Chapter 8. Workforce Models and Opportunities
This chapter covers four types of strategies to assure that
an adequate workforce exists to maintain the oral health of
1. Expand traditional delivery systems
2. Develop community-based collaborations and integrated systems
3. Increase workforce numbers, diversity and skills
4. Create methods for workforce retention and sustainability
Models take into consideration workforce size, composition,
characteristics and distribution. Current initiatives, examples
and resources are provided.
"The public health infrastructure
for oral health is insufficient to address the needs
of disadvantaged groups, and the integration of oral
and general health is lacking."
Health in America: A Report of the Surgeon General
Oral Health in America and numerous other reports and
papers referenced at the end of this chapter discuss the factors
that create this workforce crisis, especially in rural areas.
Some of the factors were covered in Chapter 1. Insufficient
numbers of dental professionals and public health professionals,
underutilization of professionals' skills to the fullest extent,
and fragmented systems of care contribute to problems accessing
preventive services and clinical treatment.
The American Dental Association's Future of Dentistry report
notes declining numbers of dental graduates and a large number
of dentists retiring from active practice or reducing the
hours they practice. Nationally, about 35% of all practicing
dentists are older than age 55. By 2014, the number of dentists
retiring is estimated to exceed the number of students graduating
from dental school. About 2.5% of all dentists specialize
in pediatric dentistry. Dentists who self-identify as public
health dentists represent just 1-3% of all practicing dentists.
A 2002 study of 845 California dentists who practice in rural
areas revealed the following demographics (WWAMI, 2003):
The American Dental Hygienists' Association reports that the
profession of dental hygiene is expected to rise by over 35
% between 2000 and 2010. Nationally, while 57.5% of dental
hygienists are between the ages of 35 and 55, only 9% are
above 55 years of age.
- 38% are over age 55
- 43% grew up in a rural community
- 88% are male and 82% are white
- 72% graduated from California dental schools
- 50% participate in Denti-Cal or Healthy Families
- 11% are specialists, but none of these practice in
small isolated communities; orthodontists and pediatric dentists
comprise 58% of the specialists
- 68% employ at least one dental hygienist; there is a vacancy
rate of 17.7%.
In the Surgeon General's A National Call to Action to Promote
Oral Health, Goal 4 addresses workforce issues. A number
are listed for this goal. Healthy People 2010 objectives
also address workforce issues.
People 2010 Oral Health Objectives
- 21.17: increase the number
of state and local dental programs with public health
- 21.14: expansion of community
health centers and local health departments with an
oral health component
- 1.8: increase racial and ethnic
representation in health professions
- Chapter 23: a number of infrastructure
objectives relate to a well-trained and competent
public health workforce.
Rural communities often experience great difficulties recruiting
and keeping certain types or levels of dental professionals.
Professional reasons mainly involve lifestyle and economic
issues, including feeling isolated or not being able to
find jobs for spouses. Community clinics may not be able
to meet the salary needs of dentists or dental hygienists
who still have unpaid professional education debts or who
have a great deal of experience and can make a significantly
higher salary working in a private practice or in an urban
area. A recent study showed that local health departments
report recruitment difficulties for dentists and dental
hygienists due to budget constraints, shortages, and salary
differentials (Mertz, NOHC, 2004.) Most dentists in the
study provided direct clinical care rather than public health-oriented
functions such as needs assessments, program planning/evaluation,
or management. Although some of these dentists were salaried,
others were contractual or volunteers. Small or isolated
communities also lack a sufficient population base to support
dental specialists such as pediatric dentists or oral surgeons,
so patients must travel great distances to receive specialty
care. Yet lifestyle and family issues also are a primary
motivation for those who choose to practice in a rural community,
e.g., small town sense of community, feeling safer, closer
to nature. Rural communities increasingly must be creative
in marketing and creating incentives that will attract potential
In Chapter 6 you discovered what dental care resources
exist in your community and where there are gaps. What workforce
issues did you identify in Chapter 1 that act as barriers
to assuring that all pregnant women and children ages 0-5
receive an oral health assessment, preventive oral health
services and counseling, as well as dental treatment? What
roles do health professionals such as physicians, nurse
midwives, physician assistants, public health nurses and
nurse practitioners currently play in oral health promotion,
prevention, and referral for oral care in your community?
