By Roger Levin, DDS, MBA
How To Build Your Hygiene Department
Some dentists will be tempted to scoff at the phrase “hygiene department” because they know most practices have only one hygienist. Although we commonly refer to the hygiene department, it is more a division of the practice than a separate group. While there are practices with more than one hygienist, Levin Group has found that more than 50 percent of dental practices employ only one hygienist, 9 percent employ more than one hygienist, and the remaining practices do not employ a hygienist at all.
Typically, the predominant role of a dental hygienist has been to perform prophylaxis and limited ancillary procedures. In at least half of general practices, dental hygienists spend most of their time exclusively focused on prophylaxis, bitewings, fluoride for children, and occasionally periodontal probing. Other services are performed only intermittently. The goal for dentists is to change this equation and view hygiene departments as opportunities to increase patient care and production by adding hygiene-related services.
Recasting the role of hygienists
Besides the doctor, the hygiene department is the largest production center in the practice. While every staff member may play a supporting role in advancing practice production, the two main centers of practice production are unquestionably the doctor and dental hygienist.
As the dentist rethinks and restructures the practice’s hygiene department, the result of this paradigm shift should be excellent patient care and an increase in practice production. While an enhancement in patient quality is always the first priority, it takes management skills to achieve this quality while increasing production. The doctor should communicate to the entire team that the role of the hygienist is no longer about prophylaxis, but about comprehensive dentistry. By examining the following three areas, tremendous patient satisfaction, higher production, and longer-term hygienist retention can be attained:
1) Education - Dental hygienists should receive a thorough education from the dentist in order to evaluate every patient for periodontal disease. Levin Group has found that more than 70 percent of dental practices do not probe and record pocket depths on a regular basis. During the more than 100 seminars I present each year, I often ask attending doctors why more practices do not probe and record pocket depths annually. The answer is usually the same: it takes time, there is discomfort to the patient, or the dentist is hesitant to explain to patients that they have periodontal disease after they have been coming to the practice for many years. While these are all logical explanations, it is really a financial issue.
If every dental insurance company stated tomorrow that they would pay once a year for periodontal probing and recording of patients, what would happen? It is not a stretch to say that there would most likely be a tremendous shift overnight for periodontal probing and recording.
Practices have an opportunity to be more proactive on this issue right now. Whether you decide to charge a small fee for periodontal probing or offer it at no additional change (for insurance and fee-for-service patients), periodontal probing and recording is the introduction to periodontal treatment. In diagnosing gingival or periodontal disease, doctors will increase the level of care for patients.
There has been extensive literature written regarding soft-tissue therapy. Several research studies indicate that some 60 percent of Americans who visit the dentist have gingival or periodontal disease. (Just imagine the rate among patients who don’t visit the dentist.) Based on this understanding, the potential for periodontal treatment is enormous and exists in most dental practices in the United States. Levin Group Method™ recommends that 40 percent of current patients and 60 percent of new patients can potentially benefit from soft-tissue therapy.
This approach to periodontal care, which requires re-evaluation and possible referral at a later time, should be considered carefully by every practice because it will increase hygiene production while enhancing oral health. This also utilizes the skills of the hygienist in a more sophisticated manner, based on the training he or she has received. Following the benchmarks established in this section will allow practices to grow by as much as $40,000 to $50,000 a year in dental hygiene services.
2) Ancillary services - Each practice should set a target percentage of patients who could take advantage of specific services. As examples, these include:
✔ Soft-tissue therapy
✔Three- to five-year full-mouth series or panoramic radiographs
✔ Whitening procedures
✔ Periodontal antibiotics
✔ Intraoral irrigation
✔ Oral cancer brush biopsies
✔ Adult fluoride sealants
While this is only a partial list of potential hygiene services, the next step is to assign the percentage of patients who could take advantage of each service. For example:
★ 40 percent of patients may undergo soft-tissue therapy
★ 95 percent of patients may accept a three- to five-year full-mouth series or panoramic radiograph
★ 20 percent of patients may be willing to accept periodontal antibiotics in conjunction with soft-tissue therapy
Each practice should establish specific guidelines for the percentage of patients who could take advantage of a service in relation to the expectations of the practice.
Doctors and staff can then challenge themselves, cast off preconceived ideas, and create opportunities for practice growth while enhancing patient care. For example, if you doubt many adults will agree to adult fluoride treatment, consider that Levin Group has clients who have a greater than 95 percent acceptance rate for adult fluoride. If you think adult fluoride should be incorporated into the hygiene department, then establish a percentage and an expectation.
Many dentists and hygienists are surprised at the percentage of patients who will accept treatment if the proper scripting and explanations are given. While educating patients takes some time, the rewards to patients and practices have lasting effects.
