A Profitable Hygiene System: Not an Undervalued Practice Resource, Part 2

Dental offices have an ethical obligation to provide the best care for their patients. All too often, dental practices cling to old beliefs such as, “Our hygiene department is a loss leader.” Experienced hygienists with excellent communication skills can easily transform a “loss leader” hygiene department, producing $600 to $800 daily, into a profitable department, achieving $1,800 to $2,500 in daily production. This can be accomplished by embracing a comprehensive, patient-focused approach to both periodontal therapy and restorative/aesthetic treatment options. Hygienists that are patient-focused spend about 50% of their time providing services with insurance codes (CDT 2009 to 2010, American Dental Association) in the D4000 to D4999 range. In addition to periodontal services, a comprehensive hygienist will offer oral cancer screenings, discuss occlusal guard therapy, sealants, tooth whitening, orthodontic alignment, and more. To achieve this level of success, having a comprehensive practice philosophy, along with the right team members to implement it, is a must.

ONLY “SUPERSTARS” NEED APPLY 

In Part 1 of this article series, we discussed the use of personality profiles in the selection of the right hygienist for your practice. There are numerous other essentials to perform during the hiring process (ie, the one-on-one interview, advertising, etc) For the sake of brevity, let us once again emphasize the use of the personality profile to avoid hiring the wrong person. You should always strive to employ only “SUPERSTARS” on your team. Let’s now look at some other helpful suggestions for the successful selection process.
You should have a working interview where the dental hygienist candidate does a prophylaxis for a team member, the doctor, and/or scheduled patient. It is imperative that the new hygienist get to know the other team members as quickly as possible. This can be accomplished with a lunch outing with the office team. (We suggest that the doctor stays out of this meeting.) This provides an excellent opportunity for interaction between team members and the potential employee outside the dental environment.
An important part of the selection process is to always check references. Check with the candidate’s past employer to try to determine if there was a willingness to merge their personal standard of care with that of the doctor. Hygienists will come and go, but leadership and the philosophy of care should remain the same or improve, regardless of the hygienist you employ. One final word of advice, do not hire someone you do not like. Furthermore, never hire someone out of desperation. Stick to your guns and hold out for the dental hygienist that will meet your expectations, meet the needs of your patients, and support your practice goals.

CLARIFY EXPECTATIONS

Once the dental hygienist has been hired, the next step is for the doctor to clarify any and all expectations. Stephen Covey, in his book The Seven Habits of Highly Effective People, states that, “The cause of almost all relationship difficulties is rooted in conflicting or ambiguous expectations around roles and goal... Unclear expectations in the area of goals also undermine communication and trust… Make expectations clear and explicit in the beginning.”
This takes a real investment of time and effort upfront, but it saves great amounts of time and effort down the road. Discord, after the “honeymoon period,” is almost always traced back to unclear expectations and assumptions. It is a good idea to prioritize the expectations according to the practice philosophy. Without proper preliminary communication of your clinical and management expectations, you may find yourself surprised and disappointed after hiring what seemed like the right hygienist.


Table 1. Expectation Issues for the Hygienist.
Hours of patient care
Professional demeanor, attitude, and dress
Hours of administrative duties, team meetings, morning huddles, working lunches, team trips, etc
Management of the dental hygiene department by the hygienist
Clinical goals of the department
Participation in continuing education
Financial goals of the department
Tracking all (hygiene) relevant patient and production statistics
Responsibility for representation of restorative/aesthetic diagnoses pending treatment
Interaction with other team members
Regular and meaningful communication with the dentist at scheduled intervals
Performance reviews at regular intervals with behavior modification if needed

HYGIENE SYSTEM MANUAL

We have listed (Table 1) some issues that need to be discussed between the candidate and the doctor during the hiring process. It is a worthwhile and necessary exercise for the doctor to write down (and clarify) a personal corresponding expectation on each of the topics listed. To avoid potential disharmony, every office should have them in a dental hygiene manual to avoid potentially unpleasant surprises. If you do not have a manual, utilize the list in Table 1 to develop such a manual.

