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Personnel planning for the next generation of orthodontic patients
SPECIAL ARTICLE
Personnel planning for the next generation of orthodontic patients H. Barry Waldman, BA, DDS, MPH, PhD ~
Stony Brook, N.Y. Projections by the Bureau of the Census indicate that there will be an additional 10.4 million youngsters between 5 and 19 years of age living in this country by the year 2000. Estimates are developed for each state and region of the needed numbers of orthodontists to maintain current practitioner levels. The availability of needed practitioners is considered in terms of the number of graduates from orthodontic training programs. A major shortfall is projected in the number of training program graduates needed to maintain current orthodontist-to-population ratios in 2020. (Am J Orthod Dentofac Orthop 1996;110:520-6.)
T h e US Bureau of the Census projects that between 1993 and 2020 there will be an increase of 10.4 million persons 5 to 19 years of age (a 19.2% increase).* However, these changes will not be uniform throughout the country. In four states (Iowa, Ohio, Pennsylvania, and West Virginia), there will be decreases in the number of youngsters. By contrast, there will be an increase of 1.1 million youngsters in Texas and 3.5 million youngsters in California (Table I). The variations in the changing numbers of youngsters will be a component of the overall changes that the Bureau of the Census projects for the general population. For example, during the next two and a half decades, the population growth in Florida, Texas, and California will far surpass the numerical growth in each of the other s t a t e s increasing by 5.7, 7.6, and 16.6 million residents, respectively. In addition, the population changes will vary by race and Hispanic origin (the latter may be of any race). Between 1993 and 2020 California will have the largest numeric increases of white, AsianAmerican, and Hispanic populations. Florida will have the largest numeric increases of AfricanAmericans. Arizona will have the largest increaseof American Indians. By 2020, California will have largest white, Asian-American, and Hispanic popu*Throughout this presentation, the term youngsters will be used to refer to persons in this age group. Although many older persons are treated by orthodontists, the most significant numbers of patients are 5 to 19 years of age. For purposes of developing manpower projection requirements, emphasis will be placed on this age cohort. aProfessor and Chairman, Department of Dental Health, School of Dental Medicine, State University of New York at Stony Brook. Reprint requests to: Dr. H. Barry Waldman, Department of Dental Health, School of Dental Medicine, State University of New York at Stony Brook, Stony Brook, NY 11794-0715, Copyright © 1996 by the American Association of Orthodontists. 0889-5406/96/$5.00 + 0 8/1/62008
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lations. New York will have the largest AfricanAmerican population and Arizona will have the largest American Indian population? The overall increases in the general and youngster populations will be occurring at a time of marked decreases in the numbers of dentists, which will result in the lowest ratios of dentists-to-population that have been recorded throughout the twentieth century. 2 Providing orthodontic services for the evolving distribution and overall increases in the numbers of youngsters (particularly the increasing numbers of minority youngster for whom there have been limitations in the delivery of needed dental services) 3"4 requires a review of the projections of the future availability of orthodontic personnel. An earlier retrospective presentation in the
American Journal of Orthodontics and Dentofacial Orthopedics considered the changing number and distribution of orthodontists in 1982, 1987, and 1991. 5 The following presentation will relate the Bureau of the Census population projections to available data from the American Dental Association on the numbers, age, and distribution of orthodontists in private practice. The intent will be to develop an estimate of the number of orthodontists needed to both replace the current population of practitioners and provide for the 10.4 million additional youngsters-in effect maintain the 1993 orthodontist-to-youngster ratios in each state in the year 2020. PROCEDURES AND ASSUMPTIONS
The most recent published study by the American Dental Association (ADA) on the number, age (divided into less than 40 years of age and 40 plus years), and distribution of orthodontists is for 1991.
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Table h Number of youngsters 5 to 19 years of age, by region, and state: 1993, 20201 Region and State
1993
2020 (in thousands)
New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont
2,513 613 256 1,106 228 189 120
2,645 677 256 1,129 255 200 126
132 64
Middle Atlantic New Jersey New York Pennsylvania
7,397 1,498 3,544 2,354
7,823 1,765 3,720 2,338
426 267 176 -16
South Atlantic Delaware Dist. of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia
9,055 140 88 2,529 1,489 981 1,382 784 1,282 381
11,029 167 96 3,133 1,888 1,276 1,648 910 1,571 340
1,974 27 8 604 399 295 266 126 289 -41
East South Central Alabama Kentucky Mississippi Tennessee
3,399 906 817 628 1,047
3, 711 1,073 824 641 1,170
312 167 7 13 123
East North Central Illinois Indiana Michigan Ohio Wisconsin
9,200 2,458 1,226 2,058 2,339 1,119
9,685 2,711 1,296 2,221 2,319 1,138
485 253 70 163 -20 19
West North Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota
3,991 620 566 1,000 1,120 368 145 172
4,222 594 645 1,061 1,197 388 147 191
West South Central Arkansas Louisiana Oklahoma Texas
6,438 532 1,027 720 4,159
7,866 580 1,125 818 5,342
L428 48 98 98 1,183
Mountain Armona Colorado Idaho Montana Nevada New Mexico Utah Wyoming
3, 408 848 756 279 193 274 388 549 118
4,403 1,141 922 349 220 381 531 711 147
995 293 166 70 27 107 143 162 29
Pacific Alaska California Hawaii Oregon Washington
8, 756 148 6,602 236 644 1,126
13,166 211 10,163 357 868 1,567
4,410 63 3,561 121 224 441
United States
54,158
64,551
10,393
NOTE: Totals may differ as a result of A D A data listings or rounding.
