The COVID-19 pandemic saw the beginning of the Great Resignation, with dental hygienists representing one of the largest exoduses in the dental industry. But even as the pandemic wanes, few hygienists have returned to the field.
COVID-19 exacerbated a voluntary reduction in the workforce by 3,300 dental hygienists, or 1.6 percent, as of August 2021, according to a February study published in The Journal of Dental Hygiene. Less than half of those who left employment early in the pandemic had returned to the workforce by August 2021.
Dental hygienists have continued to be one of the most recruited for roles at dental offices during the pandemic, with 33.1 percent of dental practices recruiting dental hygienists in March alone, according to a poll from the American Dental Association.
Here, 17 dental practitioners share with Becker's reasons why dental hygienists left the field and why they aren't returning:
Editor's note: Responses were lightly edited for clarity and length.
Harvey Lee, DDS. Chief Clinical Officer at Virtual Dental Care: I think the biggest driving factor was the vast amount of hygienist furloughs and layoffs during the COVID-19 shut down. Few practices remained open, and even the ones that did for emergencies were still operating for limited hours. My guess is that many dental hygienists decided to pivot their careers to hedge for any future pandemic-related problems that may arise. We are seeing more dental hygienists starting their own mobile dental hygiene practices using our cloud-based software, Teledentix. By starting a mobile business, hygienists can build their own patient base and partner with organizations to expand their footprint outside a traditional dental office setting using teledentistry and mobile dental delivery models.
Practices are experiencing challenges in recruitment simply because of a supply and demand problem. With fewer hygienists in the workforce, practices need to increase compensation and work flexibility to attract their clinical staff. But considering so many dental offices are still recovering from the financial impact of the shutdowns, it's causing significant issues for how they are able to pay for the increased wages we are seeing for dental hygienists.
Susan Fredericks, DDS. Southern Cal Smiles (Woodland Hills, Calif.): Dental front line help, assistants and hygienists dropped out of the workforce, either due to age and health issues surrounding their own health or that of family members, or left due to having younger children to care for.
Prior to COVID-19, surveys of dental hygienists often cited not feeling valued or respected as one of the primary reasons they would seek a different occupation. Burnout and feelings of frustration have only gotten worse, as the percentages of patients canceling their appointments a few days before or same day remains much higher than pre-COVID. The lack of respect for the service they provide and the care they have for oral health seems to be surrounded by a dismissive attitude, even from long-standing patients. It is demoralizing to these healthcare workers.
The pandemic has had a significant effect on the U.S. labor market, particularly among women. A variety of factors, including school and daycare closures, the unequal burden of caring for aging parents and risk of infection being higher in female-dominated occupations have caused a major exit of women from the labor force overall. These effects could be long lasting, persisting even after the pandemic comes under control. Dental hygiene has been well documented as a female-dominated profession; they are 94 percent of the workforce.
Even with significant pay raises, dental offices are still having issues attracting hygiene staff. It is likely that this shortage will persist for some years. The Great Resignation has been significant with hygienists. Higher salaries and more flexible work schedules may not entice many to come back.
Rajdeep Randhawa, DDS. Innovative Dentistry (Colts Neck, N.J.): Long-stretched uncertainty compounded by COVID-19 stress and burnout in high-volume, high-stress offices and DSOs where the whole compensation system is production and incentive based with having very high expectations from dental hygienists. That is the reason why, while burning out their army of hygienists during the COVID-19 time frame, they are now not only vigorously trying to recruit them but also trying to keep them by talking about work-life balance after still burning them out on a daily basis.
Dental practices are still struck with very old outdated business models of recruiting, compensating and retaining dental hygienists that do not work in the current work and business environment, and they are dealing with a very smart group of individuals who understand everything and feel the system is not fair to them as their compensation is very low as compared to the hard work and risk they take in the current COVID-19 environment. Dental practices that have lost the trust of the hygienists have to work very hard to gain their trust back, and may never get it back, as the same hygienists that used to motivate the younger generation to get into dental hygiene may tell them it is not worth it.
Laurence Stone, DDS. Doylestown (Pa.) Dental Solutions: There are many reasons why dental hygienists may be leaving the workforce, including the COVID-19 pandemic, inadequate pay, difficult working conditions and the expansion of dental franchises, corporate practices and DSOs. Dental practices are experiencing difficulty in recruiting dental hygienists for some of the same reasons and, depending on your location, the inadequate number of dental hygiene training programs.
Michael Davis, DDS. Smiles of Santa Fe (N.M.): Firstly, fees for dental services, especially revenue generated from dental hygiene care, have actually declined due to inflation. These fees were already often at loss-leader low levels to begin with. Numbers of insurance companies have held their fee schedules static or near-static for many years. Plus, added COVID-19 infection control safety measures elevated overhead expenses and time to process patients through a hygiene operatory.
