Recently, I had the great opportunity of interviewing 60 bright dental students who were seeking admission to the orthodontic program at Saint Louis University (SLU). I asked the applicants a general question from a script about their plans for the future, assuming that they succeeded in becoming orthodontists. One applicant waffled around a bit, jumping from idea to idea, but then he started to incite my interest because his overriding goal was to become a full-time teacher in orthodontics. At first I thought that he was just saying what he thought I might like to hear, but as he went on, I cast that aside in favor of the optimistic hope that he was sincere in his interest in an academic career. When he finished, and in a moment of extreme curiosity, I jumped off the script and asked a question I had never asked before. “A lot of students have amassed a large educational debt; do you think that such debts will affect their career choices?” His instant response was, “It won’t affect mine!” He went on to explain his situation in detail. He would have nearly $250,000 in student debt when he graduated from dental school (this is about average); the tuition at SLU would add approximately $100,000 more (he had done his homework), and he thought he would need about $100,000 for living expenses during the 30-month program (he estimated this amount based on the fact that his wife was pregnant with their second child and could not work); finally, he noted that his wife has $50,000 in student loans also. So … enter the 500,000-pound gorilla.

Not dismayed about what he had just told me, he smiled and said that even though his interest payments might be about $4000 per month, he thought that he would be able to pay off his loans with his teaching salary and a part-time practice. He said that a comfortable lifestyle, a large family, and the satisfaction that he would derive from teaching are important to him.

The applicant’s enthusiasm was charming, and beyond that he had been a great dental student and a model person. So, he will be selected at SLU, if that is his preference. Thus, whereas his dream of becoming an orthodontist will be fulfilled, one might wonder whether his desire to become a full-time teacher will be realized. I would argue that the answer is “no,” unless the future is somehow different from the present.

The story you just read was intentionally obfuscated to blur the identity of the applicant, and it was conveniently constructed to make a point, but the scenario described is real. The general problem of student debt in the United States is a huge issue and is relatively new. Enrollments in colleges and universities have doubled during the last 20 to 30 years, and tuition has doubled, tripled, and sometimes quadrupled. As a result, more than 44 million people now have student loans to pay off, and the total tab is nearly $1.5 trillion—more than the total credit card debt of the United States.

In dentistry, this situation is particularly amazing, where loans to graduate and professional students account for approximately 30% to 40% of all student debt. Dental student debt has doubled since 2001, with the current average approximately $247,000 (estimates by American Dental Education Association). How did this happen?

About 25 years ago, federal policies began encouraging borrowing on a mass scale to cover rocketing educational costs. Policymakers believed that the borrowers could afford the debt because those with degrees would be able to make sufficient incomes to repay the loans. At present, students are confronted with a long list of loan and grant opportunities (Stafford loans, Perkins loans, subsidized and unsubsidized direct loans, Direct Plus, and so on), all of which are intended to help them afford higher education. Although they are always well-meaning and carefully crafted so as not to arouse the sensibilities of taxpayers, these opportunities have had to be modified repeatedly in response to unanticipated difficulties (eg, the recession greatly affected the ability of many to repay their loans). In addition, the maximum amount that a student could borrow has increased to the point that the funds available are basically unlimited (Direct Plus Loans are also referred to as Grad PLUS loans, to support graduate and professional students). In many ways, students have been encouraged to request the maximum amount available and then further encouraged to “manage” their debts. The result is that many highly educated professionals are, in a way, paupers.

What remedies have been developed to help the debtors? Many opportunities have been devised: loan deferment, loan refinancing, and income-based repayment programs, to name a few. The discharge of a loan might also occur in certain situations. For example, new teachers in schools serving students from low-income families for a certain period of time can have their debts modified or forgotten. Some government and nonprofit employees, including attorneys, physicians, dentists, and dental specialists, can have their loans forgiven by working in public service positions or underserved areas. Of course, these repayment opportunities affect the person’s ability to express his or her choice of career.

Closer to home, a recent article entitled “The effect of education debt on dentists’ career decisions” points out that dental student debt has a material effect on the choice of whether to go into practice or to pursue education as a specialist; unfortunately, the relationship between them is inverse. According to the article, the same is true of those considering whether to go into practice or pursue a faculty position; the greater the debt, the less likely a graduate will seek a faculty position.

To assess the situation in my world, I asked a sample of orthodontic students 4 pertinent questions. (The sample size was 42: a captive sample of SLU orthodontic students who respond to such surveys 100% of the time.)

• 1.

  Did you attend dental school in the United States or somewhere else?

• 2.

