Making Hygiene Profitable

One growing trend in dentistry involves the design of hygiene departments and their workflows to achieve profitability. Practices are creating environments where both the dentist and hygienist work together to provide the highest level of care to the patient and turn an impressive profit while doing so. But how do these business models work?

"Traditionally, the dental hygienist cleans teeth, the dentist checks whether the hygienist did it adequately, and in more advanced offices, the hygienist picks up some of the patient's dental needs and relays them to the dentist," says Timothy G. Donley, DDS, MSD, a periodontist from Bowling Green, Kentucky. Unfortunately, that model merely scratches the surface in terms of maximizing the potential of the dental hygienist.

"Regular maintenance visits present an unbelievable opportunity to educate, motivate, and turn the patient into a supporter and believer of your practice as well as to accomplish a whole lot for the patient over time," Donley continues. "It requires multiple visits, and the least important part is cleaning the teeth."

Although hygiene "can be a profit center, it shouldn't become one in lieu of performing excellent high-care hygiene—well managed, well-run, thoughtful, conscientious, and without overtreatment," says Robert G. Ritter, DMD, a restorative dentist from Jupiter, Florida. "There are some practices that will let the hygienist see every patient for an hour, others have 40-minute appointments, and some practices employ a hygiene assistant for the hygienist so that the hygienist can see more patients in a day."

Katrina M. Sanders, RDH, BSDH, MEd, RF, a consultant for Sanders Board Preparatory in Phoenix, Arizona, says that the economic crash of 2008 demonstrated the importance of hygiene departments as a possible profit center. "During the Great Recession, people watched their 401(k) plans and savings accounts get emptied, and many lost jobs," she explains. "Dentistry, as a whole, recognized that patients were not likely going to be coming in for adult orthodontics with clear aligners, full-mouth rehabilitations, or veneers. However, dentists identified that their profit margins could be supplemented by hygienists because patients were still coming in for preventive and routine visits covered by third-party payers. Consultants got smart and recognized that there had to be a way for us to be able to build on that."

An expanded hygiene role, Sanders notes, should never be about "adding on and selling treatment but rather looking at your patients as if they're members of your family and treating them based on the risk or presence of disease in their mouths."

Opinions vary about what a dental practice's hygiene profit margin should be; however, the ultimate number achievable will be informed by the individual characteristics of each practice, including size, the number of hygienists employed, and the model of compensation offered.

Sally McKenzie, who is the chief executive officer of McKenzie Management, a dental management solutions company in Tarpon Springs, Florida, has a simple "one-third" formula. "The industry standard is 33%," McKenzie says. "One-third goes to the hygienist, one-third goes to the overhead of the department, and one-third goes back to the business."

For Ritter, the way to figure out the profit margin is to first figure out what your overhead is at the practice. "If you're at 65% overhead, you have to be able to make a profit of at least 35% in hygiene. Otherwise, you're losing money seeing hygiene patients," he says. "It works better in a fee-for-service environment where you're getting the full fee. This can still be done in a preferred provider organization (PPO) environment, though; 30% of our patients are part of a PPO."

In terms of compensation, McKenzie states that "there are three main ways to pay a hygienist: guaranteed base salary, commission, or guaranteed base salary plus commission." She finds that most dentists pay a guaranteed base salary, but a problem with this model is that cancellations and no-shows result in a situation where "the hygienist is still getting paid but not producing." McKenzie notes that if she owned a dental practice, she would pay a base salary plus commission.

Donley, who also follows the one-third formula, is a strong believer that there has to be incentive. "That's what drives everybody," he says. "It has to be commission."

At Ritter's practice, hygienists are given a flat salary, and there are two different bonus structures in place. "For the first bonus, once we determine what hygienists produce in a day, for anything over that number, they get 10%. So, if the hygienists typically produce $1,000 per day, and on a given day, they produce $1,300, they get 10% of the $300," he says. "For the second bonus, for any treatment that results from a hygienist's proper, thorough, and ethical diagnosis, the hygienist gets 10%. So, if the hygienist finds the patient needs two crowns at $1,500 per crown, the hygienist gets 10% of that. With their base pay and the two bonus structures, they have the potential to make much more than hygienists who are only receiving a straight salary."

Joshua A. Bresler, DMD, a pediatric dentist in Philadelphia, Pennsylvania, notes that it is often more difficult to make hygiene a profit center in a pediatric dentistry practice. "Most 1- or 2-year-old children don't require a lot of deep scaling or extensive cleaning, so those appointments are pretty quick from a hygiene standpoint," he explains. "You don't have to ‘sell' treatment plans in pediatric dentistry. If there's a problem, you fix it. Insurance reimbursements for pediatric hygiene procedures tend to be less than for adults, but because the appointments often don't take as long, there is potential to see a higher number of patients."

