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Watterson: New hygienist in an overcrowded hygiene department pads her production figures

Dec. 13, 2016
New hygienist in an overcrowded hygiene department pads her production figures

By Dianne Watterson, RDH, BS, MBA

Dear Dianne,

Another hygienist and I were hired as full-time dental hygienists in May 2016. The previous hygienist left the practice, because she felt like she was underpaid, mistreated, and disrespected. Evidently there have been problems getting hygienists to stay. The practice is owned by a retired dentist who no longer practices dentistry. In fact, he owns three practices and hires employee dentists to perform the dentistry while he manages the practices.

Not too long ago, an old friend of the business owner was looking for a hygiene position. When she called him and asked for a job as a dental hygienist, he welcomed her with open arms and told her there would always be a place for her.

Now there are three dental hygienists in the practice; however, the practice is not large enough to support three hygienists. The next thing that happened was our hours got slashed! When we inquired about the situation, the office manager told us that the third hygienist is now the "lead" hygienist, that her schedule is a priority and that's what the owner wants. She was brought in to the practice to boost production.

Interestingly, this new hygienist gets paid by production. My coworker and I are paid hourly. The worst part of this sordid story is that the new hygienist boosts her production by doing unethical things, such as taking panoramic films on four-year-old patients, diagnosing and placing sealants on every patient she sees, and taking impressions without direction from the doctors. In a nutshell, she is money-driven. Her mantra is quantity rather than quality. Her driving force is to do anything possible to increase production, whether it is needed or not.

The first week she started, I was scheduled every day. Toward the end of the day, I got a text message telling me that I would not be working the following day because the schedule had "fallen apart." The only day I was scheduled the following week was Saturday. (I suppose the "Queen Bee" didn't want to work on Saturday.) My coworker was guaranteed a full-time position just like me, but she has only been getting a half day here and there.

The employee dentists are concerned about this new hygienist being money-driven. According to them, the owner and office manager are aware of the unethical practices, but they don't see a reason to change anything. They like the extra production. It's really sickening! What do you suggest that we do in this situation?

Unhappy RDH

Dear Unhappy,

I find it ironic that the former hygienist left because she felt "underpaid, mistreated, and disrespected." That is exactly what is happening to you and your coworker. I see

a pattern of poor leadership and lack of morality on the part of the owner.

If what you described to me is accurate and the hygienist is performing unnecessary services to "pad" her production, it is not only unethical but fraudulent. I find it unsettling that any dental professional would engage in such behavior and risk losing his or her license, and possibly even go to jail! Greed can lead people down the path to financial and professional destruction.

As with most wrongdoing, it starts small. The individual becomes emboldened when, seemingly, there are no consequences for the wrong that is committed; the financial rewards become a way of life. This hygienist may even rationalize that what she is doing somehow "helps" the patients.

As for radiographs, the prudent dental professional is supposed to abide by the ALARA principle, which means "as low as reasonably acceptable." There may be a situation, such as an accident involving teeth, where a panoramic radiograph is needed on a four-year-old. But under normal circumstances, we would not expose children needlessly to potentially damaging radiation.

You also mentioned sealants. In March 2008, the ADA published "Evidence-based clinical recommendations for the use of pit-and-fissure sealants." According to the article in the Journal of the American Dental Association, a panel of 10 experts addressed the following clinical questions:1

  • Under what circumstances should sealants be placed to prevent caries?
  • Does placing sealants over early (noncavitated) lesions prevent progression of the lesion?
  • Are there conditions that favor the placement of resin-based versus glass ionomer cement sealants in terms of retention or caries prevention?
  • Are there any techniques that could improve sealants' retention and effectiveness in caries prevention?

There is strong, high-grade evidence for placing sealants on the permanent teeth of children and adolescents when it is determined that the tooth, or the patient, is at risk of developing caries. However, the evidence for sealants on adult teeth was Grade D, meaning that evidence is weak. There might be a rare occasion where an adult tooth could benefit from placement of a sealant, but the experts published that, generally speaking, evidence for their benefit is lacking.

The thing is, patients are not stupid. If the owner allows a hygienist to abuse the patient trust by doing unnecessary procedures just to jack up the bill, patients will leave and go somewhere else.

There is a legal concept called "complicity," which is "the act of helping or encouraging someone to commit a crime." It is also called aiding and abetting. When the business owner knows a staff member is practicing fraudulently and does nothing about it-even encourages it-that makes the owner an accomplice. Gregory Mellema, writing for the International Journal of Business and Social Science, posited that "in the moral sphere a person can sometimes be complicit in the wrongdoing of another through silence or through the failure to prevent, or to attempt to prevent, the wrongdoing."2

Another legal concept is called Respondeat superior. Literally, it means "let the master answer," which means the dentist/owner is directly responsible for the acts of omission or commission of employees who are engaged in the delivery of care to patients. When the fraud is uncovered, the dentist will ultimately be responsible.

Not only has the dentist/owner been disrespectful to you and the other hygienist, he's also aiding and abetting the actions of a staff member who is practicing fraudulently. If I were in your shoes, there is no doubt in my mind that I'd be looking for another job. Besides that, you need a conference with the person in charge of staffing. I'd say this: "I was hired with the expectation of X number of hours per week. Then you bring in another hygienist and cut my hours. How do you expect me to pay my bills?" I'd probably also say, "Are you aware that the new hygienist is padding her production by performing unethical and unnecessary procedures?"

Good luck, my friend. It sounds like the owner of the practice is more interested in profits than ethics. It's a sure way to destroy a practice and ruin relationships. Unfortunately, it happens far too often.

All the best,



1. Beauchamp J, Caufield PW, Crall JJ, et al. Evidence-based clinical recommendations for the use of pit-and-fissure sealants: A report of the American Dental Association Council on Scientific Affairs. Journal of the American Dental Association. 2008;139:257-268. http://www.ada.org/~/media/ADA/Science%20and%20Research/Files/report_sealants.ashx?123

2. Mellema G. Complicity and business ethics. International Journal of Business and Social Science. 2011(abstract 33);2(12)296-299. http://ijbssnet.com/journals/Vol._2_No._12;_July_2011/33.pdf

DIANNE GLASSCOE WATTERSON, RDH, BS, MBA, is an award-winning speaker, author, and consultant. She has published hundreds of articles, numerous textbook chapters, an instructional video on instrument sharpening, and two books. For information about upcoming speaking engagements or products, visit her website at www.wattersonspeaks.com. Dianne may be contacted at (336)472-3515 or by email [email protected].