Nationwide Dentist and Executive Director Surveys of Community Health Center
Retention and Recruitment Issues, Work Environment Perceptions, and Salaries
Introduction
Access to dental care is still a challenge for millions of the underserved (1, 2). A major
factor contributing to the problem is the difficulty in recruiting and retaining dentists to
provide that care. For many years, the federal government has taken steps to make dental
care more available to low-income people. The primary vehicle for this has been
Medicaid, a joint federal and state health financing program for more than 40 million
people from low- income families and poor aged, blind, or disabled people. The State
Children's Health Insurance Program (SCHIP) covers about 2 million additional lowincome children who do not qualify for Medicaid. Still other programs support
community and migrant health centers and other facilities and medical personnel in
locations where low-income people live. These programs, although relatively small
compared with Medicaid, extend health care services to many additional low-income and
vulnerable populations.
The four major federal programs other than Medicaid and SCHIP that target services or
providers to underserved or special populations with poor dental health: 1) the Health
Center program (Public Health Service 330 grant funding), 2) the National Health
Service Corps (NHSC), 3) the Indian Health Service (IHS) dental program, and 4) IHS
loan repayment program--currently have a limited effect on increasing the access to
dental services that low-income and vulnerable populations have. The Health Center
program supports community and migrant health centers in medically underserved areas,
while the IHS loan repayment program provides incentives for health professionals,
including dentists, to practice in sites serving American Indians and Alaska Natives.
However, these programs are not able to meet the dental needs of their target populations.
NHSC was able to fill only one of every three vacant dentist positions in underserved
areas in fiscal year 1999 (2).
Governmental incentives such as the scholarship program and loan repayment program
operated by the National Health Service Corps (NHSC) have not been completely
successful. Too few health care professionals participate, retention rates are low, and
underfunding of programs consistently occurs (2,3). Anecdotal reports of numerous
vacancies for dentists in Community, Migrant, and Homeless Health Centers (CHCs)
persist and reasons for difficulty in recruiting and retaining dentists continue to be topics
of intense speculation. However, few published studies exist which attempt to analyze
the reasons for such problems, or even if the problem of recruitment and retention of
dentists in CHCs is prevalent enough to warrant concern. This study attempts to answer
some of these questions and quantify the magnitude of these issues.
The aims of this study are: 1) to identify characteristics of dentists who currently serve in
CHCs, 2) determine the proportion of dentists that intend to remain in CHCs for the
remainder of their careers, and 3) explore associations of factors which may affect the
1
retention of existing dental providers. Executive directors of CHCs with dental
components were queried for exact figures dealing with numbers and duration of
vacancies for dentists and dollar amounts of compensation ranges for existing
practitioners as well as for potential recruits.
Methods
Survey Instruments and Implementation.
Two separate survey instruments were used (Appendices 1, 2). The survey instruments
were addressed to all dentists employed by CHCs and executive directors of CHCs with
dental components. Questionnaires were designed for the two groups based on input
from the Health Resources and Services Administration (HRSA) Regional Dental
Consultants, Dental Directors from key Community, Migrant, and Homeless Health
Centers, the author, and other interested parties. The dentist survey consisted of 26
questions dealing with years of experience, advanced general dentistry education,
practice experience prior to working in the CHC, current position in the CHC, current
compensation and perquisites, perceptions of work environment, and other general job
satisfaction determinants. Finally, the dentists were asked if they planned to remain in
their CHC position and, if not, how soon they planned to leave.
The executive director survey asked 19 questions relating to the number of dentists
employed, number and duration of vacancies existing, methods currently being used to
recruit for vacancies, numbers of applicants for vacant positions, reasons for applicants
rejecting firm offers for employment, compensation currently being paid to existing
dental providers, and budgeted compensation for new positions ranging from entry level
dentist with no experience to experienced level dentist (10 years or more). Both
questionnaires offered total anonymity and were approved by the Baylor College of
Dentistry institutional review board.
Addresses of dentists were obtained from HRSA Regional Dental Consultants or their
counterparts in the ten HRSA regions. Executive Director addresses were obtained from
the most recent available roster of Public Health Service 330 grantees. An attempt to
query every CHC which had at least one dentist employed and all executive directors of
CHCs with dental components was made. To the extent of the accuracy and completeness
of the provided names and addresses, the anonymity of the survey, and the incomplete
ability to track responses based on ZIP codes on the postmarked returned envelopes, it is
not known if this goal was indeed accomplished. A total of 569 mailings were made to
dentists and 345 mailings to executive directors in February and March of 2002. A selfaddressed postage paid envelope was enclosed with each mailing. Response rates were
73.8% from the dentist mailings (420/569) and 46.1% from the executive director
mailings (159/345).
Analysis
Data from the responses to both survey instruments were entered on Microsoft Excel
spreadsheets and transferred to SPSS PC version 11 for analysis. For each question
answered on the survey a frequency analysis was performed. To measure associations
2
between variables, various statistical tests were performed as indicated. Contingency
table analysis was performed to obtain chi-square values and, where the assumptions for
the chi-square test were not met, Fisher’s exact test was used. T-tests were used to
compare between-group means for continuous variables. Bivariate logistic regressions
were performed on six selected variables with “intention to leave community health care
dentistry” as the dependent variable. Variables were categorical with the exception of
salary, which was a continuous variable. The seven independent variables were 1) salary,
2) position (dental director, staff dentist) 3) years of dental practice, 4) freedom to
exercise professional judgment in the treatment of patients, 5) altruistic motivation, 6)
high value placed on loan repayment, and 7) amount of administrative time available for
those dentists with administrative duties. Variables which met a significance level of
p<.05 in each bivariate analysis were placed in a multivariate logistic regression model to
measure extent of these associations, with the exception of variable number 7, which did
not apply to the entire group, but to a subset: dental directors.
