedures and remains in the dental office or treatment facility while the procedures are being performed by the allied dental personnel, and will evaluate the performance of the allied dental personnel.

4. General supervision: The dentist is not required to be in the dental office or treatment facility when the procedures are being performed by the allied dental personnel, but has personally diagnosed the condition to be treated, has personally authorized the procedures, and will evaluate the performance of the allied dental personnel.

The ADA policy statement on this issue declares: “General supervision is not acceptable to the American Dental Association because it fails to protect the health of the public.”⁸ This issue is important for public health programs because, without general supervision, it is far more expensive for dental hygienists to provide care in schools, nursing homes, and other institutional settings. Where general supervision is permitted, dentists in private practice can allow a hygienist to provide recall prophylactic services while the dentist is away from the office.

These policies of the ADA have no direct control on the practice of dentistry because the regulation of dental practice in the United States is determined by state licensing boards, not by the professional organization. Each state can have its own definition of supervision requirements and scope of practice, and indeed there is considerable diversity among states. The moves by the ADA to limit the scope of auxiliaries’ practice are occurring as dental hygienists are working for a greater degree of autonomy, so conflicts are to be expected.

A dental hygienist is an operating auxiliary licensed to practice dental hygiene under the laws of the appropriate state, province, territory, or nation. In nearly all jurisdictions, to be licensed, hygienists, like dentists, must satisfy certain qualifications such as (1) completion of an approved period of education in an approved institution (only Alabama permits on-the-job training of hygienists),^81,⁹⁹ (2) demonstration of competence, and (3) demonstration of satisfactory personal qualities. Hygienists are recognized auxiliaries in a number of countries, in which their duties and deployment are essentially similar.⁶²

Dental hygienists have traditionally been concerned with prophylaxis, the health of the supporting structures of the teeth, and prevention of further diseases by direct clinical procedures and by the education of individual patients and groups. In most places, hygienists work under the supervision of dentists, either in private dental practice or in institutional settings such as health departments, nursing homes, or school dental programs.

The expanded-function dental auxiliary (EFDA) (sometimes called an expanded-duty dental auxiliary) is a more recent development among operating auxiliaries in the United States and Canada. An EFDA is usually a dental assistant, or a dental hygienist in some cases, who has received further training in duties related to the direct treatment of patients, although still working under the direct supervision of a dentist. Not all states in the United States recognize EFDAs, and the duties permitted in those that do vary considerably.

A dental assistant is a nonoperating auxiliary who assists the dentist or dental hygienist in treating patients but who is not legally permitted to treat patients independently. Traditionally the dental assistant’s duties include immediate chairside assistance in the handling of dental equipment and materials used by the dentist or dental hygienist in treating patients.

Voluntary certification programs for dental assistants exist in many countries. Certification is the process by which a nongovernmental agency or association grants recognition to an individual who has met certain predetermined qualifications specified by that agency or association.⁸⁵ However, a dental assistant is not required to be legally certified or registered or to have completed any particular duration or amount of education. The vast majority of the world’s dental assistants are trained on the job. However, to provide certain services, such as the exposure of radiographs, a growing number of American states require either some form of formal education or certification.

The dental laboratory technician is a nonoperating auxiliary who fills the prescriptions provided by dentists regarding the extraoral construction and repair of oral appliances. Denturist is a term applied to those dental laboratory technicians who are permitted in some American states, some provinces of Canada, and some other countries to fabricate dentures directly for patients without a dentist’s prescription. These denturists must be licensed. Illegal denturists are also known to operate in other jurisdictions. The term can have strong political overtones in jurisdictions where denturists are trying to achieve legal recognition.

Dental nurse and dental therapist are more or less synonymous terms that describe an operating auxiliary who in some countries is legally permitted to treat special population groups, usually children, with little direct supervision from a dentist. The extent of their duties varies from one country to another, as does the degree of supervision required, but all dental nurses and therapists require specific training, licensure, and registration. Preventive dental nurses and therapists are trained in some countries to provide preventive services only, usually in a school dental service. Because their period of training is shorter than the training for dentists and their duties are limited, these auxiliaries can provide preventive services to specified groups at lower cost than can dentists or hygienists.

SUPPLY OF DENTISTS IN THE UNITED STATES

Table 8-1 shows the dentist/population ratios in several countries as of the late 1990s to give a perspective on the relative availability of dentists in the United States. The range is wide, with an especially large gap between developed and developing countries, and even within the more economically developed countries, the range is considerable. The numbers are given as the number of dentists per 100,000 population and as persons per dentist. The 55 dentists per 100,000 people in the United States in the mid-1990s are equivalent to 1810 persons per dentist.

