A Survey of Dental Practice in Lebanon
Author: Lamia Abi Aad Khoury.
LDS, DU Oral Biology, DESS in Community Oral Health and Epidemiology.
Associate Clinical Instructor, Department of dental Public Health.
Lebanese University School of Dentistry, Beirut, Lebanon.
Objective: The aim of this study was to evaluate the income of Lebanese dentists and analyze factors that could influence it.
Materials and Methods: Collected information was based on a questionnaire distributed to the participants of two dental meetings. The number of participants was 365 dentists and their ages varied between 22 and 70 years. T-Test, One Way Anova, and Chi-Square were performed to analyze the data. The software used was SPSS virgin 20.
Results: For the majority of participants, their monthly income varied between 1000usd and 5000usd. Statistical analysis showed a positive relationship between dentists’ average income and several variables such as sex, specialty, location of practice, having an academic position, origin of diploma, and years of experience.
Conclusion: The incomes of Lebanese dentists are considered to be low compared to the high cost of living in Lebanon specially in the capital. Several factors including the low access to dental care, the absence of dental insurance and the unstable economic and political situations can have an impact on the economic situation of dentists. Moreover, the oversupply of dentists will surely be a factor that will decrease the income of dentists.
No surveys have been made to date in Lebanon pertaining to dental fees as well as dentists’ income. In the United States of America, A Survey of Dental Practice is a House of Delegates mandated survey and has been conducted annually since 1982. It is the principal means by which the American Dental Association (ADA) collects the most comprehensive and reliable statistical information on the private practice of dentistry in the United States (1). This one was conducted in 2013. It was based on what dentists declare their net income. They were inconsistent in reporting financial information. A financial global world recession began in 2009. Historically, net income levels for dentists have fluctuated with economic conditions (2). American Dental Association reported that dentists were deeply affected by the 2009 recession and mentioned that it was a difficult year for dentists (3). Dr. Jeffrey Cole, chair of the Council on Dental Practice’s Subcommittee on the Economy in ADA; said” Economic data from survey of dental fees 2011 suggest the average incomes of dentists have been declining over the past ten years and so have the number of dental services being sought, he explained “ if your strategy is only to wait out a bad economy, financial health will be harder to achieve” (4). The ADA Health Policy Resources Center (HPRC) reported that dentist incomes have been stable since 2009 till 2013 (5). Average annual general practitioner’s income was $192,392 in 2011. (5)
Income began to decline in the mid-2000s, several years before the start of the Great Recession (5). They reported there are important differences in dentist earnings by location, gender, and type of employment arrangement that warrant further analysis (5). Further analysis in 2011 showed that a broad set of factors contributed to the decline in net income, a very important one being a steady decrease in the utilization of dental care among the population (5). In Lebanon, global recession of 2009 and especially the weakened economic outlook in the Gulf countries affected the Lebanese economy (6). Besides recession, Lebanon was exposed to political and security shocks that would adversely affect economic and financial conditions (6). Theoretically, the net income of dentists would be affected, but one cannot deduce if or how the net income of dentists has declined for the reasons that there is no data to compare with this above survey and the questionnaire does not mention how the income is affected by economic and political situations. This study addresses the data related to the net monthly income and analyzes which other factors than the economic one, may influence income of dentists. It also discusses income’s differences in relation to multiple factors practice (ownership, demographic characteristics, geographic location, gender, and specialty).
MATERIALS and METHODS:
This survey was conducted in 2013 and about 500 questionnaires were distributed by the author (LAAK) during two main dental events: the biannual International Convention of the Lebanese University in June and during the Beirut International Dental Meeting (Lebanese Dental Association) in September. Dentists participating in this survey were in private practice. Employed dentists were excluded. A dentist in private practice is either a solo who works with no other dentist or non-solo is the dentist who works with one or more other dentists.
The questionnaires were filled by the dentists themselves and were recollected also by the author in the same day.
400 questionnaires were returned, 35 were not completely filled and were excluded. 365 questionnaires were included in this survey. 58.6% responses were collected in June and 41.4% in September.
The questionnaire was anonymous and included two parts: the first one contained socio- demographic data concerning age, sex, location of practice, status of the practice (private solo practice, polyclinic or dispensary), working with a dental assistant, years of experience, country of graduation, specialty, academic position, if any, presence of computer or network. The second part concerns the average net monthly income. Dentists’ net incomes are defined as gross billings minus total practice expenses. Net income was ranged in several average < 500usd, from 1000 to 2000usd; from 2000 to 3000usd; from3000 to 5000usd; from 5000 to 7500usd ; from 7500 to 10000usd ; from 10000 to 15000usd; from 15000-20000usd; >20000usd.
Data were processed and analyzed using SPSS program. The statistical tests used were Sample T-Test, One Way Anova, and Chi-Square with p < 0.05.
