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3
The Oral Health Care Workforce
T
he oral health care workforce is a critical component of access
to care for vulnerable and underserved populations in that access
is dependent, in part, on the availability of a sufficient supply of
competent oral health care professionals. The extent to which the different
professionals interact with each other can vary greatly. In addition, the ser-
vices that may be delivered by each professional often vary by state. These
issues are not dissimilar to those which have been faced in other health
care professions.
This chapter gives an overview of the oral health workforce including
basic demographics, how professionals are educated, what kind of care they
provide, and how they interact. The chapter continues with a discussion
of the regulation of the health care workforce in general, and the dental
workforce specifically. Finally the chapter concludes with descriptions of a
variety of innovations in workforce education, training, and use to improve
access and care for underserved and vulnerable populations. The capacity
and efficiency of the oral health care system (including consideration of the
adequacy of the workforce) is discussed in Chapter 4.
THE DENTAL WORKFORCE
As with other health care professions, it can be difficult to definitively
quantify the dental workforce for a variety of reasons including changes
in employment status, differing measures (e.g., licensed vs. active profes-
sionals), the holding of more than one position per professional, and the
presence of multiple and overlapping job titles. Aside from sheer numbers,
83
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84 IMPROVING ACCESS TO ORAL HEALTH CARE
consideration is needed for geographic distribution and racial, ethnic, and
gender diversity. This section provides a general overview of the basic de-
mographics of the dental workforce.
General Description
Most professionally active dentists are general dentists (ADA, 2009d)
(see Box 3-1 for types of dentists). Recognized specialties include orthodon-
tics and dentofacial orthopedics, oral and maxillofacial surgery, pediatrics,
periodontics, prosthodontics, endodontics, oral and maxillofacial pathol-
ogy, oral and maxillofacial radiology, and dental public health. Almost all
professionally active dentists (92 percent) work in the private practice set-
BOX 3-1
Types of Dentists
A professionally active dentist is primarily or secondarily occupied in a
private practice, dental school faculty/staff, armed forces, or other
federal service (e.g., Veterans Administration, U.S. Public Health
Service); or is a state or local government employee, hospital staff
dentist, graduate student/intern/resident, or other health/dental
organization staff member.
An active private practitioner is someone whose primary and/or second-
ary occupation is private practice.
A new dentist is anyone who has graduated from dental school within
the last 10 years.
An independent dentist is a dentist running a sole proprietorship or one
who is involved in a partnership.
A solo dentist is an independent dentist working alone in the practice
he or she owns.
A nonowner dentist does not share in ownership of the practice.
An employed dentist works on a salary, commission, percentage, or
associate basis.
An independent contractor contracts with owner(s) for use of space
and equipment.
A nonsolo dentist works with at least one other dentist and can be an
independent or nonowner dentist.
NOTE: Each of these types can be either general or specialty practitioners.
SOURCES: ADA, 2009b,d.
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THE ORAL HEALTH CARE WORKFORCE
ting (ADA, 2009d). (See Chapter 4 for more on the private practice setting
of care.) Occupations of other professionally active dentists include1
• Dental school faculty/staff member (1.7 percent)
• Armed forces (0.9 percent)
• Graduate student/intern/resident (1.3 percent)
• Hospital staff dentist (0.4 percent)
• State or local government employee (0.8 percent)
• Other federal service (0.8 percent)
• Other health/dental organization staff (1.0 percent)
In 2009, 48 percent of dental school graduates planned to enter private
practice immediately while 30 percent planned to pursue advanced educa-
tion, 10 percent planned to enter some form of government service, and less
than one-half of 1 percent planned to enter the fields of teaching, research,
or administration2 (Okwuje et al., 2010).
Dental hygienists are found in most settings where oral health services
are provided, but they are mainly employed in private dental practices.
They also work in educational institutions and in public health settings such
as school-based clinics, prisons, long-term care, and other institutional care
facilities (ADHA, 2009b; Mertz and Glassman, 2011). In private dental
practice, the work of dental hygienists is generally billed under the dentist’s
contractual agreement with an insurance company using the supervising
dentist’s provider number. However, as of June 2010, 15 states allowed
their state Medicaid departments to directly reimburse dental hygienists for
their services (ADHA, 2010c).