Results
Dentist Survey
Of the 569 surveys mailed to dentists, responses from 420 dentists were received; a
response rate of 73.8 percent. The mean years since graduation from dental school was
15.0±11.2 with a median of 12 years. The mean number of years worked in a CHC was
7.1±6.9 with a median of 4.5 years. The majority of respondents (56%) had >10 years of
dental practice experience, 20.2% had between 5 and 10 years, 17.3% between 1 and 5
years, and 6.5% had <1 year of practice experience. The single predominant activity prior
to employment in a CHC was private practice associate or employee (33.5%).
Percentages of responses in six categories of prior activity are listed in Table 1.
TABLE 1
Activity Prior to CHC Employment (N=409)
N Percent
Private practice/Associate or employee
137
33.5
Dental Student
105
25.7
Private practice/Owner or partner
86
21.0
Graduate program/Specialty program
40
9.8
Commissioned Officer in military or PHS 39
9.5
Retired
2
0.5
Dentists were asked to rank reasons they chose to work in a community health care
organization. The three most prevalent responses were: 1) “felt a mission to the dentally
underserved population” (72.7%), 2) “wished to practice dentistry in a community based
setting” (66.5%), and 3) “attracted by the work schedules and leave policies of
Community Health Center” (58.6%). The least selected reason for choosing Community
Health Care was “sold private practice, or retired from government service” (15.1%).
Totals are more than 100% due to multiple possible responses.
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Respondents classified themselves as staff dentist 53.6% and as dental director 45.2%.
The majority (93.6%) categorized themselves as general dentists. Of the 383 general
dentists, 27.4% had advanced training in general dentistry: 19.5% completed GPR
programs and 7.9% had completed AEGD training. The remaining 72.6% had no
advanced training in general dentistry. Other specialties reported were pediatric dentistry
(1.7%) and dental public health (4.6%).
When dentists were asked if they perceived complete freedom to exercise their
professional judgment in treating patients in a CHC environment, 65.7% answered that
they were completely free to do so, while 34% did not feel completely free. In the areas
of work environment and perceptions of working conditions, dentists responded in a
generally positive way. Perception of facility quality, including building, equipment, and
supplies was good or very good in 66.7% of responses (275/412). Less than 2%
considered the quality as poor. On-call weekend and evening duties were reported as
occurring either seldom or never by 76.2% of the respondents (311/408). Less than 3%
felt the on-call duties were excessive. Continuing education allowances were offered to
89.0% of employed dentists with a median number of 5 days and a median of $1500
reimbursement reported. The mean number of days offered for vacation was 17.9 ± 5.9
with a median of 20 and 81.5% of respondents felt this was an adequate amount. For
those dentists with administrative duties (N=208), only 28.8% felt they were allowed
enough time for those duties. A total of 71.1% felt that there was either not enough time,
or no administrative time was allowed in their schedules. The next lowest frequent
positive response was for production incentive plans--only 29.4% of dentists reported the
availability of such plans. Other indicators and perceptions are displayed in Table 2.
Self-reported salaries for dental directors and staff dentists are shown in Table 3. Further
salary breakdown by region and by position are given in Appendix 3.
TABLE 2
Indicators Receiving “Yes” Responses from Dentists
Continuing Education Allowance
Salary Incentive Plan Offered
403b or Similar Plan Offered
Adequate Insurance Coverage
Adequate Amount of Leave Time
Adequate Number of Dental
Assistants
Adequate Quality of Dental Assistants
Adequate Clerical Support
Adequate Administrative Support
Adequate Administrative Time
Allowed
4
N
356/400
116/395
324/389
302/380
312/383
285/408
Percent
89.0
29.4
83.3
79.5
81.5
69.9
349/404
267/399
300/391
60/208
86.4
66.9
76.7
28.8
TABLE 3
Dentist Self-Reported Pre-Tax Salary Annualized (N=357)
Mean
Median
Minimum
Maximum
Std. Deviation
Staff Dentist (N=178)
81,603
80,000
30,000
200,000
23,775
Dental Director (N=179)
91,653
90,000
39,000
210,000
23,038
Finally, the dentist survey asked “Do you intend to remain in Community Health Center
based dentistry?” Respondents were asked to answer yes or no to this question. Dentists
answering in the negative were given a follow-up question asking how soon the dentist
planned to leave their current position in the CHC. Over two-thirds (68.8%) of the
respondents indicated an intention of remaining in CHC dentistry (278/404). The
remaining 31.2% indicated they did not intend to remain in Community Health Dentistry
(126/404). Of those indicating this intention, 12.7% intended to leave as soon as another
opportunity opened. Thirty percent intended to leave within the next year and 41.3%
within two to five years. Those planning to leave due to retirement numbered 16%.
Chi-square tests were used to compare the reported salaries of staff dentists and dental
directors who intended to leave community health dentistry versus those who did not.