Change 1993-2020
23 27 11 6
-
231 26 79 61 77 20 2 19
521
522
Waldman
The most recent publications by the Bureau of the Census on future population changes is based on estimated populations for 1993. An estimate of orthodontist-to-youngster ratios by age for each state and region was developed using the 1991 ADA data and the 1993 Bureau of the Census data. The assumption was made that, while the orthodontist-to-youngster ratio was not ideal in any particular state, it at least could serve as a starting point for manpower planning purposes. The assumption was made that essentially all orthodontists 40 years of age and older, in 1991 will no longer be in practice in 2020, having died or having reached the age of 69 or more years, will be retired. The assumption was made that "all" orthodontists less than 40 years of age in 1991 will continue to be in practice in 2020. Thus, if we are to maintain the estimated 1993 ratios of orthodontistto-youngster, in 2020 only "replacements" would be necessary for orthodontists who were 40 years of age or more in 1991, plus any additional orthodontists needed to meet the youngster population increases (or fewer orthodontists in cases of youngster population decreases). In actuality, the assumption that all practitioners less than 40 years of age in 1991 would continue to be in practice in 2020 is counter to the reality of early part-time or full retirement and the death of practitioners at earlier ages. Thus more "replacement" orthodontists would be required. The process chosen will reflect conservative estimates of the dental personnel needs at the state and regional level to maintain the 1993 orthodontist-to-youngster ratios in 2020. (See the following section for assumptions regarding nonprivate practice orthodontists and graduates from orthodontic training programs.) CHANGING NUMBERS OF YOUNGSTERS Regional level
Between 1993 and 2020, the number of youngsters 5 to 19 years of age will increase in each region, ranging from an increase of 132,000 in the New England Region to 1.9 million in the South Atlantic Region and 4.4 million in the Pacific Region. The projected increases in the Pacific Region represents 42% of the total projected national increase (Table I). (Note: see Table I for a listing of the states in each region.)
American Journal of Orthodontics and Dentofacial Orthopedics November 1996
State level
As noted previously, in four states, there will be minor decreases in the numbers of youngsters (a combined decrease of approximately 100,000 persons). By contrast, the projected marked increases of 4.7 million youngsters in California and Texas represents more than two of every five increases (45.6%) throughout the country (Table I). NUMBER OF ORTHODONTISTS
In 1991, there were 8941 professionally active orthodontists including private practitioners (8342), educators, administrators, and researchers. 6 ORTHODONTISTS LESS THAN 40 YEARS OF AGE
The report by the ADA on the number of orthodontists provides age distribution information only for dentists in private practice. In 1991, 1964 or 23.5% of the 8342 orthodontists in private practice were less than 40 years of age-ranging from 0 in Wyoming and between 1 and 5 in each of six states (Alaska, Delaware, Montana, North Dakota, South Dakota, and Vermont) to 100 in Texas, 112 in Pennsylvania, 183 in New York, and 268 in California (Table II). For purposes of determining the numbers of "new" dentists needed at the national level to replace nonprivate practice orthodontists, it was assumed that the percent of orthodontists in nonprivate practice positions, who were less than 40 years of age, was comparable to those in private practice (23.5%). Of the 599 orthodontists not in private practice, 458 would be 40 years of age or greater. ESTIMATED ORTHODONTIST-TO-YOUNGSTER RATIOS Region level
Nationally in 1993, there were 15.4 private practice orthodontists per 100,000 youngsters, ranging from 11.3 per 100,000 youngsters in the East South Central Region and 11.8 in the West South Central Region to 19.8 per 100,000 youngsters in the Middle Atlantic Region and 22.7 in the New England Region. State level
At the state level, the ratio ranged from 8.5 orthodontists per 100,000 youngsters in Wyoming and 8.8 in Arkansas to 27.9 per 100,000 youngsters in Connecticut and 34.1 in the District of Columbia (Table II).
