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Dynamite Diagnosis…Empowered Performance

Would you like to see thousands of dollars of restorative treatment scheduled from hygiene every day? Would you like to see this happen without having to enroll the treatment yourself? Of course you would. I am going to share with you some of the inside secrets I have learned from years as a hygienist in high-performance practices and years as a hygiene consultant helping practices grow. There are key steps to building a hygiene department that builds the entire practice, happily.


Unfortunately, we hygienists are sometimes stifled by what we can't do versus being inspired by what we can do. So when you say to your hygienist that you would love to see more restorative treatment coming out of hygiene, your hygienist might look at you and say, What part of hygienists can't diagnose do you not understand? If she doesn't say it, there is a good chance shes thinking it. What I have discovered is that when hygienists say, I can't diagnose, what they are really saying is, Show me a way through this barrier. Your hygienist may be resistant initially to your suggestions for more discussion about patients restorative needs. What the hygienist needs is a sense that you support his or her efforts and will empower him or her to deliver the best care and share in the practices success.

Illustration by Brian C. Green

Empowering your hygienists to maximize what they can do is powerful. When this shift occurs, hygienists are in a position to begin a whole new phase of their career, one filled with satisfaction and challenge. Don't forget that on the other side of breakdown is breakthrough! The same can be said for burnout. Many hygienists feel burnout, but shifting to a mindset of empowerment and opportunity can turn that burnout into a breakthrough. This breakthrough may be the biggest gift you can give your hygienists. It may result in a renewed sense of dedication and energy for their career. That new energy might be just what you need to turn hygiene from a loss-leader into a thriving source of growth for your practice.

This brings up the first of a series of steps in creating a powerful hygiene department that keeps your schedule full with comprehensive care.


Empower your hygienist by clearly stating that you are confident in his or her dental knowledge and skill. Then set out your expectations regarding co-diagnosis. It may sound something like this:

I respect you as a highly skilled dental professional. To support our patients effectively in staying healthy, I need your help. Patients trust you and your opinions. To work as a team, we must all have the same beliefs in what is best for our patients. I would like to spend time with you reviewing my personal treatment philosophy and why I make certain treatment recommendations. This will allow us to discuss areas in which we may have different opinions on treatment and resolve them. Although it is my job to make a final diagnosis and treatment plan for our patients, I do expect you to contribute to that diagnosis with thorough observation and patient education. I will give you all the tools you need to feel comfortable doing this, including specific training on how I diagnose and treatment plan a variety of dental conditions.

Creating an empowering environment sends a message to your hygienist that you respect his or her ability to contribute to patient and practice health. It is passing the baton for patient education and care. It is a relay to the finish line that is defined as patient health and career satisfaction. And guess what? It can take a lot of pressure off of your shoulders. How would you feel if you could see hygiene delivering thousands of dollars of treatment to your schedule every day? It's possible, and can result in increased revenues of more than $100,000 per year.

A very tangible way of encouraging this type of co-diagnosis with the entire team is to develop a team bonus. Giving back to those who support your efforts every day works wonders for morale and motivation. Find a system that creates a win-win situation for both you and your team, and implement it consistently.


Give your hygienists permission to observe restorative needs and begin educating patients on those conditions. This includes permission to participate in diagnosis, not only for periodontal disease but for restorative needs as well. Give permission to think in a broader sense when reviewing x-rays, intraoral photos, etc to think beyond calculus and gingival health and begin to think about what might have caused that abfraction on tooth No. 11; to think about what you might recommend to strengthen that broken second molar; to look at x-rays and analyze the root tips as well as the bone level.

I want to be very clear here: the doctor makes the final diagnosis and creates the final treatment plan. That being said, it is well within the parameters of the hygiene position to offer information to patients about what conditions he or she has observed in the patients mouth. This prepares your patients for your recommendations.

Every practice has a gold mine waiting in the charts in the form of treatment that has been planned but not scheduled. In cases where all treatment planning is completed at the new-patient visit, a perfect opportunity exists for hygienists to view the next phase of treatment and bring this to the patients attention without the specifics of diagnosis being an issue. For example, taking photos of the quadrant reminds the patient of his or her problem and opens lines of communication before the doctor even enters the room.


Clearly communicate your treatment philosophy. Often, dentists assume that since their team members work with them each day, the team is familiar with the dentists treatment philosophy. This may be true, but staff may sometimes need more information about specific aspects of treatment. Confusion about your treatment philosophy feeds inaction. When your hygienist is not totally confident with your treatment philosophy, she may be reluctant to reinforce recommended care to patients. Being unsure about how you would plan a restorative case is another key challenge that must be overcome before consistent enrollment takes place in hygiene.

Do you have one hygienist in your practice who is great at reinforcing treatment that you have diagnosed, while the other hygienist never mentions it? Chances are, the first hygienist has a clear understanding of your treatment philosophy and feels a benefit from practice success. The second hygienist may have been working with you just as long, but for some reason you have never had a heart-to-heart discussion about your treatment philosophy. This creates doubt and fear, causing a shutdown in the area of co-diagnosis.

If your goal is to increase the amount of restorative treatment enrolled and scheduled from hygiene, you must first work through the most common barriers for achieving this: confusion between the dentist and hygienist regarding treatment philosophy.

