3

The Oral Health Care Workforce

The 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 services 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 professionals), the holding of more than one position per professional, and the presence of multiple and overlapping job titles. Aside from sheer numbers,



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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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85 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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87 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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89 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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91 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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