Table 8-1 Number of dentists per 100,000 population for 15 countries at various stages of economic development ¹⁰⁸

Country	Dentists per 100,000 Population	Population per Dentist
Sweden	143	700
Finland	98	1024
Denmark	92	1090
Norway	91	1100
Argentina	83	1200
France	72	1390
Switzerland	62	1613
United States	55	1810
Canada	54	1834
Spain	40	2525
Singapore	29	3500
Turkey	21	4668
Thailand	10	9800
India	3	36,538
Cameroon	1	119,200
Ethiopia	<1	1,200,000

Note: Rounded to the nearest whole number.

Counting dentists and other dental personnel is not as straightforward as it might at first appear. Membership lists from professional associations and licensing lists are the most common source of counts, but these are seldom completely accurate. For example, some dentists maintain association membership even when they are retired or otherwise not actively engaged in professional practice; others are not members of a professional association. Dentists can hold a license in more than one jurisdiction, which leads to overcounting. As a result, one does well to realize that virtually all enumerations of dental personnel are estimates and that, in an attempt to be more precise, the counts are often qualified as all dentists, active dentists (those actually engaged in some activity related to dentistry), or practicing dentists (which often excludes dentists in full-time teaching, research, or administrative positions). Numbers obtained from different sources therefore can differ because they are based on different subgroups. This nomenclature is by no means standard and is often not clearly defined in source documents. Usually the differences are not of great consequence, but when interpretations are made within small geographic areas the differences can be important. For example, in a community where there is a dental school or a government agency that employs a number of dentists in nonclinical positions, a count of all dentists for that community could greatly overestimate the availability of dental care.

As of 2000, the ADA estimated that the number of professionally active dentists in the United States was about 168,000. Approximately 5000 of these were in the armed forces and other federal agencies.²¹ About 155,200 dentists were in private practice in 2000, a more than 55% increase since 1975.⁹³

From 1920 until the early 1980s, 1%–3% of dentists were women,^75,⁸⁹ but since the early 1980s this percentage has increased. In 1998, over 13% of dentists were women, and almost one third of dentists who had graduated within the previous 10 years were women.²⁶ In 1969–70, women constituted only 1.3% of first-year enrollment in dental schools,⁵⁴ but by 1980–81 the first-year class was 19.8% female.⁵⁵ By the early years of the twenty-first century, dental school enrollments were over 40% women.¹⁴

Not all observers agree on the implications of the growing proportion of female dentists.^10,^66,^71,^75,^88,^90,^102,¹⁰³ Although it is too early to be sure about trends, there are indications that women dentists are more likely to practice part time and to interrupt their practices for an extended period of time, thus spending fewer actual hours in practice during a career. Any differences between men and women in retirement patterns will also affect productivity, and it will be several decades yet before these can be observed. Further, it is likely that the practice patterns followed by those women in decades past, when women in the profession were rare, may be of little help in predicting the future practice patterns of the women now becoming dentists. Although any substantial shift in the average productivity of dentists would affect the adequacy of the dentist supply, it is at present not clear how the increasing proportion of female dentists is affecting productivity.

Not only are the numbers of women increasing, but dentistry is becoming more ethnically diverse. Although approximately 90% of dentists in practice as of 1995 reported themselves to be white non-Hispanic,²⁵ the picture for dental students indicates a decided shift. At the turn of the century, about 25% of dental school graduates listed themselves as other than white.²³

Foreign-trained dentists, in contrast to foreign-trained medical graduates, have never been present in large numbers in the United States, in no small part due to difficulty in gaining licensure. Graduation from an accredited U.S. or Canadian dental school was for a long time a prerequisite for licensure in most states. However, rapid population growth, especially the growth of immigrant communities, is forcing some states to look at more radical ways of increasing dentist supply. California, for example, is considering accrediting certain foreign dental schools in a bid to attract dentists from other countries. The future of such policies remains uncertain, but their very existence certainly represents a major break with tradition. This is a rapidly changing area, and up-to-date information on the details for any particular state is usually available on the website of the ADA.^12,³⁰

Dental Specialists

The early development of dental specialists was informal, and such specialists did not require certification.⁶⁰ Varying patterns of formal training and certification developed as each specialty grew and matured relatively independently. Examining boards that certified specialty competence came into being, as did specialty societies, such as the American Academy of Pedodontics (now Pediatric Dentistry) and the American Association of Orthodontists, which maintained educational and experiential qualifications for membership. In addition, some states established specialty licensure following examination by the state board of dental examiners.

Under guidelines originally set by the ADA House of Delegates and the Council on Dental Education, and now maintained by the Commission on Dental Accreditation, examining boards have been established in nine areas of specialty practice: dental public health, endodontics, oral and maxillofacial pathology, oral and maxillofacial radiology, oral and maxillofacial surgery, orthodontics and dentofacial orthopedics, pediatric dentistry, periodontics, and prosthodontics. Minimum criteria for those entering a specialty are full-time limitation of practice, plus either the completion of at least 2 years of approved advanced study or specialty licensure by a state board. Certification as a diplomate by one of the specialty boards is not a prerequisite for limitation of practice. The stated purpose of specialty boards is to provide leadership in elevating standards for the practice of the specialty and, through examination and certification, to recognize those individuals who have demonstrated unusual competence. Numerous additional dental specialty groups are not officially recognized by the ADA, and the ADA actively discourages the announcement of practice limited to any area other than one of the nine recognized specialties.

