The Hygiene Department From the Doctor’s Perspective

During over 35 years of practicing dentistry and consulting with dentists and dental practices, it has been my studied observation that one of the keys to complete treatment plans and a successful reconstructive and/or aesthetic dental practice is an outstanding hygiene department, with emphasis on nonsurgical periodontal therapy (soft tissue management) and a continuing care program. This conclusion may seem a bit incongruous, but it is based on simple human psychology—you must value something highly before you will take action to preserve it or enhance it.

Over the years, I have witnessed many dentists presenting extensive treatment plans to patients (most of whom also had extensive periodontal problems) only to have a large majority rejected. All the bells, whistles, intraoral video cameras, models, photos, etc, were not enough to “sell” these patients high-end dentistry. Why? Because they had never learned to value or understand the importance of maintaining their oral health. Why, then, would they be willing to pay thousands of dollars to restore something that has little perceived value to them? The reality is, without enough information and understanding of the importance of oral health to their overall health, a decision to do nothing makes eminently more sense, and is probably the right decision for them. Why replace missing teeth (place crowns or veneers) if they are all going to eventually be lost anyway? Why not a nice- looking denture?

The obvious solution to this continuing dilemma is to adopt a thorough and all-encompassing periodontal therapy program in your practice that demonstrates to the patient that: (1) you are interested in their oral health, (2) oral health is critical to total health, and (3) their teeth and gums are worth whatever investment it takes to maintain them. The periodontal therapy and continuing care programs then become an ongoing and reinforcing continuing education program for the patient.

The only way to effect this outcome is with a “top drawer” hygiene, continuing care, and nonsurgical periodontal therapy/soft tissue management (STM) program. By having an in-depth hygiene/perio program, patients become aware of the problems in their mouths, and learn that with treatment and home care they can maintain their teeth and oral health for a lifetime. Instead of futility, they now have hope. As they see continued improvement in the condition of their mouths, both immediately and sustained over time, they become “believers.” This new attitude now becomes a paradigm shift to oral health being something of high value and worth whatever it takes to maintain it for a lifetime, instead of an uninformed, “who cares, I’d rather buy jet skis” attitude. The difference this approach will make in your practice is remarkable.

The hygiene department, coupled with a nonsurgical periodontal therapy/STM program and continuing care program, will have a tremendous impact on increased treatment acceptance of comprehensive dentistry and aesthetic dentistry. With a properly orchestrated protocol, those patients who did not accept and follow through with treatment in the past can now be motivated to do so by the hygienist at the recall appointment. This ability to motivate patients is the greatest value the hygienist contributes to the office. Hence, the communication skills of the hygienist are of paramount importance.

Hygiene is the stable base of the practice. The recall patients that you see year after year are very important, not only as ongoing referral sources that are invaluable to the practice, but because many who did not complete treatment presented at an earlier time make a wonderful source of treatment planned but not completed dentistry. Further, these patients truly become friends and are dear to both you and your staff. The following points should be made regarding recall patients and the role of the hygiene department:

(1) It is important to continue to make these patients feel welcome and happy. Most will continue to refer new patients to your practice; they are proven missionaries.

(2) In order for the practice to grow and thrive, it is imperative that you maintain a stable patient base; otherwise you are simply replacing lost patients. Practices without a solid hygiene program spend a lot of time and money on marketing to attract new patients.

(3) Many patients will have incomplete treatment plans or stabilizing treatment plans. This means hygiene is a repository for future dental treatment. Continuing care and hygiene can have a tremendous impact on increasing treatment acceptance. Again, those patients who did not accept and follow through with treatment in the past can now be motivated to do so by the hygienist at the recall appointment. This is the greatest value the hygienist contributes to the office; hence, the communication skills of the hygienist are very important.

(4) The hygienist should always have enough time with the patient to not only perform the prophylaxis, but also to build a relationship with the patient. There should be enough time during the appointment to talk with the patient about their treatment needs and wants and to review oral hygiene instructions, if needed.

(5) Hygiene can and should be a profit center; it provides “bread and butter” income, estimated to be 20% or more of total practice income. In addition, the income potential from previous incomplete or stabilizing treatment plans can be substantial (the ubiquitous “million-dollar file cabinet”).

The hygiene “flex check” exam can be performed by the doctor anytime during the last 15 to 30 minutes of the recall appointment. There is no reason to wait until the very end of the appointment; the flex check prevents wasting valuable patient, hygienist, and doctor time. The exam by the doctor is very thorough, and is carefully orchestrated with the hygienist. The optimal result is for the patient to feel as if they have just received the most thorough exam possible. This exam is not a cursory, 60-second observation with the doctor jumping up and saying, “Everything looks fine,” especially when everything does not look fine, ie, 4- to 6-mm pockets, bleeding, and recession. These symptoms are indicative of serious problems, and this type of “quicky” exam can undo everything the hygienist has spent nearly an hour doing.

