The talk is that there isn`t enough hygienists applying for jobs, but the swaggering walk implies some ulterior motives
Christine Nielsen Nathe, RDH, MS,
Deborah B. Bauman, BSDH, MS,
Michele Darby BSDH, MS,
Deanne Shuman, BSDH, MS
Dentists in many states report local shortages in dental hygiene manpower, although no published data can be found confirming such a shortage. Access to dental hygiene care has received much attention in the dental literature lately. Even though the American Dental Hygienists` Association has issued a report suggesting an adequate supply of hygiene manpower, many state dental associations continue to report statewide manpower shortages.
Because of dental hygiene`s responsibility to serve the public, it is important that the profession study the manpower concerns. Unfortunately, many issues in the dental community lead to legitimate concerns about the difficulty in hiring and retaining dental hygienists. In order to understand the current dilemma, it is necessary to be aware of the issues surrounding the situation and to identify the supply of, and the demand for, workers.
One reaction to a shortage is preceptorship
In many states, dental organizations have proposed preceptorship training and the opening of new dental-hygiene programs to alleviate these "reported" shortages. The significance of these proposed solutions is important to all dental hygienists, dentists, legislators, and, ultimately, the public.
A dental-hygiene manpower shortage may lead some dentists to advocate employee-sponsored training, synonymously referred to as preceptorship. Preceptorship, if legalized, would allow dentists to train individuals as "limited" dental hygienists.
The concept raises the issue of whether dentists are qualified to educate dental hygienists. Data from the American Dental Association show that dental students receive a mean of 298.69 hours in periodontics, whereas dental-hygiene students receive a mean of 741.2 hours of instruction in periodontal and dental hygiene clinical sciences. The instruction includes periodontology, periodontal assessment, periodontal probing and charting, initial periodontal therapy, and oral health education. In addition, a study which compared the content of board examinations revealed that dentists may not be qualified to teach dental-hygiene science, simply because dentists are not tested on this science as part of their national board examination.
These issues underscore the importance of dental hygienists educating potential dental hygienists.
Studies reveal that 90 percent of the population have periodontal diseases, which emphasizes the need for periodontal treatment. Furthermore, one study suggests that 90 percent of the treatment needed to address all periodontal needs would be prophylaxis and that 11 percent of treatment time would be devoted to extensive scaling and surgical intervention.
In fact, most periodontal treatment needs can be provided by dental hygienists.
The primary role of the dental hygienist is to provide preventive dental and periodontal treatment, which is evident in the increasing usage of dental hygienists in initial periodontal therapy. Moreover, the curriculum guidelines for periodontics published in 1992 state that dental students should be taught to consult with and refer to dental hygienists those patients needing nonsurgical periodontal therapy and supportive periodontal treatment.
This evidence validates the dental hygienists` formal educational qualifications for treating people with periodontal involvement, while decreasing the credibility of dentists to train individuals in dental hygiene and nonsurgical periodontics.
To an individual interested in pursuing a lifelong career, the time invested in college is an assumed commitment. Hard-working, motivated individuals choose careers that offer challenge. Education is needed to prepare individuals for entering professional careers. Decreasing educational standards for dental hygienists would deter career-minded individuals from entering the dental-hygiene field. Preceptorship or alternative training would decrease career marketability to potential, qualified students, decreasing the future supply of educated dental hygienists.
Alabama is the only state that prepares hygienists with the preceptorship training method. Interestingly, a 1990 study revealed that Alabama exhibits a dental-hygiene shortage. This finding suggests that preceptorship training has not achieved adequate dental hygiene manpower in Alabama.
How much training protects the public?
A workforce shortage of hygienists would decrease the availability and quality of services provided to the general public. Some state dental associations may believe that preceptorship will not have a negative effect on public health. However, the policy of the ADA Commission of Dental Accreditation states that a two-year, formal educational program is the minimum required to provide adequate public protection. A study conducted by Mescher suggests that over 70 percent of educational programs take more than two academic years of preparation. Further, a study conducted by the ADA revealed that 81 percent of students entering dental-hygiene school had at least one year of college, and the mean number of years required within all dental-hygiene programs was 2.25 years, which exceeds the two-year requirement. Thus, most dental hygienists have completed well over three years of academic study.
