Every progressive and profitable dental hygiene department has these five characteristics in common: solid clinical protocols, statistics and benchmarks, appropriate service mix, confident communication skills and “A-Team” hygienists. I will discuss all five in this article.
Solid clinical protocols
Having solid evidence-based clinical protocols for each hygiene procedure is the cornerstone of a progressive and profitable hygiene department. It's essential that these protocols are agreed upon and understood by every team member. The doctor(s), as well as the hygiene team, must recognize disease in its earliest stages and diagnose active infection with the same parameters. AAP case typing should be applied to each perio patient and treatment planning for treating periodontal disease follows agreed upon prescribed protocols and parameters.
See an example of what your clinical protocols for a preventive prophy might include below. As you read these protocols, keep in mind the ADA 1110 descriptor states following: Removal of plaque, calculus and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors.
Solid clinical protocol for 1110
- Health history and risk factor assessment, every visit
- Blood pressure screening, every visit
- Current radiographs showing alveolar bone, when necessary
- Head and neck exam/oral cancer screening, including the use of visual enhancement technology if available, once per year
- Restorative evaluation and discussion, including pending and new treatment options, using an intra-oral camera and caries detection device if available, every visit
- Periodontal screening, every visit (unless providing a comp perio evaluation)
- Spot check: record pockets and bleeding only
- Comprehensive periodontal evaluation at least once per year regardless of case type, which includes:
- Six-point/tooth pocket measurement
- Bleeding sites
- Clinical attachment loss
- Tissue response
- Personalized patient education and treatment planning when disease activity is present
- Personalized home care products and techniques, every visit
- Personalized adjunctive therapies as needed:
- Treatment rinses
- Whitening gel
- Speciality procedures
- Personalized recall interval, every visit
While these clinical protocols serve as a guideline for every prophy appointment, as clinicians we understand that we must use our clinical care skill and judgment with each patient to customize the appointment and manage our time. The patients' priorities, chief concerns and needs always come first.
Statistics and benchmarks
In a lot of ways, this is a misunderstood topic. Often, when the topic of statistics comes up, hygienists react adversely, because we immediately think production. While production is a part of the equation in a dental hygiene department, it's actually so much more! Tracking performance statistics, that is how much of each procedure you perform, can tell you a lot about your overarching treatment philosophy and clinical parameters.
Let's look at a few examples from profitable dental hygiene departments:
- An office in California, with three doctors and five hygienists were providing periodontal procedures at 21 percent. A perio percentage of 21 percent might appear high, but in this case, it primarily represented patients in maintenance, rather than active treatment. During coaching, this office discussed what they believed about treating periodontal disease, and guess what they discovered? They weren't walking their talk. After they tuned up their solid evidence-based clinical protocols their perio increased to 31 percent. They experienced a 64 percent increase in periodontal infections treated with non-surgical therapy. (4341/2) This shift came as a result of identifying a lack of clinical continuity, which was revealed in this practices statistics and benchmarks.
I'd like to share two more examples of how statistics and benchmarks can confirm that each hygienist is ‘living' the treatment philosophy and clinical parameters of a profitable dental hygiene department.
- Brooke is a member of a five-doctor practice and one of eight hygienists in this busy Alabama office. In just three short months, she raised her personal perio percentage to 31 percent. She is spending 31 percent of her time providing periodontal care for her patients. This is also reflected in her production, which has increased by $120/day!
Let's look at another example.
- Kristy, one of five hygienists in a three-doctor Arizona practice, a full year following initial training, is maintaining a perio percentage of 36 percent, with an average hourly production of $222, up $92 from her beginning production per hour.
It's clear from these statistics that these ladies are 'living' their treatment philosophies and making sure that the patients in their care are receiving periodontal therapy when it's needed. And the fact that their dental hygiene departments are profitable proves that they are providing a high level of service and professional care for their patients. If you haven't already done so, setting some reasonable and clear goals for the dental hygiene department provides benchmarks for performance so that each Hygienist can measure their progress and success. Below you will find the current industry standards. Use these guidelines to help set your goals.
Hygiene industry standards:
- Perio percentage 35-40 percent
- Open time percentage 8-10 percent
- Hygiene production 3x salary + benefits
- Prophy (1110) to perio maintenance (4910) ratio of 3:1
Balanced service mix
Balanced service mix is a reflection of your clinical philosophy. Looking at service mix is essentially looking at the variety of services, beyond a basic prophy, that are being offered and delivered in your dental hygiene department.