Complete the Self-Assessment on Workforce to identify assets
and gaps that you can use to later develop an action plan
to address workforce issues.
Strategies to Manage Dental Workforce Problems
Expand traditional delivery systems
There are numerous ways to expand services using traditional
dental providers or systems:
- Dental teams or individual providers provide care
in community-based settings such as Head Start, schools
and community centers; simple examinations and preventive
services do not require much, if any, dental equipment per
se, only some instruments and supplies. Other procedures
may require portable equipment. Many communities in California
are doing this with First 5 funding.
- Create special license status or subsidize license renewal
or malpractice insurance for inactive practitioners to volunteer
in community-based programs. Idaho's legislature passed a
bill that allows the Board of Dentistry to grant a "volunteers
license" to retired dentists, establishing immunity from
liability for performing volunteer services in community health
clinics. States such as Georgia, Maine, Oregon and South Carolina
have used the subsidy approach. A new federal program called
the Free Clinics Federal Tort Claims Act Medical Malpractice
Program provides malpractice liability coverage to volunteers
through the federal government. For an application, go to
- Use mobile vans (self-contained clinics) to travel to community-based
sites, using dental staff or volunteers (see Chapter 6).
- The HRSA Bureau of Primary Care is increasing the number
of Federally Qualified Community/Migrant/Homeless Health Centers
across the country, and making an effort to require an oral
health component. http://www.hrsa.gov/grants/preview/primary.htm#hrsa05103.
- Engage practitioners in volunteer service to provide care
in their own offices or in community sites. An excellent resource
for doing this is a manual on Volunteer Retention and Recruitment
by Volunteers in Health Care. http://www.volunteersinhealthcare.org/Manuals/ddsrecruit.pdf.
- Use teledentistry technology to deal with supervision issues
for hygienists providing community-based care or for consultations
with specialists at other locales (see Chapter 6).
- Contract with an itinerant dentist or team that
works out of multiple offices for selected periods of time
or visits an area to provide specialty care for an agreed
upon number of hours per week or month. This works especially
well for pediatric dentists, orthodontists, oral surgeons,
or specialists who work with children who have special needs.
The Alaska State Oral Health Program contracts with a pediatric
dentist to provide itinerant services for children enrolled
in Medicaid on the Kenai Peninsula.
- Also in Alaska, there is a Medicaid continuing care agreement
to assist with transportation and lodging expenses for dentists
in areas where public health nurses have provided information
that the area is "underserved". This is a stipulation
in part of their Medicaid state plan.
- Offices/programs share a dental hygienist who primarily
sees young children, especially those who are on public assistance
or who have no dental insurance.
- Expand office/clinic hours and make use of part-time
personnel, volunteers, or staff who rotate.
- Expand hospital services to include a dental outpatient
clinic, mobile services, new mother/infant oral care programs,
or operating room services with general anesthesia (see
- A few states have expanded the roles of dental hygienists
or relaxed supervision requirements in public health settings.
See information on California's RDHAP program (sections 1774
and 1775 of the Business and Professions Code) at http://www.dbc.ca.gov/index.html
- Alaska has created a new provider category, Dental Health
Aide, under the Alaska tribal health programs' Community Health
Aide/Practitioner program. There are three levels based on
type of training.
for a description of this program.
Develop community-based collaborations and integrated
systems of care
This category expands on the previous one to add
more coordination and to develop systems of care for various
levels of need. Many recent federal grant programs such
Healthy Tomorrows or the State
Oral Health Collaborative Systems (SOHCS) grants require
such a focus.
- Use outreach workers or promotoras--members of the community
who can speak the languages of the various subcultures (or
use interpreters) and are hired to help enroll families for
health and other benefits, provide some health education and
other information, and refer for services.
