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Special report: An in-depth look at new dental schools

Having ceased to be a critical component of their sponsoring universities’ missions, seven dental education programs closed their doors for good between 1986-2001. All of them were private, not-for-profit institutions.

Image: Special report: An in-depth look at new dental schools

Since that time, eight institutions have opened new dental schools, and at least two others have announced their intent to do so. Two are public universities; the rest are private, not-for-profit programs.

It should be a time to celebrate, with evidence that dental education is on an upswing—a robust profession with more dentists than ever able to help meet the country’s access needs. So why are so many worried about the future of the profession?

It’s a subject that has caught the attention of the American Dental Association and its members. Officers of the American Dental Education Association have met twice this year with the ADA Board of Trustees—in April and June—to share information about the new programs.

Related content

Two additional stories and charts illustrating trends in dental education can be found here:

The ADA Council on Dental Education and Licensure held a mega-issue discussion of the subject in November 2010 and carefully studied a resolution on the impact of existing and emerging models of dental education, as directed by the 2010 House of Delegates.

This year’s House will feature “The Dentist in 2030: Demographics, Changes in Dental Education and Our Ability to Influence Developments in our Profession” as its annual mega-issue discussion.

Workshops on new dental education programs and related issues took place at the ADEA Council of Deans meeting (November 2010); the ADEA 2011 annual session; the American Association of Dental Boards 2011 mid-year meeting; and the 2011 ADA President-Elect’s Conference.

Constituent dental societies are taking a watchful approach with the new schools. Some of their members have voiced concerns, but during opening ceremonies at new schools in Illinois and North Carolina this fall, constituent society representatives will be on hand to welcome students to the profession.

According to experts in higher education, the recent growth in dental education programs is happening primarily for three reasons: dentistry continues to be an attractive profession with considerable interest among young people; there is a perceived need to have more dentists to provide oral health care and offset the anticipated surge in retiring dentists; and many of the universities starting new schools are in an academic health center growth phase and desire to have dentistry as part of their program to provide students with interprofessional learning experiences.

But the expansion of dental education may come at a price for many young dentists saddled with increasing levels of educational debt, and the soaring costs of dental education show no signs of abating.

Six of the eight schools that have opened between 1997-2011 are private schools, and at least two others in the works for 2012-13 also are private. With limited or no state subsidies, these programs are more dependent on student tuition and fees. According to the 2008-2009 ADA Health Policy Resources Center Survey of Dental Education, student tuition and fees comprised 18 percent of public dental school revenue on average. At private dental schools, tuition and fees account for 51 percent of revenue.

Average costs for students at private and public schools have risen dramatically over the last 10 years—68 percent for private schools and 104 percent for public schools.

Starting a new dental education program is a costly endeavor for sponsoring institutions. That’s because dental schools are providing clinical education—including preclinical simulation and training along with direct patient care—within clinical operations maintained by the dental school, said Dr. Richard Valachovic, executive director of the American Dental Education Association.

“This is very expensive. Medical students, on the other hand, have basic and clinical science lectures in the medical school, but essentially all of their clinical education and training occurs in clinical operations that are not financial liabilities for the medical school, such as hospitals and non-university based clinics,” said Dr. Valachovic.

Some university administrators say they invested heavily to bring dental education on board, but they believe they can keep costs down by training students in basic sciences using resources that exist within their academic health centers and getting them out into community sites for patient care as soon as they can. For Midwestern University, which has dental schools in Glendale, Ariz., and Downers Grove, Ill., having dentistry as part of its health profession offerings simply outweighed the costs.

“Why did we do it? It’s very expensive to start up and maintain, but for Midwestern, it’s part of our mission,” said Kathleen Goeppinger, Ph.D., president and CEO of Midwestern University. “We are solely a health care university and do not offer any degrees that aren’t related to health care. We have to look at the driving needs of society in starting any new college.”

At the University of New England, the largest health care workforce provider in the state of Maine, establishing a new dental school has been easier with state support. “When we went to the legislature and said we wanted to open a college of pharmacy, they said that’s nice but what we really need is a dental school,” said Danielle Ripich, Ph.D., president of UNE, which is on track to open its new school in 2013.

“We’ve had tremendous support. For example, we just received $3.5 million in state bond monies to help establish a teaching clinic at the dental school,” said Dr. Ripich. “We believe in the new medical model where everybody will be teaming up to deliver the best, most effective care. We had all of the health professions except dentistry. That was the jewel in the crown.”