  By the time you graduate from orthodontics, how much student debt will you have accumulated?

• 3.

  With your anticipated debt, would you be interested in considering a career as a full-time faculty member?

• 4.

  If somehow your educational debt could be canceled, would you consider a career as a full-time faculty member?

The results showed that 37 students went to dental schools in the United States, and 5 studied somewhere else. Interestingly, none of the 5 foreign students reported that they would be in debt when they graduated from the orthodontic program—none! For the students who were educated in the United States, the answers were startling: the span of reported debt ranged from $0 to $650,000! The mean was approximately $300,000. With these debt loads, only 1 person expressed interest in pursuing an academic career. But if the debt could somehow be canceled, 20 students would consider a full-time career in academics! Does debt affect choice? Yes! Could debt affect the future of orthodontic education? Yes!

Now, my generation might address the situation in a scolding tone, suggesting that these youngsters should not have gotten themselves into so much debt; although that may be true, it will not solve the problems that we presently face and will face in the future. And it seems that we will soon encounter additional challenges. Several political candidates running for high office would like to make college free for everyone. This type of program most likely will not be really free at all but is, rather, a presidentially inspired triple back tax. *

* A triple back tax occurs when your back is turned, and someone reaches into your back pocket and takes back money from your wallet.

Problems involving faculty recruitment and retention have been on our minds for some time, particularly over the last 10 years. In considering the main issue, we used to focus on the income chasm between orthodontists who teach and those who practice. That chasm is still a concern, but it is also clear that we must now consider the real effect of student debt now and how big the gorilla will be in 25 years. I would argue that over the next quarter century, the number of available faculty will continue to decline unless new ideas and strategies are adopted.

I am resigned that an editor, by writing an editorial, cannot find the answers needed to properly address the general debt problems of orthodontic students. For most orthodontists, I suspect that the answer will be to spread their debt out across their patients. But what about the orthodontic student who wants to teach? Are there any new ideas or strategies that might be considered? I believe there are. I am encouraged in such a stance by a recent article in the McGill Advisory , “Use a Tax-Favored Student Loan Repayment Program as a recruiting tool.” This article points out that one of most important recruiting tools available to encourage dental graduates to accept positions in corporate dentistry and other companies might be a limited student loan forgiveness program. The article explains how this might work: A new graduate with $200,000 in debt would be offered a starting salary at the low end of a typical starting salary range and receive a low-interest loan that would be used to pay down the student’s debt. The company could make additional low-interest loans each year, and finally the accumulated low-interest loans provided by the company could be canceled. Importantly, the tax situation could be favorable for the corporation and the new doctor. Perhaps the model could be applied in a university setting by creating an endowed fund to make low-interest loans to newly hired faculty, with the university loans forgiven after some years of credible service. Of course, such a model might not be allowed by universities and state and federal laws, but at least it is an idea that can be considered.

As a second thought, perhaps organized dentistry could lobby state or federal governments to expand the Teacher Loan Forgiveness Program. This program already exists and is intended to encourage people to enter and continue in the teaching profession. At present, this program involves certain elementary and secondary schools and educational service agencies that serve low-income families or disabled children, and it can also apply to teachers of mathematics, sciences, foreign languages, or any other field of expertise determined by a state education agency to have a shortage of qualified teachers in that state. Because of the importance and value of well-trained dentists and dental specialists, the decreasing numbers of people interested in becoming dental faculty, and the increasing numbers of dental schools and programs, dentistry might be considered underserved now and increasingly so in the future. A dental school can be built seemingly overnight, but building high-quality teachers takes time and money.

Although these ideas might not apply in orthodontic education, it is appropriate to begin a dialogue about the problem and its consequences. Perhaps the American Association of Orthodontists, the American Association of Orthodontists Foundation, educators, dental schools, and universities might consider the issue with new eyes and thoughts. What we do now, or don’t do, could be felt for the next 25 years or even longer.

Should we be thinking that far in the future? Indeed we should. The applicant in the story above will soon have 2 children in his family. With his $500,000 debt, many reasonable questions could be asked. Will he be able to pay off his student debt, buy a house, and open a practice? Will he be able to pay for his kids’ education without taking on more debt (or his kids taking out loans themselves)? Will he be able to put money aside for retirement and still have discretionary money to support charities, his community, and the schools he attended? And, finally, if there is interest, choice, and opportunity 25 years from now, will his children be in a position to seek admission to an orthodontic program … and will there be any good teachers available to teach them when they get there?

Choice depends on the freedom to choose and if you are shackled with debt you don’t have the freedom to choose.