Amid the whirring drills and bright lights of dental practices, there’s a growing problem: the dental hygienist shortage. Dentists are scrambling to find qualified dental hygienists to meet the needs of their practices and patients. It’s a stark shift from 20 years ago when graduates like myself faced fierce competition for jobs.
One of the more popular suggested resolutions among dentists is to allow assistants to scale supragingivally with limited training. Along with Kansas, Illinois recently passed a bill allowing assistants to scale supragingivally on patients 18 and under.1,2
However, many fail to acknowledge that allowing assistants to scale is not a new concept, and in some cases, assistants are allowed to operate fully as registered dental hygienists. The Alabama Dental Hygiene Program has been around for over 50 years. This program enables assistants who have completed 24 months of full-time employment as a chair-side assistant to become registered dental hygienists without the same CODA-accredited education that hygienists must obtain in all other states. In the case of Alabama, the state board of dental examiners “accredits” and administers the program.3
For comparison, the Alabama Dental Hygiene Program requires a total of approximately 306 hours of combined clinical and didactic instruction, while the CODA-accredited dental hygiene program I attended, Florida State College at Jacksonville (FSCJ), requires 1,320 hours of combined clinical and didactic instruction. The Alabama Dental Hygiene Program does not require any basic science courses or didactic prerequisites, while the FSCJ Associates in Science requires several basic science courses, such as microbiology, chemistry, and nutrition, among others.4,5
A quick assessment of the numbers would show this is not a valid resolution. The Alabama Dental Hygiene Program pumps out 100 to 200 dental hygienists a year, yet there is still a hygiene shortage and a lack of access to care in Alabama.3
However, what really concerns me about dentists pushing for this is that they seem to be okay with lowering the level of education needed and, ultimately, the quality of care for their patients. It seems those pushing for this are just looking to fill the position rather than looking introspectively at what could be done to attract better candidates for their open positions. It is like a Hail Mary at the expense of their patients.
Programs Like The Alabama Dental Hygiene Program Are Not a Solution
The alleged premise of the Alabama Dental Hygiene Program is to provide better access to care in rural areas of Alabama. The conundrum is that Alabama hygienists must work under direct supervision. Therefore, pumping out upwards of 200 hygienists a year does not improve access to care if there are no dentists working in rural areas in the first place.3
As of 2017, estimations show there are 2.7 dentists per 10,000 population in rural Alabama. Additionally, in 2017, there were three counties with no full-time dentists in the entire county. In 2023, the former executive director of the Alabama Dental Association stated that “at least five counties in Alabama do not have a dentist serving the area.”6
The problem appears to be getting worse over the years. I recognize we had a pandemic, which may be playing a role in the lack of access to care. Nonetheless, the guise that the Alabama Dental Hygiene Program is to allow better access to care is not holding up too well.6,7
Even with 150-200 hygienists being licensed in the state of Alabama in April 2024, 49 out of 67 counties (with data available) have a dental professional shortage for the entire county.8 Additionally, there is also a shortage of dental assistants, which would be counterproductive in “certifying” them to act as dental hygienists.9
Nationwide, the American Dental Association (ADA) reported dentists were recruiting dental assistants at a higher rate than dental hygienists from October 2020 through July 2022, with 39.7% of dentists recruiting assistants and 36.0% recruiting dental hygienists. This indicates that assistants may be scarcer than hygienists.9
In short, the idea of “certifying” assistants to provide dental hygiene services to alleviate the dental hygienist shortage or improve access to care is not the solution many dentists think it is, as is evident by the history of the Alabama Dental Hygiene Program.