Dental assistants primarily work in a clinical capacity, but other
roles include front-office positions, practice management, and education
(McDonough, 2007). Most dental assistants work in private practices and
as assistants to general dentists, but many dental assistants work in spe-
cialty practices. Currently, there are multiple job titles for dental assistants
across the country in different states (ADAA/DANB Alliance, 2005; DANB,
2007). These titles are generally grouped into four categories: entry level
(e.g., trainees), dental assistants, certified or registered dental assistants,
and expanded functions dental assistants (EFDAs) (DANB, 2007). Each
of these categories includes multiple titles, depending on the state. For
example, while the title of EFDA is commonly used to describe all dental
assistants who can perform extended duties, there are many other titles used
(e.g., expanded duties dental assistant, advanced dental assistant, registered
restorative assistant in extended functions), and many states permit dental
1 Does not total 100 percent due to rounding.
2 The remaining graduates reported “other/undecided” for their future plans.
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86 IMPROVING ACCESS TO ORAL HEALTH CARE
assistants to perform specific extended functions (e.g., coronal polishing,
administration or monitoring of sedation, pit and fissure sealants) (DANB,
2007). In fact, some states permit certified dental assistants to act at the
level of an EFDA, even though titles such as certified dental assistant or
registered dental assistant are used (DANB, 2007). As stated by the Dental
Assistant National Board, “Without a single, nationally accepted set of
guidelines that govern the practice of dental assisting in the country, it is
difficult to execute a concise overview” of the profession (DANB, 2007).
(EFDAs are discussed further later in this chapter.)
Dental laboratory technicians (also known as dental technicians) create
bridges, dentures, and other dental prosthetics. Dental technicians work in
a variety of settings including dentists’ offices, their own private businesses,
or small privately owned offices (BLS, 2010e). While dental technicians cre-
ate devices based on the prescription of a dentist, denturists are trained and
licensed in some states to work independently in taking impressions and
making, fitting, and repairing dentures. Denturists were first recognized as a
profession in Oregon, where licensure began in 1980 (Oregon State Dentur-
ist Association, 2011). Seven states currently regulate denturists (National
Denturist Association, 2011). Denturists are not typically considered part
of the traditional dental team.
Current Numbers and Future Demand
As mentioned previously, determining the exact number of profession-
als can be difficult because of differences in terminology, differing measures,
and employment characteristics. According to the Bureau of Labor Statistics
(BLS), dentists held approximately 141,900 jobs in 2008, with about 85
percent of those practitioners being general dentists (see Table 3-1). In that
same year, an American Dental Association (ADA) survey found that there
were 181,725 professionally active dentists, of which 79 percent were gen-
eral dentists and 21 percent were new dentists (graduated within the previ-
ous 10 years) (ADA, 2009d). Similarly, it can be difficult to estimate the
dental hygiene workforce. As shown in Table 3-1, dental hygienists held just
over 174,000 jobs in 2008, but this is likely an overestimate, since many
dental hygienists hold more than one job. A 2007 survey commissioned
by the American Dental Hygienists’ Association (ADHA) found that there
were about 152,000 licensed dental hygienists in the United States and that
130,000 were actively practicing (ADHA, 2009b). About half of all dental
hygienists work part time (ADHA, 2009b; BLS, 2010c).
Table 3-1 also shows the BLS estimates of numbers of jobs held by and
increases in growth of all dental professions. The BLS predicts a 36 percent
growth in the employment of both dental hygienists and dental assistants
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THE ORAL HEALTH CARE WORKFORCE
TABLE 3-1
Employment of Dental Professions and Occupations, 2008 and
Projected 2018
Profession/ Number of Number of Projected Increase in
Occupation Jobs, 2008 Jobs, 2018 Growth (%), 2008–2018
Dentists 141,900 164,000 16
General dentists 120,200 138,600 15
Dental hygienists 174,100 237,000 36
Dental assistants 295,300 400,900 36
Dental laboratory
46,000 52,400 14
technicians
SOURCES: BLS, 2010b,c,d,e.
between 2008 and 2018, ranking them among the fastest growing of all
occupations.
Income
The BLS reports a mean annual wage of almost $143,000 for salaried
general dentists (BLS, 2010d). This is similar to the ADA estimate of the av-
erage net income (from the primary private practice) for employed dentists
of $132,000 (ADA, 2009c); however, as noted above, employed dentists
account for only a small portion of all dentists. Dentists’ income can vary
depending on setting and type of employment (see Table 3-2). Incomes also
vary slightly depending on whether the practice is incorporated or unincor-
porated, the age of practitioner, the number of years since graduation, and
the number of hours worked per year. In comparison, a survey of executive
directors of health centers reported an average salary for the highest-paid
dentist on staff of $125,000; the average budgeted salary for a dentist with
10 or more years of experience was $145,000 (Bolin, 2010).
