Help Wanted
Addressing the staffing shortage in dentistry
Carol Brzozowski
Similar to many other occupational sectors, dentistry took a big hit to its workforce as a result of the COVID-19 pandemic. Although industry observers such as the California Dental Association (CDA) note that the effect was boosted by pre-pandemic labor shortages resulting from a declining number of working-age adults and a lull in wage growth,1 the pandemic itself was the primary driver of the current staffing shortage. "Following the pandemic's onset, many left the dental profession out of fear of the in-person nature of the work, the need to be home during lockdowns to supervise school-age children who were learning online, the desire to not wear an N95 mask all day, and other factors," says Roger P. Levin, DDS, CEO of the Levin Group, an international dental consulting firm that provides marketing and managing services.
According to the US Chamber of Commerce, additional factors that pertain to the US workforce in general include that people are searching for greater flexibility, an improved work-life balance, increased compensation, and a strong company culture. They note that during the pandemic, many resignations were fueled by boosted unemployment benefits, stimulus payments, and child tax credits, whereas some others simply took early retirement.2
In a March 2020 survey of 19,000 dentists, the American Dental Association (ADA) found that 76% of the respondents had closed their offices to all but emergency patients.3 As practices slowly reopened to provide regular care, many realized that the shutdown had had a profoundly negative impact on staffing. Today, concerns about inflation are driving a small uptick in the return to work; however, the US Bureau of Labor Statistics notes that there were 146,200 jobs in dentistry in 2021 and that employment in the profession is projected to grow 6% from 2021 to 2031, which is about as fast as the average for all occupations.4
The Challenges
A November 2021 poll from the ADA Health Policy Institute indicated that 9 out of 10 hiring dentists believed that it had been "extremely" or "very" challenging to recruit dental hygienists and dental assistants during the previous year.5 The ADA estimates that approximately 8% of all US dental hygienists left the workforce in 2020,6 which left many dentists to perform cleanings and do the other work that hygienists traditionally did. However, according to JoAnn Gurenlian, MS, PhD, RDH, of the ADA, even before the concerns of the pandemic, hygienists were reporting growing dissatisfaction and concerns over a lack of respect and appreciation.7
Levin calls the dental staffing shortage a crisis and says that it may take as many as 10 years before acceptable staffing levels are regained nationwide. "In a national survey that we just completed, 46% of the responding offices reported that they were looking for at least one team member right now," he says. "Another issue is that dentistry has become more complex. Dental technology and infection control are more advanced, so it takes longer to train people today than it did 30 years ago.
In a February 2022 Forbes article, Ato Kasymov, co-founder and CEO of Zentist, notes that recruiting administrative staff is a challenge for more than 70 percent of dental offices.8 This has resulted in a situation in which those in clinical roles sometimes have to perform the functions of administrative staff, further complicating practice workflows. Individuals with billing skill sets are in short supply, and going forward, more jobs will require analytical skills and the ability to interpret and manage data.
Dental Workforce Shortages: Data to Navigate Today's Labor Market, a collaborative research effort of the ADA Health Policy Institute, the American Dental Assistants Association, the American Dental Hygienists' Association, the Dental Assisting National Board, and IgniteDA, found that the workforce shortage has been a driving factor behind an approximate 10% reduction in dental capacity nationwide and that one in three dentists report an inability to fill their appointment schedules.9 Unfortunately, this reduction in dental capacity only exacerbates the existing shortage of oral healthcare providers that is already affecting some areas of the country. In a February 2022 meeting of the US Senate's top health committee, which convened to address the nationwide shortage of providers in all areas of healthcare, Senator Bernie Sanders (I-VT) noted that almost 70 million people have no dentist at hand and pledged that the committee would produce meaningful legislation to address the underlying problems that would receive bipartisan support.10
Kirk Behrendt, the owner of ACT Dental, a dental consulting company focused on creating "smart and healthy" cultures by studying algorithms, watching best practices, and putting systems in place, explains the effect that the pandemic had on the mindsets of those in the dental workforce. "If you were already on the fence about working for a company, you just rethought everything," he says. "If you had a terrible boss who didn't really care about you or the other team members, that became more meaningful during the COVID-19 pandemic." Behrendt notes that the dentists who were able to retain their teams took actions like immediately telling them that although they didn't know what was going on regarding the shutdown, they had their interests at heart. He references a Florida practice that rented a tent during the shutdown and told staff that they were going to meet outside in a socially distanced manner until they had figured everything out together. In some practices, team members were simply furloughed and left to figure out matters on their own. "Team members are also leaving practices for opportunities to make more money," Behrendt adds. "However, people usually won't leave for more money unless they're also unhappy. They don't want to leave a great culture just for more money."
