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Compassion & production: Can they coexist?

Nov. 1, 2018
Assuming ethical treatment and production are at odds is a mistake. Awareness of how you contribute to a practice can improve patient outcomes and your work satisfaction.

Words like “production” and “goals” used in reference to hygiene departments can create contention. After all, we are health-care providers, not salespeople, so why do the numbers matter?

Some might say that a focus on increasing production is not in the best interest of the patient. How many times have we heard or thought, “It’s all about production and making money, but my concern is for the patient”? Should it be our production numbers or the numbers of lives we are able to touch that measure us? What I have learned is that these two measures are not mutually exclusive, and in fact work in concert with each other.

For those of you who don’t agree, I understand. I once felt the same way. My change of view does not imply that I support overtreatment or suggesting services that are not necessary. We are not in the business of selling. We are oral health prevention specialists who have the responsibility to inform and educate patients. We are often the first in the office to build relationships with our patients and to see the signs of, or risks for, disease. We help guide the patient to the best possible treatment or prevention strategies ethically, responsibly, and as early in the process as possible.

Are we meeting patients’ needs?

It can be easy for us to ignore the concept of the numbers, retreat to the operatory, and perform what is on the schedule for that day to the best of our ability. But is the scheduled treatment in the best interest of the patient? I think about the countless times that I’ve worked harder instead of smarter, with much discomfort to myself and probably my patients, performing heroic measures that spanned far beyond what a prophy is supposed to be.

Also by the author:

• Do your patients really know what you do?

• Hygiene instrumentation, hand health, and ergonomic harmony

How do the procedures we regularly perform line up with the statistics? According to the American Academy of Periodontology, 47.2% of American adults over 30 and 70.1% of people over 65 have periodontitis.1 When we consider the amount of periodontal disease treated with D4000 CDT therapeutic code procedures in our practices, how do our numbers line up? The National Institute of Dental and Craniofacial Research states that dental caries is still the most prevalent chronic disease in both children and adults, despite its being largely preventable.2 Do our offices use risk assessments to guide patients to the best prevention strategies customized to their individual needs, or do we base our recommendations on the limitations of insurance benefits?

Consider unscheduled treatment. Industry standards show that 75% to 80% of restorative treatment recommendations come from hygiene appointments. Are we reviewing unscheduled treatment with our patients at each visit so that they are hearing a consistent message and are not eventually faced with more extensive, costly treatments?

Do we ever make assumptions about what patients will do based on finances or insurance, and do these assumptions limit our recommendations? We know not all patients will accept treatment, but do we give up explaining after one or two attempts? The process of guiding patients toward better health and an elevated “dental IQ” takes patience, understanding, listening, and sometimes more time. As experts in our field, we have an obligation to promote the best possible care, regardless of what we think our patients will accept.

Limitations and constraints

We are faced with many constraints in dentistry that impact the way we propose and deliver care. We experience constraints of time, scheduling, patient resistance, fear, finances, insurance limits, differing team member philosophies—the list goes on. Over time, we may adapt the way we work so that we can function in the face of these constraints.

For example, let’s consider the patient who presents with localized active periodontitis during a “routine” visit. By the time we assess the patient, educate the patient on our findings, involve the dentist who needs to diagnose, and bring in the business staff to determine the financial piece, the precious clock that we live by has most likely run out. An alternative to this might be to “clean out the pockets really well and reevaluate in six months.”

My question is, did we just do localized nonsurgical periodontal therapy—without consent—and disguise it as a prophy? If the tissue doesn’t respond, will the actual treatment we perform next time be different? Why do we wait six months to reassess? At that point, the disease could be more extensive and treatment more costly. It can be a disservice to the patient and the practice, not to mention the potential liability issues that can accompany undertreating or not reporting what we actually did. As health-care providers, we are legally and ethically bound to use the CDT codes established by the American Dental Association (ADA) to code for what we do.

I also think about the patients who refuse periodontal therapy. If you are required by your office to see these patients despite their refusal, it can be hard to see them and not perform covert therapy during their visit. For some of us, the pull to get to the base of those pockets is too great. Is this the ethical and right thing to do though? These patients have not consented to that treatment. In fact, they’ve refused it. Regardless of their reasons, we don’t have the right to perform that treatment. Further, it certainly doesn’t seem fair to the patients who, respecting and valuing our recommendations, find a way to commit to treatment.

Values and beliefs

We also have to think about our own thoughts and beliefs and how those impact our decisions. I was recently involved in a conversation with a colleague who was uncomfortable with the one-to-three teeth code for localized scaling and root planing. She felt it was too expensive for the patient. There was also a recent discussion in a dental hygiene forum in which someone asked about taking bitewings at six months. A good number of responders felt it was “overkill,” “greedy,” and “not a covered expense,” and would not support it. What surprised me were those who were able to confidently arrive at this decision without information such as the risk factors or history of the specific patient. The ADA guidelines for prescription radiographs outline specific situations where more frequent bitewings are the recommended standard. My question was, “If we resist ideas and don’t place value on the specificity and necessity of the treatment indicated, how can we expect a patient to behave any differently?”

The business of dentistry

We work as part of a business with expenses and overhead. Dental consultants commonly say that just to open the door to a practice costs 50% to 60% of collections. This doesn’t include salaries, lab fees, and supplies. Also, remember that not all of the money produced will be collected. Consider offices that are in-network providers for insurance plans. The amount collected can be significantly less than what is produced. There is also the issue of uncollectable debt—unfortunately, some patients don’t pay for services rendered.

