Reports indicate an estimated 11% reduction in national dental practice capacity caused by the shortage of dental assistants and dental hygienists in 2022, while the COVID-19 pandemic led to an approximate 8% decrease in dental hygienist employment. Furthermore, enrollment across the United States in dental assisting programs has faced a decrease since 2015 and research indicates that 1/3 of the dental assistant and dental hygienist workforce expect to retire in five years or less. As we work to authorize and implement dental therapists across the states, it is important to ensure there is a supportive working environment for them as well as other dental professionals.
As a result, 74% of private clinicians declare that it is "extremely challenging" to recruit qualified dental hygienists, and another 19% consider it as "very challenging." Correspondingly, 84% of the clinic owners say that it is extremely or very challenging to recruit dental assistants. Dental therapists work as part of the dental team and a shortage of other members of the team reduces everyone's ability to care for patients and provide health services to diverse sectors of society.
In 2022, the Dental Assisting National Board registered that the top job factors for a satisfactory environment were salary, work/life balance, and feeling like part of a team. The report also demonstrated that satisfaction among dental assistants in their workplace has been on a decline since 2016, decreasing by 20 percentage points between 2016 and 2022. Experts attribute this concerning pattern to six main reasons: insufficient pay, negative workplace culture, excessive workload, lack of growth opportunities, inadequate benefits, and communication concerns.
Exploring exit factors: unraveling the dynamics of dental workforce departures
Insufficient Pay and Benefits
A 2022 report conducted by the American Dental Association’s (ADA) Health Policy Institute and collaborators revealed that the majority of the interviewed dental assistants (78%) and dental hygienists (89%) have never received a raise, and among those who have, it was an increase in the 1-3% range. Additionally, it was found that in private solo or group practice, benefits such as health insurance, paid sick time, paid vacation, and continuing education or professional development funds are often not available to dental hygienists and assistants, even though they consider these benefits "very desirable."
Cristina McKay, MPH, PCMH CCE, Senior Manager of Clinical Integration for the Illinois Primary Health Care Association, emphasized, “People within the community do not feel the motivation to pay months of tuition to attend the schooling and then having a salary that compares to the one in the retail industry where, in some cases, no specific certificate or educational qualifications are required.”
Research has consistently demonstrated the correlation between employee benefits and levels of job satisfaction and engagement. However, findings from an ADA 2023 poll indicate that only 49% of employers overall reported offering health insurance, with a mere 39% of dentists engaged in solo practice responding "yes" to providing health insurance. This aligns with the insights from the ADA’s 2022 report, revealing that only 22% of dental assistants and 15% of dental hygienists received paid leave.
Workplace Culture and Communication
Some of the main factors that contribute to dental assistants’ and dental hygienists’ satisfaction are being valued, having opportunities to advance in their professional career, and having good communication with the team and with their supervisors. Jean Moore, DrPH, FAAN, Director of Center for Health Workforce Studies affirmed that similar research has corroborated that workforce issues are at least partly related to workplace culture. Their research shows that staff satisfaction is associated with being treated as partners, as people who have something to contribute, rather than as employees who merely receive orders.
Workload and Growth Opportunities
As documented in the Addressing Health Worker Burnout report in 2022, when health workers find themselves in burnout from an overwhelming workload, they may spend less time with patients and make more medical errors. Those factors could result in poor quality care and a loss of trust by patients. Moreover, constantly replacing staff is also linked to a loss of clinic owners' resources, such as time, energy, and money.
Actions to improve dental team wellness include offering paid time off to recharge, mental health services, regular team meetings, regular one-on-one meetings with team members, and training opportunities on addressing burnout, among others.
The concerning impact on communities: a glimpse into the future
The potential consequences of this trend suggest strong effects in rural areas, which already face health access challenges. Experts suggest that as one major impact, people won't be able to find a dental appointment due to the lack of workforce, which can cause generalized health problems, since research has linked chronic dental infections to diabetes complications, heart disease, and life-threatening conditions.
Sahira Khalid, who is a clinical workforce specialist at Northwest Regional Primary Care Association (NWRPCA), states that rural communities would suffer greater challenges due to the time and effort that a community puts into building confidence in a health worker. She explains that once the funding stops for rural programs or oral health care workers leave, it becomes profoundly difficult for a community to rebuild that trust again, sometimes even impossible. Furthermore, Robyn Weiss, PT, M.ED, Director of Workforce Development at NWRPCA, explains that a lower staff ratio, particularly in rural areas, weighs on all healthcare providers. She states that when a patient comes to the primary care physician in the community with oral health needs and the provider may not be able to fulfill those needs due to limited resources, the provider may perceive it as a failure and a lack of support network needed to provide integrated health care.
Alternate routes: exploring solutions and recommendations
Increasing benefits such as health insurance, wage growth and paid leave is "very desirable" in the industry, especially in private clinics. Wages should be in accordance with the price increase in the cost of living each year in addition to implemented policies in line with creating a safer and just work environment.
"In many ways, we have some of the solutions at our fingertips, but we don't pay attention to them, or we don't have the political will to move things forward", highlights CHWS’s Jean Moore. Moore's team has been struggling with creating more access to preventive services in the community, allowing dental hygienists to work in schools, Head Start programs, nursing homes, and communities to create better dental care access. However, Moore declared that the scope of practice for dental hygienists is very restricted and limited in many states, adding that it is very hard to change policies regarding dental hygiene scope of practice, even though it is in the best interests of the patients.
The number of days of poor mental health and burnout experienced by U.S. health workers increased in 2022 in comparison with 2018. Workplaces should not promote or replicate the unsafe conditions, such as working without adequate personal protective equipment, that were faced by many institutions during the pandemic. Instead, employment settings are highly encouraged to reduce administrative and documentation burdens along with the cognitive load and increasing flexibility in work scheduling.
Candace Owen, RDH, MS, MPH, Senior Director of Education and Strategic Partnerships at the National Network for Oral Health Access, recommends having a minimum of two dental assistants working clinically to support one dentist. Additionally, she encourages clearly defining the roles and responsibilities of dental assistants and front office administrative team members to avoid burnout. The U.S. Surgeon General Vivek Murthy warns that we must join forces as a society to build a health care system where patients, communities, and health workers can all advance and protect one another.
Jonathan Ricardo Diaz Masaya is a dental student from Guatemala and a 2024 fellow with the U.S. State Department’s Community Engagement Exchange Program currently working with Community Catalyst.