Attrition and Retention Factors
The ADA investigated nationwide attrition factors for both dental assistants and dental hygienists. The following are the top three reasons dental hygienists and dental assistants left or are leaving the profession (in order):9
- Dental Assistants
- Insufficient pay
- Feeling overworked
- Negative workplace culture
- Dental Hygienists
- Negative workplace culture
- Insufficient pay
- Feeling overworked
There seems to be a theme here. This means that improving pay, reducing workload, and improving workplace culture may be a start in alleviating dental hygiene and even dental assistant shortages.9
When dental assistants and dental hygienists were asked about what factors they value that have kept them in their current position, the top three retention factors were 1) work-life balance, 2) positive workplace culture, and 3) ability to help patients. Of interest, it seems that insufficient pay may be a factor that is negotiable in the right work environment.9
Proposed Solutions
I try not to bring problems to the table without proposed solutions, so the following are my proposed solutions for the dental hygienist shortage. Admittedly, I would look for these things in a workplace, so it’s not an “all or nothing” solution – it’s more of a starting point to consider.
Fair Wages
Fair wages are the first thing to tackle. I recognize some dental hygienists are asking for unreasonable high wages. I previously wrote an article about it, which you can read more about here.
A fair wage is meant to be fair for both parties, the employee and the employer. Therefore, I propose that hygienists be paid, on average, 33% of their production after insurance adjustments. I know many hygienists feel that insurance adjustments should not be part of the equation, but money cannot go out if money is not coming in.
I suggest all hygienists ask how insurance-driven a practice is before accepting a position. Finding a fee-for-service office may be difficult, but it could also be conducive to higher wages because insurance adjustments are taken out of the equation. Make sure you understand insurance reimbursement, fee schedules and/or office fees will play a role in your wages.
Create a Positive Work Culture
Creating a positive workplace culture seems to be one of the easier things to achieve. There are a few things to consider here. First, stop micromanaging, including allowing office managers to dictate how hygienists should manage, appoint, and treat patients. Dental hygienists are well-versed in proper treatment protocols, but most office managers are not.
The only exception may be an office manager who was previously a dental hygienist, in which case a respectful conversation can be had without micromanaging. Office managers can often make or break the workplace culture. Ensure your office manager is contributing to a positive experience and not a negative experience for all other employees.
I want to recognize the fact that I have worked with some amazing office managers. This is in no way meant to be an attack on office managers. Nonetheless, recognizing that they play an intricate role in workplace culture is imperative in creating a positive workplace experience.
Asking dental hygienists to clock out when patients cancel or do not show up is another simple change that can be made to improve workplace culture. This is often illegal, but perhaps more importantly, it is disrespectful. It is confounding that dentists request dental hygienists clock out when they don’t have a patient, but the same rules do not necessarily apply to other positions within the office. I’m not implying it should, but it makes dental hygienists feel unappreciated.10
Workplace culture can also be improved by allowing employees to take time off without guilt, attending, for example, their children’s school functions, doctor appointments, or even their own health care appointments. Along the same lines, allow your hygienist to be sick. We are human, and humans are known to be susceptible to viruses and other infectious diseases. Allowing them to rest and recover without guilt is an important part of a positive workplace culture.
Additionally, it is not the responsibility of the sick hygienists to find a temporary hygienist to cover their patients. This is the responsibility of the practice owner or office manager. Attempting to guilt your hygienist for being sick and further kicking them while they are down by requiring they find someone to cover their patients is unreasonable and creates a negative workplace culture.
Eliminating guilt for taking time off creates a better work-life balance as well as a positive workplace culture. Employers cannot expect their employees to function well when they cannot take care of themselves and their families. Positive workplace culture includes valuing the employee’s well-being as much as their performance.
I’m not sure why it needs to be said out loud, but in most cases, employees’ families come before their jobs, as they should. Employers expect their employees to care about their business as much as they do, which is an unreasonable expectation. However, employees will care more if they are treated well. This is a perfect segue to address feeling overworked.
Appropriate Appointment Times
Please allow your dental hygienists the proper amount of time to treat their patients. Ideally, a one-hour appointment for recare patients is appropriate. I understand that, in some cases, 45 to 50 minutes will be acceptable, but allowing your dental hygienist to determine the appropriate time for the delivery of treatment would easily alleviate the feeling of being overworked.
Additionally, consider hiring multiple part-time dental hygienists for a full-time position instead of only focusing on accepting resumes from those looking for full-time. A selling point for me when I decided to go to dental hygiene school was the fact that I could work part-time while my children were young.