Both the American Association of Dental Schools (AADS) and the ADA Commission on Dental Accreditation hold that preceptorship training does not meet the commission`s minimum educational standard of two years of formal education designed to help assure adequate patient protection. The AADS also has resolved that preceptorship training for dental hygienists endangers the quality of education in that field. Moreover, the ADA Council of Dental Education maintains the following position:
"The growing need to treat an older population with a wide variety of medical complications, together with the imperative that infection-control procedures be well established and carefully monitored by the dentists as well as the auxiliary staff, lend credence to efforts to maintain, rather than reduce, the educational requirements."
Some state dental associations may develop additional dental hygiene programs within the state because of a "reported" manpower shortage. History has revealed that opening new programs does not translate in enrollments and graduates. More dental hygiene programs does not necessarily increase the pool of practicing hygienists. In addition, it is always important to investigate the actual manpower of an occupation before advancing solutions to personnel deficits.
Who`s counting the manpower?
To understand the issue, it is necessary to be knowledgeable about what constitutes a manpower shortage. Manpower shortage often is used as a term to conveniently describe a variety of situations - some of which generally are not considered an actual shortage. The fact is, some job-market conditions are incorrectly called shortages.
A shortage occurs only when adjustment is slow in one of three areas:
- Supply of workers.
- Demand for workers.
- Wage rate.
So a shortage is eased when higher wages attract more workers as a result of increased labor costs. A slowdown is felt in the economy or a switch in production methods is implemented that requires less labor.
Types of manpower shortages include the following: false labor shortage, supply inflexibility, short duration, wage inflexibility, increased demand, and geographically-located shortages. These various manpower shortages are the product of different situations and require unique management approaches.
Information published by the Institute of Medicine regarding health manpower shortages suggests:
"Reported vacancies should be viewed with caution because they do not always represent a shortage. If, through one mechanism or another, wages are kept below the level that would bring demand and supply into equilibrium, employer demand will always exceed the number of allied health personnel who want to work at the going wage. Such excess demand cannot really be characterized as a shortage but rather as an imperfection in the operation of the market."
False labor shortages are seen when employers will not raise wage rates or improve working conditions. Then, employees will find employment opportunities in other areas until the prevailing wage rate is increased and working conditions improve. This suggests that dental hygienists will change careers when the dentist devalues dental hygiene by decreasing compensation or demoting the working conditions. In theory, most labor shortages should disappear as employers increase wages to attract more workers.
The most common type of workforce shortage occurs when increases in the compensation offered by employers fail to attract a sufficient number of potential employees. Such supply-inflexible shortages most frequently occur in occupations that require a college education. When an education is needed to acquire the knowledge necessary before entering an occupation, there may be a lag between the time the employer enhances the working conditions and when the manpower of that occupation increases. When an increased demand for dental hygienists is projected, dentists must enhance the attractiveness of employment immediately to avoid a shortage.
Labor shortages in occupations that require a minimal level of training generally are of short duration. However, the supply of workers can be relatively inflexible or slow to adjust and may consistently occur. Many workers are reluctant to accept jobs believed to have low status or associated with undesirable working conditions. This fact should be kept in mind when lowering the educational standards for dental hygienists is proposed as a solution to the demand for dental hygienists.
Many individuals may be unwilling to accept dental hygiene positions because of the low status associated with preceptorship training. This phenomenon already is observed in dental assisting where on-the-job training has done little to attract and retain dental assistants.
Wage inflexibility also may be the cause of a personnel shortage. An employer may prefer to endure the ill effects of a labor shortage rather than raise wages, which may increase overhead costs. A dentist may choose to forego hiring a dental hygienist rather than pay a wage that is perceived to be incongruent with the job requirements.
Interestingly, one study revealed that 90 percent of dentists experienced dental-hygiene turnover, yet this study substantiated no actual manpower shortage. This suggests that the difficulty in retaining dental hygienists may be due to wage inflexibility or unpleasant working conditions.
Increased demand by consumers and employers for a particular service may outpace the market`s capacity to supply workers. For example, increasing awareness of periodontal disease on the part of consumers and dentists may increase the use of hygienists in practices. Dentists striving for quality also may use the hygienist in nonsurgical periodontal therapy - solely because of the hygienist`s expertise and knowledge in this area. Ultimately, this would increase the demand for dental hygienists in private dental practices.