Waldman
American Journal of Orthodontics and Dentofacial Orthopedics Volume 110, No. 5
NUMBER OF ORTHODONTISTS NEEDED TO MAINTAIN 1993 RATIOS IN 2020
On the basis of the need to "replace" all current orthodontists 40 years of age and older and practitioners needed for the addition of 10.4 million youngsters between 1993 and 2020, 7977 "new" orthodontists would be required (6378 to "replace" current practitioners and 1599 for the added numbers of youngsters) (Tables II and III). At the regional level, the need for "new" orthodontists would be smallest in the East South Central Region (319 needed) and the West North Central Region (439 needed) and greatest in the Middle Atlantic Region (1177 needed), the South Atlantic Region (1206 needed) and the Pacific Region (1943 needed). At the state level, the greatest number of "new" orthodontists would be needed in Texas (546 needed), New York (572 needed) and California (1511 needed) (Table III). However, the need for 2629 "new" orthodontists (or 32.9% of all required practitioners) in California, New York, and Texas to maintain the 1993 ratio must not overwhelm the recognition of the need for additional orthodontists in each state and the District of Columbia. Whether the need is for 25 or less orthodontists in each of seven states and the District of Columbia, or the scores of orthodontists in the other state jurisdictions, there is a continuing need for "replacement" and additional practitioners in each jurisdiction. PRIVATE AND NONPRIVATE PRACTICE ORTHODONTISTS
At the national level, 10,651 orthodontists would be needed in 2020, including: • 9941 orthodontists in private practice. • 141 current nonprivate practice dentists less than 40 years of age. • 458 "new" orthodontists to "replace" all current nonprivate practice dentists of 40 years of age and older. • 111 "new" nonprivate practice orthodontists for the added numbers of youngsters (Table III). PROJECTING THE AVAILABILITY OF NEW ORTHODONTISTS
Between 1984 and 1993, there was a total of 2795 graduates from orthodontic training pro-
523
grams, or an average of 279.5 graduates per year. 7 During the past 20 years there have been variations in the annual numbers of graduates from orthodontic training programs-decreasing from 360 in 1974 to 256 in 1980, then increasing to 291 in 1988 and followed by fewer graduates in the 1990s (between 257 and 273). 7) Assuming that this average number of graduates is maintained between 1994 and 2020, there would be a total of 7546 graduates from orthodontic programs. However, not all orthodontic training program students are residents of the United States. Many foreign graduate dentists receive their advanced training in the United States and then return to provide services in their native country. The A D A Survey Center reports that between 1989 and 1993, 233 graduates (or 17.1% of all graduates) from orthodontics training programs were not residents of this country. 8 However, data are not available to determine the number of these graduates who remained or eventually will return to this country to practice dentistry. For purposes of determining the available manpower for the year 2020, it was assumed that foreign resident graduates from the orthodontic programs would not remain and/or eventually practice in this country. Therefore between 1994 and 2020, of the prospective 7546 graduates from the orthodontic programs, 6256 graduates would be available in the United States. However, this would be 1721 graduates less than the estimate of the number needed in 2020 to maintain the 1993 private practice orthodontist-to-youngster ratio, and 2290 graduates less than the number of orthodontists needed in 2020 for the estimate necessary to maintain the 1993 professionally active orthodontist-to-youngster ratio (Table III). FEMALE PRACTITIONERS
No discussion of orthodontist manpower projections for the next generation of youngsters could be complete without a review of the dramatic increases in the numbers of women entering the specialty and their increasing representation in orthodontic programs. For example, in the 1993-94 academic year, women represented 36.9% of the total dental school student body. 9 Between academic years 1983-84 and 1992-93 female representation in orthodontic programs increased from 16.1% to 26.2%. 1° But the findings from a recent ADA report indicate that female dentists work fewer hours per
524
Waldman
American Journal of Orthodontics and Dentofacial Orthopedics November 1996
Table II. Total number of private practice orthodontists, number less than 40 years of age in 1991, ratio per 100,000
youngsters 5 to 19 years of age and numbers needed in 2020 by region and state 1'6 1991
1993
Number under age 40
2020
Number orthodontists per 100,000 youngsters 5-19 yrs of age
Total number orthodontists needed to maintain 1993 ratio
Number of "new" orthodontists needed
Region & State
Total number
New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Middle Atlantic New Jersey New York Pennsylvania South Atlantic Delaware Dist. of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia East South Central Alabama Kentucky Mississippi Tennessee East North Central Illinois Indiana Michigan Ohio Wisconsin West North Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota West South Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington
571 169 38 260 45 39 20 1465 340 720 405 1266 17 30 356 190 182 166 91 193 41 385 98 103 54 131 1315 377 142 292 358 145 534 81 66 152 147 55 16 17 761 47 133 78 504 513 113 160 41 27 28 38 100 10 1529 20 1156 42 118 192
120 37 8 51 13 7 4 372 77 183 112 327 2 7 84 62 37 45 24 54 13 100 32 30 8 30 315 86 35 63 93 38 126 13 16 37 39 16 1 4 152 10 28 14 100 104 26 37 6 3 7 8 17 0 348 4 268 13 23 40
22. 7 27.9 14.8 23.5 19.7 20.6 16.7 19.8 22.7 20.3 17.2 13.9 12.1 34.1 14.1 12.8 18.6 12.0 11.6 15.0 10.8 11.3 10.8 12.6 8.6 12.5 14.3 15.3 11.6 14.2 15.3 12.9 13.4 13.1 11.7 15.2 13.1 14.9 11.0 9.9 11.8 8.8 12.9 10.8 12.1 15.1 13.3 21.2 14.7 14.0 10.2 9.8 18.2 8.5 17.4 13.5 17.5 17.8 18.3 17.0
600 189 38 265 50 41 21 1549 401 755 402 1533 20 32 442 241 237 198 105 236 37 419 116 104 55 146 1385 415 150 314 354 147 565 78 75 161 157 58 16 19 928 51 145 88 646 665 152 195 51 31 39 52 129 12 2291 28 1779 63 158 266
480 152 30 214 37 34 17 1177 324 572 290 1206 18 25 358 179 200 153 81 182 24 319 84 74 47 116 1070 329 115 251 261 109 439 65 59 124 118 42 15 15 776 41 117 74 546 561 126 158 45 28 32 44 112 12 1943 24 1511 50 135 226
8342
1964
15.4
9941
7977
United States
NOTE: Totals may differ due to rounding; number of orthodontists and number less than 40 years of age are as presented in the A D A publication.
