Question: I’m writing to find some help. I care a lot about my patients, and I take my role as a hygienist seriously. I feel accountable for their oral health overall. If they’re bleeding or if they develop caries, I feel like I’ve failed them, especially when this is a compliant patient who comes in every six months and does everything I ask.
I understand that some things are outside of my control as far as patient compliance goes, but my question is this: How am I supposed to take the best care of my patients if I don’t always have the authority to do so? What I mean is, I can’t control appointment length. I don’t choose instruments or technology. I don’t decide on products or the preventive approach. This system doesn’t seem to work, at least for me. Help.
Answer from Sarah Crow, RDH: I love this question, and I can feel your frustration wholeheartedly. What you’re describing is very real, and I want to say this clearly: your feelings are valid. This is not a personal failure, and it’s not about blaming a specific role in the dental office or the industry at large. This is a systems issue—not a character flaw in the least.
Responsibility without authority creates ethical strain
At the core of your question is something many hygienists experience but rarely say out loud. As a health-care provider, you are educated and trained to influence health outcomes with your patients. But when you’re required to practice within someone else’s beliefs, priorities, or outdated protocols, rather than your own clinical judgment, you can start to feel less like a health-care provider and more like a puppet. The problem is simple but couldn’t be truer … responsibility without authority creates ethical strain. That discomfort you feel isn’t a flaw; it’s actually a sign that your ethical compass is working exactly as it should.
So why does this happen so often in dentistry?
Historically, dentistry has prioritized production, efficiency, and predictability. Prevention, however, doesn’t fit neatly into those boxes. In years past, hygiene was always described as a loss leader. By definition, a loss leader is a product or a service sold at an unprofitable price (or at below cost) to attract customers, with the expectation that they will purchase other, more profitable items during their visit, thereby increasing overall sales and fostering customer loyalty. This is one reason why I believe patients come in just wanting their “free cleaning.”
Hygienists are educated to manage disease, influence behavior, and deliver health outcomes, yet they’re frequently constrained by time-based scheduling, legacy protocols, and a “this is how we’ve always done it” culture. We’ve assigned hygienists responsibility for health outcomes while limiting their ability to practice true prevention. That contradiction is at the heart of your frustration.
The bigger problem of this disconnect shows up quietly over time. You work hard yet feel ineffective. You carry emotional responsibility for outcomes that don’t change. Over time, you lower your expectations just to get through the day. Eventually, exhaustion starts to feel like personal failure.
Preventing disease is key
I think what you really want is to feel alignment with what you were taught to do—prevent disease. This will not only free you of your feelings of accountability when patients show up with disease, but it will motivate you to curate your care until you see the outcomes you so desire.
When responsibility and authority move closer together, outcomes improve, burnout decreases, and prevention finally becomes what it was always meant to be: possible.
