Whos yanking those strings?

Oct. 1, 1997
Organized dentistry continues to wield control over dental hygiene, despite the advice of consultants.

Organized dentistry continues to wield control over dental hygiene, despite the advice of consultants.

Talisa Williamson, RDH, EF

Dental hygiene has long been of economic importance to dentistry - first as a loss leader and now as a profit center. It is this transition to profit center that has introduced a dichotomy of management between organized dentistry struggling to keep dental hygiene under its control and the management philosophies of private dentistry seeking profit. While organized dentistry struggles to keep dental hygienists subservient and deskilled, private dentistry advocates upskilling and utilizing hygienists to manage the profitable hygiene department.

The question of who manages dental hygiene is perhaps the most important question in the battle for economic control facing dentistry today.

In an effort to maintain an economic stronghold over dental hygienists, the American Dental Association, which represents organized dentistry, has long adopted and continues to entrench itself in the management philosophy of the "yellow dog contact." Benjamin Shimberg, PhD, has studied licensing and certification for 30 years, and borrows this term from labor history to describe the hygienists` situation:

"Hygienists entered into a yellow dog contract. Yellow dog contracts are entered into under duress and put one party at a severe disadvantage. When hygienists initially got licensure, they knew they couldn`t get it without, in a sense, acquiescing to the power of the dentist. And so the dentist made hygiene into a subservient occupation, always under the dentist and subject to his economic power."

Consequently, from the days of the yellow dog contract, dentistry has controlled the education, licensure, and practice standards of dental hygiene. Organized dentistry maintains control over dental hygiene by assuming jurisdictional power over its educational and accreditation standards through the American Dental Association`s Council on Dental Education.

Melvin Carlson, DDS, wrote in the May 1994 issue of RDH, "It has been said that dentists` scientific technology is growing at an enormous rate, but social technology is gridlocked where it has been for the last 60 years."

Why the yellow dog is still around

Meeting society`s changing needs by updating the dental hygiene curriculum has historically been a challenge with the current accreditation process that rests solely in the hands of the ADA. The association last revised its 10-year-old accreditation standards in 1992. The American Dental Hygienists` Association drafted and recommended many changes. Most of the changes were designed to increase the knowledge and skills of hygienists to allow them to work with complex cases in a variety of health care settings. The ADA in its revised standards, however, instituted very few of these changes.

The dental hygiene profession continues to have little say in the future of dental hygiene.

While the ADA effectively maintains the status quo, the political forces within organized dentistry seek to "deskill" dental hygienists. In a 1991 joint report, the Councils on Dental Education and Dental Practice reported, "Some dentist-employers believe that dental hygienists are presently being educated beyond the level of understanding and skill they need in most dental practices." The report outlines the advantages of lesser educated or "deskilled" dental hygienists. The councils advocated the "provision of an auxiliary whose skill level and compensation expectations are consistent with the perceived needs of many dentists-employers." The report recommended increasing the "availability of dental auxiliaries capable of providing clinical oral hygiene services under direct supervision by a dentist."

In 1992, the ADA`s House of Delegates passed a number of resolutions threatening dental hygiene educational standards and right to practice. One resolution endorsed flexible or alternative training programs while another recommended dental hygiene programs be administered and directed by dentists.

A third resolution called for a survey to determine the immediate needs of dentists for support personnel who can assist in providing limited dental hygiene services. The ADA`s 1994 Annual Report revealed the survey was conducted in 1993. Dentists in private practice received the survey. "Other communities of interest" (such as managed care and public health dentists and, particularly, dental hygienists and dental hygiene educators) were not considered necessary for the survey.

Alarmed, the ADHA warned that "although the survey results have not been made public, it appears as though the stage is set for implementation of a plan to create a new auxiliary who will be less expensive to operate and whose skill level will not present a threat to the dentist-employer."

New resolutions adopted at the 1996 ADA House of Delegates in Orlando substantiate the ADHA`s warning. The resolutions indicate the 1996 ADA agenda is now fully vested in its "deskilling" philosophy:

- Advocating changing the word "assistants" to "auxiliaries" so that dental hygiene duties can be delegated to dental assistants.

- Adding language shifting the responsibility of deciding what is acceptable as a delegable function under general supervision to the dentist.

- Passing a resolution that opposes both general supervision of hygienists and local anesthesia administration.

- Passing a resolution for appointing a special committee to study alternative pathways for training dental hygienists.

- Passing a resolution that officially opposes dental hygiene self-regulation (often confused with "independent practice."

Another tactic adopted by organized dentistry is the construction of the dental hygiene shortage paradigm. Formulated by the ADA, the paradigm asserts that an inadequate supply of dental hygienists exists. This causes a reduction in access to hygiene services, which is detrimental to public dental health. The shortage results in increased consumer costs when dentists must provide hygiene services.

