The Root of the Problem

Virginia’s dental industry braces for change as new legislation takes effect. Will it help the hygienist shortage?

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Health

After months of growing tensions over staffing shortages, the dental hygienists took matters into their own hands.

Using black markers, the hygienists at Commonwealth Dentistry on Forest Hill Avenue scratched out “ask your dentist” and wrote “ask your hygienist” on informational posters about measuring gum decay and periodontal disease.

An act of protest, the marked-up posters symbolize the widening rift between dentists and hygienists in the state.

As the shortage strains patients and local practices, possible solutions meant to ease the deficit of trained hygienists, introduced by lawmakers in a pair of bills Gov. Abigail Spanberger signed this April, have instead led to even more friction.

Scope of the Shortage

Hygienists fill a role similar to nurses, seeing patients before a dentist’s visit to scale and polish teeth, take X-rays, and assess patients’ oral health. Dentists say hygienists are highly valued and that there aren’t enough of them, making it difficult to schedule patients for routine visits and procedures in a timely fashion.

Dental hygienists typically enter the profession after completing two or three years of study in a certified associate degree program. In Virginia, they must then pass a clinical exam and a state test to obtain a license.

Dentists must complete four years of undergraduate study for admission into a dentistry school and a further four years of combined academic and clinical experience before graduation. To practice, dentists must pass two national board exams while completing their dentistry program and pass a state licensing exam in their final year.

The main difference between the two professions is that hygienists focus on preventive care, while dentists are authorized to perform surgical procedures to correct problems caused by oral diseases.

​​Dr. Curt Killar of Woodlake Family Dentistry in Midlothian says not having enough hygienists forces dentists to attend to more preventive procedures and cleanings, taking time away from more intensive procedures. Routine visits for patients who need more frequent care can also be deferred, he adds. ​​

Ryan Dunn, CEO of the Virginia Dental Association, says there is a statewide shortage of more than 1,000 dental hygiene professionals. An analysis completed by the organization in 2024 found that the challenge is most acute in Richmond and Northern Virginia.

He says the main issue is that there isn’t enough funding for dental hygiene programs in Virginia’s public and private colleges, resulting in just 135 new graduates each year. “If you do that math, we’re really never getting out of this hole without either major expansion of hygiene programs or something else,” Dunn says.

Dunn cites the high cost of dental programs as the tightest point in the bottleneck. Myriad professional teaching requirements and a small roster of qualified and willing instructors restrict class sizes.

Virginia Commonwealth University has the state’s only dentistry school and graduates just 20 hygiene students a year. The school is currently seeking to build a 314,000-square-foot center to replace its current building on the MCV campus in downtown Richmond, which needs tens of millions of dollars in deferred maintenance. The Virginia General Assembly has so far allocated $5.2 million for the planning phase of the capital project.

Meanwhile, the Virginia Dental Association has been lobbying for a $30 million budget amendment to fund high-cost degree programs in the state’s community college system. The money, Dunn says, could help bring back a dental hygiene program at Virginia Peninsula Community College that paused admissions in 2024 because of funding challenges.

Kerry Ragano, vice president for academic affairs at the community college, says about 10 people graduated from the program annually, but that the college struggled to cover high costs for teaching staff, specialized equipment and other requirements.

“There are a number of regulations and standards that we have to meet and get in place, including hiring the appropriate number and type of faculty and a director for that program. That doesn’t happen quickly,” Ragno says. “It could be as long as 18 months to two years before we have our first class of students coming in.”

There are currently only four other community colleges with dental hygiene programs. However, a VDA spokesperson said in June that Eastern Shore Community College and Piedmont Virginia Community College are opening dental hygiene programs, with classes expected to begin in 2027.

Still, in the meantime, Dunn says, there’s a need for immediate relief. “We would prefer to have 1,000 more hygienists tomorrow. That would be the absolute best thing we could ask for, but that’s not where we are,” he says. “So, we’ve come up with what we think are some pretty reasonable approaches to help try to deliver healthcare, because it’s getting worse instead of better.”

Legislative Repairs

One of the bills, House Bill 970, permits dental assistants to perform some of the work that hygienists typically do. The other, House Bill 1036, allows the state Board of Dentistry to license eligible foreign-trained dentists as dental hygienists. Both take effect on July 1.

Dental assistants in Virginia require a license that can be obtained by passing an exam from the Dental Assisting National Association. Their work can involve preparing and sterilizing equipment and giving instructions to patients, but they are largely relegated to a support role that needs no more than six to 12 months of training. The new law permits them to obtain certification and perform some of the work that hygienists typically do, including the routine cleaning and polishing of teeth.