In 2008, dental hygienists had a median annual wage of about $66,500
and dental assistants had a median annual wage of about $32,000 (BLS,
2010b, 2010c). Nearly 30 percent of dental hygienists do not receive any
benefits (ADHA, 2009b). In 2008, dental technicians had a median annual
wage of about $34,000 (BLS, 2010e).
Age
The ADA estimates that 35 percent of all professionally active dentists
are age 55 and older, with an average age of 49.6 years (ADA, 2009d).
Among independent dentists in private practice, 43 percent are age 55 or
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88 IMPROVING ACCESS TO ORAL HEALTH CARE
TABLE 3-2
Private Practice Dentists’ Net Income by Type of Employment, 2007
Net Income from Total Net
Primary Private Income from
Practitioner Practice ($) Dentistry ($)
All independent dentists 234,000 237,000
Independent general practitioners 206,000 208,000
Independent nonsolo general practitioners 232,000 237,000
Independent specialists 353,000 360,000
Independent nonsolo specialists 392,000 405,000
Solo general practitioners 195,000 196,000
Solo specialists 334,000 338,000
n/aa
Employed dentists (weighted) 132,000
Employed general practitioners 122,000 n/a
Employed specialists 181,000 n/a
New employed dentists 114,000 n/a
Independent contractors (weighted) 114,000 n/a
aN/A = not available.
SOURCE: ADA, 2009c.
older, with an average age of 52.3 years (ADA, 2009b). This may add to the
burden of need for dentists as these practitioners near retirement. The mean
age of dental hygienists is about 44 years of age (ADHA, 2009b), which,
like dentists, may lead to concerns about the numbers nearing retirement.
Gender
About 79 percent of all professionally active dentists are male (ADA,
2009d). However, the gender gap is slowly closing; 63 percent of new pro-
fessionally active dentists are male, and only 56 percent of first-year dental
students in the 2008–2009 academic year were male (ADA, 2009d, 2010a).
Overall, dental hygienists and dental assistants are virtually all female
(ADHA, 2009b; McDonough, 2007). This is not likely to change drastically
in the near future; among all students enrolled in accredited programs in
2008–2009, 97 percent of dental hygiene students and 95 percent of dental-
assisting students were female (ADA, 2009a).
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THE ORAL HEALTH CARE WORKFORCE
Racial and Ethnic Diversity
The racial and ethnic profile of the dental workforce is not representa-
tive of the overall population (see Table 3-3). While diversity among the
dental professions students has increased in the previous decade (see Table
3-4), the numbers still are not significantly changed.
Evidence shows that a diverse health professions workforce (including
race and ethnicity, gender, and geographic distribution) leads to improved
access for underserved populations, greater patient satisfaction, and better
TABLE 3-3
Dental Professions by Percentage of Race and Hispanic Ethnicity, 2000
General Dental Dental
Population Dentists Hygienists Assistants
Whitea 75.1 82.8 90.9 75.8
Black or African
12.3 3.3 2.3 5.6
Americana
Asiana 3.6 8.8 2.0 3.6
Hispanic or
12.5 3.6 3.7 12.6
Latino Origin
aCategory excludes Hispanic origin.
SOURCES: U.S. Census Bureau, 2000, 2002.
TABLE 3-4
Percentage of Dental Professions School and Program Enrollment
by Race and Hispanic Ethnicity, 2000–2001 and 2008–2009
Enrolled Dental Enrolled Dental Enrolled Dental
Assistant Studentsa
Students Hygiene Students
2000–2001 2008–2009 2000–2001 2008–2009 2000–2001 2008–2009
White 63.4 59.9 82.3 78.6 68.4 60.2
Black 4.8 5.8 4.2 4.4 12.5 15.1
Asian 24.8 23.4 4.6 7.0 2.9 4.8
Hispanic 5.3 6.2 5.7 7.3 9.7 11.1
aIncludes only dental assistant students enrolled in CODA-approved programs.
Racial and ethnic diversity of entire dental assistant workforce may be different.
SOURCES: ADA, 2002, 2009a, 2010a.
