Dentists, public health advocates, and policy-makers across the state agree on the need to improve access to affordable dental care in Washington.

Access is a complex issue. The growth of the “gig economy” means fewer individuals have traditional dental benefits coverage, and individuals without dental benefits are less likely to get regular dental care. An increasingly diverse population means that language barriers must be overcome to reach underserved and vulnerable populations. And the state’s absurdly low Medicaid reimbursement rates limit the number of dentists able to accept patients who rely on Medicaid.

Another increasingly significant driver of the access problem is the growing shortage of dental assistants and dental hygienists in Washington.

This shortage touches every corner of the state and is felt in private practices and community health centers alike. Rural areas can suffer from a lack of trained candidates, while the skyrocketing demand for assistants and hygienists in fast-growing urban areas of the Central Puget Sound region makes it difficult to fill openings. 

“We don’t have a dentist shortage,” says Cathy Dahlquist, a former state legislator now serving as the executive director of the Seattle-King County Dental Society. “What we have is a serious dental professional shortage.” 

FEWER APPLICANTS, LONGER WAIT TIMES 

In public health clinics, the shortage of assistants and hygienists is making it harder for underserved populations to get the preventive care they need to avoid more serious problems down the road.

Statistics from the 2018 Seattle/King County Clinic tell the tale. Nearly 70 percent of the patients surveyed at the clinic reported that it had been more than a year since they last saw a dentist, and over 40 percent said that it had been more than two years. Patients overwhelmingly sought cleanings (59 percent), while another 35 percent requested either a filling or an extraction. Many of these restorative procedures could have been avoided with timely preventive care.

Dr. Sarah Vander Beek, chief dental officer of Neighborcare Health, a federally qualified health center, must deal with the effects of the shortage daily. 

“We’ve had problems finding assistants over the last three years or more,” said Dr. Vander Beek. “The challenges in finding hygienists is newer for us. We’re not even getting applicants for open positions.”

She notes that previously Neighborcare would post a hygienist opening and very quickly receive multiple applicants. But the center has had a hygienist opening for more than a month, with no applicants at all. With Neighborcare hygienists seeing an average of 10 patients per day, four days per week, a persistent opening translates into 150-160 patients not receiving care each month.

The impact of unfilled positions is felt in other ways too, according to Dr. Vander Beek. With fewer staff, appointments must be booked farther into the future. Some local public health agencies report scheduling appointments up to 90 days out, although Neighborcare has consistently maintained more reasonable, though far from ideal, three- to four-week lead times, she says. 

Additionally, clinics sometimes are forced to block out dentists’ schedules for lack of staff to support their work. Other times, dentists end up doing hygiene work, which can create backlogs in their restorative work. Longer waits for service make for less satisfied patients and higher no-show rates.

“Is access being able to get in to find out what your problems are?” Dr. Vander Beek asks. “Or is it being able to see providers and get those problems cared for in a timely manner? I’d say it’s the latter.”  

Dr. Sue Yoon, director of dental services at the Community Health Center of Snohomish County, also reports serious problems in filling dental assistant positions, despite competitive salary, benefits and signing bonuses. 

“Our providers can’t function at the top of their licenses if they don’t have adequate support staff,” Dr. Yoon says. “We’ve made it work thus far, but our operations could definitely run smoother if we were consistently fully staffed.”

PRIVATE PRACTICES ALSO IMPACTED

Assistant and hygienist hiring challenges aren’t limited to community health centers. In a recent survey of WSDA members, dentists in private practices across the state reported difficulties hiring auxiliary staff.  

More than a quarter of dentists surveyed in King, Pierce and Snohomish Counties were actively searching for qualified hygienists. Those that had successfully filled vacancies within the last two years reported that the process often took two to six months, or even longer. The search for qualified assistants was similarly time consuming for many dentists.

Dr. Robin Henderson, who practices in Clarkston, a small community along the Idaho border, has had an opening for a chairside assistant for more than eight months.

“It keeps me from being as productive, from seeing as many patients as I would like to see,” Dr. Henderson says. “It means longer wait times for appointments, overworking my existing assistants, and less flexibility to squeeze in emergency visits.”

Dr. Henderson sees a variety of factors contributing to the shortage in her area, including increased turnover, a strong economy creating more competition for good employees, a cumbersome and back-logged state registration system for dental assistants, and a lack of training programs nearby. On-the-job training has become a virtual necessity, but brings its own challenges. 

“It takes about a year for someone to become fully proficient in how to do the job,” she says. “In the meantime, that’s another burden on the rest of the staff.”

Other private practices hiring for hygienists and assistants cite additional factors contributing to the shortage. They note that assistants are often younger employees who may pursue other opportunities as they begin their work lives. Lack of understanding about the opportunities available, language and cultural barriers, increased licensing requirements and the related cost of training programs — both to the institution and the student — are other often-mentioned problems.