Dental practice owners had tough choices to make. Some were in a demographic in which they could raise fees to cover the actual overhead expenses for these hygiene services, but not many. Others elected to run their hygiene staff on an assembly line treadmill. If enough patients were run through the process quickly enough, regardless of favorable patient outcomes, production revenue could keep up with overhead outlays. Concurrently, salaries for hygienists were held to the status quo. Naturally, professional hygienists burned out. Many have left the dental industry forever.
Holli Perez. Co-founder and Chief Marketing Officer of DirectDental: Prior to 2020, the dental field was already suffering from a shortage of hygienists. The pandemic definitely exacerbated it. Not only did many hygienists leave the field completely, but the hygienists that continued to work are putting their health and families before their careers. The hygienists that are willing to work won't work more than three days a week.
Reasons why they are leaving the workforce or working part-time:
- Their health — many don't feel comfortable returning to work either due to COVID-19, the vaccine mandate or just their mental health.
- They decided to stay at home with their kids — several hygienists I have spoken with haven't returned to work or returned their children to school. They are now homeschooling them.
- Left the operatory — many found careers outside of dentistry or stayed in dental but either started their own business or broke into sales.
- Retired early — a huge amount of my hygienists simply retired.
It is predicted that dental practices are going to continue to struggle with hiring hygienists for years to come, which means offices should:
- Offer pay above the average rate and post that at the top of the job listing.
- If you need to hire someone for three or more days a week, try splitting it between two or more hygienists.
- Offer benefits to your hygienists.
- When you get an applicant, call and text them right away.
- Have a fast hiring process; don't let another office scoop them up.
- Work with your local schools and recruiters.
Mina Kim, DDS. Bryant Park Dental (New York City): Many dental hygienists who were close to retiring decided to leave during COVID-19. They have the most exposure to airborne pathogens on the dental team. Hygienists also say they feel overworked and undervalued by their practices. There is a smaller supply of hygienists and greater demand. This disparity is leading to difficulty in recruiting hygienists.
Charles Rim, DDS. Oregon State Hospital (Salem): Early in the pandemic, federal, state and local regulatory agencies recommended dental facilities to postpone elective procedures, surgeries and nonurgent visits, and prioritize urgent and emergency visits and procedures until further notice due to dental healthcare personnel being at very high risk for exposure to COVID-19. In response to the early pandemic recommendations, oral health facilities provided limited dental services or temporarily closed. With limited supply of personal protective equipment and dental services, many DHCP left the workforce involuntarily and voluntarily. As the job market is stabilizing with ample opportunities and higher pay attracting DHCP to find work elsewhere, oral health facilities will continue to experience challenges with recruiting and retaining DHCP, including dental hygienists.
Robert Boff, DMD. Ramsey (N.J.) Family Dental: Insurance reimbursement for procedures performed by the hygienist aren't keeping up with hourly pay demands. Dentists are being forced to shorten hygiene appointments and/or cut back on services performed to create a profitable appointment. Hygienists are being forced to work harder and faster, resulting in a less rewarding work experience. Not being happy with the daily work experience is chasing hygienists away from the dental workforce.
As far as recruiting, we're seeing more dental offices poaching hygienists from their current offices. Dentists are desperate to find a hygienist and will offer whatever it takes to hire one, even if they are currently employed. DSOs are bigger and can offer more in the benefit package than most solo practitioners can provide … very hard to compete with that.
Flavia Lamberghini, DDS. Apple Dental Care (Chicago): The dental hygienists leaving the workforce could have several multifactorial explanations that started long before the COVID-19 era, child-rearing responsibilities being the first reason listed in a 2007 study, followed by health reasons and pursuing a different career. COVID-19 has just aggravated the situation, with dental hygienists being one of the most exposed roles when we talk about virus transmission.
Dental practices are experiencing challenges in recruiting any type of help these days, with dental hygienists probably being the most required job in the field. A combination of hygienists leaving dentistry in high numbers together with dental hygiene schools not graduating classes at the same rate as dental schools has aggravated the situation and made the shortage more noticeable.
David Keller, DDS. Granite Dental (Vancouver, Wash.): I believe two forces are combining. Initially when COVID-19 struck, there was a lot of information that seemed to indicate that the clinical practice of dental hygiene would be very risky to hygienists. As more data comes out, that risk appears to have been overstated. Nevertheless, to many dental hygienists it is simply easier to step away from the profession, especially when the short- to medium-term loss of that income doesn't cause too much discomfort. The second force was how dentist/owners responded to the COVID-19 concerns raised by team members. Having concerns not responded to in a positive way again gave a valid reason to step away for a time and consider alternatives to the current working environment.
Concerns about safety in clinical practice remain, especially among inexperienced hygienists who simply haven't practiced long enough. This gap can create a space where demand for compensation packages exceeds the income earning potential of hygienists. The employee/employer relationship can also remain fragile when hygienists have expectations regarding PPE or infection control that exceed what might currently be mandated, such as requiring a negative pressure room, to see patients at all.
