Wild swings in the practice of clinical hygiene

The trend of lower pay and unreliable schedules is affecting many American workers, including dental hygienists.

Last week, I asked an RDH colleague to recommend a topic to write about. She suggested I go down memory lane and nostalgically recall some details about clinical dental hygiene practice in the 1980s and 1990s. Back then, I was working only part time, but I received benefits and vacation pay. The dental practices I worked in were part of the disappearing cottage industry with "fee-for-service" reimbursement. Hygienists typically saw seven to eight patients a day, sometimes even fewer. PPO plans didn’t define the dental benefit market as they do now, and dental practices didn’t participate in several dental benefit plans. These were great times for RDHs in the United States and jobs in private dental practices were plentiful. At that time, I was paid daily - not hourly - and I had my choice of clinical positions.

I belong to several dental hygiene chat groups on Facebook and LinkedIn, and I have several concerns about the future practice of clinical dental hygiene under supervision. Read along as I explore the wild swings I see in the U.S. I’ll begin with some of the changes that took place in the 1980s.

Hygienists transitioned from performing “gross scaling” in the 1970s to soft tissue management (STM) in the 1980s. Periodontal disease was beginning to be managed non-surgically, anesthetizing one quadrant at a time.1 In the early days of STM (mid-1980s), there was a gradual paradigm shift away from manual scaling to ultrasonics and a growing understanding that “root planing” to achieve a glassy smooth root surface might not be achievable.  Instead, hygienists began to focus on goals of decreasing gingival inflammation and promoting pocket healing. 1 Research at the time began to focus on tissue response when comparing manual to ultrasonic instrumentation. 1

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In the early 2000s, dental practice management consultants learned from dental hygienist-consultants that about 20-40 percent of dental hygiene revenue could come from nonsurgical periodontal procedures. 1 Dental hygiene consultants began teaching their dentist-clients how to incorporate nonsurgical periodontal therapy into their hygiene department schedules in order to increase productivity. The adjunctive use of sustained release local antimicrobials and professional oral irrigation were added to scaling and root planing (SRP) regimens to further increase productivity in the dental hygiene department.

Around the same time, dental practices were beginning to transition from "fee-for-service" to PPO and HMO reimbursement plans. Dental practice reimbursement revenue started to fall as dental practices accepted these plans with reduced fees.

In 2018, practicing dental hygiene clinicians have a lot of concerns about the future of their clinical positions in private dental practices, and many are struggling to find job satisfaction. Most of the complaints voiced in chat groups deal with lack of respect and inadequate time to perform quality services.

In exploring hygienists’ dissatisfaction and angst, I see several forces at work. The creation of large group practices, dental service organizations (DSOs) and reimbursement challenges in all dental practices have resulted in practice management challenges and the necessity of monitoring production and performance metrics. Successful hygiene departments will seek input from dental hygienists and make sure dental hygiene clinicians have adequate time and proper equipment to perform dental hygiene services to their satisfaction.

Another factor at work in the U.S. that greatly impacts dental hygienists is the perception by the public and others that dental hygienists are no different from other staff members in the dental practice. Dentists are not the only providers in the practice and hygienists need assistance and adequate time to perform quality services. All staff members are important and should be treated with the utmost respect for their unique roles as part of the entire dental team.

Today’s American workers, including dental hygienists, serve and care for people in many healthcare roles. Many of us are women and we are racially diverse. It’s our responsibility to stand up for good working conditions and respect for the care we deliver. In order to provide complete and comprehensive care for patients, we need a good working environment. Our needs as workers must be recognized and that includes fair remuneration. Too often, like other female caregivers in society today, including dental assistants, we’re invisible and undervalued for what we do. The disrespect dental hygienists feel, I believe, comes from a new trend to reduce pay, cut back on benefits and provide unreliable schedules. This trend is one that’s affecting a lot of American workers, including those in the professional middle class.

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Many dental hygienists I chat with are leaving the profession altogether or are telling me they’re expected to perform dental hygiene services in 30 minutes instead of an hour. A colleague of mine told me last week that a hygienist in the room next door finished a periodontal maintenance procedure in 14 minutes! Hygienists in some practices are being “double booked” and are working harder with no assistance. Some hygienists I talk to don’t even get a bathroom or lunch break. Cheaper, poorer quality materials and equipment are sometimes being used, and even infection control is compromised because unassisted dental hygienists don’t have sufficient time to adequately disinfect and turnover their rooms.

“No one is coming to save us, so we’ll have to save ourselves.” I heard this statement made on National Public Radio by a teacher who was joining a movement to improve his pay and working conditions. The lesson here is that we must continue as a profession to push forward in a way that will give us better working conditions in every setting. We must negotiate for adequate time and assistance and not settle for poor working conditions and pay. Hygienists who are concerned about working conditions and remuneration shouldn’t be afraid to meet with the owner/manager of the practice.

It may not always be possible in certain locations to meet all your requirements, but it’s always possible during a demonstration of your skills and patient satisfaction to show your employer why you’re valuable to the practice. Demonstrating your value to a practice will at the very least give you greater job security, and you’ll hopefully be recognized for what you do. Having a greater sense of security during the current economic climate isn’t a bad thing. These are challenging times and the wild swings in the dental practice continue undiminished.


1. Slim LH, Rutledge C. Nonsurgical periodontal therapy then and now: changes since the early 1980s. Access Mag. May/June 2005: 32-38.