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Expanded hygiene: A winning concept for everyone

July 20, 2021
Dr. John Wilde asks: Can you imagine a McDonald’s open 32 hours a week, 48 weeks a year? Do you believe dentistry’s business model is superior to theirs? Expanded hygiene can be the solution. Here’s how.

As many dental offices work on a backlog of recare appointments, they face a time issue. Expanded hygiene may be a possible solution when managed properly. When I was in practice, I managed to build a program that was beneficial for my dental hygienist, my patients, and the well-being of my practice.

Because no practice can achieve its full potential without maximizing hygiene productivity and profitability, numerous offices drastically and chronically underperform. But ancient wisdom proclaims that where one stumbles, there lies their treasure, and in no venue is dentists’ lack of business acumen more glaring or a viable option to enhance returns more feasible than in hygiene.

But here’s the rub—especially since the COVID-19 pandemic struck, many hygienists are disenchanted, feeling overworked and undercompensated, some seeking alternative careers, while numerous dentists consider hygiene a money-losing, time-gulping, pain-in-the-rump necessary evil. Both factions have valid points, but a significant portion of this conundrum results from the fiscal inefficiency of an entrenched system steeped in decades of ineptitude. This failure to excel rebounds painfully to hygienists, dentists, and patients alike—but the situation doesn’t have to stay this way.

My office utilized expanded hygiene for some 30 years. During that time, seven hygienists graced our premises, all producing similar fiscal results, so we are discussing a system rather than the individuals who ran it. Expanded hygiene necessitates two rooms and a dedicated chairside assistant, but it allows us to comfortably accommodate 12 patients a day rather than eight—which creates an instant 50% production increase.

Did we sacrifice the quality of care for the almighty dollar? Hardly. With classic hygiene, the eight patients seen in the age-old norm of eight hours each receive 60 minutes of staff time. Our enhanced system allows 12 people to be cared for during 16 total staff hours, so 80 minutes are devoted to every patient. The pace is more leisurely, and additional time is available for relationship-building, a key to case acceptance. (Patients ask staff candid questions they never would address to dentists—e.g., “Are the implants the doctor recommended really a good idea?” And since staff answers aren’t self-serving, they are more credible to the patient.)

Consider how the system flows: At 8:30, as our hygienist finishes care in room one, the assistant seats another patient in the second already prepared room. The assistant helps fill out or review medical history, exposes needed x-rays or imaging, takes blood pressure (BP) readings, and answers questions. (Having films awaiting the hygienist and doctor is helpful, and we’ve identified numerous wildly uncontrolled hypertension cases, such as BP of 220/120. Would you want to inject that guy?)

After our hygienist completes care on her original client, she moves to the patient in room two. As the assistant enters room one, she notifies me: “We are ready for our first check in room one.” The assistant then polishes and flosses (state law permitting), applies fluoride, reviews cleaning techniques or any adjuncts/medicaments prescribed by the hygienist, and schedules the patient’s next recare visit. (The assistant also sterilizes instruments, helps with periodontal charting and sealant placement, and works chairside during messy periodontal procedures.) If I’ve yet to arrive after these tasks are accomplished, my assistant will inform me, somewhat stridently, “Dr. Wilde, Mr. Businessman is ready for his second check.” That’s code for “Get in here now!”

This system means I seldom have to interrupt our hygienist’s expensive talent and force her to wait while I do my examination, talk too much, and put her none-too-pleased self behind schedule. It also allows at least a 20-minute window for me to perform the examination when it is most convenient. One must explain everything to patients in a manner that illustrates all choices are made with their best interests in mind. Leaving for a hygiene check, I would say, “Wow, you’ve been an amazing patient and earned a break. Rest and relax for a few minutes before we finish up.”

Having the assistant do the recare scheduling prevents bottlenecks in the reception area, and as this team member is aware of any special needs or circumstances, time may be allocated in a way that maximizes efficiency and productivity. If the patient chatters incessantly, is challenging to treat, or builds up deposits quickly, for example, we can anticipate these scenarios and make ideal time allotments. Accurate scheduling is a significant part of what makes an office run on time.