Manpower shortages can also be geographically located shortages. Underdeveloped, rural areas tend to be the locations where health professionals are found in short supply. To remedy shortages related to geography, employers must understand the reason a shortage occurs in certain areas and how to remedy this situation.
For example, if a dentist is having difficulty filling a position, perhaps a more aggressive marketing strategy is in order. Unfortunately, many times the advertising technique seen in dental-hygiene programs consists of an "employment opportunity" bulletin board with names and addresses of potential employers. In contrast, college programs in other fields frequently host on-site interviews for prospective employees (college students). A dentist interested in a dental hygienist may employ this technique to secure an employee.
It may be fiscally irresponsible to increase the number of dental-hygiene programs on the sole premise that more dental hygienists are needed to ease a "reported" dental hygiene shortage.
Determining the `active` statistic
To understand the manpower of the hygiene profession, one must first identify the supply and demand of workers in the occupation. Because organized dentistry seems most interested in supplying dental hygienists for private dental practices, as well as the fact that dental hygienists must be supervised by dentists (except in Colorado), supply must be viewed in light of the number of dentists available to employ dental hygienists.
Most occupations can study manpower supply by using a worker-to-population ratio. Dental hygienists, though, are unable to provide care to the population without the supervision of a dentist. So the supply of dental hygienists is directly linked to the number of dentists available to employ them. In fact, even when dental hygienists may practice independently, a dentist is needed for referral.
Numerous studies have suggested that the most common hygienist-to-dentist employment ratio is 1:2. For every two dentists, one dentist employs, or would like to employ, one full-time dental hygienist.
When studying a work force issue, it is necessary to identify the supply of workers willing to work in the particular occupation. One topic that merits discussion is the number of dental hygienists not employed in the work force. To understand this manpower issue, it is necessary to have current data of the supply of both practicing dental hygienists and dentists. In fact, one study points out that, while 22 percent of dental hygienists in Virginia were not practicing, 21 percent of licensed dentists also were not practicing. It is imperative to have information on both nonpracticing dentists and dental hygienists when studying manpower issues.
The ADHA reported that 27 percent of dental hygienists are not actively practicing in the United States. However, no data could be found to determine the practicing status of dentists in the United States. Without this data, projections would be inconclusive.
How to determine demand in your neighborhood
To study dental hygiene manpower in any jurisdiction, the paradigm depicted in the related article can be used. In this paradigm, the two populations studied consist of all licensed dental hygienists and dentists residing in the licensing jurisdiction. The populations can be geographically divided into specific components - components of the dental hygiene and dental associations, for example, or counties within the state. Identifying the number of hygienists and dentists by geographic location assists in determining the work force distribution or maldistribution within regions of the licensing jurisdiction.
A list of licensed dental hygienists and dentists residing in the state can be obtained from the state regulatory body. Data can then be divided by counties, resulting in a frequency distribution of dental hygienists and dentists in the state. This data can be translated into a ratio and compared with the national dental hygiene-to-dentist employment ratio of 1:2.
To calculate the number of dental hygienists and dentists currently not practicing, secondary data can be obtained from the state regulatory body or previous studies conducted. If no studies can be found, a survey to determine the number of practicing dental hygienists and dentists can be used.
One limitation of this paradigm may be that the demand for dental hygienists within the community may be greater than the demand within the dental community. Consumers may demand oral health care more than employers perceive or acknowledge. The paradigm reflects the demand as foreseen by the dental community and not necessarily foreseen by consumers.
Supervisory requirements exist in all states that limit the employment opportunities for dental hygienists. Because legislative barriers to the public`s access to dental hygiene care exist, this paradigm studies manpower as determined by the availability of employment positions.
Many constituent dental societies hold the assumption that a dental hygiene workforce shortage exists. This perception has allowed the manpower issue to be a focus before it has been documented as a problem.
Few would argue that before a problem can be solved it first must be verified and documented. Considering the logic of this statement, the first step in addressing a manpower issue is to validate a manpower shortage and assess the manpower distribution. This paper presents a paradigm that can be followed when studying dental hygiene manpower in individual states.
The mission of the ADHA is to advance the art and science of dental hygiene by increasing the awareness of and ensuring access to quality oral health care; promoting the highest standard of dental hygiene education, licensure, and practice; and representing and promoting the interests of dental hygienists. The mission of the ADA is to encourage the improvement of the health of the public, to promote the art and science of dentistry and to represent the interests of the dental profession and public which it serves.
