How to Profit From...Hygiene  Ten Reasons Hygiene Fails to be a Profit Center

by Robert E. Hamric, DMD

How many times have you attended a great seminar, gone back to your practice with every intention of making changes, and within two weeks, have gone back to "business as usual"? We all have done that. Why? Because change is difficult, change is slow, and people have difficulty working "outside the box."

One of the most productive and important phases of a great practice is what I call "soft tissue management." STM® is a structured approach to nonsurgical periodontal therapy. The concept of Soft Tissue Management® was created by Pro-Dentec®, Inc. This is the model we use in our office. We also have taken advantage of their continuing-education seminars.

STM is important and productive for several reasons:

The American Dental Association (ADA) states that 80 percent of the American population has some form of periodontal disease (PD). Granted, perhaps 30 to 40 percent of the total may have simple gingivitis (Type I). That means that of the eight out of 10 people who have PD, three would have Type I disease and the remainder would have Type II, III, or IV. Types II and III can be treated easily in the general dentist's office.
This is production completed by the hygiene department. When STM is fully implemented, it is not unusual for hygiene production to triple. A few hygienists are simply "prophy mills," and they are not properly probing and checking for periodontal disease. In my opinion, that is major malpractice. A PSR (Periodontal Screening Record) must be done on every patient.

PSR is an effective early detection system to screen patients for periodontal disease, and it summarizes necessary information with minimum documentation. The ADA and the American Academy of Periodontology recommend that a PSR be conducted and properly recorded in each patients' chart as an integral part of oral exams. Among the benefits are: early detection, requires only a few minutes to complete, does not require expensive equipment, recording ease (requires six scores, one for each sextant), and risk management (appropriate documentation to satisfy dental-legal requirements). To learn more about PSR, contact the American Academy of Periodontology.

How do you wish to be treated when you go to the dentist or hygienist? Do you prefer a quick "wipe off the stain" or a complete exam with PSR? Most professionals know what is best. Why would you give your patients anything less? Once again — is it malpractice to do prophys on infected gums? Is it malpractice not to inform your patients that they have a problem? Is it malpractice not to take current radiographs? You know the answers.

So, what are the barriers that need to be overcome before you can implement a solid early perio therapy program? Here is what I found in several offices:

An unmotivated or ineffective hygienist. A few hygienists are not team players, or they have imperious attitudes. We will fire assistants if they have such attitudes, so why do we tolerate the same in hygienists? There is no place in a productive practice for laziness at any level. Solution: Replace that person immediately.

The dental team does not understand behavior modification techniques. For an EPT program to be successful, effective verbal skills are extremely important. If a patient has been brushing poorly for 40 years, flossing occasionally, and now has PD, it will take four to six weeks of continuous instruction. Moreover, it takes a patient who is willing to change his home-care habits to arrest the disease. If patients keep doing what they have always done, they will keep on getting what they always get — periodontal disease. No longer can you keep telling a patient with PD to "brush and floss." It is not working. Solution: Something has to enter the therapy to help modify the patient's behavior. In our practice, we use the Rota-dent® periodontal appliance and other cleaning devices.

Lack of patient involvement. For years, many hygienists have allowed patients to sit in the chair passively while they scrape calculus, polish the stains, give the patient a rinse, check X-ray films, call in the doctor for two minutes, and then out they go. This methodology must change. Solution: Co-diagnose. The patient must become actively involved with the diagnostic process and be encouraged to observe what the hygienist is doing. Intraoral cameras are excellent for this. Alternatively, the patient should hold a hand mirror as the hygienist teaches about oral care.

To do that, the hygienist must learn the verbal skills to keep the patient involved. She can use statements and questions such as, "Today, we will examine your gums before we examine your teeth. Do you see the pus around this tooth? How long have you had this infection?" Patients must understand that they have a problem before they will be motivated to do something about it. Verbal skills are key to co-diagnosing.

Lack of commitment. The commitment of the doctor and staff is a must. We all have heard the adage, "Plan your work and work your plan." Once a new program is fully integrated into your office, it's easy — but getting there is difficult. Going to a seminar and "really wanting to change" is not enough. You must stop the ship! Schedule a solid, day-long staff meeting. Bring in a facilitator and truly make a commitment to work your plan. I have found that if the doctor is not committed to every phase of the program, it will fail. Often, the doctor must step forward and say outright, "This is what we are going to do; if you are not 100 percent committed to the plan, tell me now." If staff members fail to commit — replace them. This is a business decision, not a popularity contest. Doctor, can you make the commitment?

No bonus plan. Establish a bonus plan. If I were a staff member who was asked to do "more" for the same amount of pay, I probably would not have my full energies committed to the success of the program. However, if hygiene production doubled or tripled, why wouldn't a production-based bonus system be a reasonable incentive? I can promise you, once a bonus plan is implemented, your staff will get "turned on." Strangely enough, some dentists just hate to share the wealth. This is a significant reason that systems fail. My personal belief is to share the wealth with the entire office, not just the hygiene department. This is a team effort from the front desk to chairside to hygienist. Share equally with a production/collection bonus formula.

Hygiene program is time-locked. The practice is overbooked in hygiene, and there is not enough time to schedule root-planing visits. This is a major obstacle when considering an STM program. When patients are told that they have a problem, you can't find any time to get them back in. Why has this happened? Why are you so booked up?

