Are more hands better?

June 1, 2007
Who really benefits from assisted hygiene?

by Cynthia A. Chillock, RDH, EF
Who really benefits from assisted hygiene?

That’s a good question! Sometimes the answer depends on who’s doing the asking. We have all read articles about assisted hygiene, and surprisingly, it can cause an emotionally charged reaction depending upon your perspective. The big question on everyone’s mind, really, is ....

Who does benefit from assisted hygiene? The doctor? The hygienist? The assistant? What about the patients? Do they get any benefit?

Doctors think they benefit if the hygienist is producing more dollars. Hygienists think they benefit if they don’t have to do the clean-up between patients. Some assistants (and some doctors too) think it’s of no benefit to assistants and a waste of their time and talent to assist the hygienist. After all, other hygienists have been working unassisted for years, so a hygienist who wants an assistant must be a prima donna. In the end, it comes down to attitude and teamwork. Sometimes, in an effort to make progressive changes, team members may still go home disgruntled and no one really benefits. You are left with an unhappy team and unhappy patients!

Let’s consider a model of assisted hygiene where everyone benefits, including the most important team member - the patient. During my 41 years in dentistry, I have worked as an assistant for five years and as a hygienist for 36 years. For the last 26 years, I have provided conservative periodontal therapy with fully assisted hygiene. I have also been the office manager for the last 16 years. My unique background has given me insight into all team members’ viewpoints, and I would like to share my vision of how everyone can benefit from assisted hygiene.

First, we need to look at some history of the hygiene appointment, the time required, and the terminology used. When I began in the dental field 41 years ago, it was possible to see a patient every 45 minutes. We placed a mirror in the mouth and looked for calculus behind the lower anterior teeth. Then we went to work polishing and removing the calculus. Hygiene was considered a cosmetic procedure. As our knowledge about periodontal disease increased, the appointment time was extended to one hour. Currently, the focus has shifted to evidence-based dental care. Today, that same one-hour appointment must include a medical history update, an oral cancer screening, X-rays, a blood pressure check, oral hygiene instructions, periodontal evaluation, possible desensitizing and fluoride varnish, and localized antibiotic or antimicrobial therapy - in addition to scaling and polishing. Infection-control protocol takes at least 10 minutes between patients. How in the world can we get all of this done in a one-hour appointment?

What about treatment notes for the appointment? Gone are the days of writing “pro, bwx, ex” in the chart at the end of the appointment. Risk management specialists say our treatment notes must pass the “amnesia test,” which basically means write a book. With all this, I definitely don’t have time to listen to my patients’ concerns.

Numerous offices still use the old terminology “recall” or “cleaning” or some equally inaccurate view of the hygiene appointment. Whenever I hear someone say, “Oh, it’s just a cleaning,” I see red! I prefer to call the appointment “hygiene services.” Hygiene services are preventive/maintenance appointments or therapy appointments. Patients are told that they are scheduled for a hygiene appointment and are charged appropriately for each procedure.

All one-hour appointments are definitely not equal. That would be the same as expecting the doctor to charge identical fees for a crown and an amalgam/composite restoration if they require the same amount of chairtime. Different procedures require different skills, materials, and equipment. I like to schedule patients for the amount of time needed to complete the procedure, taking all of those differences into consideration. The appointment fee should reflect these variables.

It’s a bit like putting a puzzle together. Each piece is equally important, even though some pieces are larger than others. It starts with good communication and requires a true team spirit. We often give lip service to that word “teamwork,” but we aren’t always supportive of all team members in the office, especially the assistants. The assistants are usually the ones who keep the day-to-day business of the practice functioning. This model of assisted hygiene gives the assistants time to develop a relationship directly with patients and hear their positive feedback. Allowing assistants to do all they are legally able to do, using their skills to their fullest capacity, enhances the practice and fosters growth and variety.

In some states, after being trained and receiving the proper credentials, dental assistants may place sealants, perform coronal polishing, and place fluoride. The assistant may give oral hygiene instructions to the patient, if that is the choice of the hygienist/assistant team. Increased hands-on care with the patient allows dental assistants to be seen as an essential part of the dental team, both in their eyes and the eyes of their patients.

