Many poor and rural Kansanslag significantly behind an accept-ed standard for dental care andoral health.

These gaps in services and careare caused in part by a limitedsupply of dentists—especially inrural areas.

Without policy intervention,these service gaps and resultingoral health problems will grow asthe supply of dentists declines.

State policies and workforceregulations help determine the sup-ply of dentists and the contribu-tions of other dental professionalsto the overall supply of services.

To improve access to dental ser-vices, policymakers could attemptto increase the supply of dentists

by establishing a dental school oran in-state extension of an existingdental school, expanding educa-tion subsidy programs, or requir-ing more students who receivesubsidies to practice in under-served areas.

Policymakers also could targetservices towards underserved pop-ulations of the state, and/or sup-port the development of new den-tal practice models, includingexpanding the types of servicesthat hygienists or other allied pro-fessionals can provide.

Dental workforce needs are diffi-cult to predict and can take manyyears to address, suggesting theneed for policymakers to monitorthe dental workforce and updatepolicies on an ongoing basis.

NUMBER 18 • JANUARY 2005

Issue Brief

Healthier Kansans through informed decisionsWWW.KHI.ORG

The DecliningSupply of Dental

Services in Kansas:Implications for

Access and Optionsfor Reform

R.Andrew Allison, Ph.D.

Major Findings

More informationThis Issue Brief summarizesthe key findings from adetailed study of oral healthneeds and the dental work-force commissioned by theUnited Methodist HealthMinistry Fund. The fullreport, as well as other KHIstudies, can be found online at www.khi.org.

The supply of dentists and the way in which dental practices operate significantlyaffect the level of care that Kansans receive. A study of the dental workforce com-missioned by the United Methodist Health Ministry Fund shows that a persistentdisparity in the supply of dentists between rural and urban areas and the mannerin which services are delivered are adversely affecting the oral health of ruralKansans. Further, the oral health of poor Kansans is suffering because of a lack ofaccess to dental care. The major findings of the study are summarized below:

2 KANSAS HEALTH INSTITUTE

The availability of dental servicesin the state of Kansas as awhole, especially in rural areas,

and the number and distribution ofdentists available to serve the poor anduninsured are reasons for concern. Toinform these concerns, the KansasHealth Institute completed a study ofthe dental workforce in Kansas todetermine if there was a shortage ofproviders and to explore policy optionsfor managing the supply of dentalworkforce professionals. Sources forthe study included the complete licen-sure records from the Kansas DentalBoard; statewide survey data on healthstatus and dental needs; dental claimsfrom the State Children’s HealthInsurance Program (SCHIP, orHealthWave); industry data on dentalsupply, pricing, and utilization; and acomprehensive review of the literature.

Rising Standards, PersistentNeeds

Oral health has improved significant-ly in the U.S. over the last severaldecades for children, adults, and theelderly. These improvements are gener-

ally attributed to widespread and sus-tained fluoridation of public water sup-plies, to increased utilization of preven-tive dental care, and to a rising publicexpectation of healthy teeth. Accordingto an analysis of survey data undertakenfor this study, levels of access in Kansasare slightly higher than the nationalaverage and are right in line with otherstates in this region of the country—such as Iowa, Missouri, and Nebraska.However, this study also revealed size-able gaps in access and dental outcomesfor low-income and rural populations. Inaddition, analyses of HealthWave claimsdata confirms earlier reports of low par-ticipation rates for dentists serving low-income children in the Medicaid andSCHIP programs. Poor access to dentalcare can have a profound impact onoverall health and well-being. Poor oralhealth can reduce productivity, diminishphysical function, and impede socialinteraction. The pain of an untreateddental problem can lead to the loss ofsleep, depression, and other psychologi-cal conditions.

Percentage of adults in Kansas whose most recent dental visit was more than one year ago

Percentage of adults in Kansas who have lost all permanent teeth

Percentage of adults in Kansas who had any unmet dental needs in thepast year

Less than $25,000

FAMILY INCOME

Low-Income Kansans Have More Dental Problems

$25,000 to $50,000 $50,000 to $75,000 $75,000 or more

0

10

20

30

40

50

0

3

6

9

12

15

0

3

6

9

12

15

The Impact of Supply onDental Needs

The price of dental services and den-tists’ profits have increased significant-ly in recent decades, while per-capitautilization of dental services hasdeclined. Taken together, these changescannot be explained solely by changesin consumer preference and need fordental services. The most likely expla-nation for observed market trends issome sort of supply constraint, whichmay occur as a natural byproduct ofdentists’ market control. Supply limita-tions may also be reflected in dentists’reallocation of their practices’ time andresources to meet rising demand forpreventive and cosmetic services, anddiminishing need—on average—forrestorative services. Whether it is mar-ket power, market shifts, or both thatare to blame for observed increases inprices and limited levels of supply, theimpact on those who live in rural areasand those who are poor is the same.This study suggests that the currentdental workforce in Kansas is bothinsufficient in number and inappropri-ately distributed geographically to meetthe dental needs of the population, andthat these shortcomings are likely todeepen as population growth strains analready tight supply of dentists.