But for other universities, the cost of a dental education program is the only consideration. With budget cutbacks for education and health care at the state and national level, Dr. Valachovic doesn’t see many public institutions expanding or sponsoring dental schools anytime soon.

“Public dental schools are under more pressure to make up for decreases in state support by increasing tuition and fees,” he said. “The differential in the total cost of a dental education at private and public institutions is becoming less and less.”

Even so, students who graduate from private schools tend to have higher rates of educational debt. Those from public schools paid an average of $124,397 for their education while those in private schools paid $223,788, according to the 2009-10 HPRC Survey of Dental Education.

These costs may hold some troubling consequences for the profession. Dentists already are graduating with high levels of educational debt that impact a number of decisions they have to make regarding whether they pursue postdoctoral education, where they decide to practice, whether to purchase a practice or seek an associateship, and whether they can afford to provide charitable care. With more students graduating from private schools with more debt, what affect will this have on the profession?

Resolution 87-2010

Image: Dr. Brian T. Kennedy
Dr. Kennedy
“The profession is—and should be—very concerned about the levels of student indebtedness because it affects the professional opportunities that dentists have,” said Dr. Brian T. Kennedy, chair of the ADA Council on Dental Education and Licensure. In the past year, his council has taken a closer look at dental education after the 2010 House of Delegates referred a resolution to CDEL, Resolution 87-2010, which called for a “study of the impact of existing and emerging models of dental education in the interest of preserving dentistry as a learned profession while meeting the changing needs of oral health for diverse patient groups in a time of economic challenge.”

“Besides student debt, there are concerns over the commitment level to research on the part of the newer schools and how the expansion of programs will impact faculty shortages,” said Dr. Kennedy.

But it’s up to the governing board of an institution of higher education to decide to open or close a dental school. “The ADA has no role in the creation of new dental schools. A professional organization cannot control supply and demand,” said Dr. Kennedy.

The universities sponsoring new dental education programs say they are addressing the need for more dentists in their communities, but Dr. Kennedy said it remains to be seen how they will do that.

“How do we know that students are going to make a lifelong commitment to public health dentistry and practice in underserved areas for their entire careers?” he asked. “We’re talking about extremely high levels of educational debt. Regardless of where you practice, you still have to be able to service that debt.”

CDEL appointed an ad hoc committee to develop a response to Res. 87, which will be transmitted to the 2011 House of Delegates. “Any directive from the House of Delegates is taken very seriously, and we wanted to give this a fair hearing,” said Dr. Kennedy.

What the council determined is that given all of the changes occurring in dental education, a comprehensive study of education, similar to the Gies Report (first conducted in 1926), should be done in the long term. However, a collection and analysis of data on existing and new schools is the first step. The council plans to take the lead and collaborate with the ADA Health Policy Resources Center, the Survey Center and Health Policy Analysis Departments and other ADA agencies, and make the findings available on a routine basis to the profession and the House of Delegates.

“The most important thing is that we agree there needs to be a study, but we need more evidence about the roles of different types of dental schools and the future of dental education, which affects the profession because education is the basis of our profession,” said Dr. Kennedy. “This is a complex issue, there are multiple variables and it’s worthy of a new study.”

Florida
Florida is an example of a state that has the potential to see a rapid expansion of its dental education programs.

Established in 1972, the University of Florida College of Dentistry in Gainesville is the state’s only publicly funded dental school and was in fact the state’s only dental school until 1997, when the private institution Nova Southeastern University College of Dental Medicine (in Fort Lauderdale-Davie) opened its doors.

Now, the Lake Erie College of Medicine School of Dental Medicine (known as LECOM), in Bradenton, Fla., near Tampa is on track to open a dental school in 2012. The college has named a dean, Dr. Robert Hirsch, and has initial accreditation from the Commission on Dental Accreditation, a classification granted to any dental, advanced dental or allied dental education program in the planning and early stages of development, or an intermediate stage of program implementation and not fully operational.

In addition, three other public universities—the University of Central Florida (Orlando), Florida Atlantic University (Boca Raton) and Florida A&M University (Tallahassee)—have initiated discussions about starting new dental schools. Though they are in the early planning stages, one—the University of Central Florida—has announced that it will function as a private program entirely funded by student tuition.

In 2010, the state Department of Health issued its 2010 Oral Health Workforce Report that showed there are enough dentists entering the profession through 2050 to offset any attrition due to retiring dentists. However, most dentists seem to congregate in South Florida, leaving rural counties in Central Florida and the Panhandle with few dentists.