DIVERSE STRATEGIES NEEDED

Seattle-King County Dental Society’s Cathy Dahlquist argues that, with multiple factors contributing to the assistant and hygienist shortage, a variety of strategies must be employed to attack the problem.

She points to the recent report of the Washington State Health Workforce Council, on which she serves. One of the report’s primary recommendations is to strengthen the dental health workforce pipeline by providing additional high-employer demand funding for dental assistant and hygienist education programs; providing institutions incentives to offer preparatory programs outside of traditional school hours; increasing marketing to students about career opportunities in these positions; and developing stronger pathways, including potentially preferential admissions, for dental assistants looking to make the move into hygienist positions.

The first step is getting more young people interested in these positions, especially as dental assistants.

“Dental assistant training schools are closing because there’s not enough enrollment,” Snohomish County’s Dr. Yoon says. “It really affects our recruitment pool.”

“As high school juniors and seniors, kids could be getting training, paid for by the state at area health education centers,” Dahlquist says. “But they’re more interested in medical assistant positions, despite the fact that dental assisting offers better pay and working conditions.”

Experts agree that getting more young people to pursue dental assistant work could eventually help improve the diversity of Washington’s hygiene workforce. 

“A dental assistant position is a way for a broad range of people to enter the profession,” says Neighborcare Health’s Dr. Vander Beek. “It’s an opportunity for them to get on-the-job training and then have opportunities for career development and upward mobility to a more livable wage.”

But today’s training models limit the progression from assistant to hygienist, many experts say. 

“We need more programs for non-traditional students,” Dahlquist argues. “A Monday-through-Friday, daytime program to get a bachelor’s degree doesn’t work for those with full-time jobs. It limits the range of students that can enroll. Graduates of those programs tend to look a lot alike — young, white women with the financial resources to attend school full-time.” 

EXPANDING SCOPE FOR DENTAL ASSISTANTS

WSDA is proposing important legislation in the 2019 Legislature to address the shortage of dental personnel by expanding the scope of practice for assistants in Washington.

The proposed legislation would permit dentists to delegate certain tasks, such as sterilization, to dental assistants under general supervision, which is not currently allowed in statute. WSDA is also considering proposing other legislation to expand the scope of practice for dental assistants in the future.

“All too often, dental assistants are dismissed as low-educated, entry-level positions,” says Dr. Vander Beek. “But many of them are truly talented, and could be doing a lot more.”

“Expanding assistants’ scope of practice has a number of benefits,” said Dr. Chris Delecki, WSDA president and senior attending dentist at Seattle’s Children’s Hospital. “First, it makes those positions more attractive for recruiting and retaining employees. It helps hold down costs to patients.”

Dr. Delecki argues that Washington should adopt models that have worked well for the military and the Indian Health Service. In these models, assistants are given specialized training to develop specific skills that can be used in a clinical environment. Generally, these are reversible procedures, such as cleaning and polishing teeth, supragingival scaling, gross debridement, or placement of restoration material. 

He believes that training those already in the field to perform reversible procedures is a much safer approach to expanding access to affordable dental care than the dental therapist model, which allows individuals with less training than a licensed dentist to perform irreversible surgical procedures. 

LICENSE PORTABILITY FOR DENTAL HYGIENISTS

Another idea gaining support is to make it easier for hygienists who have practiced and are in good standing in another state to obtain a license immediately upon moving to Washington. Over a decade ago, Washington significantly reduced the administrative barriers for dentists licensed and in good standing in another state to obtain a dental license here. These changes resulted in a significant increase in the number dentists trained elsewhere coming to Washington to practice. A similar approach for hygienists could pay similar dividends. 

Today, hygienists trained in other states face barriers to obtaining a license that do not exist for dentists. To be eligible for a limited hygiene license here, dental hygienists must not only be licensed elsewhere, but also engaged in “active practice,” which is defined as at least 560 hours of practice in the last 24 months. This can be a barrier to those who have taken a family leave or have a more transitory lifestyle, such as spouses of active-duty military.

The state also requires hygienists moving into Washington who haven’t been trained in local anesthesia to take a class in those procedures in order to practice dental hygiene beyond their first 18 months here. Again, this can limit options for those who expect to be here for a relatively short period.

WSDA’s proposed legislation would remove the “active practice” requirement, making the transition to practice in Washington smoother for hygienists from out of state.

NEXT STEPS IN CLOSING THE GAP

Shortages of dental assistants and hygienists didn’t appear overnight, and it will take time and effort to close these critical gaps. Better marketing to students, more flexible training models, expanding the scope of practice for assistants, and making it easier for hygienists to enter the state are just some of the strategies needed to attack this problem. 

WSDA will continue to pursue these strategies and work to identify other innovative responses on behalf of its members and for the benefit of quality oral health care in Washington.