Attracting Talent
With so many influences contributing to the staffing crisis, what can practice owners do to recruit and retain good employees? "Make job advertising stand out by creating ads that reflect opportunity, teamwork, collegiality, cooperation, and growth opportunities," says Levin.
Increased pay and better benefits are key factors in attracting talent in this competitive environment. According to some industry experts, benefits may include paid vacation, holidays, and sick time; retirement savings options; health insurance; reimbursement for licensing fees and continuing education; and even compensation for daycare and gasoline costs, pet insurance, dog-walking services, and the ability to work part-time from home if the job allows it.
John Murphy, vice president of talent acquisition at Aspen Dental Management, mentions that other approaches include reducing 5-day workweeks to 4-day ones. In these situations, filling a role with two part-time employees instead of one full-time employee can alleviate some of the cost burden associated with providing full-time benefits. "People from the younger generations want to work less and make more," he says. "People from the older generations also want to work less, but they do not expect to make more."
Interestingly, the desire to work less isn't the only multigenerational phenomenon that can currently be observed in hiring. Behrendt notes that applicants of all ages are prioritizing the values of their employers. "Gen X, Gen Y, Gen Z—they're all looking for purpose," he says. "They're looking for a company that stands for something."
Another factor that will contribute to the current staffing crisis in dentistry is the average age of the employees and their rate of retirement. According to Dental Workforce Shortages: Data to Navigate Today's Labor Market, 33.7% of dental assistants and 31.4% of dental hygienists indicated that they expected to retire in 5 years or less.9
To combat this, practice management specialist Eric Block, DMD, CAGS, suggests considering applicants who have unconventional experience from nondental settings. "Don't focus exclusively on people with dental experience," he says. "Look for hard workers with great attitudes who are excited about joining your team. They can be trained in dental skills if they have strong work ethics and great attitudes."11
To this end, the Delta Dental Community Care Foundation has partnered with the CDA and the California Labor and Workforce Development Agency to create an initiative called Smile Crew CA. The program provides state residents—particularly those who lost jobs during the pandemic—with new employment opportunities as dental assistants. During the 4-week training, which combines an online self-led learning module and classroom instruction with on-the-job training, participants learn about dental terminology, HIPAA compliance, infection control protocols, and more as well as undergo required certifications. It offers up to 160 hours of paid work experience.12
One way that practice owners can expand recruitment efforts is to seek out referrals from existing employees. Practices might provide a bonus to any staff member who brings in a new hire who makes it through his or her probationary period as well as a sign-on bonus for the new hire. In addition, recruiting firms and, in some cases, even patients can help to identify potential new hires.
According to Kirsty Leyland, the chief human resources officer at Heartland Dental, candidates these days are really looking to connect with the culture of a workplace. "People are looking for that engagement, that cultural connection," she says. "They want to work with teammates that they can really connect with and to feel like they're making a difference, so the culture that a practice creates is really important in terms of attracting new talent as well as retaining it."
Behrendt agrees. Because the pandemic has intensified competition for employees, he emphasizes that it's important to go all in on developing a healthy workplace culture at your practice as well as a team with strong core values, which also goes a long way in attracting and retaining employees. "My question to dentists is ‘what do you care about?'" he says. "You have to figure out how to tell the world what you care about and how your team members should communicate what you care about." To attract a steady stream of higher quality team members, Behrendt suggests having staff members promote your core values in short online videos or in newsletters.
Another creative strategy being utilized to recruit talent involves working with local high schools. In 2022, the Idaho State Dental Association noted that the shortage of dental assistants in certain areas was reducing access to care, so they set up dental assistant training programs in area high schools. These career-technical tracks teach students standard dental procedures and hygiene practices and offer internship and job shadowing opportunities as well as an opportunity to work in the field immediately after graduation.13 Setting up "career days" and offering office tours to graduating students can also serve as recruitment strategies.
Building a team of dedicated employees is the goal; however, short-term recruitment strategies may provide relief in certain situations. Such strategies include using temporary workers and outsourcing some of the practice's desk jobs. "Although these employees can help during a staff shortage, you don't get the same cultural commitment," Levin says. "They can be very good at what they do, but they're not long-term players."
Behrendt's view is that everything is on the table now. "Some tasks cannot be outsourced or performed by temporary workers or even by artificial intelligence systems, but you have to figure out that formula," he says. "If you're not open to all solutions, you're limiting your chances of succeeding."
