The giant cavity in America's dental care industry

When Elysse Morris decided to become a dental hygienist, it seemed like a natural fit. She was a fairly "sciencey" student in high school and generally liked going to the dentist. Plus, she'd always been a talker.

Eleven years into her career, Morris, now 34, knows she could probably be making more money. Her home state of Virginia has a severe shortage of dental hygienists, and temporary workers can command high hourly rates by hopping between practices. But Morris has spent four years at the same privately owned office because she's happy there. Her boss gives her decent equipment, benefits, a bonus, and — most importantly — respect. The dentist treats her like a clinician rather than a pair of hands.

"We're not workers to her," Morris says.

Her setup is what those in the business call a "unicorn" office, and the short supply of these quality workplaces is helping cause a short supply of dental hygienists across the country.

I'm not kidding when I say I love my dental hygienist. I was going to quit my dentist, who I feel like often tries to push questionable treatments on me, but then Andrea started, and she's amazing. Last time I was in the office, I mentioned my union was bargaining a new contract, and she said she wished hygienists had a union of their own. It makes sense that they don't — the United States doesn't do sectoral bargaining, and most hygienists have traditionally worked in small, private offices where organizing would be difficult — but it got me thinking. I have no idea whether hygienists, in general, are having a good time.

Turns out, they're not.

According to the American Dental Association's Health Policy Institute, only 60% of dentists report having an adequate number of dental hygienists on staff. States such as Virginia, Missouri, Texas, and California say they need hundreds more clinicians.

The problem isn't a lack of demand — the Bureau of Labor Statistics expects employment for hygienists to grow much faster than average over the next decade. The real struggle is that the field is having a hard time getting new hygienists in the door, as experienced hygienists are heading for the exits. Dental hygiene programs at community colleges and universities aren't agile enough to increase their flow of new graduates, all while veteran clinicians are deciding the physical toll, heavy workload, and lack of benefits aren't worth it.

"Burnout is so high," Morris says. You're basically "trying to be a perfectionist all day long."

The result: long wait times for patients and proposed solutions that some hygienists worry could lead to worse care.

Prior to 2020, dental hygienists weren't exactly skipping gleefully into work — there were already issues around workplace culture, compensation, and opportunities for growth. But the pandemic exacerbated many of these problems. Many offices temporarily closed, hitting staff's bottom lines. When they reopened, hygienists suddenly found themselves on the front lines, exposed to the virus in their close-contact, aerosol-generating work and managing new safety and equipment protocols — all while juggling their disrupted daily lives.

On a typical day, hygienists see eight to 10 patients, each with different anxieties, histories, and baggage. One person comes in ranting about how COVID isn't real, the next talks about their grandfather dying of it. In both cases, the hygienist must manage the emotional climate while scraping tartar from tooth enamel with microscopic precision. After months of this, many decided they'd had enough. Those who were close to retirement pulled the trigger, and others went shopping around for new careers. An estimated 3,300 hygienists left the field.

The acute issues of the pandemic exacerbated long-standing problems in the industry. Dental hygiene is a physically demanding job. Professionals find themselves hunched over for large parts of the day, and injuries to the neck, shoulders, wrists, and lower back are common. Many dental practices — especially the smaller ones — don't provide benefits such as health insurance to their workers. That may propel hygienists to pursue jobs in more corporate environments, such as dental service organizations or private equity-backed groups. These entities often have a reputation for pushing higher-cost treatments and compressing appointment times to generate higher profits. While hygienists may initially be enticed by the benefits and pay at these operations, the pace can be exhausting, resulting in a revolving door.

"They're not retaining people any better than other practice models are," says Dr. Kathryn Rothas, a New York-based dentist and spokesperson for the American Dental Association. Rothas is the dental director of Whitney Young Health, a federally funded community clinic in Albany. As we're speaking, she says they're trying to fill an open dental hygienist position. While they offer solid benefits, they don't pay as much as bigger corporate dental groups.

Brandon Patel manages the front desk at his wife's two Connecticut dental practices. He tells me they're in a similar situation. "I've had a job post up for almost six months, and we have had basically no applicants," he says. "The applicants we've had are full-time employees just looking for a better offer." His clinic is offering $55 to $60 an hour, but no health insurance, which Patel says is "very difficult to provide as a small-business owner."

Dental office dynamics are complicated. People are often working in tight quarters, and personalities can clash. Some dentists may have a way they like doing things that simply doesn't jibe with certain employees. Morris once worked for a lovely older dentist who did beautiful work — but he insisted on using old instruments, and after her paychecks started to bounce, she quit. The pay and flexibility of temping or part-time work appeal to many hygienists, but it increases the chance they end up in offices where they're not comfortable. Dental hygiene is also a female-dominated field, and some clinicians scale back their hours or stop working once they start having families.

The obvious answer to workplace shortages is to train more people, especially since dental hygiene seems pretty AI-proof, and the prospect of a high salary should make it an enticing career. That's easier said than done.