- Use case managers. Usually they are hired by programs to
help patients complete paperwork, make and keep appointments,
follow up on recommendations, pursue continuing care or specialty
care. They act as an interface between patients and providers.
Dentists perceive these services as valuable; one of their
biggest complaints is broken appointments, so they may be
more inclined to see families who keep their appointments
and follow through on recommendations (see Chapter 5).
- Community health centers generally provide multi-disciplinary
services, including medical and dental care. They may use
common record systems and share common reception/waiting rooms
and certain staff such as receptionists or billers. They also
may serve as excellent community placements for students,
interns or residents to learn community-oriented primary care
and public health approaches.
- Various MCH and early childhood-oriented programs such as
WIC, Head Start, childcare centers, or Family Resource Centers
can collaborate to share educational materials, consultants,
outreach workers and other resources to promote cross-referrals
and to make sure families don't fall through the cracks.
- The Colorado Technical Assistance Program supports travel
expenses for consultants to travel to rural areas to provide
technical assistance on challenging situations or issues.
They also have a rural-to-rural mentoring program that provides
peer consultation on specific issues.
- Nebraska developed a Midwest consortium to fund the education
of dental students who would practice in rural areas of Nebraska,
South Dakota, Kansas and Wyoming after graduation.
- Some states or local communities have subsidized capital costs for building
practices for dentists who will agree to serve the area
for a number of years.
- High schools may have vocational dental assisting programs.
For example, in Akron, Ohio a dental clinic is available to
all students in financial need who have no dental coverage.
The Board of Education pays a dentist to provide 180 hours
per year. School staff handle the application process and
scheduling. The program allows onsite clinical training for
the dental assisting students as well.
- Lake County, California has used AmeriCorps members to assist
with dental van visits and follow-up, and to teach preschool
lessons on oral health. They also use resources from Healthy
Start and Migrant Education to provide translation and transportation
Increase workforce numbers, diversity and skills
This category includes strategies for working with dental
professionals and other health professionals.
- Recently, California approved licensure by credential for
dental and dental hygiene practitioners who have a license
in another state. See http://www.dbc.ca.gov/licbycred.htm
for a list of requirements. The impact this may have on the
dental workforce is still unknown as it just took effect in
2004, but it may prove a boon for rural areas in California
that border another rural state such as Nevada or Oregon.
Previously the difficult California licensing exam was a major
deterrent for practitioners who didn't want to go through
another grueling clinical board exam.
- Hawaii recently enacted a law that authorizes out-of-state
dentists and hygienists to practice in FQHCs and comparable
facilities without obtaining a Hawaii license.
- The National Rural Recruitment and Retention Network
(3R Net) includes organizations such as State Offices of
Rural Health, Area Health Education Centers and State Primary
Care Associations. These organizations help health professionals
locate practice sites in rural areas throughout the country.
In California, contact Kerri Muraki, California Rural Health
Policy Council, 1600 Ninth Street, Room 440, Sacramento,
Tel: 916- 651-7872, Fax: 916- 651-7875, firstname.lastname@example.org.
- Mentoring programs are important for pairing students at
any level with a practitioner who is willing to serve as a
mentor; this can significantly influence their practice choices.
This may be particularly effective for recruiting people from
diverse ethnic groups into dental professions and, subsequently,
into rural practice.
- Utah and Alabama have used National Guard dental units to
provide services during active duty exercises. Given the current
situation with active war deployments, however, units may
not be available for this activity.
- Clinics are beginning to provide training and experiences
to increase staff and practitioner skills in cultural competency
and health literacy. Good resources for this include: Toward
Culturally Competent Care: A Toolbox for Teaching Communication
the DHHS Office of Minority Health devoted an issue of their
newsletter to standards for cultural and linguistic competency:
- Many organizations are promoting and providing leadership
training opportunities to prepare people for leadership or
policy positions. For example, UCSF Center for the Health
Professions administers the California Health Care Foundation
(CHCF) Health Care Leadership Program, a two-year program
that is open to dental and other health professionals; http://futurehealth.ucsf.edu/futureleaders/.