The number of respondents was 365. Descriptive Analysis showed the following results.
The mean age of participants was 40.7 and the average years of experience was 14.6.
The percentage of Socio- Demographic distribution is mentioned in (Table 1).
58.6% respondent in June; and 41.1% in September. The sample was represented by 69.2% of males and 30.8% of females.
Almost 65.5% of monthly incomes ranged between 1000 and 5000 usd. Only 20.4% were above 5000usd (Table2).
Statistical analysis showed a positive relationship between dentists’, average income and several variables such as sex (chart1); location of practice (chart 2), origin of diploma
( chart 3), specialty (chart4), having an academic position(chart5) and years of experience ( chart 6). There is no significant relationship between having dental assistant, having computer and Internet at the office, having continuing education.
“There are things affecting dentists’ income that are more than the bad economy” stated Dr. Jeffrey Cole, Chair of the Council on Dental Practice’s Subcommittee on Economic Issues in ADA (2). Some of hypothesized number of factors is Population-to-dentist ratio that could contribute to the income (7). Population-to-dentist ratio was calculated in 1999 in Lebanon; it was 100000-to-125. Compared to France the ratio was 100000-to-68, and 100000-to-61 in USA (11). For a small country like Lebanon it is an oversupply of dentists. To date (February 2014) the number of dentists is 4531 (8). This is due to the fact that there are numerous schools of dentistry and there is no political strategy to identify the number of dentists needed. The distribution of dentists in Lebanon is uneven. The majority of dentists practice in Beirut and Mount Lebanon (8). 2420 dentists are practicing in Mount Lebanon, 1051 in Beirut, 35 in Northern Lebanon, 436 in the Southern Lebanon, 413 in Beqaa, and 101 in Nabatieh (8). According to Dr. Jeffrey Cole “ what happens when we get an influx of dentists? It may be as simple as supply and demand; if there are more dentists seeing patients, competition increases and in order to remain in business, your fees need to be competitive “(2). Another factor that could contribute to the net income is dental health insurance. More than 90 percent of dental expenditures in the United States are paid for out-of-pocket or through private insurance (9). Dental health insurance is a solution for increasing, access to dental services. In Lebanon, there is neither social dental health insurance nor private insurance, moreover, preventive strategies and education that provide important health benefits to all people are non- existent or rare. These factors decrease the demand for the utilization of dental care among population, and increase the competition among dentists. While in the USA many people have access to the best oral health care in the world, still ‘there is a decline in dental, care utilization among adults (9). The available evidence indicates that while improved oral health might be a factor, increased financial barriers to care are certainly a key driving force (10). Low oral health literacy also remains an important issue (11).
Another significant factor is the location of the dentist’s office (rural or urban). This study shows that in Beirut, dentists have higher income. This is due to the fact that apartments are more expensive in the city. According to Jad Chaaban, an Economics Professor at the American University of Beirut suggested that “there is a very limited supply of rentable apartments in Beirut. Those available are big and very expensive apartments that target wealthy, individuals”. Moreover, Beirut’s combination of high-cost housing, food and energy render living in the city very expensive compared to the rest of the Middle East (12).
According to Mercer’s 2012 « Cost of living Rankings », Beirut has become the most expensive city in the Arab world (13). The average monthly disposable salary (after paying taxes) is 1,017.25usd. The monthly minimum fixed regular payment is 450usd. The price per square meter to buy an apartment in the city center is 5,460.23usd; and to buy outside the center, 2,120.15usd (14). In this study, the mean years of experience of the dentists’ was14.6 and most of them earn less than 5000usd monthly. With this income and the expensive cost of living in Lebanon, it is hard for Lebanese dentists to grow a business. This finding could explain why many dentists try to work outside the country.
This study showed that dental specialists earn more than general dentists. Situation is almost the same in the USA where, in 2009, the average gross billings per ower dentist was 727,630usd for a general practitioner and 1,004.820usd for a specialist (3).
The number of female dentists is increasing everywhere. Dentistry is becoming more and more a female profession. In the US, for example, 46.2% of dentistry graduates in 2009 were females (3). Unexplained gender differences in earnings have been reported for many health care professions. For example, a recent study in USA showed a significant gender gap in earnings among physicians that cannot be explained by specialty choice, practice setting, work hours, or other characteristics (15). Academic position of the dentist plays a positive role too. People tend to trust more academic dentists.
Economics of dentistry are changing. Due to a confluence of several factors, the profession finds itself at what could be a critical crossroads. New models of a dental practice are emerging. There is a rapid growth in large group practices and dental-service-organization- supported practice models. That is thought to be more cost-effective than traditional solo or small group practices. Increased debt loads and changing preferences related to practice and life styles among new graduates are likely to have long-term effects on the profession (16). This model may be applied in Lebanon especially for the new graduates and dentists with specialties.