Another benefit for the assistant is that the hygiene schedule usually is less intense than the doctor’s schedule and adds diversity to the daily routine. For those dental assistants who also function as the infection-control officer or do the ordering for the office, this model will free up time between patients to accomplish those tasks.

The hygienist now has time to preview patients’ charts for any diagnosed, untreated dental care, which should be discussed at the appointment. Some of the best use of the hygienist’s time is spent truly listening to patients. It builds relationships with patients so that they feel heard. Patient involvement is imperative. In the process, hygienists will learn about patients’ desires and goals for their oral health, as well as provide the information they need to make informed decisions. Whether it is reparative, reconstructive, or cosmetic dentistry, when patients feel heard and understand their options, it becomes easier for them to say “yes” to recommended treatment.

For healthy maintenance patients, the hygiene procedure could start with the obvious - i.e., the assistant cleans and sets up the treatment rooms. The assistant seats the patient, updates the medical history, takes blood pressure, dispenses and supervises the preprocedural rinse, and exposes, develops, and mounts necessary X-rays on the viewbox before the hygienist enters the room. With digital radiography, it’s even easier. The assistant can record the periodontal assessment numbers. Calling probing numbers aloud for the assistant to record will draw patients into the co-discovery process. This creates an opportunity for patient education and a greater understanding of periodontal and systemic health connections. It benefits everyone when patients become actively involved in the process of becoming healthy. The assistant remains in the room to provide high-volume evacuation when the hygienist uses power scalers. After that, the assistant leaves the treatment area to prepare for the next patient, giving the hygienist time to complete any necessary hand instrumentation. Any additional time may be used for effective dialogue with patients to help clarify their goals for oral health.

I don’t see this as a 30-minute appointment to increase patient volume in the hygiene schedule. In my experience, that is just not enough time for effective communication to occur. However, in some cases the roles of the hygienist and assistant may overlap depending on the personality of the patient and the team member. You will want the best listener and facilitator to listen to your patients. If the assistant does more of the patient facilitation, this idea of “accelerated hygiene” might be the perfect solution for your office.

Conservative periodontal therapy may include root planing with anesthesia, curettage, suture placement (where legal), and localized delivery of antibiotic or antimicrobial therapy. For these periodontal therapy appointments, the chairside hygiene assistant’s duties are different. Working in blood all day long in deeper pockets and around furcations is different than doing hygiene maintenance in healthy mouths. I have practiced assisted hygiene for 26 years and unassisted hygiene for 10 years before that. For me, assisted hygiene is better. This version of assisted hygiene is one that will improve your success rate in more advanced periodontal cases.

What I am proposing is true four-handed dentistry, with the hygiene assistant remaining in the room throughout the entire procedure. I know that I am more effective clinically with a clear field of vision. I find it physically impossible to hold a high-volume evacuator, a power scaler, and a mirror all at the same time - that’s two hands with three things to hold. I am just not flexible enough to use my feet. One thing has to go, either the mirror or the HVE. No matter which option I choose, it compromises my body to work upside down for direct vision, and I still can’t see through the water and blood. Furthermore, it creates more spatter with airborne pathogens and is just plain messy and uncomfortable for the patient.

In certain cases, you may be able to work with shorter appointment times if you have an assistant suctioning the entire time. In my case, I had to extend the length of my appointments because I could now see deposits I might have left behind. My success rate with the more advanced cases improved. Even though the time factor was the same or longer, production increased because I was now charging an appropriately higher fee for the therapy. Please don’t misunderstand my intent. I do believe in periodontists and I refer to them regularly, just not for the treatment I can do myself with an assistant.

In the past, I would periodically go home feeling dissatisfied with the service I had provided that day, even though I had tried my best. I am quite sure other hygienists occasionally feel the same. Years ago, I had a boss who said, “Cindy, some days your best is not as good as other days.” (I had no clue what he meant; I was just 22. What did I know at that young age?) I discovered that my best effort is far better when I can see what I am doing in an ergonomically comfortable position. My patients are more comfortable because of the high-volume evacuation. They don’t feel like they’re drowning, they don’t taste the blood, and they don’t get hematomas from the saliva ejector hanging in their mouths sucking in their fragile tissues. They also don’t get a shower full of airborne pathogens.

