The global healthcare system has greatly advanced over the past 40 years. When my paternal grandfather passed away several decades ago at age 73, friends and family were quick to comment that he lived "such a long life." Today when someone passes away at that age, people wonder what happened and insist he or she was "still so young."
As a result of the exponentially improved healthcare being dispensed these days, people are living longer than ever before. Current statistics state that in the United States 11,400 people turn 65 every day. This translates to approximately 4.1 million Americans turning 65 years of age every year for the foreseeable future.1
Due to better healthcare, society appears to be headed toward what could be called a "gray tsunami" of patients. In many areas of the country the number of patients is starting to exceed the capacity of the dental industry. While this is a considerable concern in and of itself, perhaps the bigger problem is that as these numbers continue to increase, a growing amount of patients will lack mobility and will need to be seen outside the traditional dental office setting.
The Numbers
Twenty-eight percent (28%) of adults 65 years of age and older receive at least 90 days of nursing home care, while 5% of US citizens 65 and older live in a nursing home.2 There were some 1.3 million nursing home residents in 2023, and this number is projected to jump to 2.9 million by 2040.3 Many of these patients are nursing home bound and unable to leave their facility for needed appointments.
What will the dental profession do to take care of this deserving and underserved population of patients?
Compounding this issue is the fact that dentistry is facing a crisis related to the decreasing numbers of dental hygienists. Since the 2020 shutdown due to the COVID-19 pandemic the number of dental hygienists in practice has fallen significantly. The number of graduating hygienists in 2022 was 6% lower than in 2021. When considering also that approximately 64% of dental hygienists work full-time, the problem dentistry-and the elderly-is facing is obvious.4
A rapidly increasing number of patients with poor or no mobility is emerging, while simultaneously a decrease in the amount of qualified preventive care personnel is happening. This would indicate that the dental profession is sitting on a ticking time bomb that may detonate in the next several years. Our scientific proficiency in keeping people alive is outpacing dentistry's capacity to provide the oral care, and thus quality of life, the older population deserves. These individuals are family members, friends, parents, and grandparents, many of whom responsibly raised families and provided their loved ones the quality of life they now enjoy. The question becomes, how can these divergent paths be corrected before the problem becomes overwhelming?
Empowering Hygienists
While technology, with all its innovation and advancements, will unquestionably play a leading role in addressing this predicament, it alone will not suffice. Staffing, or what could fittingly be called "hygienist power," is what's needed first. The profession must begin graduating significantly more dental hygienists and empower them to capably deal with this impending crisis. What's required is a large number of "super hygienists" who are legally allowed to enter healthcare facilities, gather data, and provide palliative care for patients with emergent needs. Caring, competent dental hygienists can help solve this problem, but they need to be properly trained and lawfully sanctioned to deploy their unique skillset. A new "expanded function hygienist" career category at some level needs to be established and commensurate training provided to help deal with this potential calamity. In the medical profession, nurses' roles and responsibilities have been expanded, and dentistry needs to do the same.
In addition to training, the profession also must begin a renewed effort focused on recruitment to dental hygiene programs. Dental hygiene is a wonderful profession. It allows practitioners to do a tremendous amount of good for their patients, and the psychological rewards are abundant. In addition, dental hygienists typically are afforded flexible hours, receive good financial compensation, and have high job satisfaction. For someone considering a career in healthcare, but does not feel the call to become a doctor, dental hygiene is an admirable and rewarding choice. The role of "expanded function hygienist" would also likely appeal to individuals who desire mobility and the increased responsibilities that would come with this position.
Industry analysts can determine how many hygienists are needed to meet the future demands, but conservatively speaking, at least doubling the current number is probably required. Consider that almost every dental office needs at least one hygienist, roughly a third of those in practice work part-time, and the demand is growing. The dental education system needs to step up and begin more training as soon as possible.
