Besides the six mournful concertina airs, the dentist knew one song. Whenever he shaved, he sung this song; never at any other time. His voice was a bellowing roar, enough to make the window sashes rattle. Just now he woke up all the lodgers in his hall with it. It was a lamentable wail:   "No one to love, none to caress,  Left all alone in this world's wilderness." 
—Frank Norris, McTeague

Dentists have never gotten much respect. Just look at The Hangover, this summer's surprise movie hit. Ed Helms' character, a dentist named Stu Price, is presented as a henpecked, insecure second-rater. Even his best friends don't think he deserves to call himself "doctor," a title they reserve for physicians. When novelists or screenwriters want to telegraph that a character is boring or unimaginative, they often make him a dentist—in the Harry Potter series, for example, Hermione Granger's parents aren't just muggles, or nonmagical people; they're dentists. This is of a piece with the widespread myth that dentistry is the profession with the highest suicide rate. In fact, there is no evidence that dentists kill themselves in greater proportion than the population at large. If anything, the data suggest the opposite.

Even so, during the 20^th century's final decades, a dwindling number of Americans chose to become dentists. In the early 1980s, U.S. dental schools produced about 5,750 new graduates per year. In 2007, with a population that's nearly one-third larger, there were about 4,700. It's tempting to blame this decline on movies like Marathon Man and Little Shop of Horrors, which portrayed dentistry as a profession appealing only to Nazis ("Is it safe?") and sadists ("People will pay you to be inhumane"). But a likelier explanation is that there are fewer opportunities. In 1980, the United States had 60 dental schools; today there are 58, and class sizes are smaller.

Dental schools closed and downsized because they were too expensive to maintain. Unlike medical schools, where students do their clinical training in teaching hospitals that bear the costs of such practical education, dental students get their training in clinics run—and paid for—by the universities. The cost of administering these clinics increased by just over 50 percent between 1991 and 2001. Federal grants to support dental education (and medical education generally) have meanwhile become less plentiful. This is a bigger blow to dental schools because, unlike medical schools, they can't make up the difference with research grants. Prestigious universities have been especially keen to divert resources away from dental education to programs that attract rather than bleed funds. Among the dental schools that have closed their doors in the last three decades are those at Georgetown, Emory, and Northwestern. Currently, about 600-800 more dentists enter the profession than retire from it each year, but starting around 2014, as the baby-boomer dentists who graduated in larger classes start to retire, the number of practicing dentists will decline while the U.S. population continues to grow. (See Slides 26 and 27 in this presentation.) Boomer retirement will also contribute to a growing shortfall of medical doctors, of whom as recently as 1996 the United States was thought to have a surplus.

The shortage is compounded by dentists' growing inclination to work fewer hours. In 2006, 12.1 percent of the nation's private-practitioner dentists worked fewer than 30 hours per week. One contributing factor is that more women are becoming dentists. According to a study published in the May 2004 Journal of the American Dental Association, female dentists—who represented just 2.6 percent of active private dental practitioners in 1982, 12.8 percent in 1997, and 44.9 percent of the graduating dental school class of 2006—were likelier than men to work fewer than 32 hours per week. This was especially true, unsurprisingly, for women with young children.

A common complaint by health care reformers is that the medical profession has too many specialists and too few general practitioners. The same is true for dentists. Even as the number of dental-school graduates declined over the last three decades, the number of specialty training positions in fields like orthodontia and oral surgery held steady at around 1,200 per year. Twenty years ago, one-fifth of all dental-school graduates pursued specialization; at the end of the 20^th century, the figure was closer to one-third.

This contraction is taking place at a time when the United States has far more teeth than ever before. Not only has the population grown from 227 million in 1980 to 307 million in 2009, but many more Americans are keeping their natural teeth into old age. Only a couple of generations ago it was the norm for elderly Americans to wear dentures, especially if they were working class. (That helps explain why Medicare still has no dental coverage, except in very limited circumstances when it is deemed medically necessary.) But according to a paper in the June 2000 JADA, the baby boom will be the first generation to enter retirement "with nearly a full complement of teeth." That translates into even more patients competing for fewer dentists' attention.

Economic theory says that when supply decreases or demand increases, prices go up. When both occur at once, prices go up a lot.

Next: The Oral Cost Spiral



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