WIN-WIN COMPENSATION 

Compensation for the dental hygienist can come in “many flavors.” An effective way to insure profitability is to enable the dental hygienist to take “ownership” concerning their production and compensation. Doctors get paid based on production and ideally the dental hygienist should also be paid in the same way. Compensation should depend on the services provided. Providing comprehensive care and maintaining a profitable dental hygiene department creates a winning scenario for im-proved patient health, as well as satisfied and productive dental hygienists.
Let’s take a look at some of the ways the doctor and the hygienist can experience a win-win as far as compensation is concerned. Our first premise is, “empowerment fosters comprehensiveness.” The doctor is a professional and so is the dental hygienist. When doctors empower their dental hygienists to use clinical judgment to provide densensitizing treatments, update necessary radiographs, enroll patients into necessary nonsurgical treatment, etc, it fosters a culture of being more comprehensive in their services. Consider paying a dental hygienist an average of 30% of what she/he produces based upon any comprehensive services provided. Another way to compensate a hygienist would be: the dentist and dental hygienist could agree on a guaranteed hourly (or daily salary) and any overage on the guaranteed salary, the dental hygienist would receive 30% of it.

DENTAL TECHNOLOGICAL ADVANCES 

Of all the technological advances available today, probably none have impacted the dental hygiene appointment more significantly than the intraoral camera and its use as a patient educational tool. Achieving case acceptance in the treatment room is much more easily accomplished when the patient sees what the clinician sees. However, a mistake that many practices make is in having only one camera available for the entire office. Dental hygienists should have an intraoral camera in their treatment rooms and should use it on every patient. In fact, beginning the dental hygiene appointment with a live “tour of the mouth” is a very effective way to get the patient involved. An example of one company that manufactures a “user-friendly” intraoral camera is SOTA Precision Optics. Their camera features a lightweight fingertip focus and capture button.
We are often asked, “Which power-driven technology produces the best clinical results? Magnostrictive or piezoelectric?” There is good news here in that both are clinically effective in calculus removal. However, in clinical studies, neither technology has been consistently shown to out-perform the other so it simply becomes a matter of preference by the clinician. One difference is that piezoelectric thin tips can be used on higher power settings to more easily remove tenacious deposits compared to magnetostrictive thin tips. One example of a state-of-the-art piezoelectric unit that has multiple
tip choices is the Piezon Master 400 (Electro Medical Systems [EMS]). It has a unique feature in its ability to automatically detect the tenaciousness of the deposit at the tip, and to compensate by adding or subtracting power. This unit also comes with a self-contained irrigation reservoir for water or medicament usage.

COMPREHENSIVE PERIODONTAL EXAM

Without someone to physically assist with data collection, or the use of technology to gather the data unassisted, many dental hygienists do not record adequate periodontal information at each patient visit. If no current periodontal data is recorded, routine prophylaxis patients can receive cleanings even in the presence of undiagnosed periodontal disease! Sometimes treatment is begun without proper diagnostic testing and determining the prognosis. This violates the standard of care that should be provided for patients.
The No. 1 priority in implementing a comprehensive periodontal program would be to perform full-mouth comprehensive periodontal charting (6 readings on each tooth) at least once per year. This should also include noting and recording any findings such as bleeding/exudate, recession, furcation involvements, degree of mobility, clinical attachment levels/loss, and muco-gingival involvement. When armed with this information, practices can diagnose and manage periodontal patients properly.
Fortunately, we have technology available that can expedite tedious data collection. It can also allow the dental hygienist to collect/record periodontal data unassisted and to produce a very easy-to-understand periodontal chart that will enhance patient education. The following is a descriptive list of just some of the data collection equipment and vision-enhancing equipment that is currently available:
PerioPal (PerioPal LLP; periopal.com), a voice-activated technology, allows the dental hygienist to collect periodontal data using a “verbal script.” This “verbal script” consists of commands, abbreviations, and short cuts to record data efficiently while the patient listens. It can be used in any order that the clinician chooses—in a single pass for pocket measurements, bleeding, recession, etc.
Florida Probe (Florida Probe Corporation; floridaprobe.com) is a data collection system that utilizes a controlled-force handpiece delivering a standard 15 grams of pressure to provide patient comfort and to record each measurement to 0.2 mm accuracy. This distinctive feature helps to standardize data collection between different clinicians. The patient participates by listening to the computer voice calling out their own pocket measurements, bleeding, recession, etc, while the dental hygienist collects data unassisted. The Florida Probe System provides easy-to-understand periodontal charts, patient education brochures, and a periodontal risk assessment tool.
The Dental Remote Access Terminal, or Dental R.A.T. (dentalrat.com), is another technology that allows unassisted periodontal data collection. The foot-operated mouse enables the clinician to input periodontal probe readings through individual buttons that (when pressed once) record 1-, 2-, 3-, and 4-mm pockets; or (when held down) record 5-, 6-, 7-, and 8-mm pockets. The foot mouse can also be utilized to open dental x-rays, utilize the intraoral camera, and check the schedule. The Dental R.A.T integrates with current dental software and includes a headset for patient audio feedback during probe recordings.
DIAGNOdent (KaVo) screens for dental caries and can be used by the dental hygienist. This technology utilizes a handpiece with laser florescence to shine on tooth surfaces to differentiate between healthy and diseased tooth structure. When caries are detected, a digital and audible indicator is activated so that the clinician and the patient can participate in the screening process together. This technology is clinically effective in detecting dental caries that are not yet visibly detectable with regular caries examination or radiographs.