Case review may be the most important tool in increasing co-diagnosis in hygiene. First and foremost, all the dentists in your practice must be on the same page. If you go through the case review process together before including the staff, it will create a united front for the team. I had the opportunity to coach a very large practice through this process. In my initial observation, the hygienists reported that if all the doctors examined the same patient, each would create a very different treatment plan. While each dentist has his or her own preferences and beliefs, in a large practice consistency is critical. The confusion resulted in little effort on the hygienists part to support the dentists when talking with patients about their treatment needs. Even when a treatment plan existed that was created by Dr. A, the hygienists never knew if Dr. B would change the treatment during his exam. This resulted in a lot of extra work for the doctors, confusion for the staff, and mixed messages for the patients.

The first step was getting all the doctors to create a common working treatment philosophy, with the owners setting the tone of the practice. Once that task was completed, another case review meeting was scheduled with the hygiene team. Restorative enrollment in hygiene rose dramatically, and the doctor/hygiene exams were shorter and more efficient.

During the case review you will review several patient charts, discussing the treatment plan and what brought you to create that plan. You may discuss what cues you to recommend a crown versus an onlay versus a composite filling. Do you use certain criteria to determine the best treatment? Share those with your team. Start simple by discussing the virtues of a filling versus onlay, onlay versus crown, perio, etc. This will increase the level of confidence the team has in your skills and philosophy, which in turn results in more treatment enrollment because the staff has no question about your commitment to recommending the best care for every patient.

In addition, when staff members have an idea of what treatment you will recommend for a certain condition, they can begin to educate patients around that procedure before you ever walk in the door.

The case review session is a time of open learning. It is a safe environment where there are no dumb questions or wrong answers, only opportunities to learn. When reviewing the patient charts, have on hand the x-rays, any intraoral photos, periodontal charting, and the current treatment plan. This will support your diagnosis and explanation of the plan. Go through each step of the evaluation that brings you to a conclusion of treatment. Share with the team the long-term results of a crown rather than a filling, for instance. How much tooth will be preserved? How much time and money will the patient save by having comprehensive care versus patch-and-fill dentistry? Share this with the entire team.


These case review guidelines are designed to facilitate learning between the dentist and hygiene team. The objective of case review time is to expand on the hygienists technical knowledge and improve consistency in treatment recommendations between the dentist and hygienist. Initially, this should consist of 2, 1-hour sessions in which the doctors and hygienists review the recommended treatment of a few chosen cases.

Doctors Role

Give hygienists permission to think more like a dentist when viewing diagnostic information.

(1) Instill confidence in the hygienists intelligence and technical knowledge.

(2) Utilize 1 to 2 cases with complete x-rays and perio charts. A complete treatment plan, intraoral photos, and clinical notes are very helpful.

(3) Explain what you saw during examination and give specific reasons for the treatment planned.

(4) Give the team guidelines for ideal examination according to your preferences.

Exam Guidelines From Doctor to Team

(1) These are the important items to look for when viewing x-rays (dentists, choose your top 3): alveolar bone quality, interproximal tooth structure, ratio of tooth versus amalgam, number of millimeters between pulp and restoration, periapical lesions, etc.

(2) These are the important items to look for during an intraoral exam (dentists, choose your top 3): tissue health, broken teeth, fractures, fistula, suspicious soft-tissue lesions, darkness around restorations, quality of restorative margins, etc.

(3) If x-rays look like ____, then pre-frame the patient for treatment.

(4) If intraoral photos look like ____, then pre-frame the patient for treatment.

Hygienists Role

(1) Be open to learning and asking questions.

(2) Receive the challenge to think more like a dentist as a huge opportunity for growth and to increase the level of patient care and education.

(3) Ask yourself the following:

• If I were an endodontist/periodontist/prosthodontist, what would I see?

• If fractures/cavities/ wear patterns exist, which teeth have them?

• If I see a problem on the right side, is it also present on the left side?

Review Each Case

Review each treatment plan. Ask yourself the following:

• Are any teeth questionable as to what type of restoration is best?

• Is more than one treatment route available to this patient?

• What is the most conservative treatment possible?

• What external factors (health, habits) could affect the success of the treatment plan?

Have the team develop a treatment plan:

• Hygienists create a treatment plan with the available information.

• Doctor reviews their mock treatment plan and gives feedback.

Going through such an exercise can help you in developing strong team support for your treatment philosophy. Including assistants and administrative staff in this meeting can be valuable. With every team member giving patients the same message, success is a given.


Following and implementing the steps outlined in this article will result in a noticeable increase in restorative treatment enrolled in hygiene. Related topics that may be discussed in future articles are taking diagnostic technology to the next level and monitoring your progress to see what a difference this ap-proach can make in practice profitability.

Ms. Wall is a speaker, writer, and hygiene consultant who coaches teams across the country to deliver outstanding care in a highly productive environment. For more tips and articles to help Boost Hygiene, visit inspiredhygiene.com for a free subscription to Ms. Wall's monthly e-zine. If you'd like help in boosting hygiene co-diagnosis, Ms. Wall can be reached at (877) 237-7230 or This email address is being protected from spambots. You need JavaScript enabled to view it..

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