I've long been pained by the strife between the two noble professions of hygiene and dentistry. This discomfort was most acute when the University of Iowa closed its excellent hygiene department, despite my personally sending letters to 1,400 Iowa dentists, urging them to protest this deeply disturbing decision. I believe the juxtaposition of two sets of figures can shed some acutely needed light on a primary cause of the dissension. Once the nature of the contention is established, I'd like to propose a fact-buttressed suggestion that will move everyone toward a solution amenable to hygienists and dentists alike, while also benefiting patients.
Let's begin by analyzing some facts. According to the May 1998 Dental Economics survey of dental practices, the average hygienist produced $6,835 per month, or $82,000 per year. Dental Economics' sister publication, RDH, reported in its October 2000 issue that the average annual salary for hygienists was $39,770.
This data is hardly exhaustive and could support numerous conclusions. However, the commonly accepted goal concerning the ratio of hygiene salary to total hygiene production is 33 percent. The $39,770 salary, for example, represents 49 percent of $82,000; or 1.5 times the suggested 33 percent ($27,060).
These figures suggest an imbalance that is a significant factor in the existing dissension. Hygienists feel underpaid for their valuable services, while some dentists perceive only a slight financial gain from the significant time, money, and effort required by their hygiene investment.
I contend both parties are correct in their concerns.
I'm not in any way suggesting hygienists are overpaid. Sound periodontium is the basis of all oral health. Research continues to establish the vital link between oral health and overall systemic health. Providing the excellent services needed to maintain that fitness is demanding ... a task in which few dentists possess the skills or enjoy.
The fiscal reward forthcoming should be proportionate to the high level of training and talent required, the difficulty of the task, and the results achieved. I insist that hygienists' salaries should be well above the $26 per hour average reported in that issue of RDH.
But performing dentistry and managing a practice is also demanding. The above facts illustrate that inefficient dental offices may actually lose money on hygiene. There are considerable expenses involved in hygiene in addition to salary (including a portion of rent, phone, utilities, staff salary devoted to hygiene production, supplies, etc.). It's certainly unfair for dentists not to profit from making hygiene's valuable services available.
So who is at fault here? I contend the system customarily used in contemporary hygiene - one that has remained basically unchanged for decades - no longer works! No party deserves blame, but times change and a superior strategy must be developed. An exceptional method of delivering outstanding care exists that will allow all involved to receive rewards commensurate with the value of the services they provide.
Expansion in the hygiene department
The technique under investigation is expanded hygiene. I will use our office history to demonstrate how, by implementing this superior system, the concerns and desires of both hygienist and dentist may be satisfied, as well as heightening the quality of the patients' experience. I'm sure many practices dwarf the humble results of our rural office; I can't write about them, of course, since I'm not privy to their data.
Our practice evolved into expanded hygiene about 15 years ago. This system requires one hygienist, two rooms, and an assistant dedicated to nothing but hygiene. The very same day that we switched to expanded hygiene, our productivity increased 50 percent. The average number of patients treated daily jumped from eight to 12!
About 12 years ago, we began to compensate our hygienists based on a percentage of production (derived from the startling theory that people will work harder if they can make more money). The day we restructured our compensation mechanism, we added an additional 25 percent to production, on top of the 50 percent increase already garnered by our change to expanded hygiene.
I wish this discussion to illustrate precisely the mathematical facts of our system's profitability. Precise details of the mechanisms involved in expanded hygiene are enumerated in my soon-to-be-released book, Profitable Dental Hygiene.
I believe it's critical to document that, with expanded hygiene, the quality of the patient's experience - the foundation of long-term practice success - is enhanced. Before we made the switch, our hygienist spent roughly an hour with each patient. Today, with two staff members treating an average of 12 patients daily, each client receives approximately 80 minutes of staff time. Sixteen total hours of care - eight hours from two staff members - is divided among 12 patients (16/12 = 1.33 hours per patient).
This extra attention leads to enhanced educational opportunities, more effective relationship building, less downtime, an increase in case acceptance, plus an augmented number and quality of referrals. ("At my dentist's office, they take their time. I never feel rushed, and they always answer all my questions!") Such behaviors positively impact an office's reputation and profitability.
Expanded hygiene can be an extraordinary practice builder, but let's evaluate documented facts. During 1999, my hygienist, the lovely and talented Melissa Lannery, RDH, produced an average of $133 per hour. Thus, a single hygienist, working an eight-hour day, generated a daily production of (8 x $133) $1,064. If patients were seen a conservative 200 days annually, total hygiene production would be (200 x $1,064) $212,800.
But we don't work that hard. Our actual 1999 totals were 163 eight-hour days of hygiene worked and $173,270 produced. Chances are your practice saw patients for more than our somewhat modest 163 days a year. Multiply your total days of treatment by our average production of $1,064 per day to consider how our results compare to your current hygiene production.
I hope it is motivates you to realize that if such production is achieved in our little country practice in Keokuk, Iowa, it is possible in your office also ... even if you toil in such backwaters as New York City or San Francisco.