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Table III. O r t h o d o n t i s t r e q u i r e m e n t s : 20201'6 Private practice orthodontists Private practice Number need to replace 40 yrs + orthodontists Number needed for additional youngsters Number orthodontists < 40 yrs SUBTOTAL Nonprivate practice Number need to replace 40 yrs + orthodontists Number needed for additional youngsters Number orthodontists < 40 yrs TOTAL REQUIRED Number of "new" orthodontists needed Number of "new" orthodontists available Additional number required to meet conservative estimate of requirements
Professionally active orthodontists
6,378 1,599 1,964" 9,941
6,378 1,599 1,964" 9,941
9,941 7,977 6,256 1,721
458 111 141" 10,651 8,546 6,256 2,290
*No replacements needed.
year treating patients than their male counterparts. About 77% of males and 48% of females indicated they spent between 1200 and 2000 hours per year treating patients. 11 No specific adjustment factor is available to modify manpower needs to compensate for the different work patterns of male and female dentists. Thus by using a straight numeric "replacement" by an increasing percent of female orthodontists in 2020 could once again understate the need for increased numbers of orthodontists. FINAL THOUGHTS
Again, it should be stated that: • The overall number of practitioners required to maintain the current ratio, is a conservative estimate based on the assumption that all orthodontists less than 40 years of age in 1991 will continue in full-time practice until 2020. • One can not assume that new orthodontists will distribute themselves in a uniform manner comparable to the distribution of current practitioners or in some manner that would be in line with the increasing numbers of youngsters that are projected by the Bureau of the Census. Although this review of dental manpower needs for the next: generation of youngsters suggests a marked increase in the need to increase the number of graduates from orthodontic training programs, it does not consider the need and/or demand for services, increasing use of services by older persons (i.e., 20 years and older), increasing
special patient populations, nor the reality that some components of orthodontic services for youngsters are being provided by pediatric and general dentists. No doubt for many current practitioners the idea of planning for the dental services for the year 2020 seems far beyond their own professional horizons. But the reality is that the increase in the number of youngsters will not happen suddenly at the end of the second decade of the next century. Rather it will take place throughout the next 25 years. Similarly the "loss" in the numbers of orthodontists 40 years of age and older will continue throughout the period. Yet changing the "production" of orthodontists is not analogous to turning a water spigot on (or off). Because of the long lead time necessary to produce graduate orthodontists, manpower planning is necessary to determine whether the combination of (1) evolving dentist-to-population ratios, (2) increasing numbers of female orthodontists, (3) evolving dental disease patterns, (4) demand for services, and (5) evolving third party payment mechanisms, warrant changes in the "production" of orthodontists to ensure adequate services in the many regions and states of our country. A final note of caution is essential in planning for future orthodontic personnel needs. In response to population and health profession projections made in the 1960s and efforts to encourage competition by increasing the numbers of health providers, the federal government provided a variety of financial incentives to increase the "production" of a wide variety of health practitioners. As a result, by 1978 there were 6301 first-year dental students in 60 dental schools in our country? But increasing the numbers of health practitioners did not produce the desired containment in health care
526
Waldman
American Journal of Orthodontics and Dentofacial Orthopedics November 1996
costs. In addition, there were continuing cries of an oversupply of health providers. Federal government support was curtailed. First-year enrollment in dental schools decreased by more than one third (to approximately 4000 students each year) and four private dental schools ceased operation. The dentist-to-population ratio that had been increasing peaked in 1987 and has started a decline that, in the first decades of the twenty-first century, will reach the lowest levels recorded since the first years of the twentieth century? Any effort to plan for the next generation of orthodontists must ensure that the 1970s-1980s "roller-coaster ride" in the production of dentists is
not repeated in planning for the orthodontic personnel
REFERENCES 1. Campbell PR. Bureau of the Census. Population projections for states, by age, sex, race, and Hispanic origin: 1993 to 2020. Current Population Reports, P25-1111. Washington, DC: Government Printing Office, 1994. 2. Waldman FIB. Marked increases in the general population and decreases in the numbers of dentists in the 21st century. Illinois Dent J 1994;63:99-102. 3. Waldman HB. More minority children and the need to stress dental care. J Dent Child 1993;60:403-7. 4. Waldman HB. Who uses the services of orthodontists? Ann Dent 1987;46:3-4. 5. Waldman HB. Changing number and distribution of orthodontists: I982-1991. Am J Orthod Dentofac Orthop 1994;105:128-34. 6. Bureau of Economic and Behavioral Research. Distribution of dentists in the United States by region and state, 1991. Chicago: American Dental Association, 1992. 7. 1974/75 through 1993/94 annual report on advanced dental education. Chicago: American Dental Association, 1975 through 1994. 8. Survey Center. Survey of advanced dentistry, summary sheet. Chicago: American Dental Association, 1994. 9. 1978/79, 1993/94 annual report on dental education. Chicago: American Dental Association, 1979; 1994. 10. DES data update. Chicago: American Dental Association, 1993. 11. Council on Dental Practice. A comparative study of male and female dental practice patterns. Chicago: American Dental Association, 1989.
needed for the next generation of patients!