Will having six dental schools in Florida lead to a more equitable distribution of dentists?

“Florida is plagued by an embarrassingly low Medicaid reimbursement rate and no commitment from the state to incentivize dentists to open practices in the underserved areas,” said Dr. Cesar Sabates, president of the Florida Dental Association. “It is precisely these areas of resource allocation we recommend to the state in lieu of the expense associated with a new dental school whose graduates are not likely to locate in these underserved, economically depressed areas.”

Dr. Sabates said that Florida has one of the lowest Medicaid reimbursement rates in the nation—providing dentists only 25 cents for every $1 performed. Instead of new schools, FDA supports financial incentives such as increasing Medicaid reimbursement and revitalizing the state’s student loan repayment program. They’d also like to see the Board of Governors, the agency that oversees the state’s 11 public universities, consider an expansion of the University of Florida College of Dentistry.

Image: Dr. Teresa A. Dolan
Dr. Dolan
“What we’ll be proposing is a modest class size expansion,” said Dr. Teresa A. Dolan, professor and dean of the University of Florida College of Dentistry and a member of the ADA Council on Dental Education and Licensure, who submitted a proposal to the Board of Governors Aug. 12 that included expanding the College of Dentistry’s clinical presence outside of Gainesville.

“We currently have 80 enrolled a year,” she said, “and we’d like to expand that to 100, or a total of 400 students. It’s more cost effective for an existing and well-established and successful dental school to expand than starting up new schools, particularly with the challenges facing the economy.”

R.E. LeMon, Ph.D., associate vice chancellor of academic and student affairs of the Florida Board of Governors, issued a report in March saying that the University of Florida’s ability to compete for external grants and its “robust faculty practice” are the result of long-term strategy and investment.

“Due to the magnitude of the investment required to create and then maintain new dental schools, they must be demonstrable ‘first choice’ solutions to the challenge of providing dental health care where it is most needed before they can be considered the most viable options for addressing the core of Florida’s multi-layered problem,” wrote Dr. LeMon.

It’s up to the Board of Governors to determine whether creating or expanding dental schools is an effective or fiscally sound way of improving dental health in Florida in areas where it is needed most. The agency revisits the issue this month.

Demand for dental careers
The applicant pool for dental education programs indicates that dentistry continues to hold great appeal for young people. Nationally, applications peaked in 1975 and decreased in the 1980-90s to the point where there were about 1.2 applicants for each available position. The number of applicants rose again—to 13,742—in 2007-2008. That year, there were 2.9 applicants for every available position in dental school.

In a recent presentation to the Florida Board of Governors, Dr. Dolan said that applications “are cyclical, and are related to the economic attractiveness of dentistry as a career and the perceived rate of return on investment for dental education. In general, this rate of return is favorable compared to college graduates, and dental careers are more financially rewarding than most other advanced degree professionals.”

There are indications that dental education programs are still attracting students who are highly qualified. Dental Admission Test scores have risen steadily since 1989-90, the first year entering class in which students took the DAT on the 30-point scale. Academic average scores on the DAT reached an all-time high of 19.4 in 2007-2008, and the perceptual ability test reached an all-time high of 19.3 in 2009-10.

Closures 1985-96 & openings 1997-2011
As the number of applicants declined in the 1980s, there was a perceived diminished need for dentists nationwide. Seven dental schools closed between 1985-96, all in private universities.

Image: Dr. Richard Valachovic
Dr. Valachovic
“One of the factors that influenced the decision to close some of the private dental schools in the 1980s and 1990s was that the dental school’s mission was not consistent with that of the parent institution,” said Dr. Valachovic of ADEA. “For example, many parent institutions were developing increasing focus on research and scholarship, and the dental schools were not able to respond to those initiatives as quickly as some other programs in those universities.”

Dental schools at Oral Roberts University, Emory University, Georgetown University, Fairleigh Dickinson University, Washington University, Loyola University of Chicago and Northwestern University were shuttered in this era.

But within a few years, the landscape changed, and private institutions again took an interest in dental education programs. Another common characteristic is that most of the new dental education programs are sponsored by universities that also sponsor colleges of osteopathic medicine.

One reason for this is that most of these universities have newly formed academic health centers and a dental school is an essential component, said Dr. Valachovic. The universities also see a demand for dentistry based on the number of students applying for dental school.