Unlike the situation in medicine, in which by 1990 more than 60% of practitioners were practicing in a specialty outside of primary care, about 80% of dentists are general practitioners.^25,⁹⁴ Since the early 1970s, the number of first-year positions in specialty training programs has remained stable at approximately 1200. More than 50% of all specialists work in orthodontics or oral surgery, the two longest-established specialties.

There has been strong sentiment in dentistry for some time that a further increase in the number of specialists would not benefit either the profession or the public.⁵⁹ This view was based on the contention that one of the chronic problems in the American health care system is fragmentation, the dispersal of many medical specialists and the frequent absence of coordination among them. The growth of General Practice Residency and Advanced Education in General Dentistry programs is a reflection of this emphasis on the general practice of dentistry. As of 2004 there were just over 1000 General Practice Residency and 650 Advanced Education in General Dentistry residency positions.³¹

Distribution of Dentists

In 2000 there were approximately 60.7 active dentists per 100,000 people in the United States.⁹³ These dentists, however, were not evenly distributed throughout the country, as seen in Chapter 6 (see Fig. 6-1). This situation is not unique to dentistry as a health profession nor to the United States, for it is found wherever there is relatively free choice of practice location. Table 8-2 provides data for the five most favorable and five least favorable states in terms of dentists relative to the population in 2000. The figures range from 84.7 dentists per 100,000 people in Hawaii to 39.2 per 100,000 in Nevada.⁹³

Table 8-2 The five states with the highest number of dentists and the five states with the lowest number of dentists per 100,000 population in the United States, 2000 ⁹³

State	Dentists per 100,000 Population
Hawaii	84.7
New York	83.1
Massachusetts	81.2
New Jersey	80.4
Connecticut	79.6
Alabama	43.5
North Carolina	43.1
Arkansas	42.2
Mississippi	39.7
Nevada	39.2

There are a number of reasons for this uneven distribution of dentists. The first and most fundamental is the relative freedom a dentist has in choosing a practice location. Dentists make this choice much as other people do, that is, because of personal preference: attachment to a home town, presence of good schools, or convenience to social, cultural, or recreational facilities.⁶ Second, the location of dental schools also influences distribution, and the 56 American dental schools are located in only 34 states (plus the District of Columbia and Puerto Rico). Most dental schools are in state universities, at which tuition usually is less for state residents than for out-of-state residents. A third reason is market response, meaning that the availability of dentists reflects demand for services. Areas of high income and education where demand for services is highest, such as affluent suburbs, have more dentists than do poorer areas. The low number of dentists in Nevada is largely a reflection of the exceptionally rapid growth of the population of that state in the past decade. The dental school recently opened at the University of Nevada, Las Vegas, is expected eventually to help correct some of that imbalance.

Effect of Dental Education on the Supply of Dentists

Dentists were first enumerated separately in the 1850 census. It listed 2900 dentists serving a population of 23 million,⁹¹ or 12.6 dentists per 100,000 population. With the growth of dental schools during the latter part of the nineteenth century, the supply of dentists in 1900 increased to 39 dentists per 100,000 population. By 1930, there were 57.7 dentists per 100,000 population.⁹⁸ This steady increase was caused principally by changes in dental education. Although in the second half of the nineteenth century many dentists were still being trained under an apprenticeship system, proprietary dental schools grew rapidly in response to demand (see Chapter 1). The number of dental graduates continued to grow until the closing of the last proprietary school in 1929.⁷⁰

In the United States, the federal government has no direct jurisdiction over education, and there are considerable differences among states in the priority given to education. This is notably different from most other countries, where the national government directly determines how many practitioners, and of what type, will be produced. For these and related reasons, accreditation evolved as a voluntary, self-regulatory means of establishing and maintaining nationally acceptable standards of educational quality.⁸³ Accreditation is the process by which an agency or organization evaluates and recognizes a program of study or an institution as meeting certain predetermined qualifications or standards.^84,⁸⁵ The Commission on Dental Accreditation of the ADA currently serves as the accrediting body for dental and auxiliary training schools and graduate programs in dentistry. The commission is a broad-based agency of the ADA; its membership includes auxiliaries, public members, and students in addition to dentists.

Enrollment in dental schools is obviously a prime influence on the future supply of dentists. During the 1960s and early 1970s, there was a widely held perception that more dentists were needed and that a critical shortage was inevitable if strong actions were not taken. Although the federal government in the United States has no direct control over dental education, it can provide incentives to increase supply. During the 1960s and 1970s, incentives were offered to dental schools to build new facilities and to increase the number of graduates at existing dental schools. The results were impressive, as shown/>

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