By constructing a hygiene shortage, the ADA is able to justify the creation of preceptorship programs in the guise of meeting consumer demands for hygiene services. In reality, the aim of organized dentistry is to produce hygienists in short-term educational programs to assure a steady flow of technicians that can meet the demand of hygiene services that are dentistry`s "cash cow."

Because licensure and regulation of dental hygiene varies dramatically among the 50 states, the ADA looks to individual state associations to pursue preceptorship models. In 1995, for example, the Arizona State Dental Association`s House of Delegates passed a resolution declaring a hygiene shortage. A second resolution calls for a study of "job" training or preceptorship.

The threat of preceptorship and return to direct supervision is used to discourage dental hygienists from seeking autonomy. Reducing educational standards and denying the ability of hygienists to think and make diagnostic decisions "is central to their quest to keep dental hygiene under control and exclusively in their employment," according to an article by Irene Woodall in the November 1992 RDH.

Do they really want to hire the best?

For many dentists, the hygiene shortage is a self-induced reality. These poorly managed practices are caught in a "cycle of failure," unable to keep hygienists in their employment. Therefore, what has been perceived as a shortage of hygienists is really poor management. As Walter Wriston says in the Harvard Business Review, "The job of management today is to find the best people you can, motivate them and allow them to do the job their own way."

Hygienists are very seldom managed this way. However, effective management of dental hygiene departments is essential to the financial success of most dental practices in overcoming dental hygiene`s "loss leader" status.

In the United States, dentistry unwittingly used dental hygiene procedures as a loss leader to acquire new patients for more expensive restorative procedures. More recently, managed care organizations have capitalized on this tradition by under-cutting private practice fees for hygiene services to acquire a large share of the dental market. In conjunction with the decline of dental caries and the desire for increased profits, increased competition from managed care threatens to reduce the profit margins of private dentistry. Limited in areas of expansion to increase practice revenues, dentistry seeks to capitalize primarily in two areas: cosmetics and dental hygiene.

Herein lies the dichotomy of management between organized dentistry and the management philosophies of private dentistry seeking profits. Organized dentistry wishes to maintain control over the cash cow by diluting educational standards to reduce hygienists to "technician" status. Management consultants, on the other hand, suggest control over the hygiene cash cow by promoting hygienists to producer/manager status. This latter management philosophy is in direct conflict with the ADA`s agenda for hygienists.

A review of current practice management literature concerning the role of the dental hygienist generally revolves around production and the management of the dental hygiene department. In a Dentistry Today article, Roger Levin, DDS, MBA, suggests that many practices have very low hygiene profitability: "The hygienist can become almost a loss leader for the practice without any true return on the investment. As the expense of the hygienist and running a dental practice increases, it is more important than ever to enhance revenues to gain a return on the investment and feed the rest of the dental practice."

To become profitable, consultants recognize the need for expanding the hygienist`s skills above and beyond the routine prophylaxis. Levin advocates that 40 percent of the hygienist`s time should be devoted to expanded duties such as soft tissue management programs, sealants, bleaching, etc. Not only must hygienists possess proficient clinical skills, effective communication skills are also essential to educate and motivate patients to accept recommended treatment plans. Increased knowledge is required for hygienists to upgrade their diagnostic and clinical skills, as well as to use advanced technology.

Indeed, the management consultant`s production-based dental hygienist is a highly educated, savvy professional in comparison to organized dentistry`s on-the-job trained technician needing direct supervision and lacking valuable skills such as local anesthesia. Unlike the ADA, astute management consultants understand that while deskilling the hygienist to technician status may reduce salary overhead, it will also cripple the hygiene cash cow.

Teamwork or just `blending` skills?

In their quest for increased production via a more evolved utilization of the dental hygienist`s skills, management consultants across the nation struggle to define the hygienist`s role. The concept of teamwork, "a process by a group of individuals to attain goals," was constructed and hygienists` roles were defined within this frame. However, Dental Practice & Finance noted, "Management professionals say many practices preach a team concept but worship under a more authoritarian regimen in day-to-day hygiene department operations." This incongruity stems directly from the management dichotomy between organized dentistry and more progressive management consultants.

Since consultants` salaries are paid by dentists, consultants often construct hygienists` job descriptions to appease dentists caught within the unimaginative ADA management philosophy. For example, some consultants continue to advocate that hygienists, in their down time, "assist the dental assistants by stocking supplies ... assist the other hygienists ... and, help with filing and telephoning."

Rather than recognizing hygienists as a professional entity, "teamwork" frequently advocates "blending" the hygienists with other support staff members. This "blending" continues to foster the deskilling of the dental hygiene profession. Such trends are counter-productive to the management consultants` desire to utilize hygienists for the profitability of the dental practice.