Ancillary services can play an important role in dental hygiene when it comes to increasing practice productivity. Consider product sales. While some dentists are uncomfortable with product sales - and it is an individual practice choice - many practices are having excellent success.
As an example, Sonicare toothbrushes, which are purchased by many patients, can be acquired at a professional rate and sold to patients. There are practices that sell these products at cost or for profit. Some practices maintain the profit as part of the business model, while others use the additional revenue for continuing education or staff-oriented activities.
Either way, many patients are delighted to purchase an oral health care product in the dental office. Chances are that they might not avail themselves of the recommended product if they have to travel elsewhere to purchase it. It is well known that more than 30 percent of medical prescription recommendations are never filled. While it is difficult to tell if the percentage is similar in dentistry, we can assume that many dental patients do not purchase oral homecare products that are recommended. The sale of a product within the practice benefits the practice and is convenient to the motivated patient at the time the recommendation is made.
3) Potential dentistry - Dental hygienists have between 40 to 60 minutes on average per appointment. A majority of dentists spend fewer than five minutes during a hygiene check. Many dentists view hygiene checks as distractions and inconveniences that necessitate leaving their current patients. This leads to a lack of motivation for dentists to perform comprehensive exams on hygiene patients.
In order to change this, hygienists should be well trained by dentists to determine what areas of dentistry can be identified. Potential services such as comprehensive dentistry, cosmetic dentistry, periodontal therapy, and implant dentistry are easily identifiable by dental hygienists.
Hygienists have sufficient time to identify potential treatment, educate and motivate patients, and help patients move toward decisions to have treatment. While dental hygienists are not allowed by most or all state regulations to diagnose, they can identify these potential areas, explain what services the practice can provide, and have positive discussions with patients about the benefits.
The potential production a hygiene department can refer to a dentist amounts to more than $100,000 annually. That number depends on how well the hygienist is trained to identify, educate, and motivate patients. Dentists should be careful to meet with hygienists before entering a room to perform a hygiene check so they are well briefed on what has occurred, what the patient is interested in, and what the likelihood is that the patient will accept treatment. This opportunity to increase case acceptance and overall production is significant for most practices.
As an example, John was a 47-year-old doctor who had been in practice 25 years with an annual practice production of $675,000 when he enrolled in a Levin Group Management Consulting Program. His chief concern was that he was not fitting Levin Group’s model of 75 percent of practice production coming from the doctor and 25 percent coming from hygiene. He believed his dental hygiene program could spark more production and provide excellent service to patients.
Levin Group found that the hygienist was performing prophylaxis, bitewings, and child fluoride treatments in more than 98 percent of all appointments. She averaged nine patients a day but was on a treadmill going from patient to patient. The hygienist and doctor were more than willing to change their perceptions of the hygienist’s role and implement a new hygiene system.
The first step was to put in clear systems to dictate which patients should be offered which ancillary services. They offered all patients services such as three- to five-year panoramic radiographs, soft-tissue therapy diagnosis, and whitening. Specific percentages were targeted, and scripting was established to help the hygienist and doctor communicate in a positive and effective manner with patients. Other services were also offered less frequently by the hygienist.
The second phase of education was for the hygienist to understand all areas of dentistry that were of interest to the doctor. She became excited about promoting cosmetic dentistry and was able to identify numerous whitening and porcelain laminate cases. The average porcelain laminate veneers performed in the practice until that time had been about seven a year.
The results of all of the training allowed the practice to grow during a 12-month period from an annual production of $675,000 the previous year to $921,000. Approximately 40 percent of the increase came from hygiene, and 60 percent of the increase came from increased dentistry identified by the hygienist, referred to the doctor, and accepted by the patient. In the second year, the client broke $1.1 million, and a second part-time hygienist joined the practice. Due to this growth, the original practice overhead percentage of 69 percent fell to 61 percent, increasing the practice’s profit margin.
Patient surveys were put in place, and patient satisfaction ranked “excellent” more than 83 percent of the time, “good” 16 percent of the time, and 1 percent of patients reported customer service as “fair.” As you can see, the results for this Levin Group Practice resulted from implementing the proper systems, education, scripting, and protocols to build a dynamic and productive hygiene department.
Dental hygiene is the second largest production center in the practice, and one that is underutilized in many offices. Practice management should include a focus on dental hygiene as a major practice opportunity. Increasing ancillary services by dental hygienists and the abilities of hygienists to identify potential treatment for doctors can help practices grow and provide a wider range of services to patients. Dental hygienists have existed for some time in a paradigm of prophylaxis and bitewings, and this needs to be changed into viewing them as much broader treatment providers who can contribute to practice growth.
Roger P. Levin, DDS, MBA, is founder and CEO of Levin Group, Inc., a leading dental-management consulting firm specializing in implementing documented business systems into dental practices. Levin Group can be reached at (888) 973-0000 or at www.levingroup.com.