The American Dental Association also sponsors a Leadership
program. The California Endowment sponsors a one-year Scholars
Program in Health Policy at Harvard University. "This
full-time program is designed to create a network of health
professional leaders who are capable of advancing the multicultural
health interests of California's public, nonprofit and academic
sectors. Three scholarships are awarded each year to underrepresented
minority physicians, dentists and mental health professionals
who receive advanced training in leadership and cultural competence,
leading to a Master's degree in Public Health or Public Administration."
- Teach other health professionals such as physicians, nurse
practitioners, physician assistants, certified nurse midwives,
public health nurses, some skills in oral health promotion,
oral inspection, simple preventive measures, anticipatory
guidance and active referrals to dental professionals. Communities
in many states are now using this approach. National and state
organizations have developed a number of training programs
to accomplish this. California's First 5 Oral Health Initiative
is one example. Others are listed in the Resources section.
- Increase practitioners' knowledge and skills in specific
areas such as advanced behavioral management and hospital
care, special patient care, and public health. A variety of
such courses are being offered through health professions
schools or organizations. A note of caution: increased knowledge
alone doesn't necessarily translate into practice changes.
Interactive courses with additional practice incentives are
more effective in this regard.
Create methods for workforce retention and sustainability
This category addresses the problem of recruiting professionals
to practice in rural areas, enticing them to stay, and motivating
them to stay in the profession rather than pursuing other
- Student scholarships and loan repayment programs have become
popular ways to recruit students, especially ethnic minorities,
to work in rural or underserved areas or at least part-time
with specific underserved populations, e.g. Medicaid recipients
or children with special health care needs. In one "grow
your own" model, students from a local community are
supported to attend some type of health profession school,
with the stipulation that they return to the community to
provide services after graduation for a specified period of
time. Other programs are more general and allow graduates
to practice in various underserved areas or clinical sites,
but not necessarily their home communities. The Public Health
Service, including the Indian Health Service and the National
Health Service Corps, uses this approach. Information is at
Unfortunately, the number of requests from communities or
dental clinics far exceeds the number of dental students in
this program. Most slots go to other health professions. NHSC
also grants matching funds to states to operate loan repayment
programs; for California sites, view http://www.oshpd.cahwnet.gov/pcrcd/stateloan/DentalSiteList.pdf.
The Indian Health Service sponsors the Indian Health Professions
Pregraduate Scholarship Program to encourage American Indians
and Alaska Natives to enroll in pre-medicine and pre-dentistry
undergraduate programs, and also Indian Health Professions
Scholarships for enrollment in health professions programs.
Many states have instituted loan repayment programs. Vermont
has worked with their Area Health Education Center to create
1 statewide and 3 regional loan programs where practitioners
sign contracts for patient visits, up to a maximum of $20,000
in loan credit per year. Vermont also provides $10,000 scholarships
for dental hygienists.
- Create enhanced reimbursement rates for practitioners in
rural areas. Utah and California have used this approach.
- Some dental schools such as the University of Colorado and
Loma Linda University traditionally have incorporated community-based
faculty or community-based experiences into their curricula
to bridge the "idealized ivory tower approach" criticism.
Many graduates have gone on to practice in rural areas or
to serve disenfranchised populations. Through a recent $19
million initiative from the Robert Wood Johnson Foundation's
Pipeline Project (http://dentalpipeline.columbia.edu/pipeline_projects_content.html)
and a 4 1/2 year $6.3 million initiative through the California
Endowment's Pipeline Project (http://www.calendow.org/program_areas/work_force_diversity_endow_response.stm)
, there is increasing emphasis on placing dental and dental
hygiene students in community settings for portions of their
education, especially through clinical rotations and community-based
prevention projects. The goals of the Pipeline Projects are
to: "1) recruit and retain an increased number of underrepresented
minority students; 2) reform the dental school curricula to
integrate community-based practice experience and courses
in cultural competence, public health and social and behavioral
sciences; 3) change a portion of dental school clinical programs
to patient-centered and community-based sources of care for
disadvantaged populations; and 4) create a state and national
policy agenda that will increase the number of underrepresented
minorities in the dental work force." $1 million from
the W.K. Kellogg Foundation will award an additional $100,000
for financial aid to underrepresented minority and low-income
- Arizona's new School of Dentistry and Oral Health uses advanced
information technology systems so that students can spend
more time in community settings, which are integral to their
whole education process. Recruitment is targeted to individuals
who have demonstrated a commitment to community service, with
a strong focus on selecting a diverse student body from rural
- Community service awards: Colorado has instituted
an annual Rural Health Excellence Award for a person who has
made a significant contribution to health, health care, or
the healthcare delivery system in Colorado.
