May 2020 Volume LV Number 3

 
 
 
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Feature Story

March 2020 Volume LV Number 2

Pediatric Dental Workforce Study: What Does it Mean for the Future of Your Practice?
 
AAPD Chief Policy Officer Dr. Paul Casamassimo shares his insights on the practical implications of the study, "Pediatric Dental Workforce: 2016 and Beyond," on pediatric dental practices throughout the country.
 
What are the main takeaways from the study?
  • If current trends continue, the number of pediatric dentists is projected to increase by 62 percent from 2016 – 2030. The number of children in the U.S. is projected to grow slowly during this same time. Translated into patient access to care, the supply of full-time pediatric dentists will grow from nine to 14 per 100,000 children.
  • There is unmet need for dental services among certain population groups, which are also those experiencing the greatest growth in the U.S. If currently underserved children face fewer access barriers, then demand for pediatric dentists would rise substantially.
  •  A key finding is the need for pediatric dentists in areas of lower population density. The AAPD is pursuing opportunities for pediatric dentists to succeed in these areas in our advocacy and legislative efforts.
  • Pediatric dentists are the backbone of the pediatric oral health care delivery system, helping ensure all children have access to high quality comprehensive dental services. Virtually every pediatric dentist cares for children with special health  are needs. Almost 70 percent see children on Medicaid – the highest of any recognized group of dentists in the U.S.
Why did the AAPD commission a study of the pediatric dental workforce in the first place?
In view of the increase in pediatric dentists over the last two decades, an objective look was required by an outside agency with expertise and freedom to give an unbiased view. We needed to assess progress and ask such questions as: Is the number of pediatric dentists right for population growth and caries progression? Are pediatric dentists in the right places to maximize oral health for children?
 
To answer these questions, the AAPD commissioned the Center for Health Workforce Studies (CHWS) at the University at Albany, SUNY, to conduct an exhaustive workforce study on the current and projected supply and distribution of pediatric dentists relative to their patient populations. The CHWS has a long history of research into the country’s health workforce and is respected by government and professional organizations for the quality of its work.

What kind of study is it?
First, the study gathered extensive data on the current supply and distribution of pediatric dentists, including a comprehensive survey of AAPD members. Next, it compiled information on the U.S. child population, especially regarding indispensable services to meet their oral health needs. Then, the study applied a workforce simulation model to the data to anticipate future supply and demand for pediatric dentists and help ensure children receive recommended dental services.
 
A report on the study appeared in the July issue of The Journal of the American Dental Association. You can read the full article at https://www.aapd.org/globalassets/media/policy-center/pediatric-workforce-jada-july-2019.pdf.
 
Why have we seen so much growth in our numbers during the last decade or so?
Historically, a shortage of pediatric dentists meant we were often unable to provide care to the patients in our communities who needed it most. We advocated for federal support for more pediatric dental residency programs, and we were successful.
 
Title VII funding from the Health Resources and Services Administration (HRSA) has had a significant impact on the nationwide supply of pediatric dentists, doubling the number over the past 20 years. I believe this has made a positive improvement in access to care, such as the growth trend of utilization of Medicaid dental services by children over the same time period and a reduction in untreated dental caries in our country’s youngest poor.
 
As a member of the AAPD, I am proud we chose to look at the effects of our advocacy for federal funding to see if it is still valuable for both members and children, thus being responsible with our nation’s
money. This type of objective information drives the AAPD’s legislative advocacy and policymaking.

How many more pediatric dentists are we talking about?
To be specific, the number of practicing pediatric dentists has increased from 4,213 in 2001 to 8,033 in 2018. Pediatric dentistry residency first-year positions have grown from 180 to 463 in 20 years (from
1997-98 to 2017-2018).
 
Looked at in another way, there were an estimated 6,533 full-time equivalent (FTE) pediatric dentists in the U.S. in 2016. (FTE is defined as 32.6 hours per week in patient care activities, the average number
of hours worked according to responses to the 2017 Survey of Dental Practice of Pediatric Dentists.) If current trends continue, the supply is projected to reach about 10,560 FTE pediatric dentists by 2030, an increase of 62 percent.
 
Do these projections take anticipated retirement by pediatric dentists into account?
Yes. The model for the future supply of pediatric dentists used individual-level data to simulate career decisions on the basis of collected information about patient care hours worked per week and age of intended retirement. In fact, the study offers early retirement and delayed retirement scenarios relative to current patterns.
 
What about other changing demographics, like more women in the profession?
The majority of pediatric dentists are female – 52 percent in 2019– up from 14 percent in 1998. Since 67 percent of pediatric dental residents in the 2018-19 academic year were female, we can expect the percentage of female pediatric dentists to continue to increase. 
 
Does the practice of pediatric dentistry change based upon gender?
In a few ways. Female dentists tend to be younger – an average age of 39 years compared to 45 years for male pediatric dentists. They are more likely to be employed in a dental practice (62 percent), while males are more likely to own a dental practice (57 percent). Female pediatric dentists are more likely to be practicing in the larger counties (populations of 675,000 and over) and male pediatric dentists are more likely to be practicing in smaller counties (populations of 275,000 or under).Female pediatric dentists are also more likely to treat patients covered by Medicaid.
 
A commonly held belief is that female pediatric dentists work fewerhours than male pediatric dentists. While accurate, the difference is very small – a bit over 2 hours per week on average. The proposed reason for the difference in hours is that male pediatric dentists are more likely to own dental practices, and owners tend to provide more patient treatment hours than do employed pediatric dentists.