In order for your patients to have the best possible care, the practice must have the resources to provide the appropriate equipment and to attract and retain the most talented staff. The best practices and most successful hygienists understand how to provide quality patient-centered care in a profitable practice and see the win-win. In those cases, it’s healthier patients, healthier practices, and healthier hygienists.

Knowing our numbers and being able to measure what we bring to the practice are important tools that can empower us. It is a lot easier to ask for what we feel we deserve when we have facts to back our worth and contributions to the practice, as well as knowing how we compare to industry standards. It’s important to know our hygiene department numbers and to track restoratives and other services that we helped get to the doctor’s schedule. With that, we can operate from a place of being able to communicate the bigger picture.

Any business expert will tell you that an employee who contributes to the success of a company is certainly worth more than one who is reliable but doesn’t make an overall impact. Taking this one step further, most of us would say that when we choose a health-care provider, we want the one who offers us the best care and the knowledge and freedom to make our own decisions—one who can let us do this without assumptions, judgment, and limits.

Time and patient connection

Appointment blocks must allow time for us to build relationships, educate, and provide quality care, but we all know that time is precious and limited. The most successful offices allot for appropriate time for each patient, and the most successful hygienists use that time well to add value for their patients and the practice. There is a difference between sheer speed, a longer appointment filled with superficial chitchat and poor time management, and a longer appointment that maximizes the time for the best possible outcome. You may see fewer patients per day in this model, but typically these more quality, focused appointments allow us the opportunity to guide patients to the proper treatment by talking with them, not at them, and give us the opportunity to understand their concerns and address their objections. This in turn increases the health of the practice and our patients, not to mention the physical and mental health of the practitioner.

The impact of downtime

When we talk about time, we must consider the impact of downtime. Downtime can be partly out of our control, but we cannot turn a blind eye toward it. When there is no one in the chair, it affects our ability to earn a productive living in a practice that can afford what we are worth.

For example, one hour of open hygiene time per day in an office that produces $150 average hourly production in hygiene equates to $3,000 lost per month ($36,000 per year). There is also the bigger picture of downtime as it impacts overhead costs and the restorative schedule—without patients, there can be no diagnoses for treatment. The industry standard for downtime used by consultants is somewhere between 6% to 8%.

Missed appointment fees are not always effective either. Depending on how they are enforced, they may do little to change behavior and are among the most common write-offs in the office. They are a reactive strategy, and the revenue from them doesn’t cover the time lost. Proactive offices that have good confirmation protocol, along with consistently applied “quick-fill” appointment strategies, generally see fewer holes in the schedule. Clear and consistent verbiage around missed appointments is also important. Avoid language like “that’s OK,” and don’t reward unreliable patients with the most coveted appointment times. We teach people how to treat us so value must be placed on these important appointments.

Another way to avoid downtime is to have solid recall protocols in place. Scheduling your patients’ next appointment and stressing their importance, using specific details, while patients are still in the chair can make a big impact on keeping the schedule full. It adds value to their appointments and your patients are less likely to cancel on you than they are someone at the desk with whom they do not have the same type of relationship. It is good for you to know what the recall protocol is in your office and offer suggestions and assistance where appropriate. There should be procedures in place to look ahead for patients who are due but unscheduled. Protocols, accountability, teamwork, and consistency are key in this important area of practice productivity.

When we offer our patients compassionate, thorough care with a focus on education and prevention, we help guide them to needed treatment. We add value to the office and positively impact the lives and health of the patients entrusted to our care. The feelings of accomplishment that accompany this are boundless. The numbers automatically fall into place as a secondary benefit of doing right by our patients. When we work in offices that are more productive in this way, the numbers of lives that we touch are plentiful. We have healthier patients and a healthier bottom line that can afford us more opportunity and resources to continue to grow and thrive.

Basic industry standards for hygiene

• 30% of total office production should generally come from the hygiene department, excluding exams as those are considered doctor production.

• 30% of your hygiene services should be D4000 codes (therapeutic, not preventive).

• Of those, consider how many are maintenance cases versus active therapy. Are your maintenance patients truly maintained? Consider patients who have been on “maintenance” for years, yet they present with active, progressing disease. Oftentimes, periodontal disease may need to be re-treated and/or referred to get the disease under control.

• A hygienist’s production should be about three times his or her hourly wage, including benefits.

Situations that can affect the numbers

• The doctor produces in large volume or performs a lot of cosmetic or implant cases. This high production could decrease the hygiene percentage related to total production.

• Hygiene fees are too low compared to restorative fees. Some practices are hesitant to increase hygiene fees for fear of patient complaints.

• If there is a large number of hygienists and only one doctor, the hygiene percentage of total production could be significantly higher than 30%. Also consider a doctor who has lower production compared to hygiene due to openings in the restorative schedule and/or the majority of treatment consists of services that are billed at lower fees.

Editor’s note: This article has been revised from a version previously appearing on DentistryIQ.


1. CDC: Half of American adults have periodontal disease. American Academy of Periodontology website. https://www.perio.org/consumer/cdc-study.htm.

2. Dental caries (tooth decay). National Institute of Dental and Craniofacial Research website. www.nidcr.nih.gov/research/data-statistics/dental-caries. Updated July 2018.