Dental hygienists have more responsibilities than we did 20 years ago, but where do we draw the line?
Christmas is a magical time of year and I love to slow down and reflect on my continued life’s journey. My mind also takes me to Christmas memories, like the time when our family dachshund, Fritzie was snooping around in my parent’s clothes closet, looking for treats. One year, Fritzie found a bag of Christmas chocolates wrapped in foil and he vomited it in a big pile under my bed.
The end of the calendar year is also a good time to reflect on our careers. Since I’ve often said that I graduated from Fones School of Dental Hygiene during the Jurassic era (1970s), I think about those dental hygienists just starting their careers and how different it is for them compared to my workdays after I graduated. While studying at Fones, and being a boring nerd, I used to visit the University of Bridgeport library and loved to read passages from the first textbook of dental hygiene, Mouth Hygiene. In the early 1900s, dental hygienists worked under the general supervision of a dentist and our work in schools was considered “woman’s work”—we were often called “women assistants.” If we performed our work in local schools, supervisors included a nurse and maybe a principal.1
My first full-time clinical position began in Closter, New Jersey for Arthur Ruderman, DDS. I was replacing a seasoned dental hygienist and because I was young and inexperienced, patients took a while to warm up to me. My job was fabulous, and I loved every aspect of it. I stayed at that dental practice for 4 years and until I returned to school for a BS and MS degree in Dental Hygiene. Most hygienists in the 1970s didn’t use ultrasonic instrumentation but I was on it. Having spent about 30 years in private dental practices, mostly part-time, all of these permanent, long-term positions were in dental practices in which I could excel as a clinician and provide quality care. I was respected and compensated well and developed great relationships with patients and their families. I always had adequate time to devote to dental hygiene services and usually had a healthy mix of different hygiene procedures. Providing nonsurgical periodontal therapy and periodontal maintenance were my favorite procedures to perform but I also loved working on healthy adults and children.
Back then and up until about 2005 or so, dental hygienists didn’t have to push themselves so hard that they couldn’t excuse themselves for a restroom break. All of that has changed in many dental practices and I want to talk about it.
About 20 years ago, I was working part-time for a dentist who called himself “holistic” and who many hygienists would run away from, but he treated me with the utmost respect. He called me his “periodontal therapist” and raved about me to his patients. We diagnosed and treated non-surgically a lot of periodontitis (initial therapy only) and for motivational purposes, I used a phase contrast microscope to show patients what was lurking beneath their gums. It was by far, the greatest motivational tool I’ve ever employed. Suddenly, and without much notice, this particular “holistic” dentist decided to sell his dental practice and move to another state. A new dental practice owner marched in, seemed very compassionate, and told me he wanted me to continue to offer the same high-quality service to patients. He was married, dedicated to his family, and seemed ethical. In addition, he told me he that he would involve his family in the practice. He announced that his son, who would soon be attending dental school, would be the new receptionist. This excited me because I thought that perhaps I could teach him all about preventing dental disease. For me, the surgical model of dental care was an anathema in some ways and those dental providers who focus solely on that model live in a different universe from me.
I had been working for this new employer for about 2 weeks when I noticed a change in my schedule. It was subtle at first, with an extra patient placed in a second column. It was explained that we had a lot of patients who were overdue for recare and excited about seeing me. The following week, there were 2 new patients who worked into my daily schedule in a second column and I had no assistance or time and couldn’t figure out what to do with them. Long story short, I eventually gave the new dentist a week’s notice to find someone else to take over the hygiene department, and out the door, I ran. I can still remember the day I stood in the parking lot after leaving for good and feeling that all was right in my world again.