Neither current position in the dental center (staff dentist or dental director) nor salary
was significantly associated with intention to leave (p>.05). But, length of time in service
in CHC dentistry significantly affected retention of existing providers. Of the 68.8% of
respondents who indicated an intention to remain in CHC dentistry, the mean number of
years of practice in a community health care setting was 8.29, while the 31.2% who
planned to leave community health care had a mean of only 4.69 years of CHC
employment. An independent samples t-test showed that this finding was highly
significant (p<.0001). Bivariate logistic regression verified the significance of the
association of the intention to leave community health care dentistry for those dentists
with less than one year of practice experience (OR=10.2, p<.0001), with >1 but <5 years
of experience (OR=6.9, p<.0001), and with >5 but <10 years of experience (OR=3.4,
p<.0001) compared to dentists with more than ten years of experience.
Contingency table analyses were performed on several factors which were suspected to
affect job satisfaction in CHC dental clinics: Perceptions of 1) degree of professional
freedom in treating patients, 2) restrictions involving the degree of availability of
specialty referral options, 3) level of cooperation from CHC administration, and 4) level
of cooperation from CHC boards of directors. Chi-square tests revealed significant
differences in the consideration of whether dentists intended to remain in CHC dentistry
vis-à-vis their general perception of the degree of professional freedom allowed them in
treating patients (p=.001). More specifically, intent to remain when there was a
perception of restriction of professional freedom involving the degree of availability of
specialty referral options was also significant (p=.014). A chi-square test adding a layered
variable of the dentist’s position was performed. Taking into account the dentist’s
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position in the CHC , the intent to stay in CHC dentistry, and the perception of level of
cooperation from the administration of the CHC, the association was significant for the
staff dentists (Fisher’s test p<.0001), and for the dental directors (p=.003). Similarly,
adding the layered variable of the dentist’s position to the chi-square test of the intent to
stay in CHC dentistry, and the perception of level of cooperation from the CHC board of
directors showed a significant association for the staff dentists (Fisher’s test p=.006), and
for the dental directors (p=.011). Bivariate logistic regression analysis showed that
dentists who did not perceive that they were completely free to exercise their professional
judgment in the treatment of their patients for whatever reason were twice as likely to
indicate an intention to leave CHC dentistry than those who felt they were completely
free to do so (OR= 2.0, p=.002).
Other studies have suggested that altruistic motivation is a significant factor in physicians
and dentists continuing to care for underserved populations (4,5,6). In this survey,
dentists who ranked “felt a mission to the dentally underserved population” as first in
their top five reasons for choosing a practice opportunity with a community health care
organization were significantly more likely to indicate they were remaining in CHC
dentistry as opposed to those dentists who did not highly rank that reason (p=.003) The
significance of this association was present in bivariate logistic regression analysis
(OR=2.1, p=.004).
In sharp contrast, dentists who ranked “loan repayment was offered or promised to you in
community health care dentistry” first or second in their top five reasons for choosing
CHC dentistry were significantly more likely to indicate they were leaving CHC dentistry
than those dentists who did not rank loan repayment highly in their reasons for choosing
employment in a CHC setting (p<.0001). Bivariate logistic regression analysis showed
that dentists who ranked loan repayment highly in their reasons for choosing employment
within a CHC setting were significantly more likely to indicate an intention to leave CHC
dentistry than those who did not. (OR= 4.8, p<.0001).
Respondents who identified themselves as dental director were asked about their
perceptions of the amount of administrative time allowed them in the performance of
their duties. A Chi-square test was significant in measuring the association between
dental directors who are planning to leave CHC dentistry and the perception of an
adequate amount of administrative time allowed (p=.002). Bivariate logistic regression
analysis showed that dentists who felt they did not have enough administrative time in the
performance of their duties as dental director were significantly more likely to indicate an
intention to leave CHC dentistry than those who thought they had enough administrative
time. (OR 2.97, p=.005)
The results of a multivariate logistic backwards stepwise (conditional) regression model
using the four variables significantly associated with intent to leave community health
care dentistry in bivariate analyses are listed in Table 4.
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TABLE 4
Variables Associated with Dentists’ Intent to Leave
Community Health Care Dentistry:
Results of Multivariate Logistic Regression Analysis
Variable
Estimate
Log OR
1. Not completely free to
0.784
exercise
professional
judgment in treating patients
2a.
Less than 1 year
2.116
experience when compared
to 10 years or more
2b. >1 but < 5 years
1.367
experience when compared
with 10 years or more
2c. >5 but < 10 years of
0.693
experience when compared
with >10 years
3. Did not rank mission to
0.679
the underserved as first
reason to choose community
health dentistry
4. Rank loan repayment
1.022
st
nd
highly (1 or 2 ) in reason to
choose community health
dentistry
Std.
Error
.257
Odds
Ratio
2.190
95% CI of X2
OR
1.325, 3.621
9.340
p
.501
8.299
3.106, 22.177
17.806
<.0001
.341
3.924
2.011, 7.656
16.075
<.0001
.326
1.999
1.055, 3.787
4.518
.034
.300
1.972
1.095, 3.553
5.112
.024
.284
2.779
1.592, 4.852
12.923
<.0001
Executive Director Survey
The concurrently administered executive director survey was designed to determine the
number and duration of existing vacancies within the dental component of the surveyed
CHC, as well as current salaries of dentists. Information was requested regarding
budgeted salaries as well as current salary and benefits packages being paid to dental
directors and dentists. Administrators were asked about methods used to recruit for the
vacancy or vacancies, number of applicants responding, number of offers made, and
number of offers rejected. Reasons for offers being rejected were also explored.