To accomplish this mission, it is necessary to meet the increasing demand for dental hygiene care by decreasing the barriers to the public`s access to dental hygiene care. With a collaborative effort between the dental hygiene and dental communities working toward a common goal of increasing access to quality dental hygiene care, the public will benefit ultimately by receiving oral health care by educated dental hygiene practitioners.
Christine Nielsen Nathe, RDH, MS, is an assistant professor in the division of dental hygiene at the University of New Mexico in Albuquerque. Deborah B. Bauman, BSDH, MS is an associate professor, and Michele Darby, BSDH, MS, is an Eminent Scholar and graduate program director at the university. Deanne Shuman, BSDH, MS, is professor and chairperson at the school of dental hygiene at Old Dominion University in Norfolk, Va.
- Proposed dental hygiene training program draws fire. New Mexico Dental J 1995;46:6.
- Dental hygienist training for rural New Mexico: an innovative approach. New Mexico Dental Hygiene Education Consortium, New Mexico Association of Community Colleges, 12 September 1996.
- American Dental Hygienists` Association. Report of the ADHA special committee to study hygiene manpower issues. Chicago: American Dental Hygienists` Association, 1989.
- Academy of general dentistry membership survey: confirms shortage of dental staff. AGA Impact, 1990.
- American Association of Dental Schools. AADS-CODA oppose hygiene preceptorship training in Georgia. Bulletin of Dental Education 1989;22:4-5.
- American Association of Dental Schools. Resolution 4-90-H: opposition of allied dental preceptor training programs. Bulletin of Dental Education 1990;23:2.
- American Dental Association, Board of Trustees. Resolution 73H. Chicago: American Dental Association, 1989.
- Association Report. Task Force on Innovative Dental Hygiene Curricula. J Dent Ed 1989;53:731-7.
- Hygiene Survey Results, New Mexico Dent J 1995;46:8.
- Curran A, and Darby M: Preceptorship: a risk management perspective. J Dent Hyg 1990;64:290-5.
- Darby M: Management strategies to address the demand for dental hygiene professional. Norfolk, Virginia: Tidewater Dental Association. August, 1989.
- Education research and information of the Medical College of Georgia. Study on dental hygiene manpower in the United States. Augusta, Georgia: Education Research and Information of the Medical College of Georgia, 1990.
- Gervasi R: Is dentistry trying to destroy your RDH. Access 1989;3:25-8.
- Information Report to the Dental Hygiene Faculty and the Dean of the College of Health Related Professions on Dental Hygiene Education, Manpower and Practice in the Northwest, Pocatello, Idaho: Idaho State University. November, 1988.
- Institute of Medicine, National Academy of Sciences. Allied Health Services: Avoiding Crisis. Washington, D.C., 1989.
- Joint report of the council on dental education and the council on dental practice: Study of methods to increase dental auxiliary manpower. J Dent Ed 1988;10:117-29.
- Levy, M: Proposed dental hygiene program: Thomas Nelson Community College. Peninsula Dental Hygienists` Association. Hampton, Virginia. 13 March 1990.
- Aday, B: President`s message. New Mexico Dent J 1997;48:5..
- Reidy M: Dental hygiene manpower shortage: fact or fiction. Access 1989;3:4-7.
- The importance of consensus in determining educational standards in health and human services field. Southern Regional Education Board. Atlanta, Georgia. 1990.
- Dental hygiene program: a feasibility study. Thomas Nelson Community College, Office of Institutional Research and Planning: Hampton, Virginia, 1990.
- Dental auxiliaries manpower study. Virginia Dental Association and Virginia Commonwealth University, Survey Research Laboratory. Richmond, Virginia, 1989.
- Healthcare manpower conference proceedings. Virginia Health Council, Incorporated.. Richmond, Virginia, 1989.
- Wilson R: A complex problem requiring urgent attention.Virginia Dental J 1989;66:4-5.
- Goldenberg S: Alabama dental hygiene program: what it is, what it does. Bensden, Pennsylvania. 1987.
- Kennedy M: Georgia Dental Association invitation to acquaint state dental association with the GDA`s alternative dental hygiene program. Atlanta: Georgia Dental Association, 26 May 1989.
- American Dental Association, Council on Dental Education. Supplement 9 to the 1991/92 annual report on dental education. Chicago: American Dental Association, 1992.