- Communities can apply for dental health professional
shortage area designations.
Evaluating Workforce Strategies
Tracking the numbers and movement of health professionals
is important when trying to address workforce shortages or
maldistribution. The American Dental Association regularly
conducts workforce surveys, and the American Dental Hygienists'
Association is beginning to do so. The ADA Council on Dental
Education and Licensure will conduct a comprehensive allied
dental workforce study in 2005. Clinical license renewals
also are a good way to track new, established, retiring or
inactive practitioners. Delta Dental and the Managed Risk
Medical Insurance Board track data on the amount and type
of services that dental practitioners proved to Denti-Cal
and Healthy Families beneficiaries. Research oriented organizations
such as the UCSF Center for the Health Professions or Rand
Corporation conduct workforce studies.
A useful technique that may be available to some communities
is GIS mapping technology, where it is possible to overlay
maps of populations in highest need with maps of dental care
providers to document shortages or maldistribution.
In this chapter you have learned about many strategies
to improve the workforce to assure the oral health of young
children and their families. Some involve traditional dental
team members and settings, while others focus on coordinated
systems of care and making use of the skills of other health
professionals and community members. Links to numerous resources
have been offered. After you have reviewed some of the resources,
work with other community members to develop an action
plan to address workforce problems in your community.
Resources and References
ASTDD Best Practices Approach. Access to Oral Health Care
Services: Workforce Development. http://www.astdd.org/docs/BPAAccessWorkforce.pdf
ASTHO. Issue Report. State Public Health Approaches to
the Oral Health Workforce Shortage. Feb 2004. http://www.astho.org/pubs/ISSUEREPORTOraLHealth2004.pdf
California Primary Care Association, Oral Health Initiative.
Center for California Health Workforce Studies, UCSF. http://www.futurehealth.ucsf.edu/cchws.html:
one of five regional workforce centers funded by a cooperative
agreement with the National Center for Health Workforce
Information and Analysis within the HRSA Bureau of Health
Crall JJ and Edelstein BL. Examples of state efforts to improve
oral health and access. Appendix from Elements of effective
action to improve oral health and access to dental care
for Connecticut's children and families. 2001. http://www.cthealth.org.
Look under publications.
Fos P and Hutchison L. The State of Rural Oral Health. http://www.srph.tamushsc.edu/rhp2010/litreview/10Volume1oralhealth.htm.
Henderson Tim. Challenges and Opportunities Facing the
Dental and Dental Public Health Workforce: A Synthesis for
Discussion. NCSL, ASTDD, 2004. http://www.astdd.org/docs/EnhancingtheDPHworkforcebackgroundpaper-revised.doc.
Henderson, Tim. Improving Oral Health Services in Rural Areas:
The Roles for States. NCSL. 2003. http://www.ncsl.org/programs/health/oralheaserv.htm
Increasing Dental Care Through Public/Private Partnerships:
Contracting Between Private Dentists and FQHCs. Available
Mertz E, et al. Physicians, Nurses and Dentists in the Public
Health Workforce: Recruitment, Retention and Training Needs.
San Francisco, Center for California Health Workforce Studies,
Center for the Health Professions. (2004, in press)
Mertz B. Public health dentists: Recruitment, retention and
training needs. Presentation at National Oral Health Conference,
Los Angeles, 2004. Manuscript in preparation.