Only fifty-two percent of executive directors responding indicated no current vacancies
in the dental component of their CHC (83/159). Out of the 47.8% (76/159) which did
have vacancies, the mean number of vacancies was 1.67 ± .99, and the predominant
length of the vacancy was less than 6 months (60.5%). The great majority of vacancies
was twelve months or less (81.6%). Methods used to recruit for the existing vacancy
were varied. The top four methods used were newspaper advertisements (61.3%),
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.002
postings at dental schools (58.8%), working with the National Health Service Corps
(58.8%), and dental journal advertisements (47.5%). The least used method was dental
temporary/recruiting agencies (8.8%). Totals are more than 100% due to multiple
responses.
The recruiting efforts used by executive directors of CHCs gathered applicant responses
in a wide range from zero to thirty, with a median number of 4 applicants. Offers made to
applicants ranged from zero to 7, with a median number of 1 offer. Reasons cited for
applicants rejecting job offers were primarily inadequate salary/benefits (71.0%), and
location of the CHC (51.6%). The fact that no loan repayment was available was
indicated for 22.6% of the rejected offers.
Salaries reported by executive directors were grouped by experience of the dentist, from
entry level to ten years or more of experience. Also, data were requested for the highest
and lowest amounts currently being paid to contract dentists (self-employed) versus
highest and lowest salary amounts for employed dentists. Totals are shown in Table 5.
TABLE 5
Budgeted Salary Range Reported by Executive Directors
n
Mean
Median
Std. Deviation
Entry
71
77,732
78,000
15,181
1-5 Yrs
58
86,456
85,000
19,078
5-10 Yrs
46
91,421
90,000
21,489
>10 Yrs
40
95,564
90,000
22,813
Lowest and Highest Dentist Salaries Reported by Executive Directors
n
Mean
Median
Std.
Deviation
Lowest Paid FTE Dentist
138
79,075
78,000
15,845
Highest Paid FTE Dentist
118
90,913
90,000
18,085
Lowest and Highest Dentist Contract Wages (Non-Employee)
n
Mean
Median
Std. Deviation
Annualized Lowest Contract
19
98,393
93,600
27,273
Annualized Highest Contract
21
122,978
104,000
59,445
The executive directors’ reported salary ranges are comparable to the dentists’ selfreported salary ranges in Table 3, while contract labor wages were higher. Benefits and
other perquisites reported by the executive directors are summarized in Table 6.
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TABLE 6
Number of Vacation Days, Holidays, CE Benefits Reported by Executive Directors
Number paid holidays
Number of vacation
days
CE Dollar Amount
Mean
9.7
17.7
Lowest Paid
St. Dev.
2.1
5.6
n
131
131
Mean
9.8
19.6
1,542
806
109
1,720
Highest Paid
St. Dev.
2.2
5.6
770
n
112
111
88
Executive Director Report of Other Selected Dentist Benefits
Percentages Answering Yes
Lowest
Paid Highest
Paid
Dentist
Dentist
Drug License Fee Reimbursed/Paid
66.1 (74/112)
83.7 (72/86)
Dental License Fee Reimbursed/Paid
66.7 (78/117)
81.8 (72/88)
Malpractice
Insurance
89.8 (106/118)
95.7 (88/92)
Reimbursed/Paid
403b or Other Retirement Plan Offered
92.3 (120/130)
92.8 (103/111)
Medical/Dental Insurance Provided
97.7 (127/130)
99.1 (106/107)
Other Insurance—Disability/Life
94.9 (111/117)
96.9 (95/98)
CE Allowance, no amount specified
94.6 (123/130)
94.6 (106/112)
Discussion
This study suggests that several factors other than salary and benefits are the
determinants for retention of existing dental personnel--both staff dentists and dental
directors, and that there did seem to be a high number of unfilled dentist positions in
Community and Migrant Health Centers at the time of this survey. Almost half of all
executive directors responding to the survey reported an unfilled vacancy in the dental
component of the CHC. The three main reasons that job offers made to prospective
dentists were rejected was reported by executive directors to be 1) applicants think the
salary/benefits offered were inadequate, 2) applicants didn’t like the location of the CHC
and 3) no loan repayment was available at the particular CHC site. While it is very
understandable that a person might turn down a job offer if the salary was inadequate, it
is unclear why dentists would go through the application process to interview at a
location they did not like, unless hopes of a higher than average salary might compensate
for an undesirable location. Similarly, one would think that if loan repayment were
critical to dentists seeking employment, they would inquire before interviewing for a
position in a center that could not offer that benefit. Findings from this survey seem to
suggest that salary, benefits, and the opportunity for amelioration of high educational
debts, while important in attracting new recruits to the Community Health Center
environment, are not the only significant factors in determining retention of existing
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dental personnel. There was no significant difference in the salaries currently being
earned by dentists who plan to remain in CHC dentistry versus those who do not.
However, this study found that length of service was a major determinant. This may
reflect the assumption that those who can adapt to the system of dental care delivery in a
CHC setting are self-selecting for retention, while those who do not adapt are intending
to exit. The data would suggest that this occurs in the first few years of CHC experience.