For years, consultants have told us to "never allow a patient to leave without an appointment" — six months, nine months, or whenever. Stop doing that. Do not lock up your hygiene time six months in advance. Never! Patients are responsible for their own health. Send them a reminder card. Let them call and schedule their appointment. The only patients who should be scheduled in advance are your STM patients. This should continue until their disease is under control. But for the moment, you have no time to start an STM case. You are time-locked on $50-per-hour prophys instead of $200-per-hour root-planings. That is why your hygiene department is not making any profit.

Solve this problem immediately by confirming at least two weeks out on "recall prophys." As you know, many of these advanced appointments will reschedule. This will open time for STM patients. Set up an STM call list; anytime there is a cancellation, call from that list. It will take a few months of rearranging the schedule to make enough time for new patients and STM treatments. Consider hiring another hygienist. There will be enough STM patients to warrant doing that. Consider using a hygiene assistant to do those tasks that can free up the hygienist's time. Three hygienists and one assistant can be highly efficient. With this arrangement, you could expect hygiene production to be $70,000 per month if properly scheduled.

Hand scaling is too difficult. Hygienists eventually quit doing it. Never expect a great STM program to survive by asking your hygienist to "scale everyone by hand." In today's practice, it's impossible to do with hand instruments what modern electronic scalers can do. Your STM program will fail without them. In our practice, we use the Pro-Select®3 piezo scaler from Pro-dentec®. It comfortably root-planes and is easy on the hands and grip of the hygienist. It can irrigate with chlorhexidine, fluoride, or distilled water at the same time is is root-planing. The results are fantastic. It is a positive stroke for both the hygienist and the patient. The procedure does not wear out the hygienist, nor is it uncomfortable for the patient. Rarely is local anesthesia needed. Just a small amount of topical anesthetic is used in most cases. I have found that once this technique is mastered, two quadrants can be done easily with no problem.

Fear of rejection. Many professionals lack the self-confidence and assertiveness to look a patient in the eye and say, "You have a problem." They fear that the patient might reply, "I know; my gums have been bleeding all my life. Just go ahead and clean my teeth today, and I'll think about it next time." Or worse: "I've never been told that before; I think I'll go elsewhere."

A strong personality can overwhelm a weak personality by demanding certain types of treatment. We all experience difficult patients — patients who know more about dentistry than we do, or patients who say, "If my insurance won't pay for it, forget it!"

Learning to cope with such patients is necessary to be successful. All STM programs must be well-thought- out. This is done through extensive staff-training sessions that include role playing, scripting, practicing, and review. Practice what you will say when patients ask difficult questions or "self-treatment-plan."

Never be caught by a surprise question. Prepare ... prepare ... prepare! In your office, you are the authority. Mastering excellent verbal skills, self-confidence, and knowing your professional skill level will make all the difference. A question you must ask yourself is, "Is it malpractice to do a prophy on infected gums?" Were you taught to do malpractice in dentistry? I don't think so. Therefore, endeavor to learn effective verbal skills to handle your difficult patients. Again, this involves co-diagnosis. If done effectively, the patient will want more information: "So I really have a problem?" or perhaps, "What can be done about this?" At that point, positive and efficacious treatment can proceed. Most people don't want to live with pus around their teeth. If so, ask them why they came to your office. However, some patients do not want to get their gums probed, they just want to get their teeth cleaned. So, be prepared — some patients may leave your practice.

Poor examination techniques. You must take adequate time for both the new patient and the continuing-care patient, no matter how great of a doctor you are. If your office is performing 30-minute prophys on adults who have all of their teeth, you are doing malpractice. Sooner or later, you will pay the price. Today, it is standard, usual, and customary practice to perform PSRs on every patient. If the PSR indicates a full perio exam, it is done! This is part of the co-diagnosis, and effective verbal skills are essential. Doing this procedure while the patient observes makes your practice a unique experience. It will become a practice-builder — you'll be growing with patients who value their teeth. Make sure your hygienist knows how to probe periodontal pockets correctly, and that it is done in a timely manner. An assistant can really help with staying on schedule. Some practices are now using the Florida computerized probe. I highly recommend it. Teaching how to probe properly is not difficult.

The doctor won't spend any money. This is one short-sighted practitioner! The desire to increase production and provide a service that your patients need, yet failing to invest in a sure-fire profit center will result in you becoming a dinosaur.

You also will need to establish a product center where patients can purchase the products you recommend for home use. Buy the products. Then, either sell them to patients directly or include their cost in your fee.

Buy the proper instruments. Some offices don't even own a perio probe. Buy a few! Buy a power scaler; it will pay for itself in a month. Go ahead and implement a bonus system. Great things can happen when your staff gets excited about working in the practice!

What could you do for your patients, your staff, and your family if your hygiene program started producing a nice profit? (It's OK to make a profit in your practice!) If your hygienist, who is now producing $100,000 per year, should begin producing $300,000 to $500,000 per year, would it be worth the investment? You can't help others if you don't make money. Spend your money wisely, but don't cheat yourself when it comes to developing an STM program.

Now, after you have reviewed these 10 reasons for failure, how many of them "strike home"? The good news is that they are all easy to overcome, and there is a solution to every problem. Don't be discouraged. If someone else is already doing it, it must be possible! Remember, change is gradual. The most important phase of change is your commitment to improve. Often, an outside consultant who can work with you and your staff can help you solve these problems over time. The bottom line is, what type of practice do you really want? It is up to you.

Ten Problems to Solve