There really are no industry standards for dental hygiene department service mix, which makes this statistic driven completely by philosophy and protocol. I'd like to make the assumption that if you are reading this article, you have also watched the Principle-Based Dental Hygiene course available through Spear's Course Library in the Staff Training section. Your principles of care will drive your service mix.
For example, if one of your principles includes eliminating sub-gingival bacteria, then your statistics would reveal the regular use of a locally applied antibiotic (LAA) such as Arestin. Typically, I would expect to see at least one site of LAA per quad of therapy (4341/2) and at least 30 percent of periodontal maintenance patients' receiving one, two or three sites of LAA.
Additionally, if you believe that adult fluoride application can lower caries rates, decrease root sensitivity for those with recession and help your patients protect their investment in restorative dentistry, then your statistics would reflect the regular application of adult fluoride varnish. For an office that has adopted this philosophy I would expect at least 50 percent of adult patients would be receiving fluoride. To achieve that percentage, all adults would have to be offered the opportunity to take advantage of a fluoride varnish application.
Radiographs are another area you should evaluate. What is the frequency of PANOs and FMX being sourced from your dental hygiene department? Visualizing alveolar bone is a key component of periodontal diagnosis and risk evaluation for future periodontal disease. The use of seven Vertical BWs rather than four Horizontal BWs can help you visualize all areas of alveolar bone. When radiographs are neglected, disease will be missed.
Time management and communication skills
At the dental hygiene chair we walk a tightrope between data collection, delivery of care and education/enrollment. We must make the most of the precious 60 minutes we have with each patient. The first step in this process is chart review!
You must know the following, before seating your perio maintenance or recall patient, to make a realistic plan for today's dental hygiene appointment:
- Previously reported risk factors, health history concerns, medications etc.
- Incomplete diagnosed treatment of any kind
- Periodontal case type
- Radiographic needs
Once the patient is seated, break the dental hygiene appointment down into three components, as we do at Inspired Hygiene:
- 20 minutes – Data collection/patient education
- 20 minutes – Patient education/clinical procedure
- 20 minutes – Clinical procedure/doctor exam/documentation
It's always best to provide a periodontal screening, rather than a comprehensive perio exam when radiographs and doctor exam are scheduled to facilitate time management. In addition, the doctor exam should occur in the second 20 minute time frame whenever possible. This will prevent the hygienist from having to wait on the doctor and increase case acceptance measurably.
Using words and phrases that have the biggest impact can help you get your point across quickly. A great exercise you can do as a team is "Start Saying/Stop Saying." I'll get you started; see how many more words/phrases you can come up with!
- I found ...
- You need ...
- Inflammation ...
- Little ...
- Bob, you have ...
- Sue, it's in your best interest ...
- Infection ...
- Slight, moderate, severe ...
“A-Team” Hygiene Department
Having solid clinical protocols in place is half the battle. Having the correct team members in place is the other half. All too often I find myself in a discussion with a client that involves an underperforming or negative hygienist. And after some coaching to help this team member things get better for a few weeks or even a few months. Soon, however, we are having the same discussion about the same team member again, and again. Does this sound familiar? If so, it may be time to ask yourself if you have the right players on your team.
Dental hygienists are well-paid, highly trained and skilled, health care professionals and should conduct themselves as such. An A-Team hygiene department consists of those that exhibit strong levels of commitment and dedication to not only their patients, but their team members as well. An A-Team hygienist may emerge as a leader; you will recognize them by their qualities and behaviors:
- On time and prepared for the morning huddle by having reviewed each patients' chart and treatment needs
- Timely with patient appointments
- Compassionate with patients and team members
- Mastered the art of a great handoff
- Participates actively in a positive encouraging way during team meetings
- Has a generally positive outlook with a 'can do' attitude
- Willing to try something new if it's better for the patient and the business
- When faced with a challenge will often come up with a solution
- Puts effort into using correct verbal skills and values communication
- Willing to grow and develop (with) the hygiene department
- Understands the business of dental hygiene and the importance of tracking statistics
- Seeks out advanced continuing education, rather than just fulfilling the minimum requirements
Having a solid foundation with clear systems, written protocols and agreements in place creates an environment, and the opportunity, for hygienists to function at the top of their game. Setting some reasonable and clear goals provides benchmarks for performance so that each hygienist can measure their progress and success. A-Team hygienists can be developed when these systems are in place.
(Read more dental hygiene articles by Kim Miller.)
Kim Miller, RDH, BSDH, is Contributing Author for Spear Education.