Responses to other job satisfaction determinants are interesting in that quality of facility,
numbers and quality of assistants, and other day to day operating activities of practice in
CHC dental clinics did not appear to significantly affect the retention of existing
personnel. Neither did the level of benefits such as time off, CE allowances, insurance
coverage, etc., appear to affect retention to a significant degree. However, freedom to
exercise professional judgment was highly rated among dentists. In general, those
dentists who perceive this freedom to be lacking were significantly more likely to
indicate a desire to leave the CHC practice. In particular, the degree of availability of
specialty referral options, and level of cooperation from both the administration and the
board of directors were significant factors dividing those who intend to stay from those
who intend to leave. Clearly, there appears to be a need for communication between
dentists and their non-dental administrators and members of the boards of directors
addressing each group’s expectations and the ability to fulfill those expectations in a
system with limited resources.
The finding that dentists who express an altruistic motivation to treat the underserved are
more easily retained in CHCs is not surprising since other studies have shown similar
results (4,5,6). This finding should only strengthen the efforts already in place to recruit
future health care providers from the underserved and underrepresented communities to
which they will more likely return at some point in their careers (4). However, loan
repayment may not be the best method for attracting health care providers in general, and
dentists in particular, to underserved areas. The finding that dentists who highly ranked
loan repayment as a reason for choosing employment in CHC dentistry were up to 5
times more likely to leave the CHC setting than stay is intriguing. One explanation could
be that a dentist may have been promised loan repayment if a position is accepted at a
particular Community Health Center, but the repayment does not occur. The shifting
sands of HPSA (Health Professions Shortage Area) status for any given CHC, eligibility
for qualifying for loan repayment programs, and chronic underfunding of loan repayment
“slots” for designated HPSAs are possible contributing factors to this finding. After a
couple of years the dentist, burdened with student loans, cannot survive on the salary
being offered and decides to leave for the greener pastures of private practice. Clearly
there needs to be a more reliable way to ensure that loan repayment, if available, will be
delivered in a timely manner to those who depend on that program to earn a livelihood.
And certainly, recruiters or executive directors must not offer the carrot of loan
repayment to simply “fill a position” knowing that there is a possibility that it may not
happen. Conversely, this finding may indicate that those who rated loan repayment
highly and have benefited from loan repayment to its maximum extent simply move on to
other areas of interest, having paid off their educational debts in a short period of time.
However, is private practice the best option for dentist employment? Comparing
compensation from a dental position in a community health center to solo ownership of a
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private practice, a salaried position in academia, private non-owner dentist positions, and
other government related jobs (IHS, PHS, Armed Services) is a formidable task fraught
with numerous variables which confound the bottom line. For example, most community
health centers and academic teaching positions have benefits that are provided by the
employer. Vacation days, sick leave, company paid medical insurance and other
perquisites can add thousands of dollars in value to a job that a private practitioner or
private nonowner dentist would have to self-finance. Similarly, allowances for housing
and special pay or loan repayment through government service may be non-taxable and
would therefore equate to a higher taxable salary offered in the private sector. In addition,
self-employed practitioner income varies by the number of hours worked. Therefore,
persons who choose to take more vacation time or who consider full-time practice to be
less than the usual 40 hour work week may have a different compensation per hour than
those in standard salaried positions. Perhaps more efforts should be made by CHC
recruiters to present potential dentist employees with a more accurate comparison of
CHC compensation, either with or without loan repayment benefits.
Many question the degree to which salaries offered in other areas of dental practice
adversely affect the recruitment and retention of dentists in Community and Migrant
Health Centers. While this survey was not designed to specifically answer this question, a
brief salary comparison is presented in Table 7. Net income figures for private
unincorporated sole proprietors and nonowner dentists are from the ADA 2000 Survey of
Dental Practice, Income from the Private Practice of Dentistry (7), using data collected in
1999. Faculty salaries are provided from the ADEA Faculty Salary Survey, Guaranteed
Annual Salary: 2000-2001(8). At the time of this writing, these are the most recent
published salaries available and are reasonably contemporaneous with the ADA survey
numbers. Military and Indian Health Service compensation methodologies are readily
available from their respective websites and are not included in this comparison. CHC
dentist salaries are based on information received in the Spring of 2002.
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Table 7
Comparison of Salaries of Selected Dentist Positions
Employment Status
General Practitioners:
Nonowner Dentist
(Employees/Associates)
General Practitioners:
Sole Proprietors
(Unincorporated)
Full-Time Faculty:
Guaranteed
Annual
Salary
Assistant Professor
(All Dental Schools)
Full-Time Faculty:
Guaranteed
Annual
Salary
Associate Professor
(All Dental Schools)
Staff Dentist
Community Health Center
(All Regions)
Dental Director
Community Health Center
(All Regions)
Mean
1st Q
Median
3rd Q
S.D.