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Personnel planning for the next generation of orthodontic patients H. Barry Waldman, BA, DDS, MPH, PhD ~
Stony Brook, N.Y. Projections by the Bureau of the Census indicate that there will be an additional 10.4 million youngsters between 5 and 19 years of age living in this country by the year 2000. Estimates are developed for each state and region of the needed numbers of orthodontists to maintain current practitioner levels. The availability of needed practitioners is considered in terms of the number of graduates from orthodontic training programs. A major shortfall is projected in the number of training program graduates needed to maintain current orthodontist-to-population ratios in 2020. (Am J Orthod Dentofac Orthop 1996;110:520-6.)
T h e US Bureau of the Census projects that between 1993 and 2020 there will be an increase of 10.4 million persons 5 to 19 years of age (a 19.2% increase).* However, these changes will not be uniform throughout the country. In four states (Iowa, Ohio, Pennsylvania, and West Virginia), there will be decreases in the number of youngsters. By contrast, there will be an increase of 1.1 million youngsters in Texas and 3.5 million youngsters in California (Table I). The variations in the changing numbers of youngsters will be a component of the overall changes that the Bureau of the Census projects for the general population. For example, during the next two and a half decades, the population growth in Florida, Texas, and California will far surpass the numerical growth in each of the other s t a t e s increasing by 5.7, 7.6, and 16.6 million residents, respectively. In addition, the population changes will vary by race and Hispanic origin (the latter may be of any race). Between 1993 and 2020 California will have the largest numeric increases of white, AsianAmerican, and Hispanic populations. Florida will have the largest numeric increases of AfricanAmericans. Arizona will have the largest increaseof American Indians. By 2020, California will have largest white, Asian-American, and Hispanic popu*Throughout this presentation, the term youngsters will be used to refer to persons in this age group. Although many older persons are treated by orthodontists, the most significant numbers of patients are 5 to 19 years of age. For purposes of developing manpower projection requirements, emphasis will be placed on this age cohort. aProfessor and Chairman, Department of Dental Health, School of Dental Medicine, State University of New York at Stony Brook. Reprint requests to: Dr. H. Barry Waldman, Department of Dental Health, School of Dental Medicine, State University of New York at Stony Brook, Stony Brook, NY 11794-0715, Copyright © 1996 by the American Association of Orthodontists. 0889-5406/96/$5.00 + 0 8/1/62008
520
lations. New York will have the largest AfricanAmerican population and Arizona will have the largest American Indian population? The overall increases in the general and youngster populations will be occurring at a time of marked decreases in the numbers of dentists, which will result in the lowest ratios of dentists-to-population that have been recorded throughout the twentieth century. 2 Providing orthodontic services for the evolving distribution and overall increases in the numbers of youngsters (particularly the increasing numbers of minority youngster for whom there have been limitations in the delivery of needed dental services) 3"4 requires a review of the projections of the future availability of orthodontic personnel. An earlier retrospective presentation in the
American Journal of Orthodontics and Dentofacial Orthopedics considered the changing number and distribution of orthodontists in 1982, 1987, and 1991. 5 The following presentation will relate the Bureau of the Census population projections to available data from the American Dental Association on the numbers, age, and distribution of orthodontists in private practice. The intent will be to develop an estimate of the number of orthodontists needed to both replace the current population of practitioners and provide for the 10.4 million additional youngsters-in effect maintain the 1993 orthodontist-to-youngster ratios in each state in the year 2020. PROCEDURES AND ASSUMPTIONS
The most recent published study by the American Dental Association (ADA) on the number, age (divided into less than 40 years of age and 40 plus years), and distribution of orthodontists is for 1991.
American Journal of Orthodontics and Dentofacial Orthopedics Volume 110, No. 5
Waldman
Table h Number of youngsters 5 to 19 years of age, by region, and state: 1993, 20201 Region and State
1993
2020 (in thousands)
New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont
2,513 613 256 1,106 228 189 120
2,645 677 256 1,129 255 200 126
132 64
Middle Atlantic New Jersey New York Pennsylvania
7,397 1,498 3,544 2,354
7,823 1,765 3,720 2,338
426 267 176 -16
South Atlantic Delaware Dist. of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia
9,055 140 88 2,529 1,489 981 1,382 784 1,282 381
11,029 167 96 3,133 1,888 1,276 1,648 910 1,571 340
1,974 27 8 604 399 295 266 126 289 -41
East South Central Alabama Kentucky Mississippi Tennessee
3,399 906 817 628 1,047
3, 711 1,073 824 641 1,170
312 167 7 13 123
East North Central Illinois Indiana Michigan Ohio Wisconsin
9,200 2,458 1,226 2,058 2,339 1,119
9,685 2,711 1,296 2,221 2,319 1,138
485 253 70 163 -20 19
West North Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota
3,991 620 566 1,000 1,120 368 145 172
4,222 594 645 1,061 1,197 388 147 191
West South Central Arkansas Louisiana Oklahoma Texas
6,438 532 1,027 720 4,159
7,866 580 1,125 818 5,342
L428 48 98 98 1,183
Mountain Armona Colorado Idaho Montana Nevada New Mexico Utah Wyoming
3, 408 848 756 279 193 274 388 549 118
4,403 1,141 922 349 220 381 531 711 147
995 293 166 70 27 107 143 162 29
Pacific Alaska California Hawaii Oregon Washington
8, 756 148 6,602 236 644 1,126
13,166 211 10,163 357 868 1,567
4,410 63 3,561 121 224 441
United States
54,158
64,551
10,393
NOTE: Totals may differ as a result of A D A data listings or rounding.