Instead of "blending" dental hygienists, progressive consultants realize office production is significantly increased when the hygienist`s "down-time" is used creatively to promote public relations, construct treatment plans, and follow-up on patient care and compliance.

In the 1990s, departmentalization replaced the traditional teamwork concept as emphasis on profitability increased. The "hygiene department" became the new buzzword in management seminars as consultants realized the complex interdependence of dentistry and dental hygiene. Realizing the dentists/employer could not manage both "departments," and wishing to motivate hygienists to be responsible for their production, management consultants elevated hygienists to managerial status. They constructed the "producer" paradigm, which is a process of:

- Job enlargement (allocation of a wider variety of tasks to make the job more challenging).

- Increasing job scope (additional tasks).

- Job enrichment (upgrading tasks to increase the potential for growth, achievement, responsibility, and recognition).

- Job depth (degree to which hygienists can plan and control the work involved in their jobs).

Consultants advise employers to hire "motivated, creative, forward thinkers" or "entrepreneurial-minded" hygienists. Hygienists` job descriptions now include new skills in management, leadership, motivation, supervision, and communication. An understanding of accounting, marketing, and business skills are also needed to manage the hygiene department with effectiveness (ability to select and achieve appropriate goals) and efficiency (making the best use of available resources in the process of achieving goals).

Big stick, little pay

As management consultants redefine the roles of dental hygienists in their "producer paradigm," the question of compensation arises. Ironically, while the management dichotomy between organized dentistry and management consultants widens, economic control of hygienists solidifies between the two groups. Consultants, paid by dentists/employers, often construct compensation packages for hygienists to appeal to dentists caught, once again, within the unimaginative ADA management philosophy. Consultants across the country advocate compensation of hygienists based on production.

Dental Practice & Finance stated, for example, "Management pros suggest hygienists should generally be paid no more than about one-third of what they produce." However, the definition of production varies dramatically. Production may include all procedures performed by the dental hygienist or only prophylaxis and soft-tissue procedures. X-rays, exams, impressions, bleaching, fluoride treatments, irrigation, etc., in any combination, may or may not be included in production figures. In addition, what is virtually universal is that a hygienist`s production-based compensation does not include any other contributions made to the overall production of the practice.

Dr. Levin uses a production model that "50 percent of the dentist`s production should come from hygiene operatories." Hygienists are typically not rewarded for this enormous contribution unless the practice offers a profit-sharing bonus incentive based on total office production.

In the 1996 RDH Salary and Benefits Survey, only 21 percent of hygienists received profit-sharing bonuses. Additionally, unlike other team members, the survey revealed 29 percent received no paid vacation, 37 percent no paid holidays, 60 percent no health insurance, 57 percent no sick leave, and 33 percent no pension plan. Compensation for dentists increases an average of 68 percent ($61,998) for dentists in the profession 15 to 19 years and only 8 percent ($2,917) for hygienists.

Further, when consultants recommend that hygienists perform "teamwork" duties assigned to other team members, compensation once again does not reflect the contribution to the practice. In the same manner, when a hygienist participates in any form of a staff meeting to improve office efficiency and productivity, unlike other team members paid hourly or by salary, compensation for production-based hygienists is not only denied, but prohibited due to attending the meeting. The hygienist is also not compensated for the redefined role of manager of the hygiene department.

Hygienists continue to be the employee with the greatest potential for profitability, but remain piecemeal workers. These production-based compensation models are riddled with inequitable protocol contrary to accepted theories of equity. They are rooted in the desire for organized dentistry`s demand for professional and economic control over dental hygienists that has existed since the "yellow dog" days.

Growing in the right direction

Management, according to the book Management by Kathren Bartol and David Martin, is the process of achieving organizational goals by engaging in the four major functions of planning, organizing, leading, and controlling. Often lacking in the dental practice are well-defined organizational goals, strategies (action plans to achieve long-term goals) and structures (linking tasks of employees in a formal pattern of interaction and coordination) needed to obtain organizational success.

The relationship between organizational structure and the ability of a business to produce results and to grow have been well documented. Peter Drucker, author of Managing for Results, wrote, "The right structure does not guarantee results. However, the wrong structure aborts results and smothers even the best directed effort."

The chosen structure by management consultants for the dental practice is that of functional departmentalization (the clustering of individuals into departments according to their function or area of specialization). Typically, only two departments exist - restorative and preventive-therapeutic. While the structure is appropriate, often the dental hygiene department consists of an isolated department of one. Inadequate vertical (between employer and hygienist) and horizontal (between staff and hygienist) coordination frequently exists.