Table 2. Four Important Considerations When Choosing Loupes.

1. Resolution - determined by the quality of the design and the use of precision lenses.
2. Field width - the size of the operating field when looking though the loupes. (Wider fields produce less eye fatigue).
3. Field depth and declination - the range of focus delivered by the loupe and accompanying working angle.
4. Magnifying power - the size of the image seen when looking through the loupes, generally ranging from 2.0 to 4.9 times the original size. Most dental hygienists utilize loupes with magnifying power around 2.5.

Orascoptic (orascoptic.com) and Sheervision (sheervision.com) are companies that make a variety of magnification and portable illumination systems for the dentist and dental hygienist. Utilization of magnification and illumination for the dental hygienist has become “nonnegotiable” for many dental hygienists in this technologically advanced world. Both from the vantage point of increased visualization and improved ergonomic positioning which can prevent severe back pain, enhanced visualization systems are considered indispensable. See Table 2 to learn the important factors that you should take into account when purchasing one of these products.

SUMMARY

In this 2-part article, we have addressed the correct methods to use in selecting the right hygienist and the importance of creating a purposeful vision for your dental hygiene department. We have touched on the role of having the doctor discuss practice expectations, and the qualities and traits a dental hygienist should possess. Finally we have briefly reviewed some ideas regarding hygienist compensation as well as the integration of the new technologies to help you build a successful, productive, and profitable dental hygiene department.
Many of today’s practice owners have invested hundreds of thousands of dollars in updated facilities and state-of-the-art technology. They have invested in management and leadership courses, developed their business acumen, and have worked to insure that their clinical assistants’ skills stay sharp. However, when it comes to dental hygiene, too many practices still operate a 1980s-style “prophylaxis mindset palace.” The time has come for more dentists to embrace up-to-date dental hygiene practice standards.


Dr. Doherty is a certified financial planner, national lecturer, and CEO of Doctor's Financial Network. For more information on his future upcoming “Financial and Management Boot Camps for Dentists,” or to receive a free newsletter Doherty’s Bottom Line, please contact him at (772) 225-3021 or hughdohertydds@comcast.net.

Dr. Doherty did not report any disclosures.

Ms. Davis earned her bachelor of science in Dental Hygiene degree from Midwestern State University. She is the owner and founder of Cutting Edge Concepts, and she lectures internationally. She is also a senior consultant of The JP Institute. She can be reached at (972) 669-1555 or karen@karendavis.net, or visit her Web site at karendavis.net.

Disclosure: Ms. Davis is affilated with The JP Institute, OraPharma, Philips, and PreVisor.

Ms. Miller is a senior consultant and partner of The JP Consultants Institute, and is also a director and featured instructor of the JP Institutes’ postgraduate curriculum certification program in Carlsbad, California. She can be reached at (800) 846-4944 or visit the Web site at jpconsutlants.com.

Disclosure: Ms. Miller is an employee of JP Institute and is paid per diem when she provides office training for dentists, workshops, seminars, etc. She lectures occasionally for OraPharma, and is currently providing Webinars for Philips Oral Health Care, receiving honorariums on a project basis from both companies.