Change 1993-2020
23 27 11 6
-
231 26 79 61 77 20 2 19
521
522
Waldman
The most recent publications by the Bureau of the Census on future population changes is based on estimated populations for 1993. An estimate of orthodontist-to-youngster ratios by age for each state and region was developed using the 1991 ADA data and the 1993 Bureau of the Census data. The assumption was made that, while the orthodontist-to-youngster ratio was not ideal in any particular state, it at least could serve as a starting point for manpower planning purposes. The assumption was made that essentially all orthodontists 40 years of age and older, in 1991 will no longer be in practice in 2020, having died or having reached the age of 69 or more years, will be retired. The assumption was made that "all" orthodontists less than 40 years of age in 1991 will continue to be in practice in 2020. Thus, if we are to maintain the estimated 1993 ratios of orthodontistto-youngster, in 2020 only "replacements" would be necessary for orthodontists who were 40 years of age or more in 1991, plus any additional orthodontists needed to meet the youngster population increases (or fewer orthodontists in cases of youngster population decreases). In actuality, the assumption that all practitioners less than 40 years of age in 1991 would continue to be in practice in 2020 is counter to the reality of early part-time or full retirement and the death of practitioners at earlier ages. Thus more "replacement" orthodontists would be required. The process chosen will reflect conservative estimates of the dental personnel needs at the state and regional level to maintain the 1993 orthodontist-to-youngster ratios in 2020. (See the following section for assumptions regarding nonprivate practice orthodontists and graduates from orthodontic training programs.) CHANGING NUMBERS OF YOUNGSTERS Regional level
Between 1993 and 2020, the number of youngsters 5 to 19 years of age will increase in each region, ranging from an increase of 132,000 in the New England Region to 1.9 million in the South Atlantic Region and 4.4 million in the Pacific Region. The projected increases in the Pacific Region represents 42% of the total projected national increase (Table I). (Note: see Table I for a listing of the states in each region.)
American Journal of Orthodontics and Dentofacial Orthopedics November 1996
State level
As noted previously, in four states, there will be minor decreases in the numbers of youngsters (a combined decrease of approximately 100,000 persons). By contrast, the projected marked increases of 4.7 million youngsters in California and Texas represents more than two of every five increases (45.6%) throughout the country (Table I). NUMBER OF ORTHODONTISTS
In 1991, there were 8941 professionally active orthodontists including private practitioners (8342), educators, administrators, and researchers. 6 ORTHODONTISTS LESS THAN 40 YEARS OF AGE
The report by the ADA on the number of orthodontists provides age distribution information only for dentists in private practice. In 1991, 1964 or 23.5% of the 8342 orthodontists in private practice were less than 40 years of age-ranging from 0 in Wyoming and between 1 and 5 in each of six states (Alaska, Delaware, Montana, North Dakota, South Dakota, and Vermont) to 100 in Texas, 112 in Pennsylvania, 183 in New York, and 268 in California (Table II). For purposes of determining the numbers of "new" dentists needed at the national level to replace nonprivate practice orthodontists, it was assumed that the percent of orthodontists in nonprivate practice positions, who were less than 40 years of age, was comparable to those in private practice (23.5%). Of the 599 orthodontists not in private practice, 458 would be 40 years of age or greater. ESTIMATED ORTHODONTIST-TO-YOUNGSTER RATIOS Region level
Nationally in 1993, there were 15.4 private practice orthodontists per 100,000 youngsters, ranging from 11.3 per 100,000 youngsters in the East South Central Region and 11.8 in the West South Central Region to 19.8 per 100,000 youngsters in the Middle Atlantic Region and 22.7 in the New England Region. State level
At the state level, the ratio ranged from 8.5 orthodontists per 100,000 youngsters in Wyoming and 8.8 in Arkansas to 27.9 per 100,000 youngsters in Connecticut and 34.1 in the District of Columbia (Table II).