Open lines of communication with increased decentralization (the delegation of power and authority) are vital to the success of the dental hygiene department. Often, the hygienist/manager is granted responsibility (the obligation to carry out duties and achieve goals) and mandated accountability (the requirement to provide satisfactory reasons for significant deviations from duties or expected results). Missing is the needed authority or ability to make decisions, carry out actions, and direct others.

To expand the hygienist`s role into management, the employer/dentist must willingly delegate both the responsibility and the authority necessary to achieve organizational goals. Providing hygienists with a strong management base will facilitate the hygienist`s acceptance of management tasks. Deskilling hygienists to technician status clearly contradicts upskilling hygienists to management status.

Organized dentistry must redirect its agenda to deskill dental hygienists if it desires profitability for its ADA members. Increased education, not preceptorship, for dental hygienists clearly becomes the solution.

Dental hygiene has been a school-based profession since 1913. The ADA defines entry level preparation for dental hygienists as a two-year professional course of study with 1,948 hours of curriculum, which includes 600 hours of clinical instruction. The American Dental Hygienists` Association is committed to the goal of baccalaureate entry level and advocates dental hygiene curricula reflect the changing practice of dental hygiene. Dental hygienists are uniquely qualified to provide preventive and therapeutic oral health care acquiring far greater curriculum clock hours to perform dental hygiene treatment than dentists.

Management of the hygiene department must be in the hands of the dental hygienist. Because dental hygiene is primarily a female profession of traditional social mores, course work in management, marketing, accounting, and business would assist the hygienist/manager in expanding into more entrepreneurial roles not associated with the traditional employees.

While profitability of the hygiene department influences compensation for hygienists, the opposite is also true. Compensation must be equitable for the hygienist for the success of the business.

Drucker writes: "If a business is to focus on economic performance it must ... reward men for proven capacity to contribute to the company`s goals and results, for demonstrated ability at the economic tasks, and for willingness to work for the business rather than only as specialists in one function or in one technical area."

Equity issues are important because individuals tend to compare compensation for their work to others. Equity theory argues that "we prefer situations of balance, or equity," according to Bartol and Martin. The authors state that equity exists when we perceive the ratio of our inputs and outcomes to be equal to the ratio of inputs and outcomes for a comparison other."

When we realize that the salary of the average dentist practicing 15 to 19 years increases 68%, compared to an 8% increase for hygienists within the same time frame, a hygienist`s motivation is deterred. Motivation also lags when there is a failure to compensate for additional responsibility and when the "deskilling" of their chosen profession is advocated.

Rather than maintain control over dental hygienists, leaders of organized dentistry can only benefit from assuming a proactive stance in redesigning the role of the dental hygienist as a co-provider of health care. Irene Woodall, nationally known dental hygiene leader, said it best in the November 1992 RDH, "We should work with our supporting, individual employers and colleagues in dentistry to notify organized dentistry that a quest for continued control is not necessary to provide quality care." Hygienists must become managers of their own profession if dentistry is to succeed.

Talisa Williamson, RDH, EF, has been a clinical hygienist for 24 years and is in private practice in Tucson, Ariz. She is enrolled in the College of St. Francis` degree completion program for hygienists and is past president of the Southern Arizona Dental Hygienists` Society.


- Melvin H. Carlson, DDS, "Self-Regulation Requires Your Immediate Attention," RDH 14 (May 1994): 6.

- ADHA Governmental Affairs Staff, "Issues Watch," Access (September-October 1994): 62.

- Access Extra Highlights, "ADA House Adopts Anti-Hygiene Resolutions," Access (November 1996): 16.

- Irene Woodall, Ph.D., "Let`s Take the Steps to Keep Our Basic Education Intact," RDH (November 1992): 6.

- Roger P. Levin, DDS, MBA, "Practice Productivity," Dental Economics (December 1995): 72.

- Dianne Monk-Arguelles, RDH and Janice Hurley, "How to Have Your Hygienist (And Staff) Be a Valuable Team Member," Dentistry Today (April 1996): 118.

- Bob Kehoe and Dave Wiethop, "Perfect Recall," Dental Practice & Finance, (July - August 1996): Supplement S4.

- Travis McFee, DDS, "Super Hygiene: Keep `em Coming Back, and a Few Other Critical Factors," The Profitable Dentist 85 (April 1995): 16.

- Mark Hartley, "Top Dollar, Low Benefits," RDH 16 (October 1996): 28.

- Mark Hartley, "Income Ceiling Doesn`t Motivate," RDH 16 (October 1996): 4.

- Kathryn M. Bartol and David C. Martin, Management (New York: McGraw-Hill, Inc., 1994), p. 6.

- Peter F. Drucker, Managing for Results, (New York: Harper & Row, Publishers, 1986), p. 216.

- Irene Woodall, Ph.D., "Let`s Take the Steps to Keep Our Basic Education Intact," RDH (November 1992): 7.