The landscape of dental hygiene is changing. Of the dental hygienists who responded to a 2022 Inside Dental Hygiene survey, 59% indicated that they work full time and 41% indicated that they work part time. Seventy-six percent reported that they treat patients at one office, whereas 24% reported that they work at two or more offices. In the February 2023 issue of Inside Dental Hygiene, Tonya Lanthier, RDH, the founder and president of DentalPost, a job board and online community for dental professionals, notes that DentalPost receives more job postings and resume search requests for dental hygienists than any other position. "Overall pay and job satisfaction are up for dental hygienists, and career opportunities abound," she says.14
State dental associations and other professional groups can help with recruitment as well. The CDA suggests that a job posting should stand out in such a way that it answers the question ‘Why would a candidate want to work for me?' The answer will most likely center on wages, benefits, and perks.1 Michelle Coker, PHR, a CDA practice support analyst, notes that there are several social media groups based in the state that offer opportunities for dentists and dental staff to post available jobs, such as the Los Angeles Dental Peeps or the Sacramento Dental Hygiene Subs.1 CDA's career center helps connect practice owners and job seekers through job alerts, customized profiles, and a resume bank.
Offering higher wages is one way to offset the cost of hiring and training new employees who ultimately leave seeking a higher-paying job. According to the most recent data from the Society for Human Resource Management, employers spend an average of $4,683 per job in hiring costs.15 Although published surveys differ, the US Bureau of Labor Statistics reports that dental hygienists are paid an average of $77,810 per year or $37.41 per hour.16 Katie Fornelli, CDA's director of early career dentist engagement, cautions against offering unsustainable wages and recommends setting a budget to ensure that staff overhead costs remain below the collections margin.1
Helpful Mitigation Strategies
Block employs several management strategies to help mitigate the effects of staffing challenges. With many patients now working from home or having hybrid schedules, he takes advantage of their increased flexibility to optimize his practice's patient schedule. Instead of asking patients for their preferred appointment dates and times, his staff is instructed to offer several options for open times, which puts them in control and enables them to fill the schedule as desired. When staffing levels permit, his front office also fills holes in the schedule with same-day appointments. "Making same-day appointments can provide a significant revenue source to reach your daily production goals, but you must have the staff power and systems in place to do it," Block says.11
Beyond optimizing the patient schedule, another way to improve a practice's bottom line during a staffing shortage is to add low-stress treatment modalities that can be performed with limited staff. "It's important to stay in your comfort zone when pursuing continuing education and training, regardless of any staffing situation but especially if you're short on staff," Block says. "Last year, I added clear aligners, and next year, I plan to add airway and sleep apnea treatments."11
According to Levin, offsetting the effects of the staffing shortage and inflation has required practice owners to engage in smarter business practices, including raising their fees. "Insurance companies are lowering reimbursement rates in many cases and rarely raising them," says Levin, adding that fee-for-service patients can help to offset some of these fee increases. "Consider ways to lower overhead, such as through bidding out the most expensive services to get a sense of where the market is and joining buying groups to do bulk purchasing."
Another strategy to mitigate the effects of staffing challenges is to adopt technology. Digital technologies that incorporate artificial intelligence can create greater efficiencies in charting, scheduling, and filing claims. The Colorado Dental Association notes that specialized software can be used to connect to thousands of payer systems to run automated checks for each individual patient to help catch claim errors ahead of appointments, reduce denials, accelerate the process, and help prevent errors related to manual data entry.17 The adoption of technology can also create greater efficiencies in the performance of clinical tasks, which can reduce the labor involved. For example, using an isolation device that illuminates and suctions patients while propping their mouths open allows Block to perform many procedures by himself. This enables his assistant to tend to other tasks, such as scanning another patient for a night guard.11
Although technology can offer many benefits, it should be carefully implemented to ensure that it is appropriate for a practice, especially with increased compensation rates impacting practice profitability. "Adopting technology is more about helping your team members do their jobs more productively than replacing them," says Levin.
Retaining Talent
According to some industry experts, retention efforts—which reduce the effects of staffing shortages-should include annual wage assessments that incorporate performance measurement, improved communication, clear job descriptions and expectations, recognition, promotion, and bonuses. Levin suggests offering longevity bonuses at different intervals for team members who stay with a practice. "It's always less expensive to keep a long-term team member than to hire a new team member," he says.
Establishing career path plans for the different team roles can also aid in retention by providing employees with long-term goals and incentives. "One area that has been very important to candidates in the past year is the opportunity for personal development and career development," says Leyland. "Our ability to build out a tremendous educational curriculum has helped us attract candidates, but our ability to create career paths toward leadership positions has also been impactful."
Levin believes that effective retention strategies follow the philosophy of treating the team members as customers. "Today, you can't treat your team members as workers," he says. "The days of transactional employment, which is ‘I pay you, you do work,' are over. Now we pursue relationship-based employment in which we develop great relationships with our team members."
Practices should seek to create workplace cultures that set key values and establish a mission and purpose for the employees in their work. "If they have that, they'll be much more satisfied and motivated and likely stay longer," says Levin. "It's key to have a big picture vision of what the practice is trying to achieve and where it is going in the next 5 years; however, it's also important to see the small picture with what we call ‘surprises' to appreciate employees, which range from things like bringing in pizza and doughnuts to giving away $100 prizes through numbers under the chairs at a staff meeting and doing fun things in the community."