Even for hygienists who start out gung-ho and want to work 40-plus hours a week, the job is physically and mentally demanding. There may come a time when they are interested in cutting back on their work hours. Support this decision, and don’t try to guilt them into continuing to work more hours than they are comfortable with. Guilting them is a great way to push them out of the profession altogether due to burnout.
In Closing
Changing laws to allow assistants to provide dental hygiene treatments is not a viable answer to the dental hygienist shortage. The Alabama Dental Hygiene Program is a perfect example of how this model does not address real problems, including the dental hygienist shortage and lack of access to care.
Further, allowing assistants to provide the same “care” as dental hygienists is a disservice to patients who have garnered our trust. A better and potentially quicker solution would be to make changes within individual practices to offer better work-life balance, fair wages, and the ability to treat patients without time constraints.
The pandemic allowed many hygienists to reflect on their satisfaction with their profession. Though the majority remained in the field, many opted for careers that offered benefits, better work-life balance, and more appreciation. Be willing to have an open conversation with potential hires on what they are looking for in a potential employer.
The dental hygienist shortage will not right itself quickly, no matter what your idea of a solution is. Bills that would allow assistants to provide dental hygiene treatment take months to years to implement. Not to mention, there is no evidence that this alleviates the dental hygienist shortage and would likely further contribute to the dental assistant shortage.
Making changes within individual practices may be a quicker, albeit not instant, solution that more dental practice owners should consider.
Before you leave, check out the Today’s RDH self-study CE courses. All courses are peer-reviewed and non-sponsored to focus solely on pure education. Click here now.
Listen to the Today’s RDH Dental Hygiene Podcast Below:
References
- Bill Status of HB4501. (2022, May 27). Illinois General Assembly. https://www.ilga.gov/legislation/billstatus.asp?DocNum=4501&GAID=16&GA=102&DocTypeID=HB&LegID=137957&SessionID=110
- Kansas Dental Practices Act: Determining the Impact of the 1998 Changes to the Act. (2007, July). Kansas Legislative Division of Post Audit. https://www.kslpa.org/wp-content/uploads/2019/08/r-07-23.pdf
- Alabama Dental Hygiene Program: Instructor and Student Program Overview & Information Handbook. (2023, August 28). Alabama Board of Dental Examiners. https://dentalboard.org/wp-content/uploads/2023/08/BDEAL-ADHP-Instructor-Student-Handbook-REV-08282023.pdf
- Alabama Dental Hygiene Program 2024-2025 Lecture/Exam Schedule. (2024, February 14). Alabama Board of Dental Examiners. https://dentalboard.org/wp-content/uploads/2024/02/2024-2025-ADHP-Lecture-Exam-Schedule-02142024_FINAL_.pdf
- Dental Hygiene Associate in Science. (2023, May 23). Florida State College at Jacksonville. https://www.fscj.edu/docs/default-source/programs/2300/as-dental-hygiene.pdf
- Rocha, A. (2023, November 13). At Least Five Alabama Counties Lack Dentists, says Former Dental Association Director. Alabama Reflector. https://alabamareflector.com/2023/11/13/at-least-five-alabama-counties-lack-dentists-says-dental-association-director/
- Alabama Rural Health Talking Points – 2017. (2016, March 15). Alabama Rural Health Association. http://www.alabamacounties.org/wp-content/uploads/2017/08/rural-health-handouts.pdf
- Health Professional Shortage Areas: Dental Care, by County, April 2024 – Alabama. (2024, April). Rural Health Information Hub. https://www.ruralhealthinfo.org/charts/9?state=AL
- Dental Workforce Shortages: Data to Navigate Today’s Labor Market. (2022, October). American Dental Association. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/dental_workforce_shortages_labor_market.pdf
- FLSA Hours Worked Advisor. (n.d.). United States Department of Labor. https://webapps.dol.gov/elaws/whd/flsa/hoursworked/screenER78.asp
