A dental education leads to one of the most rewarding careers a young person can choose. The cost, however, is increasingly out of reach for many and unless we reimagine how we run the business of our dental schools, it may become so expensive that it will lead to a chronic shortage of dentists in the future.
The root of the problem is how dental educators use tuition as one of three main sources of funding for dental schools. An upcoming paper by Allan Formicola and Lisa Tedesco, “The 21st Century Study: Time for Dental Education to Advance” highlights the alarming trend of increasing dental school tuition that has led us past the brink and into the midst of crisis.
A Decline in Government Funding
Since the start of the 21st Century, dental schools have mainly relied on funding from three sources: tuition, patient care revenue, and government support. This approach became a problem 20 years ago when government support for public and private schools began to decline significantly. From 2004 to 2012, state and local government support of dental schools decreased by 17 percent.
Many schools reacted to this decline in funding by increasing tuition dramatically. By 2022, government funding for dental schools overall had declined to 10%. (See: Table 1.) With one source of funding reduced, we have no choice but to reimagine how we fund dental education. Tuition has increased to a staggering percentage of the operating budget of dental schools in the past decade, reaching nearly 70% in some cases.
What is clear is that we cannot simply continue to place the burden on future students. Doing so will create a barrier to dental education that will deprive most aspirants of the ability to pursue a rewarding career. The result will be that elevated tuition costs will reduce access to care. Short of establishing new government support to offset the cost of the care we deliver, we must seek other remedies.
Ways to Shift the Burden
There are two other ways that we might be able to shift the burden away from our learners. First, by increasing clinic efficiency, we can generate more revenue. The present common dental model is to have faculty members who spend one day in clinic with patients, two or three days working directly with learners, and a day in the lab or otherwise engaged in research. While educational specialists are critical there is no margin generated to offset the educational or research missions and having them as the majority of the faculty is probably unsustainable.
Patient care revenue had been essentially unchanged for over a decade, it was 20.1% in 2012 and 20.2% in 2022. Aggressively working to increase clinic revenue can improve the financial health of our schools while removing some of the burden from the students. One way to do this might be adopting a different model where we add more oral healthcare specialists to our faculty rather than relying on generalists. A larger number of talented clinicians focused on patient care is another way to generate more clinic revenue. Let’s consider adding full-time clinical faculty, who see patients 40 or more hours a week like many of the medical disciplines at our academic health centers.
A second way that we can reduce the debt burden on students is through greater efficiency of our curriculum. Rather than maintain the enormous clinics that in many institutions are only in use limited daytime hours five days a week, we could prioritize early clinical activities for inside our schools and send the students into the community for expanded practical education.
Students benefit from working in outside clinics. One weakness in university-centered dental education is that the focus is often on the student, rather than the patient. Community-based dental education (CBDE) is a proven way to shift this perspective.
One advantage is that seeing more patients in a day builds the empathetic connections needed to be a successful clinician. Additionally, student confidence is bolstered by learning in a community-based setting. Dental students who learn procedures by working on typodonts or virtual reality often feel underprepared to work on actual patients. Their skills can be built in our clinics and their confidence then enhanced by spending time in CBDE rotations. Student's self-perceived skill level increases as they perform procedures on real patients.
An added benefit of CBDE is that students who work in the community have stated that they are more likely to accept Medicaid-eligible patients in their future practices. They were also more likely to consider the needs of the patients in their own communities when setting up practice for themselves. This would counter the current trend where students are so burdened by debt upon graduation that they have very little flexibility in their options. Overloading the students with debt drives them toward only the most profitable career paths. Even if they entered dental school with the desire to serve their communities, the reality of decades of loan repayments upon graduation will often change their minds.
Inaction is Not an Option
There is little downside to adopting these measures. Increasing dental schools’ clinical revenue is something that we must do to sustain our operations. Putting the students into the community allows us to provide them with higher quality practical education that benefits their skills and confidence.
Failing to address this problem now is not an option. If the current trends continue, the burden on students will become so great that it will be unsustainable. If we do nothing, the result will be that we will fail our students and without providing a realistic pathway into the profession, we will fail society.
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TABLE 1.
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Fiscal Year
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Tuition & Fees
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State & Local Support
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Patient Care Revenue
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2012
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32.9%
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12.5%
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20.1%
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2013
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34.2%
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11.1%
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19.8%
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2014
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37.7%
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11.2%
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20.5%
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2015
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39.2%
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12.0%
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21.0%
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2016
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40.6%
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11.5%
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21.3%
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2017
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40.4%
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11.0%
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21.2%
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2018
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41.1%
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10.4%
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21.0%
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2019
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42.3%
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10.3%
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21.5%
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2020
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45.3%
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10.6%
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17.4%
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2021
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44.8%
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9.9%
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18.6%
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2022
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43.1%
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10.2%
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20.2%
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Public and Private Dental Schools Revenue Source Percentages, 2012–22
Source: American Dental Association, Health Policy Institute, Commission on Dental Accreditation. Survey of Dental Education, Report 3. Finances: Table 1. Fiscal Statistics for All Dental Schools, 2022–23.