An entrepreneur's reckoning
In our ultra-competitive modern era, I believe hygienists who wish to excel must become not just employees, but entrepreneurs. The primary concern of any businessperson is net, so let's examine overhead.
Depending on the availability of hygienists in an area (the law of supply and demand has not been repealed), let's forecast a range of remuneration from 20 percent ($26.60 per hour at $133 production) to 33 percent ($43.89 per hour at $133 production).
These aren't suggestions - I have enough people mad at me. These figures are merely hypothetical numbers employed to facilitate our illustration. We've established the 1999 average hygiene salary to be $26 per hour. So our illustration - based on a premise of outstanding production - tends toward the higher side of the wage range, as I feel hygienists should be compensated.
A hygiene assistant is an entry-level position in our office, requiring outstanding people skills more than dental experience and expertise. However, hygiene assistants are capable of significant production in their own right. Let's assume the beginning salary range for this team member varies from $7 to $10 per hour. The difference is primarily based on average pay in one's geographic area.
One must factor in overhead in addition to salary - a difficult figure to define precisely for hygiene. But in our low-overhead, highly efficient office (our group practice averaged a 48 percent true overhead during the last three years), overhead amounts to approximately $18 per hour of hygiene care.
This $18 overhead (beyond salary) represents my best educated guess. I arrived at this figure by noting that hygiene produced about 25 percent of our total revenue. I assumed 25 percent of rent, phone, utilities, janitorial, and front-office salary was dedicated to hygiene's behalf. I next calculated the expense of typical hygiene supply expenses (gloves, prophy paste, prophy heads, fluoride, toothbrushes, floss, etc.) for a six-month period. I then doubled this figure to estimate annual total dollars of hygiene supply expenses. Adding all the above-listed items results in nonsalary expenses. I divided this figure by the number of hours our hygiene department saw patients during the year reviewed to reach this $18 hourly estimate. Again, this is merely my best informed speculation, but I'm confident we are close to accurate.
We have now established:
- A low range of $26.60 for the hygienist's hourly salary
- $7 for the assistant's hourly salary
- $18 (nonsalary hourly overhead).
This amounts to $51.60 per hour of total overhead. If we calculate the high range referred to above ($43.89, hygienist's salary; $10, assistant's salary; $18, nonsalary overhead), the total overhead per hour is $71.89. At $133-per-hour production, this leaves the practice with a remaining hygiene profit of from $61.11 to $81.40 per hour. ($133 - $51.60 = $81.40 or $133 - $71.89 = $61.11)
To make these figures personally relevant, one must calculate a practice's current average hourly hygiene production. This is a primary figure in profitability, but one for whom few hygienists or dentists can venture a close estimate. Be a businessperson and perform this simple calculation. In knowledge lies power.
Based on 200 eight-hour days, we're discussing an annual net profit ranging from $98,000 (200 days x 8 hours x $61.11 net/hour) to $130,240 (200 days x 8 hours x $81.40 net/ hour), which occurs from hygiene alone!
By repeating my overhead computations with figures from your practice, you can determine:
- Profit or loss from current hygiene.
- By comparing our production to your own, you can derive the potential that exists with expanded hygiene.
Most offices squander enough potential profit in hygiene alone to increase hygienists compensation 50 percent and fully fund a pension plan for the entire team every year from remaining revenue.
In my 30-some years of practice, I have yet to discover a hygienist incapable of offering fine care when provided effective systems, proper equipment, motivated by significant potential financial rewards, and valued and supported by a team that realizes periodontal health is the foundation upon which all dentistry resides. But hygienists require the co-leadership and support of a understanding dentist to create an environment in which they may thrive.
The system I've briefly outlined will increase time spent with every patient, thus improving their level of satisfaction, reduce failed and cancelled recare, stimulate referrals, and augment treatment acceptance.
It will allow dentists to increase hygiene remuneration significantly, while boosting their profits. (Few dentists will gladly raise hygiene salaries if it means reducing their own remuneration. But only the most foolish of businesspersons would object to paying more in wages, if, in return, they enjoy greater financial rewards. Establishing such a win/win fiscal scenario is vital to hygienist/dentist unity.)
Hygiene working conditions should be markedly improved. The finest equipment will now be easily affordable for hygiene, justifying the creation of state-of-the-art facilities. The aid of an assistant relieves hygienists of some of the drudgery inherent in offering care (OHI, flossing, exposing and developing X-rays, and scrubbing and sterilizing instruments, etc., are only fun the first 10,000 times.), while adding a supportive teammate.
Wisdom consists of accurate information that is acted upon. One must act to achieve such valuable benefits. Begin by approaching your dentist with this article. The doctor should be excited by the dramatic increase in possible practice profitability. I hope this information will serve as the impetus for a deepening synergy between dentists and hygienists, as both parties unite to establish a superior system that benefits everyone involved.
Happy patients, happy hygienists, and happy dentists create a wonderful environment for the entire team. And in such a joyful place, achieving excellence and experiencing bliss in all one does becomes much easier.
Dr. John A. Wilde is the author of more than 100 published articles and five dental books, including the soon-to-be-released Profitable Dental Hygiene. To place orders for the book, call GP Publications at (888) 522-6402.