- Nathe C and Logothetis D: Comparison of dental hygiene and dental national board examination content. J Dent Hyg 1996;68:9-10.
- Brown LJ, Brunelle JA, and Kingman A: Periodontal status in the United States, 1988-1991: prevalence, extent and demographic variation. J Dent Res 1996;75:672-83.
- Oliver RC, Brown LJ, Loe H: An estimate of periodontal treatment needs in the US based on epidemiologic data. J Perio 1989;60:371-80.
- Perry DA, Beemsterboer PL, and Taggart EJ: Periodontology for the Dental Hygienist. Philadelphia: WB Saunders Co. 1996:43.
- Darby ML and Walsh MM: Dental Hygiene Theory and Practice. Philadelphia: WB Saunders, Co., 1994:8-9.
- Phagan-Schostok P, and Maloney K: Contemporary Dental Hygiene Practice. Chicago: Quintessence Publishing, 1988.
- Curriculum guidelines for periodontics. J Dent Educ 1992;56:773-778.
- Erdmann D: An examination of factors influencing student choices in the college selection process. J College Admissions 1983;100:3-6.
- American Dental Association, Commission on Dental Accreditation. Statement on Dental Hygiene Education. Chicago: American Dental Association, 1980.
- Mescher, KD: A new look at the educational preparation of dental hygienists: exploding the myth. Dent Hyg 1984;58:71.
- American Dental Association. Commission on Dental Accreditation. Informational Report on the Length of Dental Hygiene Programs. Chicago: American Dental Association. May 1992:727-738.
- American Dental Association, Council on Dental Education. Position on Dental Hygiene Educational Standards. Chicago: American Dental Association, 1980.
- Goral V: Trends in dental hygiene education. The Advisor 1988;8:19-21.
- Sargent J: Labor shortages: menace or mirage. Occupation Outlook Quarterly
- Strom T: Trends in dental team wages. Dental Teamwork. 1990;3:59-61.
- Elliot-Anderson P: Staff salaries levels are down for 1983. Dental Economics 1985;77:46-51.
- Elliot-Anderson P: Hygienist`s daily pay up, but annual pay may not be. Dental Economics 1988;78:83-90.
- Elliot-Anderson P: Salaries increasing for auxiliaries.Dental Economics 1989;79:27-34.
- Elliot-Anderson P: More staff, higher salaries sum up staffing patterns. Dental Economics 1995;85:56-64.
- University of Washington Center for Health Services Research. Assessment for antitrust actions affecting dentistry. Seattle, Washington: University of Washington, 1980.
- Wilson B: Staff salaries and benefits: national and regional survey. Dental Management 1987;27:20-29.
- Nathe C, Bauman D, Darby M and Shuman D: Dental hygiene manpower distribution in Virginia. Thesis: Norfolk, VA, Old Dominion University. 1990.
- Nathe C: Senate Bill 661 Testimony on Dental Hygiene Manpower in New Mexico. Santa Fe, NM. 28 February 1997.
- Bauman D, and Shuman D: Senate Bill Testimony on Dental Hygiene Manpower in Virginia. Richmond, VA. 11 November 1996.
Paradigm for identifying dental hygiene manpower
Step One: Demand
> Identify the dental hygiene employment opportunities in your jurisdiction, by
> Identifying the hygienist-to-dentist employment ratio if restrictive legislative barriers exist to prevent access to care (the national ratio of 1:2 can be used), or
> Identify the dental hygienist-to-population employment ratio if your jurisdiction enables dental hygienists to practice without restrictive barriers.
Step Two: Supply
> Obtain a list of licensed dental hygienists and dentists residing in your jurisdiction
> Utilize counties within the state to determine locality distributions
> Segregate the supply of dental hygienists and dentists by zip codes and place into the respective counties.
> An optional step which may be useful would be to utilize the past data or conduct a survey to identify the practicing status of dental hygienists and dentists.
Step Three: Manpower
> Calculate the frequency distribution of dental hygienists and dentists in the jurisdiction
> Calculate the ratio of dental hygienists to dentists in the locality
> Compare these ratios to dental hygiene and dental employment ratio
> Depict the surplus and deficit status of dental hygienists in the counties
> If you have the practicing status of dental hygienists and dentists, you may utilize the practicing status of dental professionals in these aforementioned frequency distributions and ratios.