“Universities exist to provide education,” he added. “There clearly are many highly qualified applicants who are being denied an opportunity to become a dentist because there are not enough first-year slots. These universities create opportunities for Americans who seek to improve their lives and their families’ lives by joining a highly regarded profession.”

All of the new dental schools cite meeting the access needs of their communities as a part of their programs. Said Dr. Valachovic, “Many of these universities have missions to serve the communities and states in which they exist. Many of them see the access to dental care challenge and believe that they are helping respond to that challenge by educating more dentists.”

According to the American Association of Colleges of Osteopathic Medicine, osteopathic physicians—known as a D.O.—are licensed to practice the full scope of medicine in all 50 states. They practice a holistic approach to patient care in a variety of settings and constitute 7 percent of all U.S. physicians. Nearly 1 in 5 medical students in the U.S. today is attending an osteopathic medical school. Membership in the American Medical Association is open to physicians with doctor of medicine degrees or doctor of osteopathic medicine degrees.

There is no significant difference between a D.O. granting medical school and an M.D. granting medical school, said Dr. Valachovic. “The D.O. schools have more of a focus on primary care than M.D. schools overall,” he added. “D.O. graduates compete for the same premier residencies as M.D. graduates. All D.O. and M.D. physicians are usually licensed by the same state boards of registration in medicine.”

Images: Dr. Lex MacNeil
Dr. MacNeil
“I knew very little about osteopathic medicine when I came here from Canada two years ago, but I find the D.O. approach to be very akin to some of the things we’re trying to do in dental education with regard to interprofessional learning and practice with a primary focus on the patient,” said Dr. Lex MacNeil, dean of the Midwestern University College of Dental Medicine in Downers Grove, Ill., a suburb of Chicago. The first group of 125 students at the private, not-for-profit institution began classes in August. Though they share the same sponsoring institution, it’s a separate dental school from the Midwestern University College of Dental Medicine in Glendale, Ariz., which opened in 2008.

“Osteopathic medical programs want to fill out that health care quilt, if you will,” said Dr. MacNeil. “This university was not involved in dentistry prior to the establishment of the Arizona program. In addition to medicine, there were programs in physical therapy, pharmacy, physician assistants, podiatry, occupational therapy, etc., but dentistry was missing. Wanting dentistry to be part of all that tells me they truly understand the value of what dentistry can contribute to the entire health care team.”

As an example of what dentistry can offer other medical programs at Midwestern, Dr. MacNeil said he recently met with the dean of Midwestern’s osteopathic medicine program who was interested in collaborating on teaching and research related to ergonomics in dentistry.

“No one’s tapping into this resource,” said Dr. MacNeil. “I find the potential for collaboration and the willingness to collaborate incredibly strong in this setting.”

Research
Whether the newer dental education programs would include research as part of their program has been a matter of debate. “We need to look at more evidence to find out what impact schools with more modest research agendas have on the profession,” said Dr. Kennedy, chair of CDEL.

Building a research program doesn’t happen overnight, said Dr. Valachovic. “It takes many years and a lot of investment. Most of the dental schools that are now considered ‘research-focused’ were very committed to clinical programs until some dean with a strong research record and experience was hired,” he said.

“Just initiating research activity takes time,” said Dr. MacNeil of Midwestern Illinois, adding that the school will feature a Ph.D./D.M.D. joint degree program. “Here at Midwestern Illinois, we have an exceptional opportunity because we have a robust basic science program that supports all the health professions education programs. We have approximately 50 biomedical scientists, all of whom do research of one type or another. We just opened a new science hall, which was built with the intention that these scientists can do more research, have state-of-the-art physical space and be more attractive to granting agencies.”

Image: Dr. Jack Dillenberg
Dr. Dillenberg
“We have our niche and it’s working for us,” said Dr. Jack Dillenberg, dean of the A.T. Still University Arizona School of Dentistry and Oral Health in Mesa, Ariz., which opened its doors in 2003. He was among several deans who, along with ADEA officials addressed the ADA Board of Trustees in April, and will be a speaker at the House of Delegates’ mega-issue discussion in October.

Right now the Arizona School of Dentistry and Oral Health has several research projects in the works, including a multicenter project on lasers; another evaluating pain medications for TMD; and the use of smartphone texting for preventive dentistry and education. Students also pursue collaborative research projects with other dental schools. Dr. Dillenberg is proud that Dr. Robert Trujillo, an ASDOH student who graduated in 2011, won the 2010 ADA/DENTSPLY Student Clinician Research Program.