Therefore, every staff member in Bresler's eight-location group practice receives a straight salary. "One child might need a couple of sealants and one might need two crowns, yet the staff who are working on the less reimbursable procedure might work 10 times harder," he says.

In hygiene departments that are modeled for profit, the hygienists are expected to provide more services, but which services they provide will largely be determined by their level of expertise and the needs of the practice and its patients. McKenzie believes that the hygienist should provide a maximum of "whatever services are legal in the state that he or she has a license."

At Ritter's practice, hygienists are taking necessary radiographs and more. "Our hygienists can anesthetize patients and do quadrants of scaling and root planing, provide fluoride treatments, perform a cursory oral cancer exam, and discuss caries control and what patients can be doing to optimize their at-home care," he says. "They can also recommend home care products like special fluoridated toothpastes, mouth rinses, and electric toothbrushes that may be sold by the practice."

"We have to look at the hygiene visit as a wellness visit," Donley says. "Take advantage of the opportunity to screen and manage the factors that put patients at risk for oral and systemic disease. My production has improved dramatically in my hygiene department because of wellness evaluation." Donley adds that patients leave knowing what their body mass indices are as well as other useful information about their health. "We assess their weight category and their blood sugar levels, we get information on vitamin D levels, we assess their stress and coping mechanisms, we offer nutritional counseling, and we screen them for sleep apnea. And, importantly, we don't extend the appointment. It's a lot, but it can be done efficiently," he says.

Sanders says hygienists like to have more opportunities to support their patients by screening for vital sign issues, possible oral-systemic disease, medical conditions, and airway obstructions as well as to further educate patients about nutrition, tobacco cessation, and oral hygiene. "As hygienists, we have so many additional adjunctive tools in our tool belts to really help support our patients," she adds. "Those tools range from oral cancer screening detection devices and point of service HbA1c or blood glucose screening devices to fluoride varnishes, silver diamine fluoride, local antibiotics, laser treatment, desensitizers, and in-office products that we can send our patients home with to support their oral health."

Bresler sees the relationship between the dentist, hygienist, patient, and parent as a partnership with the hygienist as the frontline caregiver. "They're our first set of eyes and ears, they see what the problems are, and they're great teachers of lifelong oral health habits for these patients and their parents," he says.

Donley believes that dentistry often focuses on the problem and the procedure, not the overall outcome. "We have to educate patients that we're trying to improve their overall level of wellness and inform them of what is necessary to get there, and I think everyone has to play a role in that," he says. "I think that would redefine dentistry."

McKenzie strongly emphasizes that dealing with these issues is not the job of the hygienist. "Hygienists should not be filling their own schedules," she says. "They are producers—the same as the dentists. Appointing patients for hygiene is a business operational system and should be performed by a business employee, not multiple people, which can result in a lack of accountability. It should be the responsibility of a business employee to keep the hygienist producing."

Donley employs a team approach and strives to add value. "If the team is providing wellness services beyond teeth cleaning, it gives people a reason to want to come in and keeps the schedule full," he notes. "We kind of take the ‘oil change approach.' When you get your vehicle's oil changed, they give you that long checklist of everything that they did in order to show you the value. We do the same thing, and patients are more likely to keep their appointments if they see the value."

Ritter believes that hygiene departments designed for profit have a bearing on appointments being filled. "It trickles down to the other people in the office who also make a bonus from keeping the hygiene schedule full," he explains. "Each day that the hygienists have full schedules and meet their goals, the hygiene coordinator makes a bonus as well."

The national average for no-shows "is probably more than 20%," Ritter says.

Concerning no-shows, McKenzie notes that they "teach that there should be no more than one-half of an opening per day. It's all about the numbers."

"Everyone wants to keep that schedule full," Bresler says. "We're pretty well booked out for hygiene and for operative, but we try to keep some spots open to appoint new patients for hygiene."

Modeling hygiene for profitability isn't just about adding more people. "You can have a practice that sees patients every 30 minutes, but the negative is that only minimal patient education regarding interceptive periodontal treatment is being given," McKenzie says. "The industry standard is that 33% of the hygiene production should be in interceptive periodontal treatment. We normally see way below that, so hygiene departments are missing out on this opportunity."

"Allocate the available time better," Donley notes. "A lot of the information that we need—height, weight, tobacco-use status, and feedback as to stress and dietary tendencies—can be collected from a health history without any chairtime."