When the doctor arrives in the operatory, the hygienist’s notes should already be entered into the chart, the x-rays should be mounted and placed on the view box, and a clean mirror, explorer, and periodontal probe should be in place on the tray. The hygienist should use the patient’s name and verbalize the health history update to the doctor, and any concerns that the patient has. Starting with tooth No.1, the hygienist verbalizes the condition of the mouth and any areas of concern, talking over the patient in a manner similar to the new patient exam. Simultaneously, the doctor examines the patient’s mouth, and together, doctor and hygienist verbalize, including the soft tissue exam and oral cancer check, in dental terms so the patient can hear it all. The hygienist will then proceed forward (similar to the new patient exam) by asking the doctor what treatment he or she recommends. The doctor explains in dental terms to the hygienist all of the treatment needs, and the hygienist records this in the chart. The doctor then explains to the patient that the hygienist is going to review his or her treatment needs with them, but if there are any questions or concerns, the doctor will be glad to discuss them again. At this point, the doctor can dismiss him/herself, and the hygienist resumes the treatment presentation, using the appropriate visual aids. 

The exam, treatment presentation, and financial presentation are all handled identically to the comprehensive new patient exam process. If the treatment needs are the same ones presented at a previous appointment, then the hygienist may need to determine why the patient did not follow through with the treatment at that time. Listening skills are very important in this instance. Query the patient as to why he or she did not have the suggested treatment, and proceed from there.

Normal adult hygiene appointments are 1 hour (20 to 30 minutes is hardly enough time to provide oral hygiene instructions and an adequate prophy). Why this much time? In order to be able to fully discuss dental needs with the patient. Unfortunately, in the majority of practices that I have worked with over the years, the only thorough exam a patient usually has is the new patient exam. From that time forward it is often year after year of 60-second hygiene checks. Periodontal problems and other conditions can and do deteriorate dramatically over the years. You need to allow your hygienist(s) enough time to tell patients about their ongoing dental health needs.

Simply reminding the patients at the hygiene appointment that treatment previously recommended but not completed should now be done is usually enough for them to take the steps to complete it. But the doctor or hygienist has to take the initiative. Chances are excellent that you have a lot of incomplete treatment sitting in the files just waiting to be finished, but someone has to suggest it. Usually conditions have deteriorated, and if the hygienist tells the patient so, it starts to become much more compelling for the patient to take action.

It is important to suggest elective treatment such as bleaching, cosmetics, etc, but don’t belabor it. If the patient doesn’t want it done, note it in the file. However, always remind patients about periodontal problems whether they want to hear it or not, remembering that you want to keep them in the practice. You are legally responsible to tell patients of disease states (many lawsuits have been filed because neither the doctor nor the hygienist informed the patient of serious periodontal problems). It is then up to the patient to decide whether to proceed with treatment. Sometimes it may even be necessary to state in writing that a patient has refused necessary treatment, and have him sign a release.

A STM program is essential in every practice. If you have not established a nonsurgical periodontal therapy/STM program in your practice, you should take the steps necessary to implement one as soon as possible. Effectively instituted, the STM program can significantly boost your hygiene income. An important point to remember: Be consistent with patients and hygienists in the parameters you have established to place a patient in the STM program. Stick to your guidelines and don’t vary them.

Areas of concern such as pockets, open margins, missing teeth, etc, need to be re-checked periodically. This also constitutes an excellent reason, in addition to the prophy, for the patient to return for recall. Do not say to patients, “you’re in great shape,” if they have 6-mm pockets or open margins. This does not constitute great shape. If they hear “great shape” then they’ll start to believe it and stop coming back, or worse, go to another office when they find out that they are in anything but great shape (a possible legal problem). Always inform the patient of the condition of their mouth, even when they don’t seem to want to know it.

Your continuing care program also helps set the stage for complete treatment plans and even cosmetic dentistry. If the practice over time has shown great concern for the patient’s periodontal health and made patients aware of proper home care, a strong bond has been forged between the patient and both the doctor and the hygienist. This, of course, makes presenting needed treatment far easier because the patient trusts the hygienist and the doctor to guide them to the optimum solutions for their oral health and restorative needs. This bond extends further to aesthetic dentistry, especially since the patient has attained optimum oral health and now wants to address aesthetic considerations. In many instances, patients are concerned about spending substantial amounts of money on an elective procedure if there is a good chance down the road they will end up losing their teeth. When they feel comfortable that they will keep their teeth long term, they are far more likely to embrace rehabilitative or cosmetic dentistry.

Hygiene is a stand-alone, productive part of the practice. It is not primarily a convenience to the doctor so he or she can do other more “productive” things (although that is an important benefit), and it is not a “loss leader” as some would categorize it. It should be a productive, money-making part of your practice. Hygiene production and treatment presented at the hygiene appointment is an extremely important and valuable adjunct to the practice, with the goal of offering complete care to its patients on an ongoing basis.

Dr. Havill is owner and president of Dental SolutionsNOW (DSN), a company dedicated to providing dentists with timely information to increase practice growth, organization, and income through its widely acclaimed Complete Practice Operating System. Dr. Havill is a dental practice management consultant in Louisville, Ky, and has been involved in all areas of dentistry, including general practice, consulting, and practice systems development for over 35 years. Dr. Havill coauthored the Complete Practice Operating System, an in-office practice management system (formerly Dentistry 2000), that—together with the DSN manuals and office forms—has been successfully implemented in dental practices for over 15 years in 48 states, Washington DC, Puerto Rico, Canada, and Australia. Dr. Havill can be contacted at (502) 394-0150 or (888) 809-2138. For additional information about Dental SolutionsNOW, visit


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