To increase the net income of dentists in Lebanon, it is crucial to study the need of dentist ratio to the population. The number of new dentists graduating from domestic universities (LU, USJ, BAU), must be limited. This is a task of the government and the two Orders of Dentists. The number of dentists should be evenly distributed in Lebanese mouhafazats. Finally, dental health insurance, and social medical insurance coverage are keys factors in increasing utilization of dental care. Nowadays, and more than ever, it is crucial for dentists, the public, educators, and policy makers to work together to reduce barriers to dental care in order to ensure all that Lebanese have the opportunity to be dental and mouth-healthy for life.
Table 1: Socio-Demographic Distribution of respondents:
|Origin of Basic Dental Diploma|
Table2 : Dental Income
|Frequency||Percent||Valid Percent||Cumulative Percent|
|Valid||< usd 500||10||2.7||2.8||2.8|
|500 – 1000||39||10.7||10.9||13.7|
|1000 – 2000||79||21.6||22.1||35.8|
|2000 – 3000||77||21.1||21.5||57.3|
|3000 – 5000||80||21.9||22.3||79.6|
|> 20000 usd||4||1.1||1.1||100.0|
Chart 1: Income by Gender:
Male dentists have higher incomes than females (p<0.05%). Approximately, 23% of male dentists have an income above 5000 usd compared to 13% of female dentists.
Chart 2: Income by location of practice:
The location of practice (chart 2) seems to have an impact on the income. Dentists working in Beirut and Mount Lebanon have higher income when compared to dentists working in other areas. The percentage of dentists who earn more than 5000usd is 32% in Beirut, comparing to 18% of dentists working in Mount Lebanon and 14% who practice in other areas.
Chart 3: Income by basic dental qualification source.
Income of dentists is related to the origin of basic dental diploma (chart 3). Dentists graduating from Western Europe have a higher income than their counterparts.
Chart 4: Income by Specialty.
Dental specialty represents a factor in income variation (chart 4).
Dentists with a dental specialty have a higher income (25% of specialized dentists can reach more than 5000usd and only 16% of non specialized dentists can reach the same income)
Chart 5: Income by academic position.
Teaching Posts have an impact of the income (31% of dentists with academic position can reach an income higher than 5000usd compared to 17% to dentist with no academic position.
Chart 6: Income by years of experience.
Higher income is correlated with dentist’s years of experience.
1-2010 survey of Dental Practice;’’ Income from the Private Practice of Dentistry”. ADA American Dental Association. www.ada.org June 2011
2- Kelly Soderlund, ‘outlines shift in dentists’income since before economic downturn’; J.American Dental Association April 23, 2012.
3- Dental Practice. 2009 Survey of Dental Practice. Income from the private practices of dentistry. SDPI-2009/SDPI-2009D American Dental association.
4- 2011 Survey of Dental Fees. American Dental Association.
5- Vujicic M, Lazar V, Wall T, Munson B. An analysis of dentists’ incomes, 1996-2009. JADA 2012;143(5):452-460.
6- International Monetary Fund. Lebanon- 2009 Article IV. Consultation Mission Statement March 5, 2009. www.imf.org.
7- Doughan. B: Thèse de doctorat en sciences odontologiques à l’Université Libanaise: Contribution à la planification des besoins en personnel de santé bucco-dentaire au Liban (1999).
8- Document: number of dentists in Lebanon. Lebanese Dental Association 2014. www.lda.org.lb
9- Kelly Soderlund ‘ outlines shift in dentists’ income since before economic downturn
Primary reason is drop in dental visits’, Journal of Americain Dental Association April 23, 2012.
10- American Dental Association, Breaking Down Barriers to Oral Health for all Americans: the Role of Finance. Chicago: American Dental Association: 2012.
11- American Dental Association, 2012 Consumer Awareness Survey. Chicago: American Dental Association, 2012.
13- Adam Hedengren: » Beirut is now more expensive than Abou Dabi ». Junuary 22.2013. www.yourmiddleeast.com
14- Cost of Living www.numbeo.com/cost-of-Living.
15- Lo Sasso A, Richards M, Chou C, Gerber S. The $16,819 pay gap for newly trained physicians: the unexplained trend of men earning more than women. Health Affairs 30. No. 2(2011):193:201.
16- : Guay A, Wall T, Petersen B, Lazar V. Evolving trends in size and structure of group dental practices in the United States. Journal of Dental Education 2012; 76(8):1036-1044.
17- Dental Crisis in America. A Report from Chairman Bernard Sanders Subcommittee on Primary Health and Aging U.S. Senate Committee on Health, Education, Labor & Pensions February 29, 2012).