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90 IMPROVING ACCESS TO ORAL HEALTH CARE
communication (HRSA, 2006; IOM, 2004). The Agency for Healthcare Re-
search and Quality 2010 National Healthcare Disparities Report (AHRQ,
2010) stated:
Workforce diversity increases the opportunities for race- and language-
concordant health care visits. It also can improve cultural competency
at the system, organization, and provider levels in several ways. These
include appropriate program design and policies, organizational com-
mitment to culturally competent care, and cross-cultural education of
colleagues [Nickens, 1992]. As such, diversity is an important element of
a patient-centered health care encounter.
Health care professionals from underrepresented minority (URM)
populations, in part due to patient preference, often account for a dis-
proportionate amount of the services provided to URM and low-income
populations (Brown et al., 2000; HRSA, 2006; IOM, 2003; Mitchell and
Lassiter, 2006). For example, a 1996 survey by the ADA revealed that
nearly 77 percent of white dentists’ patients were white, while 62 percent
of African American dentists’ patients were African American and only
27 percent were white (ADA, 1998; Brown et al., 2000). More recently,
among dental students graduating in 2008, 80 percent of African American
students and 75 percent of Hispanic students expected at least one-quarter
of their patients would be from underserved racial and ethnic populations;
nearly 37 percent of the African American students and 27 percent of the
Hispanic students expected at least half their practice would come from
these populations (Okwuje et al., 2009). In comparison, only 43.5 percent
of white students expected at least one quarter of their patients to come
from underserved racial and ethnic populations, and only 6.5 percent ex-
pected at least half of their practice to comprise these populations (Okwuje
et al., 2009). It is important to note that the recruitment of low-income
students (regardless of race or ethnicity) may also be important for the care
of vulnerable and underserved patients (Andersen et al., 2010). A 2011
study of dental students found that students who were female, from URM
populations, or had low socioeconomic status expressed greater attitudes
of altruism than other students (Carreon et al., 2011).
Several factors complicate recruitment of URM students including lack
of exposure to and knowledge of the dental profession, minimal oppor-
tunities for mentorship from dental professionals, and competition from
other health professions for underrepresented minority students who are
academically qualified (Haden et al., 2003). Other barriers may include lack
of financial resources or knowledge of available financial aid.
Several Title VII grants are specifically targeted to increase the diversity
of the health care workforce. Dental schools with significant enrollment
of URM students are eligible for Centers of Excellence grants to improve
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THE ORAL HEALTH CARE WORKFORCE
recruitment and training of URM students.3 Health Careers Opportunity
Program grants are available to dental and dental hygiene schools to estab-
lish or extend programs to identify, recruit, and support students from dis-
advantaged backgrounds.4 Scholarships for Disadvantaged Students grants
provide funding to dental and dental hygiene schools for financial aid to
disadvantaged students.5 Experiences with bridge and pipeline programs
to recruit students from URM, low-income, and rural populations are dis-
cussed later in this chapter.
Distribution of the Dental Workforce
The distribution of the dental workforce, both in geographic disper-
sion as well as specialization, is a long-recognized challenge (Brown, 2001;
Hart-Hester and Thomas, 2003; Mertz and Grumbach, 2001; Saman et al.,
2010). In 1957, Dr. Wesley Young stated, “A recurrent problem in dental
manpower is the tendency of dentists to concentrate in urban areas, leaving
sparsely settled sections of the state understaffed” (Young, 1958). In 2001,
Brown noted that while the workforce may be adequate at the national
level, there are imbalances at the regional level (Brown, 2001). Part of the
reason for maldistribution has to do with the ability of a dentist to sup-
port private practices in rural areas because of population size or income
(Allison and Manski, 2007; Wall and Brown, 2007; Wendling, 2010). These
same issues may affect the development of independent dental hygiene
practices (Brown et al., 2005). One way to estimate geographic distribu-
tion is to look at the ratio of dentists per population. In 2007, there was an
average of about 59 professionally active dentists per 100,000 population,
ranging from about 40 dentists per 100,000 population in Mississippi and
Arkansas to about 102 dentists per 100,000 population in the District of
Columbia (ADA, 2009d; U.S. Census Bureau, 2010). The lowest ratios
occur across the southernmost states in the United States (Kaiser Family
Foundation, 2011).
Within these numbers, there are variations in the types of dentists avail-
able in each region and across the country. For example, there are 0.7 pro-
fessionally active periodontists per 100,000 adult population (age 18 and
above), or more than 144,000 adults per professionally active periodontist.
In contrast, there are about nine pediatric dentists per 100,000 population
of children aged 17 and under, translating to more than 11,000 patients
per pediatric dentist (about 3,200 children under age 5 for each pediatric
dentist). But this varies even more when looking at individual states. For ex-
3 42 U.S.C. §293.