Productivity in Dental Hygiene
Productivity in dental hygiene wasn’t talked about until the 1990s. Roger Levin, CEO of the dental practice management consulting firm, the Levin Group, started discussing hygiene profitability in the mid 1990s. He described hygienists as “a loss leader for the practice without any true return on investment.”2 Levin encouraged dentists to upgrade services provided by hygienists, making them more productive. His model was that 50% of the dentists’ production should come from the hygiene operatory and dental hygienists should become more adept at selling elective services.2,3
Next came articles and discussions like this one in 1997: “How to profit from . . . Hygiene Department”4 Robert Hamric, DMD spent 3 years studying traits of 10 dental practices that grossed over $1 million dollars annually. Staff had motivating, effective incentive-bonus programs and he referred to the staff in these practices as part-owners. He mentioned that in the past, 25% of gross production came from hygiene. Dental hygienists would “clean teeth and look for work for the dentists to do.”4 In the million-dollar practices, hygiene production was as much as 50% of production, mainly due to the diagnosis of gingival and periodontal diseases and treating periodontitis non-surgically.4
When managed care organizations under-cut private practice fees for hygiene services in order to acquire a large share of the dental market, profit margins in private dental practices started to fall. Dentistry knew it had to increase production in hygiene and cosmetic dentistry to make up for the decreased revenue.3 In addition to diagnosing periodontitis and treatment planing nonsurgical periodontal therapy quadrants, locally-applied antimicrobials like Arestin were added to the quadrant fee, making hygiene departments even more profitable.
In our current climate, employment rates of dental hygienists are projected to grow 9% over the next 10 years, faster than the average for all occupations and compensation is robust for skilled talent. The Covid pandemic pushed many dental hygienists out of the field because of personal health challenges and childcare issues.
Another challenge that isn’t much talked about is the fallout of dental hygienists from the growth of managed care. More Americans are covered by some form of dental care, but many dental hygienists are falling into traps where they are “paid for performance.” Today’s dental hygiene providers are great clinicians who continue their education without being asked and they are great clinicians who communicate well with patients. These dental hygiene providers are working smarter and harder than ever and differently from the hygienists of yesteryear in traditional fee-for-service practices.
Progressive and profitable hygiene departments have solid, evidence-based clinical protocols, statistics and benchmarks with a monitored-service mix and they embrace new innovation and technology. Sounds exhausting and it is.
Introducing the HYG-BOT
There is another growing class of dental hygienists I have observed over the last decade and I call them HYG-BOTS, or Hygiene-Bots. These are dental hygienists who are being asked by their supervisors to perform routine tasks and achieve benchmarks without any input in their schedule or daily routine. They have been hired to achieve practice management benchmarks and they work tirelessly and burn out quickly, either because the stress is unbearable or repetitive stress injuries shorten their careers. Sometimes, well-meaning dental practice consultants, in consultation with dental practice employers, leave dental hygienists out of the mix when it comes to the dental hygiene department. Not only is it disrespectful to do this, but dental hygienists are also licensed providers whose outcomes depend on a successful interaction with each patient. Dental hygienists aren’t robots: we must deal with live patients and smile, even when they complain or even abuse us to excess.
One of my dear friends left dental hygiene to become a flight attendant. She was employed by a large group practice and forced to become a HYG-BOT. It was the usual scenario where the dental practice put profit over the welfare of a dental hygiene provider. This dental hygienist was expected to work several staggered columns throughout the day and ran into numerous problems, all of which were ignored by management. Scaling and root planing appointments (SRP) became gross scaling with a powered instrument and sometimes those appointments would be reduced to 30 minutes for two quadrants of scaling. There were 7-8 dental hygienists working each day and there was no regular operatory to work out of. Hygienists would switch out of about 10 treatment rooms. Each dental hygienist had a hygiene assistant, but the assistant was helping more than 4 hygienists at a time. The dental assistant was supposed to take radiographs, run into the operatory for perio and restorative charting and they were supposed to sit in on the dentist exam. This particular dental hygienist would then run to the next operatory and she witnessed a hygienist completing 4 quadrants of scaling and root planing (SRP) in 45 minutes.
Working with efficiency and within a system that rewards excellence is doable but dental hygienists aren’t robots who are always precise and consistent with repetitive tasks. Patient-centered care requires a human being with emotions and they play an important role in the caring process. Decision-making and assessment of patients is a complex process and cannot be rushed. All healthcare professionals know that they cannot treat their fellow human beings in an objective manner as just a simple task.
Guidance for HYG-BOTS
Happy Holidays to all the hard-working dental healthcare professionals out there who deserve a much-needed break!