Research is not a major component of ASDOH’s program, he said. “For a school with a community service goal, we’re giving our students research experiences and doing research on our own. We’ve built it up over time,” said Dr. Dillenberg.

From day one, ASDOH has emphasized community service as part of its mission. “We don’t need more dentists to go to places dentists have always gone,” said Dr. Dillenberg. Half of the American Indian dentists who were accepted to dental school last year are at ASDOH, and all students graduate with a dental degree and a certificate in public health.

Is ASDOH’s program creating dentists who will practice in areas of need? Dr. Dillenberg thinks so.

“We are producing dentists to work in underserved communities and it’s in demand. Last year, we received over 3,200 applications for 76 positions,” he said. “In our most recent graduating class, 38 of 59 went into residencies, either advanced education in general dentistry or a specialty program. Seventeen went into some form of practice. Of that 17, 65 percent went into some sort of service, either community health service or the military. Over five years of the graduates we have had, 36 percent went into some sort of community service or the military.”

A.T. Still University, based in Kirksville, Mo., is now planning to open “distant campus sites” for dentistry in Kirksville (in 2013) and San Diego (2013 or 2014). Dr. Wayne Cottam has been appointed vice dean of ASDOH-Missouri. He reports to Dr. Dillenberg.

ATSU’s vision for ASDOH-Missouri is for students to spend the first two years on campus in Kirksville and then split up in their third and fourth years in rotations at four community health centers in Missouri.

Accreditation
So far, all eight of the new schools that have opened since 1997 have either been approved by the Commission on Dental Accreditation with no reporting requirements or have initial accreditation. LECOM in Florida, which plans to open in 2012, has also received initial accreditation. All sponsoring universities are also accredited by regional accrediting agencies.

According to CODA, accreditation standards are routinely reviewed and revised to ensure that dental education programs are preparing competent practitioners who are ready for unsupervised practice and to meet the oral health needs of the public. Dental schools invest a considerable amount of resources into becoming accredited and undergo a rigorous review that applies to the sponsoring institution as well as the school itself.

Image: Dr. Donald R. Joondeph
Dr. Joondeph
“There are significant start-up costs and ongoing costs involved with opening a dental school; the most significant being facilities, equipment and hiring personnel,” said Dr. Donald R. Joondeph, chair of the Commission on Dental Accreditation.

Dr. Joondeph explained how the process works. New schools submit an application for initial accreditation in addition to addressing the accreditation standards, then CODA conducts site visits of the new schools three times before the first enrolled class graduates. The first occurs prior to the enrollment of any students, the second as the first enrolled class completes their second year and the third takes place right before the graduation of the first class.

The purpose of the first site visit is to give CODA access to the program for a study of several critical issues.

Said Dr. Joondeph: “Before students are even enrolled, site visitors take a close look at the financial underpinnings of the school; the fully developed curriculum, including class schedules, quizzes and tests for the first two years of the program; the school’s plan for attracting and retaining faculty; and an analysis of the potential patient population that would be treated in the clinics.”

With a team of seven peer reviewers who have expertise in curriculum, clinical, financial and basic sciences, the site visits last three days.

CODA’s Predoctoral Dental Education Standards were strengthened in 2010, following a three-year revision process that included hearings during the 2008 and 2009 ADA Annual Sessions. The new standards become fully implemented in 2013. Significant changes include:

(1) A new standard on diversity (Standard 1-4).

  • references to diversity threaded throughout the standards (Standards 1-3; 2-16; 2-25; 4-4);
  • additions to the preface which refer to diversity as one of the foundations of the standards;
  • new definitions of diversity in the preface.

(2) Weaving of evidence-based dentistry and research throughout the standards (Standards 1-1, 1-2, 1-6, 2-20, 2-21, 4-6, 5-2, 5-3, 6-1, 6-2, 6-3) and additions to the preface which refer to evidence-based dentistry and research.

  • the addition of a new research standard (6-3).

(3) Strengthening of clinical general dentistry Standard 2-23 by requiring competency assessment for:

  • screening and risk assessment for oral cancer;
  • referrals to specialists for complex treatment;
  • managing the dental laboratory process;
  • fixed, removable and implant restorations;
  • osseous disorders.

(4) Consistent format of must statements to reflect that an assessment of a competency is required to demonstrate compliance with the standard.

(5) Clarification of the term “special needs patient” to include the cognitively impaired and the vulnerable elderly.

(6) New and expanded list of definitions to ensure consistency of terminology and compliance.

(7) Modifications to the preface to provide a solid rationale and foundation for the standards.