Are you saying there are too many pediatric dentists?
No, and neither are the majority of your colleagues. Of the pediat- ric dentists surveyed in the report, 10 percent perceived a shortage of pediatric dentists in their local areas, 45 percent perceived that current supply was adequate, and 45 percent perceived there was an oversupply. These responses broadly reflected the distribution of pediatric dentists in terms of regions of the country and urban versus rural locations. In other words, if you are practicing in a pediatric dentist-dense area, you would likely say there are too many; if you are practicing in a shortage area, you would likely say you are overworked and can’t see all the children who need care.
 
The supply of pediatric dentists is not well distributed in view of the child population. There are both regional differences (such as between the West and the Midwest) and local differences (such as large population versus low population counties). Nationally, there were approximately 9 pediatric dentists per 100,000 children in 2016. The ratio of pediatric dentists to children was lowest in states with a larger part of their popula- tion living in rural areas. For example, Missouri and New Mexico had a ratio of 5.5 pediatric dentists per 100,000 children, while Massachu- setts and Connecticut had 16 per 100,000. In addition, this ratio varied substantially across regions. The Northeast and West regions averaged 12 per 100,000, while the South and Midwest region averaged 7 – 8 per 100,000 children.
 
So new pediatric dentists should forget about practicing in Manhattan, Beverly Hills or Boston?
Not at all. Opportunities for pediatric dentists continue to be found throughout the country. However, for an early career pediatric dentist, it is valuable to know that the ratio of pediatric dentists to children is low- est in states with a larger percentage of rural populations. These results suggest opportunities for providing care in areas not traditionally served by pediatric dentistry, such as the approach of satellite offices, particu- larly in smaller population centers where the need is great for oral health services for children.

How is the AAPD helping pediatric dentists locate in underserved areas?
In view of the substantial geographic disparities in the availability of pediatric dentists, we are focusing on how to attract individuals who might be willing to practice pediatric dentistry in underserved communi- ties. For example, the expansion of loan repayment assistance programs has helped place more dentists in designated Health Professional Short- age Areas. The addition of a rural outreach track to training programs may improve geographic distribution and offer expanded access to underserved areas. A rural track could be the basis for having a tele- dentistry component.
 
Based on the results of the workforce study, the AAPD is already initi- ating discussion with HRSA on how best to use Title VII to improve the pediatric dentist workforce of the future. For example, one of the current statutory priorities is for "qualified applicants that have a high rate for placing graduates in practice settings that serve underserved areas or health disparity populations, or who achieve a significant increase in the rate of placing graduates in such settings."
 
Pediatric dental residency programs can play a consequential role as well. The AAPD supports the development of education-based programs that encourage residents to practice in settings serving health disparity populations. For example, residency programs might arrange for pediatric residents to spend time in such underserved settings as FQHCs, and to track graduates to see where they choose to practice in terms of location and practice setting.
 
More research is needed to better understand the extent to which new pediatric dentists are familiar with and taking advantage of existing and new programs that might facilitate dentists working in underserved communities. This includes federal and state programs for loan repay- ment, as well as local efforts to help attract dentists to the community.
 
How does the projected increase in number of pediatric dentists compare with the predicted demand for oral health services?
If current dental care use and delivery patterns for children remain unchanged, demand would only grow by about 2 percent, or 140 FTEs, by 2030. (This flat growth reflects that the number of children in the
U.S. is projected to grow slowly.) If policy or other changes could remove current barriers to accessing care, then demand would increase by about 30 percent, or 2,100 FTEs, according to the study projections.
A pertinent finding relative to future demand for pediatric dentistry services concerns unmet need for dental services among certain popula- tion groups, which are also those experiencing the greatest growth in the U.S. For example, children in low-income families have almost 20 per- cent fewer annual dental visits compared to children in households with average incomes. As another example, 20 percent of U.S. children have special health care needs, and dental care is their most prevalent unmet health care need. If currently underserved children received oral health care services in a way similar to children with fewer access barriers, we would see an increase in the demand for pediatric dentists.
 
What policy changes or other efforts should we start with to remove access barriers?
The study’s results suggest solid strategies to increase utilization of oral health services for children. One of the most critical recommended actions is improving Medicaid policy that affects the quantity – and the quality – of dental benefits for children. This is an ongoing effort of the AAPD, and we have seen an increase in dental visits for children covered by government programs as well as a rise in treatment of caries. We still have a long way to go, especially in terms of policy changes to support pediatric dentists’ participation with Medicaid programs. The study’s results confirm the pivotal and perhaps indispensable role of pediatric dentistry in Medicaid care of children in this country.
 
Other pivotal action steps are to create initiatives to encourage referrals from pediatricians and primary care physicians, such as an online network that provides information on open appointment times for nearby pediatric dentists who accept a patient’s particular insurance plan. Equally salient are improvements in oral health literacy of adults parenting or caring for children, particularly the very young.
 
Predicting the future is tough. Any caveats?
Although this was a top-quality, comprehensive study from a highly reputable organization, you are right. No study can predict the impact of the wide variety of factors that could affect future demand for dental services. These factors include changes in governmental health care programs affecting dental benefits for children, increased rates of referrals of children to pediatric dentists by pediatricians and family medicine clinicians, improvements in oral health literacy, greater use of preventive technologies and materials including dental sealants and silver diamine fluoride, growth or reduction in rates of community water fluoridation, and the narrowing of oral health disparities among certain populations of children.
 
What will not change in the future is our dedication to providing crucial oral health services to our nation’s most vulnerable populations – the very young, children from low-income families, and those with special health care needs. More pediatric dentists result in more access to high quality oral health care for children and more opportunities to prevent dental disease. From this vantage point, each of us will find a place to serve children and offer a dental home.