Jason Hirsch, DMD. Dr. J Pediatric Dentistry (Royal Palm Beach, Fla.): The giant DSO/PE idea adds layers of management that requires a lot of capital in the form of revenues. Revenues come from procedures. One of the biggest sources of procedure revenue is from hygiene. If there are less RDHs, then there are less revenues. There is just not enough capital being deployed to retain RDHs, and that is why the dual problem of retention and recruitment of the same position is occurring. Experienced RDHs leave because they are not being paid for their experience, likely having to upsell a lot of nonsense, and they don't want to see double the volume of patients; and new RDHs are aware of the market dislocation and are likely asking for way above their starting range, except they don't have the experience to see as many patients per day to make the ends meet.
The bottom line is the economics are just not aligned now. Something has/had to give. When interest rates rise we are going to see even more basic economic problems that this profession never dealt with before. This profession believed it was the field of dreams. Then private equity got involved. We shall see.
Jason Korkus, DDS. Sonrisa Family Dental (Chicago): Dentistry has become a very high cost business to operate. With increased government regulation through higher taxation, there is only so much a dental operation can support as far as wages for hygiene and staff. There was a constant fear among the support staff that COVID-19 would be a continuing factor in dental practices, so they decided to migrate away from patient care. Other opportunities were afforded to them in other industries that allowed them to work from home. The decision for these support staff to return to the dental office was hindered due to the wages and the supplemental benefits that an office can afford.
We have had inflation of dental costs, COVID-19 and options for a more accommodating working environment for hygienists. Recently, the Illinois State Dental Society helped push through legislation that will allow expanded functions for dental assistants. This will help in the short time, but let's be hopeful that there will be a push for reasonable wages in all facets of healthcare that will allow a larger presence again for hygienists.
Rick Mars, DDS. Dental Care Group (Aventura, Fla.): The pandemic, DSOs and insurance compensation are just a few reasons why a dental hygienist might wake up in the morning and say, "This is not what I signed up for." That being said, the question bears asking, which hygienists are leaving the workforce? I am proud to say that in our group practice, all eight of our hygienists have maintained their full-time employment at the Dental Care Group, and this is not by accident. I believe employers must be intentional in what they do to maintain their teams, especially with key team members, which includes our hygienists. This is done by addressing concerns and being dynamic in the way we practice dentistry to accommodate the needs and concerns of our team members. In the recruitment of new hygienists, hiring the right people who fit your model and strong compensation packages are two of the keys for overcoming the current recruitment challenges.
Kai Weng, DDS. Dental Designs of Maryland (White Marsh): The primary drivers for the hygienist exodus are on-going child care issues and lingering hesitancy about the safety of our profession in relation to COVID-19. Schools have only recently begun to relax their protocols, and for many hygienists with the option of staying home, it is often a more predictable route when children are being sent home or entire classes forced to go virtual at unpredictable intervals when there is a positive COVID-19 test. There is also still hesitancy as to how safe the aerosol-laden dental environment is in regards to contracting COVID-19 and possibly bringing it home. I've spoken to many hygienists that are caretakers of elderly family members, and this is a major concern. Until COVID-19 becomes accepted as endemic or highly treatable, these will continue to be issues facing dentistry.
Challenges with hiring at this point primarily have to do with supply and demand. Private equity-backed DSOs are able to offer more competitive pay and benefits, and effectively treat hygiene as a loss leader, whereas private practices do not have the same luxury. Over time I predict hygienists prioritizing highest pay will end up in DSOs, and hygienists looking for work-life balance and quality of care will gravitate toward private or group practice. In the meantime, the lack of hygienists is a problem that affects all strata of the dental business.
Barry Lyon, DDS. Dental Director at Dental Care Alliance (Sarasota, Fla.): I believe we do not realize, nor appreciate, just how hard our dental hygienists work. Considering the toll repetitive motion takes on the hands of a hygienist over 10-20 years, and the unrelenting presence of the COVID-19 pandemic, it isn't hard to see that a moment is often reached where the decision is made to call it a career.
Dentistry, like all other sectors of the economy, is dealing with staffing shortages. For many dental hygienists, there comes a tipping point where the manually arduous tasks of daily work, coupled with required intimate patient contact during a deadly pandemic, leads to the decision to retire from hygiene practice. No wonder dentists often search for months without receiving a bite on their recruiting efforts.
Rick Singel, DDS. (Cincinnati): We dentists are absolutely stumped by the disappearance of this work force. Never expected it! The only things I can think of are that federal and state money are keeping them afloat for right now. Secondly, they may have wanted a career change and the pandemic downtime gave them the opportunity. But no doubt, it has created an emergency for the dental profession. I myself have been working shorthanded for the past months.