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NUMBER OF ORTHODONTISTS NEEDED TO MAINTAIN 1993 RATIOS IN 2020
On the basis of the need to "replace" all current orthodontists 40 years of age and older and practitioners needed for the addition of 10.4 million youngsters between 1993 and 2020, 7977 "new" orthodontists would be required (6378 to "replace" current practitioners and 1599 for the added numbers of youngsters) (Tables II and III). At the regional level, the need for "new" orthodontists would be smallest in the East South Central Region (319 needed) and the West North Central Region (439 needed) and greatest in the Middle Atlantic Region (1177 needed), the South Atlantic Region (1206 needed) and the Pacific Region (1943 needed). At the state level, the greatest number of "new" orthodontists would be needed in Texas (546 needed), New York (572 needed) and California (1511 needed) (Table III). However, the need for 2629 "new" orthodontists (or 32.9% of all required practitioners) in California, New York, and Texas to maintain the 1993 ratio must not overwhelm the recognition of the need for additional orthodontists in each state and the District of Columbia. Whether the need is for 25 or less orthodontists in each of seven states and the District of Columbia, or the scores of orthodontists in the other state jurisdictions, there is a continuing need for "replacement" and additional practitioners in each jurisdiction. PRIVATE AND NONPRIVATE PRACTICE ORTHODONTISTS
At the national level, 10,651 orthodontists would be needed in 2020, including: • 9941 orthodontists in private practice. • 141 current nonprivate practice dentists less than 40 years of age. • 458 "new" orthodontists to "replace" all current nonprivate practice dentists of 40 years of age and older. • 111 "new" nonprivate practice orthodontists for the added numbers of youngsters (Table III). PROJECTING THE AVAILABILITY OF NEW ORTHODONTISTS
Between 1984 and 1993, there was a total of 2795 graduates from orthodontic training pro-
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grams, or an average of 279.5 graduates per year. 7 During the past 20 years there have been variations in the annual numbers of graduates from orthodontic training programs-decreasing from 360 in 1974 to 256 in 1980, then increasing to 291 in 1988 and followed by fewer graduates in the 1990s (between 257 and 273). 7) Assuming that this average number of graduates is maintained between 1994 and 2020, there would be a total of 7546 graduates from orthodontic programs. However, not all orthodontic training program students are residents of the United States. Many foreign graduate dentists receive their advanced training in the United States and then return to provide services in their native country. The A D A Survey Center reports that between 1989 and 1993, 233 graduates (or 17.1% of all graduates) from orthodontics training programs were not residents of this country. 8 However, data are not available to determine the number of these graduates who remained or eventually will return to this country to practice dentistry. For purposes of determining the available manpower for the year 2020, it was assumed that foreign resident graduates from the orthodontic programs would not remain and/or eventually practice in this country. Therefore between 1994 and 2020, of the prospective 7546 graduates from the orthodontic programs, 6256 graduates would be available in the United States. However, this would be 1721 graduates less than the estimate of the number needed in 2020 to maintain the 1993 private practice orthodontist-to-youngster ratio, and 2290 graduates less than the number of orthodontists needed in 2020 for the estimate necessary to maintain the 1993 professionally active orthodontist-to-youngster ratio (Table III). FEMALE PRACTITIONERS
No discussion of orthodontist manpower projections for the next generation of youngsters could be complete without a review of the dramatic increases in the numbers of women entering the specialty and their increasing representation in orthodontic programs. For example, in the 1993-94 academic year, women represented 36.9% of the total dental school student body. 9 Between academic years 1983-84 and 1992-93 female representation in orthodontic programs increased from 16.1% to 26.2%. 1° But the findings from a recent ADA report indicate that female dentists work fewer hours per
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Table II. Total number of private practice orthodontists, number less than 40 years of age in 1991, ratio per 100,000
youngsters 5 to 19 years of age and numbers needed in 2020 by region and state 1'6 1991
1993
Number under age 40
2020
Number orthodontists per 100,000 youngsters 5-19 yrs of age
Total number orthodontists needed to maintain 1993 ratio
Number of "new" orthodontists needed
Region & State
Total number
New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Middle Atlantic New Jersey New York Pennsylvania South Atlantic Delaware Dist. of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia East South Central Alabama Kentucky Mississippi Tennessee East North Central Illinois Indiana Michigan Ohio Wisconsin West North Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota West South Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington
571 169 38 260 45 39 20 1465 340 720 405 1266 17 30 356 190 182 166 91 193 41 385 98 103 54 131 1315 377 142 292 358 145 534 81 66 152 147 55 16 17 761 47 133 78 504 513 113 160 41 27 28 38 100 10 1529 20 1156 42 118 192
120 37 8 51 13 7 4 372 77 183 112 327 2 7 84 62 37 45 24 54 13 100 32 30 8 30 315 86 35 63 93 38 126 13 16 37 39 16 1 4 152 10 28 14 100 104 26 37 6 3 7 8 17 0 348 4 268 13 23 40
22. 7 27.9 14.8 23.5 19.7 20.6 16.7 19.8 22.7 20.3 17.2 13.9 12.1 34.1 14.1 12.8 18.6 12.0 11.6 15.0 10.8 11.3 10.8 12.6 8.6 12.5 14.3 15.3 11.6 14.2 15.3 12.9 13.4 13.1 11.7 15.2 13.1 14.9 11.0 9.9 11.8 8.8 12.9 10.8 12.1 15.1 13.3 21.2 14.7 14.0 10.2 9.8 18.2 8.5 17.4 13.5 17.5 17.8 18.3 17.0
600 189 38 265 50 41 21 1549 401 755 402 1533 20 32 442 241 237 198 105 236 37 419 116 104 55 146 1385 415 150 314 354 147 565 78 75 161 157 58 16 19 928 51 145 88 646 665 152 195 51 31 39 52 129 12 2291 28 1779 63 158 266
480 152 30 214 37 34 17 1177 324 572 290 1206 18 25 358 179 200 153 81 182 24 319 84 74 47 116 1070 329 115 251 261 109 439 65 59 124 118 42 15 15 776 41 117 74 546 561 126 158 45 28 32 44 112 12 1943 24 1511 50 135 226
8342
1964
15.4
9941
7977
United States
NOTE: Totals may differ due to rounding; number of orthodontists and number less than 40 years of age are as presented in the A D A publication.
