Editor's note: The author and contributors to this article share a unique journey: they are all licensed dental hygienists in the US but were foreign-trained dentists who once practiced dentistry outside the US. Dental care delivery varies in many other countries, especially in their use of hygienists.
Australia has about 1,500 hygienists for its population of 25 million, which is a ratio of about one hygienist per 16,700 people. India has about 3,500 hygienists for a population of 1.4 billion—an extraordinary ratio of 1:400,000! In contrast, the US has 150,000 hygienists for a population of 333 million, a ratio of 1:2,200. Unfortunately, the COVID-19 pandemic created a crisis in access to dental hygienists, with some 28.8% of dental offices currently recruiting hygienists.1
One recent study indicated an 8% reduction in the dental hygienist workforce,2 which poses a significant threat to the traditional US model of care delivery. However, we believe the delivery model and treatment philosophy that is, in part, created by dental hygienists is something worth fighting for. We thought the time was right for us to share our experiences in delivering dental care both in and outside of the US.
Benefits of the US hygiene-driven model of practice
In the US, oral health care is much more a part of overall health when compared with some other countries. Although some gaps still exist like the inclusion of dental insurance in medical insurance, there is broad recognition of the importance of oral health to overall health. Dental hygienists have had a significant part in driving this culture in the US through their communities and social networks as they educate and advocate for oral health both formally and informally.
In the dentist-driven model of care in India (and other parts of the world), there is an inevitable focus on treatment rather than prevention. Dentists spend most of their time treating teeth rather than educating patients on disease prevention. Patients have lower oral health literacy and visit a dentist when a dental problem reaches an extreme; as such, dental services are more symptom-relief oriented.
In contrast, in the US, the field of dentistry is much more patient-centered and prevention-focused. People are more proactive and aware of their dental health, so dental care can be more comprehensive. Having delivered care inside and outside the US, we believe dental hygienists play a critical role in raising awareness and driving a preventive care philosophy.
Dental insurance
In many parts of the world, including India, citizens do not have (or need) dental insurance. Dental care in the US is much more costly and having insurance has become an essential component of access to care. In the US, 59% of adults aged 19-64 have private dental insurance, 7.4% have dental insurance through Medicaid, and 33.6% do not have dental insurance.3 Research has shown that some form of dental insurance (commercial or government issued) is critical in accessing care in the US.4 In fact, there is evidence that a lack of insurance is a barrier to care. A portion of the US population can afford private dental insurance if it is provided by their job. Others can receive some coverage through federal, state, and private programs such as the Affordable Care Act (ACA), preferred provider organizations (PPO), and health maintenance organizations (HMO).5
Dental care in India is much more affordable than dental care in the US, and this has two consequences: A dental career is much less lucrative; however, since dental care there is more affordable, there are negligible insurance mechanisms—almost everyone pays out of pocket. And since payment is out of pocket, there is a greater reluctance to pay for preventive care. This may be another factor that drives the symptom-relief approach to dental care in India and some other countries; few patients seek preventive services. Since patients in the US have several preventive services such as examinations and cleanings fully covered by their insurance, they are more likely to take advantage of their coverage for preventive services. Meanwhile, patients in India are likely to go to the dentist only when experiencing a dental issue.
Insurance plays a big role in dentistry in the US. Treatment planning is based on the patient's needs, but treatment choices are often influenced by their insurance plan.
Adaptation of technology
Since the average dental patient has higher oral health literacy and demands preventive services in the US, dentistry seems to evolve and improve at a faster rate here. As well, dentistry is a lucrative career, and dentists are more able to afford adaptation to new technology. Most US dental practices have one or more of the following: electronic health records, digital intraoral radiographs, cone-beam computed tomography (CBCT) systems, computer-aided designs and computer-aided manufacturing (CAD/CAM) capability, intraoral digital scanners, and intraoral cameras. In areas of India such as Delhi, Mumbai, and Chennai, dental health maintenance is better due to the use of newer technologies such as electronic health records. But in rural areas of India, there are older methods of dental care and a lack of new technologies.
In conclusion, we are at a critical juncture in the field of preventive dentistry. We need to fight hard to address the shortage of dental hygienists, who are the focal point of prevention in US dentistry. The better the dental hygienist-to-patient ratio, the better the care delivered.
We need to ensure dental hygiene programs have sufficient resources to support new and innovative recruitment strategies. Dentists must also ensure their hygiene team is operating “at the top of their license” and not just cleaning teeth. Dental hygiene schools must be active in engaging local K-12 schools to inform students about the value of a career in dental hygiene. The entire US dental profession must fight to maintain the patient-centered and prevention-focused care delivery structure that we have in our profession, and we propose that this depends heavily on the success of the dental hygiene profession.
Author acknowledgment: Sneha Shah would like to express her gratitude to Dr. Romesh Nalliah for his steadfast support while working on this project. It wouldn’t have been completed without the input of Dishant Patel and Nishantha Reddy.
References
- Tracking poll for May 17, 2021. Health Policy Institute (HPI). American Dental Association. Accessed March 21, 2023. https://surveys.ada.org/reports/RC/public/YWRhc3VydmV5cy02MGE1MjUxOGNlYjEwNjAwMTA2OThjZjYtVVJfM3BaeGhzWm12TnNMdjB4
- Study finds low rate of COVID-19 among dental hygienists. American Dental Association. February 24, 2021. https://www.ada.org/about/press-releases/2021-archives/study-finds-low-rate-of-covid-19-among-dental-hygienists
- Vujicic M, Buchmueller T, Klein R. Dental care presents the highest level of financial barriers, compared to other types of health care services. Health Aff (Millwood). 2016;35(12):2176-2182. doi:10.1377/hlthaff.2016.0800
- Eslamipour F, Heydari K, Ghaiour M, Salehi H. Access to dental care among 15-64 year old people. J Educ Health Promot. 2018;7:46. doi:10.4103/jehp.jehp_99_17
- A call for adult dental benefits in Medicaid and Medicare. American Public Health Association. October 24, 2020. https://www.apha.org/Policies-and-Advocacy/Public-Health-Policy-Statements/Policy-Database/2021/01/12/A-Call-for-Adult-Dental-Benefits-in-Medicaid-and-Medicare