97,740
65,000
90,000
120,000
49,840
46
142,720
85,000
128,000
186,920
82,930
391
70,545
60,000
70,000
79,363
NA
764
82,968
70,955
81,559
93,424
NA
641
81,604
70,000
80,000
91,250
23,775
178
91,653
78,000
90,000
102,000
23,038
179
N
Limitations of the Study
The purpose of this study was to determine the salaries currently being offered to dentists
in Community Health Centers, determine if the salaries vary significantly by region, and
quantify the extent of job vacancies in CHC dental components. Attempts were made to
determine explanations why dentists stay or leave CHC dental positions based on
associations derived from job satisfaction determinants. While the response rate from the
dentist mailing was high (73.8%), the response rate was much lower from the executive
directors (46.1%). Due to limited funding, no follow-up surveys were sent to nonrespondents. Executive directors who responded may exhibit some selection bias, i.e.,
perhaps more of the troubled program directors bothered to respond to a questionnaire
about dental vacancies. The true rate may be more or less than the responses indicate.
Also, the numbers of responses to questions regarding how many applicants responded to
recruitment efforts, how many job offers were made, and why job offers were rejected are
dependent on recollection and thus inherently subjective.
Attempts to analyze salaries by region were affected by unexpected difficulties. Since
the surveys were not marked or identified in any way, to encourage candor in divulging
12
salary information, the original plan to track regional responses by ZIP code was
thwarted by an absence of any postmark on approximately 25% of the postage paid return
envelopes. As a result, the power of our regional salary data was reduced. Since salary
data is highly confidential, it was decided that the trade off between a completely candid
salary disclosure versus completely trackable responses was worth the loss of power of
the regional data.
Finally, this survey did not reach dentists who have already left the community health
care system. While much valuable information was obtained from existing dental
providers in CHC practice, we cannot know with more certainty the real reasons others
have already left.
Conclusions and Recommendations
It is highly desirable to continually monitor factors associated with retention and
recruitment of dentists in community and migrant health center clinics. CHC
administrators must periodically be kept informed of the current conditions in the dental
practice marketplace, know what other CHCs are budgeting for dentist positions, and
receive candid feedback on dentist/health center administration relations. Therefore,
funding should be budgeted for bi-annual salary and retention surveys similar to the one
which generated this study and analysis. Future studies could have follow-up costs built
in to the budget to pursue higher response rates by doing second mailings or follow-up
phone calls to non-respondents.
Also, additional information could be obtained from dentists who leave community
health center practice in the form of a standardized anonymous exit survey, which could
be delivered to Regional HRSA consultants for review. This tactic might be especially
useful for particular geographic areas or specific CHCs within regions which have high
turnover rates of dental providers.
Executive directors or dental personnel recruiters should be able to effectively convey the
true compensation of an offered dental position. Most applicants will be comparing any
salary offer with the salaries that other friends or associates that they personally know
may be receiving. However, if the CHC representative can show how the salary and
benefits offered translate into a comparable self-employed salary amount, the applicant
may be pleasantly surprised at the calculation presented. A “total compensation
information package”, which takes into account matching FICA payments, value of paid
time off, dollar amount of medical, dental, or other insurance provided paid on behalf of
the employee, and professionally related expenses that are reimbursed or defrayed,
should be readily presentable to any qualified applicant seeking employment with a CHC.
Persons hired as dental directors should be given a clear job description of the duties
involved in being a dental director, including administrative requirements that any
particular CHC may require. Many clinicians recruited from private practice may be
unfamiliar which those types of duties and may underestimate the amount of time needed
to perform them. Similarly, executive directors must allow appropriate amounts of time
for administrative duties and alter their expectations of numbers of patients seen or
amount of procedures performed clinically by the dental director accordingly. Dental
13
directors should feel free to communicate their perceptions of adequate amounts of time
for administrative duties without fear of reprisals from the administration and without
inappropriate self-criticism.
Finally, persons in charge of recruitment of dentists for CHC employment must use the
promise of loan repayment cautiously and honestly for new dentists, who value such a
benefit very highly. Students currently exiting dental schools with up to $100,000 in
educational loans cannot realistically be expected to accept salaries far below the private
sector market for long periods of time. Loan repayment promised but not delivered
leaves a bitter taste in the mouths of those who need it.
14
References:
1. US Department of Health and Human Services. Oral Health in America: a report
of the Surgeon General. Rockville, MD: US Department of Health and Human
Services, National Institutes of Health, National Institute of Dental and
Craniofacial Research, 2000.
2. US General Accounting Office: Oral health: dental disease is a chronic problem
among low-income populations. Washington, DC: US General Accounting
Office, 2000; pub no GAO/HEHS-00-149.
3. Marwick C. National Health Service Corps faces reauthorization during a risky
time. JAMA 2000;283:2461-2.
4. Rabinowitz HK, Diamond JJ, Veloski JJ, Gayle JA. The impact of multiple
predictors on generalist physicians’ care of underserved populations. Am J Public
Health 2000;90:1225-8.
5. Mofidi M, Konrad TR, Porterfield DS, Niska R, Wells B. Provision of care to the
underserved populations by National Health Service Corps alumni dentists. J
Public Health Dent 2002;62:106-7.
6. Porterfield D, Konrad TR, Leysieffer K, et al. Caring for the underserved: current
practice of alumni of the National Health Service Corps. J Health Care Poor
Underserved (in press).
7. American Dental Association, Survey Center. The 2000 Survey of Dental
Practice: Income from the Private Practice of Dentistry. Chicago, ADA, January
2002.
