The Hygiene Department How to Turn a Loser Into a Winner

The majority of practices I have consulted with over the last 20 years typically have had hygiene departments that were, at best, marginal performers, and at worst, outright losers both financially and professionally. Many factors (or excuses) lead to this sad situation. I’ve heard almost as many as there are doctors explaining why hygiene is such a poor performer. Among some of the most common are the following:

(1) It is not possible to charge an adequate fee for hygiene to cover the cost of the service.
(2) Hygiene is not expected to be a profit center, but rather a “loss leader,” ie, something to be tolerated.
(3) Hygienists are overpaid and underworked “prima donnas” (see No. 1 above).
(4) Hygiene continually clogs up the schedule and causes overruns in the doctor’s schedule, which keeps the doctor from attending to more “productive” procedures.
(5) Hygienists do not get along with other staff members and believe they are a “cut above” the rest of the staff (see No. 3 above).

I personally believe the above explanations are mostly hogwash! Some of the most intelligent, motivated, and genuinely concerned professionals I have dealt with within the dental profession have been hygienists. Properly planned and orchestrated, the hygiene department cannot only be productive, but it can serve as the very heart of a patient-centered, professionally satisfying, and financially rewarding dental practice.
Properly orchestrated, the hygiene department can be a virtual wellspring of needed treatment and a major source of income for the practice. Many patients may have had comprehensive treatment plans presented on initial visits, but for whatever reason (usually money) did not complete or start treatment. Not surprisingly, treatment needed 10 or 15 years ago will no doubt be even more necessary now. More often than not, these patients’ conditions have noticeably deteriorated, some to the point of crisis. These patients need treatment now! There’s no longer time to wait and see.

(1) Upgrade your perio program to include comprehensive periodontal therapy. It sounds simple, but I’ve seen numerous practices where little or no periodontal treatment is available, ie, practices that are “prophy factories.”
(2) Provide patients with a comprehensive exam at least annually. A lot can happen in a year! It is truly incredible that in many if not most practices, the only comprehensive exam patients ever have is their first one. From then on, it’s 2 bite-wings, flash a mirror in the mouth, and say “everything looks (a) okay, (b) fine, or (c) great. See you in 6 months, one year, etc.” Unfortunately, in many offices, hygiene really has become nothing more than “supervised neglect” for patients, who in many instances need extensive treatment. (This could also be a legal problem.)
The fact is, hygiene should be the stable base of the practice. The recall patients that you see year after year are very important and become very special to both doctor and staff. Well cared for, they become long-term missionaries for your practice. Consider the following:
(1) It is important to continue to make these loyal patients feel welcome and happy. They will continue to refer new patients to your practice; they are proven missionaries.
(2) Further, 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.
(3) No doubt many of your patients have incomplete treatment plans or stabilizing treatment plans. This means hygiene is a repository for future dental treatment for patients who already have been informed that they need it.
(4) The reality is that hygiene can, and should be, a profit center. It provides bread and butter income—estimated to be at least 20% of total practice income. In addition, the income potential from those previous incomplete or stabilizing treatment plans can be substantial (the ubiquitous million-dollar file cabinet).

The first step in building a first-class, hygiene-driven, continuing care/periodontal therapy program is to make the decision philosophically to do so. The longer a practice has been giving maintenance care (ie, “drill, fill, and bill”) with little or no attention paid to comprehensive treatment or treatment planning, the more difficult it is to “get religion” and switch over to complete treatment and comprehensive care. A practice that has not had this philosophical approach for decades (I’ve seen many!) is going to have to be very tactful and careful in its approach. I would suggest the following scenario:
(1) Start with comprehensive exams on all new patients. This will be more comfortable than telling patients who have been long-term patients that, “all of a sudden,” they need periodontal therapy, crowns, bridges, etc. It will also prepare you for introducing comprehensive recall exams or appointments.
(2) Begin as soon as you feel comfortable with your recall patients. You may have to “walk a little gingerly” at first, especially with long-term care patients in your practice. You obviously want to be careful to not implicate you or your staff.

(1) Normal adult hygiene appointments are 1 hour; 20 to 30 minutes is usually not enough time to do the oral hygiene instructions and an adequate prophy.
Why this much time? In order to be able to discuss dental needs with the patient. Remember, in the majority of practices, the only thorough exam a patient usually has is the new-patient exam. From that time forward, it is year after year of 60-second hygiene checks. Periodontal 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 dental health and dental needs.
Remind patients of treatment previously recommended that has not been completed. Simply reminding them at the hygiene appointment that it should be done now 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. The hygienist might say: “Mrs. Brown, that treatment Dr. Jones suggested to you previously really needs to be addressed now. The condition (whatever it is) continues to deteriorate.”
The hygiene appointment also is a good time to suggest elective treatment such as bleaching and cosmetics to the patient. He or she may have been thinking about it, and sometimes a prompt by the hygienist is all that is needed. 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 diseased 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 or her sign a release.
(2) Pediatric prophies. Because assistants can do most of the appointment, ie, bite-wings, recharting, OHI, etc, little time is required of the hygienist for a prophy and polishing. Ten minutes of the hygienist’s time is normally adequate. (Some practices do not schedule hygiene time for pediatric prophies, they just work them into the schedule.)
(3) Nonsurgical periodontal therapy. A nonsurgical periodontal therapy (NSP) or program for managing soft tissue is essential in every practice. Effectively instituted, such a program can significantly elevate hygiene income and represent 50% of your hygiene revenue. An important point to remember is this: be consistent with patients and hygienists in the parameters that you have established to place a patient in the NSP program. Stick to your guidelines and don’t vary them.
(4) Areas of concern. Prob-lem areas, such as pockets, open margins, missing teeth, etc, need to be rechecked periodically. This also serves as a reason, in addition to the prophy, for the patient to return for recall. Once again, 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 where they find out that they are in anything but great shape (again, a legal problem). Always inform patients of the condition of their mouths, even when they don’t seem to want to know it.


If you have labeled your hygiene program a “loser” and treat it as such, you are truly missing the benefits of one of the most rewarding parts of your practice, both professionally and financially. Making your hygiene department an integral part of your practice will not only dramatically increase income, but will provide truly health-oriented, full-service dentistry to your patients.

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 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 more than 35 years. He co-authored and wrote the Complete Practice Operating System 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 more than 15 years in 48 states, Washington, DC, Puerto Rico, Canada, and Australia. He can be contacted at (502) 394-0150 or (888) 809-2138. For more information about Dental SolutionsNOW, visit