"Burnout only occurs when it's a haphazard schedule and people are stressed," Ritter explains. "You can have more problems when you're not full than when you're full because you're not practicing at peak efficiency. If the hygienist has a blowout on the schedule, he or she can try to find patients in whatever practice software you use." Ritter notes that his practice has two software systems that help. One allows his office to contact potential patients who are waiting for an appointment when a spot opens up, and another allows the office to analyze the productivity of hygienists, numbers of cancellations and no-shows, and the percentage of reappointments. "We monitor what the hygienists produce every single day," he adds. "After patients finish their hygiene appointments, 90% of them should have reappointed."

Sanders has concerns about the well-being of hygienists. She notes that American Dental Association research has shown that "upwards of 87% to 90% of patients across the United States are being managed with a prophylaxis in the hygiene chair, so it's no wonder that hygienists are short on time, experience musculoskeletal problems, and have hands that are in pain."

Bresler feels that there is less burnout in a pediatric practice. "Sometimes, it gets crazy, but it's also festive and fun. There are movies being shown, and we play with the kids," he says. "We tend to see less burnout in pediatric practices when the staff is scheduled appropriately, but on days when some auxiliaries have called out sick and there is not enough support staff, it is rough on everybody."

When a hygiene department is designed for profitability, the profit realized by the practice is an end in and of itself, but there are other benefits of adopting such a model that are conferred to dentists, hygienists, and patients.

One benefit of hygiene profitability is that "it allows us to add newer technology to the practice," Ritter says. "There is no better investment than one in yourself."

"A pain point for a lot of hygienists is having inadequate equipment," Sanders explains. "Doctors and practice owners need to have profitability in the hygiene department in order to obtain or acquire the equipment that hygienists need to do their jobs."

Another benefit of expanding hygiene programs for profit is in patient retention. "Let's face it. Most of the time, the patient has a better relationship with the hygienist than with the dentist because he or she ends up seeing the hygienist more often than the dentist," Ritter notes. "So having the hygienist do even more strengthens the relationship between the patient, the hygienist, and the practice and enhances connectivity, goodwill, trust, and value."

According to Sanders, "from the dentist/practice owner standpoint, productivity is huge when considering implementing or building out hygiene departments that are designed for profit. From the perspective of the dental hygienist, we always feel like we don't have enough time with our patients. Being able to have greater amounts of time with our patients in an expanded hygiene role can give us the opportunity to be better clinicians."

The hygienist has the capability to do so much more than clean teeth, affirms Donley. "If the hygienists are fulfilling their potential in assisting patients in managing their overall health, the greatest benefit to them is in terms of job satisfaction," he says. For the dentist, if his or her hygiene department is helping patients achieve "a higher level of overall wellness, then the dentistry is done in a healthy mouth, and it becomes a lot easier and more predictable."

"The more the hygienists do, the more they are compensated for it," Ritter says.

For the patient, the benefit is simply "getting the service that they should," according to McKenzie.

Donley goes further, emphasizing that "a patient becomes a believer that coming to our office has made him or her better."

When hygienists are "more cognizant of our patients' disease and when we can identify that disease in its earliest stages and treat it, we not only have the positive outcome of being able to either reverse gingivitis and/or arrest periodontitis before it continues to progress and become irreversible, but also have the opportunity to step into the upper echelons of dental providers and truly support our patients in excellence."

"If it's done wisely and equitably for all of the parties, who wins?" Ritter asks. "The dentist wins because the practice is more profitable and, potentially, can see more patients. The hygienist wins by making more income. And the patients win because we monitor them more closely than ever and prevent them from slipping through the cracks like before."

"At the end of the day, this is the good work that we are called and compelled to do as clinicians, and it permits us to fulfill our professional responsibility to the community and to society," Sanders says.

When hygiene departments are designed to achieve profitability with the hygienists taking on additional responsibilities in optimized workflows, they not only become profit centers for the practice owners but also have the potential to reduce the number of cancelled appointments and no-shows, increase the job satisfaction of hygienists, and improve the overall health of the practice's patients. Profitability in hygiene should be pursued in a manner that seeks to enhance the quality and efficacy of the care delivered to patients without merely seeking to increase the quantity of patients appointed because this can overburden hygienists and lead to burnout—not a successful hygiene program. If you'd like to increase your profit margin or feel that your operation may be suffering from inefficacy, take a look at your hygiene department from scheduling to workflow and design it to achieve profitability. It will be a win-win situation for you as well as your hygienists, office staff, and patients.