Mertz E, Anderson G, Grumbach K, & O'Neil E. Evaluation
of Strategies to Recruit Oral Health Care Providers to Underserved
Areas of California. San Francisco, CA: Center for California
Health Workforce Studies, UCSF Center for the Health Professions,
Manuel-Barkin C, Mertz E, Grumbach K. Distribution of Medicaid
Dental Services in California. San Francisco, CA: UCSF Center
for California Health Workforce Studies, 2000. http://www.futurehealth.ucsf.edu/cchws/publications.html#Dentists.
Mertz E, Grumbach K, MacIntosh L, Coffman J. Geographic
Distribution of Dentists in California: Dental Shortage
Areas, 1998. San Francisco: UCSF Center for California Health
Workforce Studies, 2000. http://www.futurehealth.ucsf.edu/cchws/publications.html#Dentists.
Mertz E, Manuel-Barkin C, Isman B, O'Neil, E. Improving
Oral Health Care Systems in California. San Francisco, CA:
San Francisco, Center for the Health Professions, 2000.
Mertz E, Grumbach K. Community Characteristics that Predict
the Low Supply of Dentists in California, Journal of Public
Health Dentistry. 61(3) 172-177, 2001. http://www.futurehealth.ucsf.edu/cchws/publications.html#Dentists.
National Rural Health Association. National Rural Health Association
Calls for Solution
to the Crisis in Oral Health Care Services in Rural America.
New England Rural Health Roundtable. December 9, 2002. http://www.newenglandruralhealth.org/news/nrha_calls_for_oral_health_policy.asp.
National Rural Health Association. Policy Brief. Oral Health
In Rural America. http://www.nrharural.org/dc/policybriefs/oralhealthbrief.pdf.
NCSL. Rural Health Brief. Where Have All the Dentists Gone?
NGA Center for Best Practices. Issue Brief. State Efforts
to Improve Children's Oral Health. 2002. http://www.nga.org/cda/files/1102CHILDORALHEALTH.pdf
Orlans, Josh, Mertz, E, and Grumbach, K. Dental Health Professional
Shortage Area Methodology: A Critical Review. San Francisco,
CA: Center for the Health Professions, UCSF, 2002. http://www.futurehealth.ucsf.edu/cchws/publications.html#Dentists.
Rural Assistance Center. Information Guide on Dental Health.
Contains many resources: frequently asked questions, tools,
funding opportunities, journals, organizations, terms and
USDHHS. A National Call to Action to Promote Oral Health.
Rockville, MD: USDHHS, PHS, CDC and NIH. NIH Publication
No. 03-5303, 2003. http://www.nidcr.nih.gov/sgr.htm
USDHHS. Oral Health I America: A Report of the Surgeon General.
Rockville, MD: USSDHHS, NIDCR, NIH, 2000. http://www.nidcr.nih.gov/sgr.htm.
Volunteer Dental Professionals to Provide Services to the
Underserved: Types and Characteristics of Model Programs"
Powerpoint Presented by Sarah Hanson and Gayle Goldin, MA
at the 130th APHA Annual Meeting and Exposition, November
11, 2002, Philadelphia, PA.
Volunteers in Health Care. Volunteer Retention and Recruitment.
Dental Providers. Manual that can be downloaded from http://www.volunteersinhealthcare.org/Manuals/ddsrecruit.pdf.
Woosung S, Ismail AI, Tellez M. Efficacy of educational interventions
targeting primary care providers'practice behaviors: An overview
of published systematic reviews. Journal of Public Health
Dentistry. 64(3): 164-72, 2004.
WWAMI Rural Health Research Center. California Rural Dentist
Survey 2003. http://www.fammed.washington.edu/wwamirhrc/Dental_snaps/California%20Snapshot.pdf.
Reports are also available from the same website on Alabama,
Maine and Missouri.
What did you learn or accomplish as a result of reading this
chapter? Did it help you to organize your thoughts about
strategies to address workforce issues in your community?
Were the resources and examples helpful? Complete the feedback form for Chapter 8 and tell us what was useful and not useful for