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Table III. O r t h o d o n t i s t r e q u i r e m e n t s : 20201'6 Private practice orthodontists Private practice Number need to replace 40 yrs + orthodontists Number needed for additional youngsters Number orthodontists < 40 yrs SUBTOTAL Nonprivate practice Number need to replace 40 yrs + orthodontists Number needed for additional youngsters Number orthodontists < 40 yrs TOTAL REQUIRED Number of "new" orthodontists needed Number of "new" orthodontists available Additional number required to meet conservative estimate of requirements
Professionally active orthodontists
6,378 1,599 1,964" 9,941
6,378 1,599 1,964" 9,941
9,941 7,977 6,256 1,721
458 111 141" 10,651 8,546 6,256 2,290
*No replacements needed.
year treating patients than their male counterparts. About 77% of males and 48% of females indicated they spent between 1200 and 2000 hours per year treating patients. 11 No specific adjustment factor is available to modify manpower needs to compensate for the different work patterns of male and female dentists. Thus by using a straight numeric "replacement" by an increasing percent of female orthodontists in 2020 could once again understate the need for increased numbers of orthodontists. FINAL THOUGHTS
Again, it should be stated that: • The overall number of practitioners required to maintain the current ratio, is a conservative estimate based on the assumption that all orthodontists less than 40 years of age in 1991 will continue in full-time practice until 2020. • One can not assume that new orthodontists will distribute themselves in a uniform manner comparable to the distribution of current practitioners or in some manner that would be in line with the increasing numbers of youngsters that are projected by the Bureau of the Census. Although this review of dental manpower needs for the next: generation of youngsters suggests a marked increase in the need to increase the number of graduates from orthodontic training programs, it does not consider the need and/or demand for services, increasing use of services by older persons (i.e., 20 years and older), increasing
special patient populations, nor the reality that some components of orthodontic services for youngsters are being provided by pediatric and general dentists. No doubt for many current practitioners the idea of planning for the dental services for the year 2020 seems far beyond their own professional horizons. But the reality is that the increase in the number of youngsters will not happen suddenly at the end of the second decade of the next century. Rather it will take place throughout the next 25 years. Similarly the "loss" in the numbers of orthodontists 40 years of age and older will continue throughout the period. Yet changing the "production" of orthodontists is not analogous to turning a water spigot on (or off). Because of the long lead time necessary to produce graduate orthodontists, manpower planning is necessary to determine whether the combination of (1) evolving dentist-to-population ratios, (2) increasing numbers of female orthodontists, (3) evolving dental disease patterns, (4) demand for services, and (5) evolving third party payment mechanisms, warrant changes in the "production" of orthodontists to ensure adequate services in the many regions and states of our country. A final note of caution is essential in planning for future orthodontic personnel needs. In response to population and health profession projections made in the 1960s and efforts to encourage competition by increasing the numbers of health providers, the federal government provided a variety of financial incentives to increase the "production" of a wide variety of health practitioners. As a result, by 1978 there were 6301 first-year dental students in 60 dental schools in our country? But increasing the numbers of health practitioners did not produce the desired containment in health care
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American Journal of Orthodontics and Dentofacial Orthopedics November 1996
costs. In addition, there were continuing cries of an oversupply of health providers. Federal government support was curtailed. First-year enrollment in dental schools decreased by more than one third (to approximately 4000 students each year) and four private dental schools ceased operation. The dentist-to-population ratio that had been increasing peaked in 1987 and has started a decline that, in the first decades of the twenty-first century, will reach the lowest levels recorded since the first years of the twentieth century? Any effort to plan for the next generation of orthodontists must ensure that the 1970s-1980s "roller-coaster ride" in the production of dentists is
not repeated in planning for the orthodontic personnel
REFERENCES 1. Campbell PR. Bureau of the Census. Population projections for states, by age, sex, race, and Hispanic origin: 1993 to 2020. Current Population Reports, P25-1111. Washington, DC: Government Printing Office, 1994. 2. Waldman FIB. Marked increases in the general population and decreases in the numbers of dentists in the 21st century. Illinois Dent J 1994;63:99-102. 3. Waldman HB. More minority children and the need to stress dental care. J Dent Child 1993;60:403-7. 4. Waldman HB. Who uses the services of orthodontists? Ann Dent 1987;46:3-4. 5. Waldman HB. Changing number and distribution of orthodontists: I982-1991. Am J Orthod Dentofac Orthop 1994;105:128-34. 6. Bureau of Economic and Behavioral Research. Distribution of dentists in the United States by region and state, 1991. Chicago: American Dental Association, 1992. 7. 1974/75 through 1993/94 annual report on advanced dental education. Chicago: American Dental Association, 1975 through 1994. 8. Survey Center. Survey of advanced dentistry, summary sheet. Chicago: American Dental Association, 1994. 9. 1978/79, 1993/94 annual report on dental education. Chicago: American Dental Association, 1979; 1994. 10. DES data update. Chicago: American Dental Association, 1993. 11. Council on Dental Practice. A comparative study of male and female dental practice patterns. Chicago: American Dental Association, 1989.
needed for the next generation of patients!
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