Derik Sven, president of the Virginia Dental Hygienists’ Association, sees a flaw in the legislative actions. While the bills were meant to address the shortage of hygiene professionals, he says, the new laws instead alienated them to make it easier for dentists to staff their offices with allegedly underqualified assistants and foreign-trained professionals.

He says the dental assistant bill is particularly concerning because it amounts to allowing dentists to hire “people off the street” to remove plaque and tartar from teeth only above the gum line, he argues, offering less than comprehensive treatment.

Sven says that could allow dentists to unethically bill patients for substandard care. “If you don’t clean the full tooth, you’re leaving disease under the gum line,” he says. “That’s where gum disease propagates.”

The other bill, which allows dentists trained in other countries to become hygienists, would also be a problem because they do not receive as much instruction and experience in preventative care as hygienists trained in the United States, according to Sven. He worries the bills will result in lower quality care for patients, putting them in danger of gum disease and complications that could require costly surgical interventions.

Dunn, the CEO of the Virginia Dental Association, disputes the notion that the bills are meant to replace hygienists. “Our leadership thought that this was a measured approach, something that would bring a little bit of relief to a system that is, quite frankly, being strained in its ability to meet the needs of Virginians,” he says.

Killar, the Midlothian dentist, says he takes offense to the characterization that those dental assistants would be untrained, noting that the bill requires 1,800 hours of clinical experience and 20 hours of supervision before they can be certified by a licensed dentist to perform above-the-gums scaling and teeth polishing.

“The specific task of above-the-above-gums cleaning is very safe and can be controlled,” Killar says. “It can really relieve the pressure that we have with the number of hygiene patients that we’re trying to deliver care to. And the truth of the matter is, it’s not solving the problem. It’s just to help.”

While the bills expand assistants’ role in the industry and make hygiene licensing easier for some, dentists have an obligation to make sure that patients are being cared for holistically, Killar says. “The thing that needs to be understood is that — whether it be an assistant or hygienist that treats the patient in my office — I’m ultimately responsible, so the care has to be at the highest level,” he explains.

Straightening the Curve

Julie Bilodeau, CEO of the nonprofit CrossOver Healthcare Ministry in Richmond, says her organization relies heavily on volunteer professionals, but still has a full-time dental director, two full-time hygienists and four dental assistants.

“I would say that finding a hygienist is really difficult, especially at CrossOver,” she says. “We can’t afford to pay top dollar in a free clinic.”

The annual median wage for a dental hygienist statewide is $82,690, according to the Virginia Health Workforce Development Authority. The median hygienist wage in Richmond is closer to $99,000, Dunn says.

Bilodeau says one of the free clinic’s hygienists had previously worked for the nonprofit as a ​​​​dental assistant before completing a dental hygiene program.

“We’re reliant on unusual cases like that, because if she hadn’t come back, we’d still be looking for a dental hygienist,” Bilodeau says. “It’s really hard for a place like CrossOver, or even [nonprofit healthcare provider] the Daily Planet, because often our positions are funded with grants. And you usually have a finite amount of time to hire someone before the grant expires. So, the pressure is really on us.”

Bilodeau adds that CrossOver did not lobby for either bill but is generally supportive of measures that increase access to high-quality care. ​​

​​​​​​​Sven, the president of the state’s dental hygienists’ association, believes future legislative efforts should focus on granting hygienists more autonomy to practice as independent professionals who can form their own practices.

“Establish them as associates, not help in the kitchen,” he says. “This is the solution to help minimize dentistry’s issues. It’s the solution to really bring people into the dental hygiene profession and stay in it.”​     ​

A few doctors acknowledged tension between dentists and hygienists following the legislative session earlier this year.

Linda Simon, executive director of the Richmond Dental Society, did not respond to an emailed interview request. Dr. Luiza Kreuzer, the society’s president-elect, declined to answer interview questions after noting concerns about relationships with her office’s hygienists.

Another local dentist, who asked for anonymity to speak candidly about the dynamic, says the dental assistant bill effectively creates a new position in Virginia’s dental care industry.

“I do not believe this is the best option, but it is the first step in trying to close the gap for patients across the commonwealth,” the dentist says. “The shortage of hygienists is a problem that will not be fixed any time soon and will need to be addressed from many angles to try to find a solution to allow greater access to care for patients.”