"In a great dental practice, the patients actually come second," says Behrendt. "When the culture of a practice puts its team members first, they in turn, are best able to put the patients first."
References
1. California Dental Association. Recruitment strategies to overcome staffing shortages in dental offices. CDA website. https://www.cda.org/Home/News-and-Information/Newsroom/Article-Details/recruitment-strategies-to-overcome-staffing-shortages-in-dental-offices. Published February 2, 2022. Accessed February 24, 2023.
2. Ferguson S. Understanding America's labor shortage: the most impacted industries. U.S. Chamber of Commerce website. https://www.uschamber.com/workforce/understanding-americas-labor-shortage-the-most-impacted-industries. Updated February 22, 2023. Accessed February 24, 2023.
3. Carey M. HPI poll examines impact of COVID-19 on dental practices. ADA website. https://www.ada.org/publications/ada-news/2020/april/hpi-poll-examines-impact-of-covid-19-on-dental-practices. Published April 1, 2020. Accessed February 24, 2023.
4. Bureau of Labor Statistics, U.S. Department of Labor. Occupational outlook handbook: dentists. BLS website. https://www.bls.gov/ooh/healthcare/dentists.htm. Updated September 30, 2022. Accessed February 24, 2023.
5. Burger D. HPI: Dentists say they need more staff to see same number of patients compared to pre-pandemic. ADA website. https://www.ada.org/publications/ada-news/2021/november/dentists-say-they-need-more-staff-to-see-same-number-of-patients-compared-to-pre-pandemic. Published November 29, 2021. Accessed February 28, 2023.
6. Morrissey R, Gurenlian J, Estrich C, et all. Employment patterns of dental hygienists in the United States during the COVID-19 pandemic: an update. J Dent Hyg. 2022;96(1)27-33.
7. Lemoult C. A dental hygienist shortage has dentist offices struggling to schedule patients. NPR website. https://www.npr.org/2022/09/12/1122482181/a-dental-hygienist-shortage-has-dentist-offices-struggling-to-schedule-patients. Published September 12, 2022. Accessed February 28, 2023.
8. Kasymov A. A cooperative approach to staffing shortages in the dental industry. Forbes website. https://www.forbes.com/sites/forbestechcouncil/2022/02/15/a-cooperative-approach-to-staffing-shortages-in-the-dental-industry/?sh=126dabb31fc9. Published February 15, 2022. Accessed February 24, 2023.
9. ADA Health Policy Institute, American Dental Assistants Association, American Dental Hygienists' Association, et al. Dental workforce shortages: data to navigate today's labor market. ADA website. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/dental_workforce_shortages_labor_market.pdf. Published October 2022. Accessed February 28, 2023.
10. McAuliff M. Fixing the health care worker shortage may be something Congress can agree on. NPR website. https://www.npr.org/sections/health-shots/2023/02/22/1158026497/fixing-the-health-care-worker-shortage-may-be-something-congress-can-agree-on. Published February 2, 2013. Accessed March 1, 2023.
11. Block E. Mitigating the effects of the staffing shortage. Inside Dentistry. 2023;19(1):8-11.
12. Delta Dental. A program to ease the dental assistant shortage. Delta Dental website. https://www1.deltadentalins.com/dentists/fyi-online/2022/mentorship-opportunities-dentists.html. Published May 6, 2022. Accessed February 24, 2023.
13. Dittenber S. Dentists turn to high schools to boost workforce amid staffing shortage. Idaho Ed News website. https://www.idahoednews.org/news/local-dentists-turn-to-high-schools-to-boost-workforce/. Published November 21, 2022. Accessed February 24, 2023.
14. Michmershuizen FW. Dentistry wants you! Inside Dental Hygiene. 2023;19(2 Special Issue 1):8-12.
15. Miller S. SHRM HR benchmarking reports launch as a free member-exclusive benefit. SHRM website. https://www.shrm.org/resourcesandtools/hr-topics/benefits/pages/shrm-hr-benchmarking-reports-launch-as-a-member-exclusive-benefit.aspx. Published April 11, 2022. Accessed February 28, 2023.
16. Bureau of Labor Statistics, U.S. Department of Labor. Occupational outlook handbook: dental hygienists. BLS website. https://www.bls.gov/ooh/healthcare/dental-hygienists.htm. Updated September 8, 2022. Accessed February 24, 2023.
17. McDermott R. Some surprising non-staff options to sidestep the staffing shortage. Colorado Dental Association website. https://cdaonline.org/news/latest-news/some-surprising-non-staff-options-to-sidestep-the-staffing-shortage/. Published January 7, 2022. Accessed February 24, 2023.