Analysis of the dental workforceindicates that access problems in thestate derive significantly, though notsolely, from the limited and unevenlydistributed supply of services available.Access gaps and unmet needs for dentalservices are concentrated among popu-lations least able to compete financiallyfor the limited number of practice hoursoffered by dentists, and those who livein rural areas where supply is eventighter. It was not surprising to find thatthe supply of dentists is significantlygreater in more urban areas of the state

than in rural areas, but one of the moststriking findings in the study is thatthese differences have not been grow-ing. The dentist-to-population ratio inthe most rural counties of the state isbelow 40 dentists per 100,000 residents,while the ratio in metropolitan countiesis above 50. These differences havechanged little over the last 13 years,which suggests that dentists are makinglocation decisions based partially on anunderstanding that traditional rural prac-tices are inherently less profitable.

Projected Decline in SupplyTo facilitate discussion about possi-

ble changes in dental workforce poli-cy, this study provides detailed base-line projections of the dentist work-force in Kansas. These projectionsindicate that if state policies and mar-ket conditions remain essentiallyunchanged, the total number of full-time-equivalent dentists practicing inthe state will increase somewhat forthe next decade and then fall graduallyto just below current levels. However,due to population growth, the ratio ofdentists to the total population—amore direct measure of the supply of

3KANSAS HEALTH INSTITUTE

-25%

-20%

-15%

-10%

-5%

0%

Projected Decrease in the Supply of Dentists

Note: This is a measure of change in the number of FTE dentists per 100,000 people. In 2002, the number was 38.

2005 2015 2025 2035 2045

dental services—is projected tofall steadily and significantlythrough at least the year 2045.

The natural uncertainty thatunderlies projections of this type,coupled with the long lead timerequired to train dentists, suggeststhat policymakers should keep aclose watch on the number and dis-tribution of dentists so that they caneffectively monitor progress inmeeting policy goals. Shortagesmay take many years to correct, andfactors contributing to them maychange in the meantime. These dif-ficulties suggest that policymakersneed to remain engaged in ongoingreview and update of policies.

Potential SolutionsState policies help determine

dental workforce supply by provid-ing educational subsidies and dentaltraining slots at the University ofMissouri-Kansas City; establishingthe manner in which dental profes-sionals are licensed and allowed topractice; and determining the scopeand autonomy with which each ofthe dental professions can practice.Policymakers might consider arange of options in order to addressthe declining supply of dentists inthe state and improve access to den-tal services for underserved popula-tions, including:

• Establish a dental school or anin-state extension of an existingdental school.

• Use advanced dental students to

meet needs in underserved areasas a part of their training.

• Expand loan repayment programsand/or educational subsidies.

• Require more subsidized Kansasdental students to locate inunderserved areas.

• Recruit foreign dentists on pro-visional or educational licenses.

• Enable changes in the dentalbusiness model by expanding thetypes of services that hygienistsor other allied dental profession-als can provide and/or allowingallied professionals to billpatients directly.

• Improve data collection, moni-toring, and reporting of oralhealth and workforce issues.

• Increase dentists’ participation inMedicaid with better and sim-pler reimbursement.

• Consider Medicaid expansions,especially for poor adults.

• Advocate for national policies thatenhance the dental workforce.

While each of these optionscould be designed to increaseaccess to dental services, manycome with significant public orprivate financial costs, most yielduncertain benefits, and some maybring with them unintended conse-quences. Thus, it may be difficultto obtain public consensus to sup-port a package of policy reforms.Nevertheless, there appears to bewidespread agreement that dispari-ties in access to care among poorand rural populations merit theattention of policymakers.

Healthier Kansans through informed decisionsWWW.KHI.ORG 4

The Kansas Health Institute is anindependent, nonprofit healthpolicy and research organizationbased in Topeka, Kansas.Established in 1995 with a multi-year grant from the KansasHealth Foundation, the KansasHealth Institute conductsresearch and policy analysis onissues that affect the health ofKansans.

KANSAS HEALTH INSTITUTE

212 SW Eighth Avenue, Suite 300Topeka, Kansas, 66603-3936Telephone (785) 233-5443Fax (785) 233-1168www.khi.org

Copyright© Kansas Health Institute 2005.Materials may be reprinted with writtenpermission.

NUMBER 18 • JANUARY 2005

“ ... The extent andseverity of untreated

dental disease—especially among

underservedchildren—is

unacceptable.”

American Dental Association WhitePaper on Access, October 2004

This Issue Brief and a full report on the topic were produced under contract with theUnited Methodist Health Ministry Fund. The contents of this brief are solely theresponsibility of the author and do not necessarily represent the views of the fundingorganization and other contributors to the project.