8. American Dental Education Association, Center for Educational Policy and
Research. Faculty Salary Survey, Summary Report: Guaranteed Annual Salary:
2000-2001, Total Compensation: 1999-2000. Washington, DC,
15
Appendix 1
Survey questions for dentists: Confidential
1. When did you graduate from dental school?______________
2. How long have you been practicing dentistry (minimum 20 hours/week)?
a. Less than one year
c. >5 but <10 years
b. >1 but <5 years
d. More than 10 years
3. What was your primary dental practice activity immediately prior to practicing in a Community Health
Care setting?
a. Dental Student
b. Graduate program/specialty program
c. Private practice/owner or partner
d. Private practice/associate or employee
e. Commissioned Officer in Military or Public Health Service
f. Dentist with the Department of Veterans Affairs
g. Retired
4. What were your primary reasons for choosing a practice opportunity with a Community Health Care
organization?
(Please rank your top five choices in order of their importance to you.)
_____a. Felt a mission to the dentally underserved population.
_____b. Wished to offer oral health care within an interdisciplinary environment.
_____c. Wished to practice dentistry in a community based setting.
_____d. Did not want to invest capital in a private practice.
_____e. Attracted by work schedule/leave policies of Community Health Center.
_____f. Loan repayment was offered or promised to you in Community Health Care dentistry.
_____g. Sold private practice, or retired from government service
_____h. Unsatisfied with associate/employee dentist arrangements currently available.
_____i. Other_____________________________________________________
5. How do you perceive your professional freedom in the treatment of Community Health Center dental
patients?
a. Completely free to exercise professional judgment.
b. Not completely free to exercise professional judgment.
6. If not completely free to exercise professional judgment, which of the following apply. (choose all that
apply) If completely free, skip to question 7.
a. degree of patient compliance with treatment recommendations or appointment attendance.
b. level of cooperation from administration (executive director or chief financial officer)
c. level of cooperation from the Community Health Center board of directors.
d. budgetary restraints involving certain laboratory procedures or specialty procedures.
e. degree of availability of specialty referral options, i.e. endodontics, periodontics, oral surgery, or
orthodontics.
7. What is your current position in the Community Health Center dental department?
a. Staff dentist
b. Dental director
If you are the dental director (or if you are the only dentist) please answer the following four
questions. Otherwise, proceed to question #12.
8. Do you feel you have enough administrative time set aside out of the clinic to manage operations of the
dental component of the Community Health Center?
a. Plenty of time
b. Not enough time
c. No time at all
9. How many clinic hours do you usually work on a weekly basis?_____________
10. How many administrative hours do you usually work on a weekly basis?________
16
11. What is the job title of the person to whom are you accountable?______________
(e.g. executive director, director of operations, medical director, or other.)
12. Are you offered continuing education time and expense reimbursement to maintain your credentials?
a. Yes #Days__________$___________. b. No time or expense reimbursement.
13. How many days are currently offered to you for vacation time? ___________
14. Is your sick leave/personal leave time adequate?
a. Yes
b. No
15. Are your medical insurance benefits adequate?
a. Yes
b. No
16. Are you offered any retirement benefits through a 403b plan or similar plan?
a. Yes
b. No
17. Is there a salary incentive (production incentive) program in place?
a. Yes
b. No
18. What is your approximate pre-tax salary, not including benefits, on a yearly basis. Pre-tax salary is
defined as gross wages before income tax or Social Security/Medicare taxes are deducted. (If part-time,
extrapolate to full-time yearly amount.) $___________
19. What is your specialty?
a. General dentistry
b. Pediatric dentist
c. Public Health Dentist (M.P.H. or equivalent))
20. Did you have advanced training in general dentistry Yes
If yes, what kind of program was it?
GPR
AEGD
No
21. How many years have you been in Community Health Care dentistry. _________
22. How would you rate your facility overall in terms of physical building, equipment, supplies, and
appearance?
a. Very good
b. Good c. Adequate d. Needs improvement
e. Poor
23. Are you required to participate in night or weekend on-call responsibilities:
a. Too much
c. Seldom
b. Often
d. Never
24. Please rate the following regarding dental clinic support.
a. Number of dental assistants.
b. Quality of dental assistants.
c. Clerical support: reception, records, billing.
d. Administrative support.
Adequate
Adequate
Adequate
Adequate
25. Do you intend to remain in Community Health Center based dentistry?
a. Yes
b. No
26. If answer is no to question 25, how soon do you plan to leave?
a. As soon as another opportunity opens up.
b. Within the next year.
c. Within the next 2-5 years.
d. Upon retirement.
17
Inadequate
Inadequate
Inadequate
Inadequate
Appendix 2
Executive Director Survey Questions
1. How many dentist FTEs are currently employed in your clinic?__________
2. How many are full-time (30 or more hours per week)?_________________
3. How many are part-time (less than 30 hours per week)?_______________
4. How many dentist positions (FTE) are currently budgeted?_____________
If no dentist positions are vacant, please skip to question #17.
For each vacancy, please answer this series of six questions.