Unlike nursing programs, where universities send students to partner hospitals for clinical rotations, dental hygiene programs must build, equip, and operate their own dental clinics. A single chair alone can cost upward of $8,000, not to mention X-ray machines, simulation labs, and other equipment. Hygienists-in-training must be closely supervised at these clinics and need to get experience with a wide range of patients and conditions. Expanding these programs can therefore be a logistical nightmare and an enormous investment.

"You have to basically be an outpatient center for clinical care, which is thinking about operating a hospital and operating a school at the same time, in essence," Rothas says. "It's costly to just expand a program by a few chairs."

To those trying to break into the profession, the process can feel bizarrely selective and unnecessarily bottlenecked.

Bryn Romero turned to dental hygiene after struggling to land a job with the data science degree he earned in 2021. He's not as worried about the shortage because, to him, it means job security. "As somebody that was unemployed for a long time, I like the idea that I'm not going to have to worry about that," he says. He's currently about halfway through the two-and-a-half-year program he started in Utah last spring, but he's been surprised at how many hurdles he had to clear to get in. He has a friend who's been a dental assistant for four years and has been rejected from the same school he's in three times. "It feels very arbitrary," he says. (Dental assistants have less training and a smaller scope than hygienists — they prepare rooms, hand dentists instruments during certain procedures, and take X-rays. They don't generally do cleanings or assess gum health.)

There are only 15 chairs in his school's clinic across its five rotating cohorts. Three instructors are there to check everything, which lengthens wait times and discourages patients from coming in. "The service itself could be better if we just had more instructors that were there," he says.

Beyond the high barrier to entry, dental hygiene simply doesn't occur to many young people as a potential career path. High school guidance counselors often point students toward other healthcare arenas, such as nursing and radiology. Dental hygiene doesn't get much attention in culture or the media, either. There's no "The Pitt" or "ER" for the dental chair.

The root cause of many of these problems isn't Big Mean Dentist, it's an industry where the economics are no longer working.

Dental insurance reimbursement rates have stagnated in recent years, all while dental office costs have continued to rise. That's led some practices to stop accepting certain insurances or pursue more out-of-network patients to help with their internal math. Rothas says new patients often land in her clinic because their prior dentist stopped accepting their insurance.

New graduates in dental hygiene and dentistry have different priorities than generations past. They want flexibility and see the appeal of high-paid temp options over going to work full-time at a local office.

"Graduating more hygienists while failing to address why existing hygienists leave the workforce is like filling a bucket without addressing the leak," says Jessica August, the president of the American Dental Hygienists' Association.

There are proposed fixes out there, but many of them are controversial. There's a push in some states, such as Arizona, Virginia, and Missouri, to allow dental assistants to be trained on the job to perform basic cleanings and other procedures traditionally handled by hygienists. Hygienists argue that this will lead to worse outcomes for patients.

"Workforce shortages should not be addressed by lowering the standard of care, substituting workers who have not received equivalent education and clinical preparation," August says.

A handful of states, including Florida and Indiana, allow foreign-trained dentists to become dental hygienists without completing a US-based program. Some hygienists seem more open to that — assuming they have to take the same board exams. Others worry it will negatively impact care, since dentists don't receive the same extensive, specialized training in hygiene and preventive care.

It's difficult for hygienists to practice in different states because they have to apply for a new license and jump through a new set of hoops. Sarah Hiller, 37, went to dental hygiene school in New York. When she moved across the country to Oregon, she had to spend $5,000 to re-up her education and take a test to get licensed there, because hygienists are allowed to place fillings in her new home. "We need more license portability and just standardization," she says.

Much of what hygienists ultimately want is increased autonomy, whether that's working under a dentist who respects their opinions and recommendations, better career growth, or even the chance to strike out on their own.

Some states, such as Colorado and Oregon, allow hygienists to practice independently without direct dentist supervision. Some states allow public health hygienists to enter settings where access to dental care is often limited, such as nursing homes, or to provide pathways for hygienists to become dental therapists, who have a broader scope.

"That's a much better kind of marriage of putting dental care where it's needed and not accessible, but also giving dental hygienists a role that's more empowering and flexible," says Lisa Simon, an assistant professor of oral health policy and epidemiology at Harvard.

Many hygienists aren't waiting for their circumstances to improve. That's the case for Angela Scott, who left the profession in 2022 after 20 years in the field. After a shoulder injury and struggling to balance her job with childcare, she decided being a hygienist "was just not sustainable anymore." Scott, who has practiced in the US and Europe, now lives in Berlin, where she's trying to break in as a UX designer after completing an internet boot camp. She's also working on an online course to try to help other hygienists who are looking to get out of the industry.

"I was at the point where I began to outgrow what I was doing, and I knew I wanted to do more, but I also knew there was no way I could get any further autonomy as a dental hygienist," she says. "There are a lot of hygienists who are also at the point where they need to do something else."

Morris, in Virginia, says she regularly overhears other dentists asking her boss how she keeps her hygienists around. She's not even sure her doctor is aware of how unique their setup is.

"That relationship that we have, that's what people want when they go into dental hygiene," she says.

Emily Stewart is a senior correspondent at Business Insider, writing about business and the economy.