I have always found it interesting that some of America’s greatest presidents in the area of domestic policy were, in my mind, failures at foreign policy. Lyndon Johnson would be my example. An argument might be made that Richard Nixon was his opposite. President Johnson’s Great Society and the programs that resulted dramatically affect our profession to this day. With that era’s emphasis on health, education and the cities, federal funds soon found their way into dental education. They came affixed to a string. Increase class size by twenty-five percent.

Universities generally lose money in the training of dental students. They do it as part of their service to the community. However, when the federal funds dried up in the eighties at the same time that there was an oversupply of dentists some institutions elected to close their dental schools and virtually all of the others reduced class size. The result is that we today graduate approximately 4,000 dentists annually, while the profession loses 6,000 to death and retirement. The population of the country grows at roughly two and a half million people a year.

Even with the reduction in dental disease over the last fifty years attributed to water fluoridation and the preventive emphasis advocated by the dental profession, it is clear that the country will experience a shortage of licensed dentists over the next decade with a resultant exacerbation of the access-to-care problem. Some of the effects of this trend may be: that dental offices will be busier experiencing fewer openings in their appointment schedules; fewer dentists will find it necessary to participate in reduced-fee programs; dentists will be better able to compete for quality employees; those employees may be offered improved benefit packages; dentists might be able to retire as young as the average American laborer does.

After a decade of fearing the demise of the fee-for-service practice model, many of us might not be able to resist a breath of relief knowing that, for at least the foreseeable future, the pendulum will swing in the other direction. Companies with unreasonably low fee schedules will probably have difficulty finding quality practitioners to participate, and as patients become frustrated with this problem many will return to more traditional quality dental coverage.

Another aspect of this situation is the shortage of full-time dental school faculty. I recently read that there is a ten- percent shortfall which represents four hundred full-time faculty openings in dental schools nationwide. Dental school tuition is already quite high with student debt a another serious concern of the profession. Universities have been almost universally tightfisted about increasing subsidies for dental education. As the average income of the private practitioner climbs, it becomes more difficult to attract dental professionals to the academic life. But before dental schools can consider increasing class sizes, they must resolve the problem of faculty shortage. It seems that we might be on a slippery slope. For though individual practitioners may experience short-term benefits, the profession as a whole may suffer long-term harm.

One possible solution to this dilemma is to raise the cost of dental school tuition the amount necessary to increase the average faculty member’s income so that it both competes with what he or she might expect to earn in private practice, and attracts graduating dentists to academic life. I do not have any idea how much of an increase that might represent. But my impression is that it would have a detrimental effect on the potential pool of dental school applicants in both quality and quantity.

A second possible solution would be for the universities to provide the funds to accomplish the above-mentioned goals. But, as we have mentioned, the universities don’t seem willing to further underwrite the cost of dental education.

Another option might be for the state or federal government to provide further funding. After all, these funds come from all the people and it is a societal problem. However, past experience shows us that government funding always comes with strings attached which often result in waste, reduced quality of care and national dissatisfaction.

Still a further suggestion might be that the government mandate the expansion of services provided by dental hygienists and expanded function dental assistants allowing them to work without any or with only general supervision in under-served areas. Following this same line of thought might be the establishment of another category of dental practitioner called the dental nurse licensed perhaps to do cavity preparations for fillings.

I, of course, find none of the above solutions acceptable. I mention them only to illustrate the seriousness of the access problem and to encourage a dialogue from those who may have thoughts to share with our dental leaders. We have had many problems and we have always addressed them in a way that served both the public and the profession. I know there is such an answer out there.