There is a severe glut of registered dental hygienists (RDHs) in many demographics. Formerly, education and training were only available through four-year academic baccalaureate programs. Today, aspiring hygienists can obtain RDH certification through a two-year community college, an 18-month private institute, or, in a few states, on-the-job training.
In such competitive labor markets, many RDHs are pushed to piece together their workweeks though two or more dental employers. In other cases, RDHs work part-time in dental hygiene and either part-time or full-time outside of dentistry. Many also scramble in the arena of temporary employment.
In several dental markets, employers may unlawfully retain dental assistants to provide dental hygiene services. If the state dental board lacks the motivation or ability to enforce its statutes, patients can and do suffer. Unscrupulous dental employers have utilized the lowest-cost provider in total disregard for the rule of law and patient welfare.
Excessive numbers of workers in any labor endeavor may lead to negative outcomes for those workers. Wages and benefits will generally be depressed. Working conditions are too often compromised. Employers may cheat workers relating to tax codes and state labor rules with a “take it or leave it” attitude. In healthcare services, professionals may be required to “assembly line” patients through a mill operation.
The View from Corporate Dentistry
Meanwhile, the growth of corporate dentistry and the dental service organization (DSO) model has had an impact on the dental profession and its regulation. For example, nearly half of the members of the New Jersey State Board of Dentistry are affiliated with corporate dentistry, with a noticeable impact on the profession.
“Yes, unfortunately, it seems that’s the way dentistry is heading. In our state, we see private offices being sold to corporations at an alarming rate, and a ‘restructuring’ of the office follows within six months of the buyout,” said Jaci Klepadlo, RDH, president of the New Jersey Dental Hygienists’ Association.
Klepadlo also noted the unfavorable work conditions for temporary hygienists and the lack of full-time positions available as a result of oversaturation, debt, or corporate dentistry.
“It’s a little bit of all of them. We cannot point a finger at just one area and place blame solely on that,” Klepadlo said.
“Over the years, there has been an increase in dental offices, corporate and private, that have scaled back on their care for their hygienists and patients. They have begun cutting hours of employment and benefits, decreasing patient chair time, and not providing essential equipment needed for hygienists to do their jobs properly and safely,” Klepadlo said.
Klepadlo is adamant in her support for the vital role played by dental hygiene professionals and in her frustration with the diminishing number dental offices taking an ethical path.
“In most cases, it comes down to how the dentist or the corporate owners value the hygienists’ roles. In the case of subpar working conditions and care for patients, they often underestimate the high value of their provider (hygienist) and therefore do not provide the necessary equipment or work conditions to keep them,” she said.
“In the offices that value the provider’s role, most will provide what is necessary for them to perform at their top peak and compensate them accordingly. These are named ‘unicorn’ offices, as there seems to be a shortage of them,” she said.
“This is a factor in why there is an increasing number of states seeking independent practice for their hygienists. We are providers that are highly trained and sincerely dedicated to providing complete and effective preventative care to all of our patients but are often left with our hands tied behind our backs due to the dentists’ choices for us,” Klepadlo said.
Two Hygienists’ Stories
One unnamed registered dental hygienist working as a temp in South Texas notes that the pros of these positions include high pay, which can be $42 per hour in the Metro-Houston area, and a flexible schedule. But there are cons, too.
“Driving distance. I can’t choose where I want to work. Last-minute cancerllations. If patients cancel appointments, they send you home early. Two weeks without receiving pay. Sometimes one feels less appreciated. No help with charting. And more,” said this hygienist, who has discontinued using temporary staffing agencies to get work assignments.
“I prefer to use Cloud Dentistry verus temp agencies. I would say that 98% of my assignments are now done through clouddentistry.com,” she said.
The ADA also offers a no-cost service for dental hygienists (or any dental professional) seeking part-time, full-time, or temporary employment at the ADA Career Center. Still, too many DSO clinics provide cause for frustration, the hygienist said.
“They overwork their hygienists and they’re underpaid. The equipment and instruments are very dull and outdated. Way too many patients are put on the schedule,” she said, noting one clinic in particular for its poor management.
“One of the doctors there, I feel, is unethical at times. He loves to diagnose decay on perfectly healthy Medicaid teeth on a daily basis,” she said.
Another unnamed registered dental hygienist detailed how employer tax cheating goes on at clinics to circumvent US Internal Revenue Service (IRS) guidelines about the differences between employees and independent contractors.
“Most (temp employment) agencies do not give W-2s,” he said. In effect, he added, most temporary employment agencies violate state and federal tax codes by misclassifying dental hygienists as independent contractors, which they clearly are not under published IRS guidelines. “Dental Force and a few other temporary professional employment agencies do payroll for the doctors and send me a W-2. If the agency doesn’t take out taxes for me, sometimes the doctor will send me a W-2. But most doctors either send the IRS 1099 form or nothing at all,” he said. Again, temporary employment dental hygienist employees are widely misclassified as independent contractors.
Professional dental hygienists face a plethora of employment challenges. Their labor market is typically flooded. Working conditions are often suboptimal. Employers frequently abuse employees with faulty IRS classification as independent contractors. Wages, benefits, and hours of employment are increasingly depressed. All the while, RDHs face ever increasing difficulties of student loan debt.
The dental industry continues to consolidate, with beneficial ownership increasingly in the hands of the private equity (PE) industry. Management of corporate dentistry operates with similar values to the PE companies from which they’re trained and experienced, such as fast food establishments and payday loan companies.
Temporary and part-time employment is increasingly a hard reality faced by dental hygienists. Some apparently seek answers in independent hygiene practice. Unfortunately, the loss-leader preventive fee schedules of the dental insurance industry and Medicaid may not fiscally support such enterprise.
Fortunately, a few professional trade associations, like the New Jersey Dental Hygienists’ Association, support their colleagues. Leaders who tirelessly explore the swamp for solutions do exist.
Dr. Davis practices general dentistry in Santa Fe, NM. He assists as an expert witness in dental fraud and malpractice legal cases. He currently chairs the Santa Fe District Dental Society Peer-Review Committee and serves as a state dental association member to its house of delegates. He extensively writes and lectures on related matters. He may be reached at firstname.lastname@example.org or smilesofsantafe.com.