The peril of self-doubt: Impossible standards can drain a hygienist's self esteem

Dianne Watterson, RDH, advises a dental hygienist who experiences self-doubt about her clinical skills.

May 1st, 2017
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Dear Dianne,

I have read a number of your articles on and thought I would write to ask for your advice/words of wisdom. I graduated at the end of 2014 and worked three days a week (mainly on patients who were diligent attenders for years) for about 12 months before relocating. I did not work clinically for six months, but now I work four to five days per week. I’m getting a lot more exposure to more challenging cases, which is great for my experience, except I’m having difficulty.

I’ve asked for help from my employer as I am not at all confident with calculus detection. Although I have a high standard, I don’t think my work is actually of a high standard. I cleaned the teeth of one of the assistants recently and asked the other more experienced hygienists to check my work for me. Indeed, I had left generalized, grainy, subgingival calculus. I was so disappointed in myself. The “patient” did have a lot of calculus and plaque to begin with, and I spent more than the usual allotted time to clean it all. I checked around with air, probe, and floss, and yet I still managed not to do a very good job.

We’ve set up a training block this week, and the poor assistant of ours is going to let me work on her again to learn to detect this calculus. The hygienists keep reassuring me that it’ll get easier, that it all comes down to practice, etc.

My problem is that this is causing me a lot of stress. I’ve literally had nightmares about it. I really don’t want to be that “nice hygienist who does a rubbish job!” I’ve been trying to pay even more attention than usual to the cleanings I do, and sometimes I think I’m making progress. Other times I don’t know what on earth I am feeling with the probe!

What really upsets me (and I know it shouldn’t) is when patients express how happy they are with the cleaning and say how thorough I am. I had one lady just last week who heaped so much praise on me when I showed her the before-and-after pictures that I felt sick with guilt. I feel like such a fraud. It’s not enough to talk the talk.

What do you think? Are some just not destined to be good at this job? Or will it really take a number of years to become good at it? Any tips? I really want to get good at this job as quickly as I can, but is that even possible? How can I fast-track my progress, or do I just need to be patient? I have a very supportive team, and I know I asked for the help; I just feel so terrible.

Kind regards,

Erin, RDH

Dear Erin,

You are not the first hygienist who has questioned his or her abilities after graduating to the real world. So here are my thoughts and observations.

There are a number of reasons why residual calculus might remain, such as inaccessibility, being deeply embedded into the cementum, dull instruments, incorrect instrumentation, visualization problems, patient discomfort, and probably more. What I want you to know is that “complete” calculus removal is a nice goal but possibly not ever realized. In 1990, the Journal of Clinical Periodontology published an article that stated that complete calculus removal is not possible or even desirable in some situations if it causes irreparable damage to the root surface. I wrote about this in the November 2014 issue of this magazine.

I’ve presented a number of “gift” seminars for periodontists over the years. One stands out - Dr. Michael Perry from Mississippi. He told me that even with a flap laid and the tooth root directly visible, there are times that the calculus is so deeply embedded that even he cannot remove all the calculus with a handpiece and diamond without doing irreparable damage to the tooth root. Did you know that if you breach the cementum and open up the dentinal tubules, you can set the patient up for pulpitis? So, overinstrumentation is detrimental too. In fact, the whole idea of glassy-smooth root surfaces has been termed “outdated overtreatment.”

So first, I want you to get over the idea of complete calculus removal. It is an unreasonable goal. I know it has been pounded into your brain and psyche that you’re a deficient hygienist if you leave one little jot or tittle of calculus. The truth is every hygienist leaves calculus every day. Not intentionally. But it is what it is. Please do not misunderstand - I am not excusing sloppy work. Hygienists are supposed to remove as much calculus as possible, and we get some impressive results when we remove calculus. However, examinations of root surfaces with electron-scanning microscopy reveal residual calculus that is not detectable with an explorer.

Also, know that calculus does not cause periodontal problems. Microbes do! So, it’s far more important in the big picture to perform an adequate debridement and spend time teaching patients how to take care of themselves at home. If you spend 99% of your time trying to reach some unreachable goal and only leave 1% of the time for teaching prevention, that’s a problem. Hygienists seem to major in calculus removal, because they got points counted off in school if they left one little speck.

Please remember that you graduated from a hygiene program, and you could not have graduated without developing the skills to pass the boards. Your skills would not have deteriorated to the point of incompetence unless you got a muscle disease or some other debilitating problem. So please stop beating yourself up. You are being too hard on yourself.

Do you wear loupes? What about a headlight? These two items are an invaluable investment in career longevity. You need both, and I can’t stress this strongly enough! I recommend Designs for Vision. The company will send a rep to your office to get the correct measurements, and let you pick your frames.

What about your instruments? Are you good at sharpening? To help hygienists with sharpening, I’ve developed a DVD that teaches sharpening with a handpiece and small green stone. This method is fast, easy, cheap, and effective! (See and click on the Products tab.)

One more thing. I love the American Eagle instruments called XP. They are advertised as “sharpen-free” and are the best I’ve ever seen. They do finally dull with use, but they stay sharp a long time.

When patients compliment you, do not listen to that negative voice in your head that tells you that you don’t deserve their accolades. What has happened here is that you set for yourself impossible standards that will only keep you in the toilet emotionally, since those standards are not attainable. Your standards are a mirage. Stop chasing it - it’s not there. No hygienist ever gets all the calculus off, no matter how clinically adept he or she is, and there is good science to support what I just said.

Finishing hygiene school with your sanity and skill set is something for which you should be proud. You would not have passed if you were not competent. YOU are your own worst enemy! I know what I’m talking about, and I’ve been where you are. I refuse to ever go back there again.

Put this part of your working career in the rearview mirror. I and all of your hygiene sisters and brothers salute you, so get your chin up and get back in the ring. You tripped over yourself, just like we’ve all done before in questioning our abilities at some time or other.

Warm regards,



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