5. What is the duration of vacancy 1 as of this survey date?
a. Less than 6 months
c. 12-24 months
b. 6-12 months
d. More than 24 months
6. What methods have been used to recruit for this vacant position? (Circle letters of all that apply.)
a. Newspaper advertisement
b. Dental journal (state or national) advertisement
c. Posting at dental schools
d. Speaking to students/residents about community based dentistry
e. Displays at job fairs/dental conventions
f. Dental temporary agencies or recruiting agencies
g. Working with National Health Service Corps
h. Networking through Primary Care Associations
i. CHC website postings
j. Other_____________________________________________
7. How many applicants have responded to any of the above methods during the
entire time since the position became vacant?_________________
8. How many applicants have been made firm offers for the vacancy?_________
9. If firm offers have been made but rejected, what were the reasons given? (circle letters of all that apply.)
a. salary/benefits inadequate
b. location of Community Health Center
c. level of staffing of the dental clinic
d. condition of equipment of dental clinic
e. no loan repayment available
f. other__________________________
10. Current budgeted amount for first dentist vacancy, including fringes.
a. Entry level position
$ _______
b. One to five years experience
$ _______
c. Five to ten years experience
$ _______
d. More than ten years experience$ _______
18
If only one position is vacant, please skip to question 17.
11. What is the duration of vacancy 2 as of today?
a. Less than 6 months
c. 12-24 months
b. 6-12 months
d. More than 24 months
12. What methods have been used to recruit for this vacant position? (Circle
letters of all that apply.)
a. Newspaper advertisement
b. Dental journal (state or national) advertisement
c. Posting at dental schools
d. Speaking to students/residents about community based dentistry
e. Displays at job fairs/dental conventions
f. Dental temporary agencies or recruiting agencies
g. Working with National Health Service Corps
h. Networking through Primary Care Associations
i. CHC website postings
j. Other_____________________________________________
13. How many applicants have responded to any of the above methods during the entire time since the
position became vacant?_________________
14. How many applicants have been made firm offers for the vacancy?______
15. If offers have been made but rejected, what were the reasons given. (check
all that apply)
a. salary/benefits inadequate
b. location of Community Health Center
c. level of staffing of the dental clinic
d. condition of equipment of dental clinic
e. no loan repayment available
f. other__________________________
16. Current budgeted amount for second dentist vacancy, including fringes.
a. Entry level position
$ _______
b. One to five years experience
$ _______
c. Five to ten years experience
$ _______
d. More than ten years experience$ _______
17. Are there any contract labor dentists retained on staff? Yes
No
If yes, lowest annualized contract amount (2080 Hours) $________
Highest annualized contract amount (2080 Hours)
19
$________
18. Current lowest paid FTE dentist.
a. salary
$ _________
b. medical/dental insurance benefits
$ _________
c. other insurance disability, life
$ _________
d. # paid holidays
________
e. # vacation days
________
f. Retirement benefits (403b or other)
g. malpractice insurance reimbursement?
Yes
No
$ ________
h. dental license fee reimbursement
$ ________
i. drug license fee reimbursement
$ _________
j. Continuing education allowance
$ __________
k. Level of experience of this dentist (since dental school graduation)
1. one year or less
2. one to five years
3. five to ten years
4. more than ten years
19. Current highest paid FTE dentist:
a. salary
$ _________
b. medical/dental insurance benefits
$ _________
c. other insurance disability, life
$ _________
d. # paid holidays
________
e. # vacation days
f. Retirement benefits (403b or other)
________
Yes
No
g. malpractice insurance reimbursement?
$ ________
h. dental license fee reimbursement
$ ________
i. drug license fee reimbursement
$ _________
j. Continuing education allowance
$__________
k. Level of experience of this dentist (since dental school graduation)
1. one year or less
2. one to five years
.
20
3. five to ten years
4. more than ten years
Appendix 3
Staff Dentist vs. Dental Director Salaries By Region
Staff Dentist
Region
1
2
3
4
5
6
7
8
9
10
N
5
14
10
17
23
12
7
9
6
34
Dental Director
Mean
75480.00
72328.57
69520.00
76500.00
70760.87
77168.33
98000.00
76404.78
93314.83
98905.88
S.D.
8071.679
17399.27
4942.289
15650.48
17576.37
19560.12
45574.12
17884.36
13103.05
23608.24
Median
80000.00
75000.00
68350.00
79000.00
75000.00
71500.00
80000.00
78000.00
90416.50
94250.00
N
13
10
11
24
14
25
4
6
10
18
Mean.
87769.23
82900.00
83547.27
84992.50
86107.14
91597.96
117750.00
86354.17
106219.80
111388.90
S.D.
22398.49
20100.86
13881.38
16430.08
18555.72
20893.03
62516.00
13514.90
19651.64
22656.36
Median
85000.00
92000.00
85000.00
81500.00
90500.00
90000.00
93000.00
82062.50
99400.00
104000.00
Pre-Tax Salary By Region: All Respondents
Region
Mean
Median Std. Dev. Minimum Maximum
1
86231.57 80000.00 21121.26 60000.00 139000.00
2
76733.33 84750.00 18909.22 38500.00
98000.00
3
76867.61 75000.00 12604.43 58000.00 100000.00
4
81471.21 80000.00 16466.25 40000.00 118000.00
5
76447.36 80000.00 18989.60 30000.00 113000.00
6
86918.08 85000.00 21326.33 50000.00 146000.00
7
101416.66 82000.00 49590.06 60000.00 210000.00
8
79891.75 78062.50 16097.01 40000.00 109000.00
9
101380.43 95400.00 18181.76 80000.00 141000.00
10
103226.92 98000.00 23826.47 45000.00 160000.00
21
n
18
24
21
41
37
37
11
15
16
52