Incorporating the Technology
In addition to generating "boots on the ground" to deal with this challenge, the profession also needs the required tools to provide care in nontraditional settings. Fortunately, all the necessary parts and equipment already exist; it's a simple matter of putting these tools to use.
The most critical piece of this puzzle is the software. One of the few silver linings to come out of the global pandemic was the increased development of teledentistry platforms. While many dentists who have never used one of these systems might only imagine a patient sending a photograph from their phone, many of these platforms can do much more than that.
Once a laptop is connected to the nursing home internet via a wireless network, the teledentistry platform (eg, Sesame, sesamecare.com; Teledentix, get.teledentix.com; TeleDent, teledent.com; The TeleDentists, theteledentists.com) allows for such functionality as charting, both restorative and periodontal; imaging, including live video; chart notes; instant messaging; and more. Essentially, almost anything an in-office practice management system can do may be done on a teledentistry platform. This would allow a hygienist to enter a facility, review the patient's health history, and communicate in real-time with a doctor who would then evaluate the data and advise treatment.
Handheld x-ray generators and universal serial bus (USB) digital sensors can enable the user to take any radiograph necessary with only a laptop. There are also many affordable USB intraoral cameras that can be used to record and store images or show those images live in real-time. Digital devices are available that can perform visual fluorescence caries detection as well as transillumination, capturing and storing these images or enabling them to be shown to a doctor through the teledentistry platform.
Portable dental units that can provide both air and vacuum may also be utilized. Many of these are "suitcase"-type solutions that can be easily rolled into a facility. The user would simply open the case, plug the unit in, and begin treatment.
Implementing the Solution
Ramping up to cope with this looming problem will take time. Especially challenging will be the task of creating the training programs for the expanded function hygienists and getting them trained. But perhaps the biggest hurdle will be persuading the existing dental power structure to accept this new level of provider. Doctors have traditionally opposed any type of new provider that is not a licensed dentist. Although difficult, this endeavor to empower hygienists is necessary.
Dental offices are already busy, and, understandably, most doctors do not have the time nor the financial incentive to interrupt their practices to participate in mobile dentistry. Some practitioners with full schedules may even look forward to an occasional cancellation so they can relax for a few minutes and collect their thoughts. Nonetheless, across the country many people are in need of dentistry who cannot make the trip to an office. Many of these patients suffer from pain, infections, or other problems that can seriously impact their overall health and quality of life. Care facilities are largely understaffed and undertrained, and, unfortunately, dental needs are often a lower priority. Unsurprisingly, a patient who has soiled themself will take priority over the person in the next room who needs help brushing their teeth. This does not mean, however, that someone's dental care should be compromised simply because they can no longer drive to an office.
Growing old is a cold fact of life that most people will face. Our older population helped get many of us to the level we enjoy today. They cannot continue to be ignored. The "gray tsunami" is about to make landfall, and as concerned professionals, dentists are obligated to care for them, just as they cared for us then. It is time for everyone in the dental profession to roll up their sleeves and get to work addressing this issue.
About the Author
John C. Flucke, DDS
Private Practice, Lee's Summit, Missouri; Dr. Flucke authors a dental blog, "The Technology Evangelist," at blog.denticle.com.
References
1. US Social Security Administration. 2024 Population Estimates. https://www.ssa.gov/OACT/HistEst/Population/2024/Population2024.html. Accessed March 26, 2025.
2. Nursing home resident demographics statistics: exploring the demographic landscape of nursing homes. Willows Healthcare blog. March 18, 2025. https://www.willowshealthcare.com/blog/nursing-home-resident-demographics-statistics. Accessed March 26, 2025.
3. Styron G. Nursing home statistics. A Place for Mom website. December 2, 2022. https://www.aplaceformom.com/senior-living-data/articles/nursing-home-statistics. Accessed March 26, 2025.
4. Morrissey RW, Gurenlian JR, Estrich CG, et al. Employment patterns of dental hygienists in the United States during the COVID-19 pandemic: an update. J Dent Hyg. 2022;96(1):27-33.