4 42 U.S.C. §293c.
5 42 U.S.C. §293a.
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92 IMPROVING ACCESS TO ORAL HEALTH CARE
ample, Massachusetts has one pediatric dentist for every 6,000 children age
17 and under (one for every 1,600 children under age 5), but West Virginia
has only about one pediatric dentist for every 23,000 children age 17 and
under (one for every 6,200 children under age 5). Similarly, Massachusetts
has one periodontist for every 18,500 adults, while West Virginia has one
periodontist for every 84,000 adults.
Concurrently, the dental hygiene workforce may also be experienc-
ing challenges owing to the maldistribution of dentists and the downturn
in the economy. For example, a 2009 survey of dental hygienists showed
that 68 percent of respondents reported finding sufficient employment was
somewhat or very difficult in their geographic area, and of these, 80 percent
felt that there were too many hygienists living in the area (ADHA, 2009a).
Based on the number of providers per population, another way to measure
the distribution of the dental workforce is to examine the designation of
Health Professional Shortage Areas (HPSAs). By regulation, the secretary of
the Department of Health and Human Services (HHS) has the responsibility
of defining HPSAs.
Health Professional(s) Shortage Area means any of the following that
the Secretary determines has a shortage of health professional(s): (1) An
urban or rural area (which need not conform to the geographic boundar-
ies of a political subdivision and which is a rational area for the delivery
of health services); (2) a population group; or (3) a public or nonprofit
private medical facility.6
Box 3-2 delineates the specific requirements for designation of a dental
HPSA.
As of March 13, 2011, there were 4,639 dental HPSAs with 33.3 mil-
lion unserved individuals; it is estimated that 9,933 new dentists would be
needed to achieve the target ratio for these populations to be adequately
served, defined as 1 dentist per 3,000 individuals (HRSA, 2011b). The num-
ber of dental HPSAs and need for dentists is on the rise; in 2009, there were
4,230 dental HPSAs and a need for 9,642 new dentists to meet unserved
needs (HRSA, 2010c). Two-thirds of current dental HPSAs are in nonmet-
ropolitan areas (HRSA, 2011b). Among all dental HPSAs, 17 percent are
designated by geographic area, 34 percent are designated by population
group, and 49 percent are designated by facility (HRSA, 2011b). Figure 3-1
shows the array of dental HPSAs across the country for both geographic
areas (including areas in which the entire county is a dental HPSA) and
population groups.
As discussed in Chapter 1, making estimates of underservice and unmet
6 Code of Federal Regulations, Public Health Service, Department of Health and Human
Services, title 42, chapter 1, part 5 (2010).
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93
THE ORAL HEALTH CARE WORKFORCE
BOX 3-2
Requirements for Dental HPSA Designation
Geographic areas must meet these requirements:
• e rational areas for the delivery of dental services.
B
• eet one of the following conditions:
M
o ave a population to full-time equivalent (FTE) dentist ratio of at
H
least 5,000:1, or
o ave a population to FTE dentist ratio of less than 5,000:1 but
H
greater than 4,000:1 and unusually high needs for dental services
or insufficient capacity.
• ental professionals in contiguous areas must be overutilized, exces-
D
sively distant, or inaccessible to the population.
Population groups must meet these requirements:
• eside in a rational service area for the delivery of dental care
R
services,
• ave access barriers that prevent the population group from use of
H
the area’s dental providers,
• ave a ratio of the number of persons in the population group to the
H
number of dentists practicing in the area and serving the population
group of at least 4,000:1, and
• embers of certain federally recognized American Indian tribes are
M
automatically designated. Other American Indian or Alaska Native
groups may be designated if the meet the basic criteria described
above.
Facilities must meet these requirements:
• e either federal and/or state correctional institutions or public and/
B
or nonprofit medical facilities, and meet specific criteria.
• ederal or state correctional facilities must:
F
o ave at least 250 inmates, and
h
o ave a ratio of the number of internees per year to the number of
h
FTE dentists serving the institution of at least 1,500:1.
• ublic and/or nonprofit private dental facilities must:
P
o rovide general dental care services to an area or population
p
group designated as having a dental HPSA, and
o ave insufficient capacity to meet the dental care needs of that
h
area or population group.
SOURCE: HRSA, 2011a.
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146 IMPROVING ACCESS TO ORAL HEALTH CARE
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