If you don’t think the public is knowledgeable about bacteria and airborne pathogens, just check out any airport restroom. Everything is done with a hands-free approach. My favorite is Chicago’s O’Hare Airport. You just wave your hand in front of the electric eye and the toilet seat cover miraculously rotates to reveal a new, clean, plastic cover for your sitting pleasure. You stand up and get a hands-free flush and walk to the sink for hands-free soap and water. There are two hands-free options for drying - one, a hot air hand dryer and the other, a magic eye that causes a paper towel the exact size necessary to do the job to automatically dispense. It’s very obvious to me that patients are concerned about disease transmission.

I hate to admit it, but one of the biggest stumbling blocks with the concept of assisted hygiene is the one between our ears. I have heard so many hygienists say, “I can do it faster myself. I’ve tried working with an assistant, and she just got in my way.” I have even said that myself. There is a learning curve! It’s no different than getting used to loupes and LED lights or chairs with arm supports. There was no such thing as ergonomics when I graduated from hygiene school. I learned hygiene standing up and then they shoved a chair under me and said, “OK, now you can sit.” I just transferred all of my bad standing habits to bad sitting habits and made the problems worse. Changing those bad habits required additional training and practice, but the benefits were well worth the effort. Because I work in less compromising positions, I have been able to practice clinical dental hygiene much longer than many other hygienists I know. Unfortunately, I know excellent clinicians in both assisting and hygiene who have left practice because of pain, just when they became exceedingly valuable to the practice.

By now, the dentists may be saying, “It all looks good on paper, but how can I afford to pay for this?” In addition to keeping track of your hygiene department’s direct production numbers, you must also start tracking the less obvious increased production that is achieved by allowing more time and assistance in the hygiene department. This one-on-one interaction time to educate patients increases their understanding. This means minimal or no chairtime in the doctor’s schedule to do the explaining. We all know the doctor’s chairtime is much more productive when used to perform other procedures.

As a consequence, you will be treating healthier patients and achieving greater results. Less inflammation means you will be packing retraction cord and taking impressions on healthy tissues for your crowns, which will ultimately achieve a better fit around the margins. Less inflammation also means less postoperative discomfort for the patient. It may even shorten the chairtime required to complete the procedure, which adds up to dollars at the end of the day.

Whether it is a $10,000 treatment plan, one crown, or a few composites, we all know that patients ask the hygienists and assistants, “Do I really need this?” Because we are not owners of the practice, they do not perceive any conflict of interest; rather, they see us as their advocates and trust our responses. The more information they get from us, the more case acceptance will increase. The increased production from better case acceptance will more than pay for an additional assistant’s salary.

Let’s go back to the main question: “Who really benefits?” If you do it right, I say the entire team - not the lip-service model of a team, but a team that works together to create a practice that focuses on patient benefits. In today’s competitive market, it is important to remember that we are in a service-oriented profession. The patients’ perceptions and experiences in your office are what count. When patients are unhappy, they vote with their feet. With assisted hygiene, patients are more comfortable during hygiene procedures and can relax in the chair. Patients are given enough time in the schedule for everyone to listen to their concerns. They truly feel heard by the entire dental team, which prompts them to tell their friends and families about their positive experiences. These are the patients who are less likely to complain about your fees and more likely to become the best marketing missionaries for your practice.

If our goal is to provide patients with the best possible experience in our offices, the practice production numbers will go up. All team members will go home at the end of the day feeling extremely satisfied and richly rewarded for the services they provided and received that day. In doing that, everyone benefits.

Cynthia A. Chillock, RDH, EF, is a consultant, speaker, author, advanced instrumentation and assisted hygiene trainer, CEO of Perio-DataTM, and creator and lead singer for the Salivary Singers. Her career has spanned more than 41 years with the last 26 years limited to conservative periodontal therapy with fully assisted hygiene. She has been senior consulting editor to Perio Reports, past president of the Arizona State Dental Hygienists’ Association, educational consultant to Sunstar Butler, and a member of the DANB-ICE committee. Ms. Chillock resides in Tucson, Ariz., and can be reached at (520) 323-5602,, or