If dismissed directly from the operatory, some patients leave without seeing the administrative staff and without, fulfilling their financial obligations. We avoid this by having the assistant escort patients to the front office and hand the record directly to a teammate. The assistant then returns to room one, cleans and sets up, and then seats the hygienist’s next patient. And the beat goes on.

Two rooms and two staff members for hygiene? Why bother? I love to hunt, fish, garden, and play tennis, and joyfully do so for free. But dentistry’s my job, and at work, I’m a hard-nosed businessman who’s all about profit. In light of that pragmatic mindset, let’s consider some hypothetical numbers, which you may personalize by inserting your practice’s figures.

Fees and salaries vary widely, but let’s assume your current excellent hygienist earns $36 per hour, or $288 for an eight-hour day. Ms. Hypothetical has a routine cleaning for $85, fluoride treatment for $40, a recall examination for $52, and bitewings costing $65, for a total investment of $242. If hygiene sees eight patients daily, the total production is $1,936 ($242 x 8), which exceeds the hygienist’s salary by $1,648 ($1,936 - $288).

With expanded hygiene, our hygienist’s salary remains at $288, but a dedicated chairside assistant at $20 per hour, or $160 per day, makes total remuneration $448 ($288 + $160). At our arbitrary charge of $242 per patient x 12 patients per day means production of $2,904 daily, which exceeds salary by $2,458 ($2,906 - $448). To simplify, I’ve ignored more lucrative periodontal procedures that should comprise one-third of hygiene care, sealant placement, panoramic x-rays, and tooth whitening, but I did not consider unfilled appointments and patients who don’t pay.

Let me help with the final math: $2,458 - $1,648 = $810 in increased production per day. If a practice sees patients 200 days per year, that would be a $162,000 annual increase in hygiene revenue($810 x 200). Adding a fully equipped room dedicated to hygiene will pay for itself in months.

Here is some food for thought. My three-doctor group saw patients 313 days per year, and with split schedules our office remained open 10­–12 hours daily. Even ignoring the added hours, the additional days resulted in $91,530 (113 x $810) more in hygiene production annually. I am a stalwart proponent of small groups. Solo practices that were once the norm are a decaying, virtually indefensible mode. Recent uncertainties have amplified the reality that it is way past time for dental entrepreneurs to wake up and smell the coffee.

Of course, overhead consists of more than salary. To determine profitability, one must arrive at a figure for general operating costs. If hygiene produced 33% of my total revenue, I assume operating costs were responsible for one-third of rent, phone, utilities, marketing, support salaries, supplies, and other sundry expenses. Feel free to sharpen your pencil as much as you like here (what does one container of prophy paste cost?), but this estimate satisfied me.

And here’s the kicker: On the first day that we switched from hourly salary to revenue-based compensation, hygiene productivity—and thus hygiene salaries—increased 25% and never declined. That’s in addition to the 50% increase achieved by going from eight to 12 patients a day.

Salary percentage was derived by taking our hygienist’s last year’s W-2 compensation (which encompassed all paid benefits, so these were not dropped but automatically included in future production) and dividing it by her total production. If our hygienist’s W-2 income for the previous year was $60,000 and hygiene production was $180,000, she would now receive 33% ($60,000 / $180,000) of every dollar she produces. We compensated the assistant in an identical manner—percentage of production.

People work harder to earn more, and unfilled time, for which neither staff member was paid, became anathema. They moved heaven and earth to fill each day, because it’s one thing to enjoy sipping coffee on full salary and quite another to earn nothing while twiddling one’s thumbs for an hour. Dentistry may be the only industry where antiquated systems remain the norm for decades. Can you imagine a McDonald’s open 32 hours a week, 48 weeks a year? And do you believe our business model is superior to theirs?

Expanded hygiene will significantly enhance practitioners’ profits, increase hygienists’ compensation, improve the work environment, and provide superior client care. Those benefits are hard to top. For those of you who are determined to excel, here is a blueprint. I wish you Godspeed. 

Editor's note: This article appeared in the July 2021 print edition of RDH.

After eight years of higher education, paying 100% of costs himself, John A. Wilde, DDS, spent two years in the Army Dental Corp before beginning a practice from scratch in Keokuk, Iowa. He was debt-free at age 30 and financially able to retire at age 40. He fully retired when he was 53, and he has written six books and published more than 200 articles. You may contact him at (309) 333-2865 or [email protected].