Improved Dental Hygiene Production by Dr. John A. Wilde

Improved Dental Hygiene Production 

Increase dental hygiene production and minimize burnout by properly compensating staff members

by Dr. John A. Wilde

I sense the dental community’s concern about the shortened or abandoned careers of some hygienists. Everyone’s reasons are complex and unique; however, burnout is a contributing factor when rewards aren’t considered commensurate with effort (certainly a malady from which dentist and staff are not immune).

Diminishing performance is not a viable alternative for skilled, caring, ethics-based professionals, so we must restore joy and equilibrium by increasing reimbursement. However, this should happen without lessening the quality of care or reducing office profitability. While there’s no single simple remedy to this complex dilemma, I can suggest concepts that, in the aggregate, can significantly benefit hygienists, dentists and patients.

Commission-based compensation

Commission-based compensation creates a potentially heftier paycheck and bequeaths a salutary sense of control. This single factor produced a powerful motivation for our hygienist to work more profitably and effectively by establishing a reward proportionate to effort. It also resulted in an immediate 25% increase in hygiene productivity (and thus salary) that has not declined over three decades or with the seven hygienists who have enjoyed this system.

While quality of care never wavered, we filled virtually all unscheduled time, tightened schedules, and additional procedures such as sealants were often seamlessly blended into the day. How many dentists would even consider asking their hygienist to place unscheduled sealants? And how many doctors, as I did, routinely outperform their scheduled daily production? How would you explain this disparity?

Commission recompense means extra work creates additional pay while unproductive time isn’t rewarded. (It’s one thing to take a break on full salary and quite another to twiddle one’s thumbs for an uncompensated hour.) Our hygienist, her assistant and one front office staff member became part of a team that considered unscheduled time anathema, personally confirming virtually every appointment and staying as long as necessary to fill the next day’s available time. We immediately rescheduled canceling patients or placed notes in a calendar file for later callback. (Not blithely advising, “Call us when you want an appointment,” only to have them disappear into the ether.)

I viewed this as part of my professional responsibility, and my patients’ appreciation of this extra effort frequently led to kind words of thanks and heartfelt referrals. But let me be succinct: Each activity enhanced my income and, because we’d already met the day’s overhead, the additional revenue disproportionately increased my profit. Shouldn’t hygienists be granted parallel opportunities?

Large bureaucracies like the U.S. Army Dental Corps and The University of Iowa College of Dentistry (with which I’ve had intimate contact) frequently and famously fail to reward effort. A military dentist placing four fillings an hour receives the same compensation as a doctor performing one. Dental school teachers hiding in the lounge are paid the same as the educators spending every available minute helping students.

To me, these flawed systems are illogical, unproductive and un-American ... in a word, stupid! Should a hygienist be compensated the same for a torturous hour of deep scaling as for sipping coffee during a failed appointment? Is it realistic to expect maximum effort without reward? Yet this disincentivizing form of aversion therapy describes today’s dominant dental compensation system.

To create a superior structure, we took our hygienist’s W-2 taxable income for the preceding year and divided it by her total production to establish the past percentage of compensation. For example, assume your hygienist’s salary for 2020 was $60,000 and her production was $180,000. The future compensation percentage would be 33% of production ($60,000/$180,000 = 33%), so she would receive 33 cents of every dollar she produces. (Because an RDH can’t control collections, I always paid on production.)

Because a W-2 includes all paid benefits including sick leave, paid vacations and continuing education compensation, they are automatically contained within this percentage. Separate payment or recordkeeping is no longer required.

Some hygienists may prefer that benefits remain separate. This simplifies adjustments: Simply remove the benefits from last year’s W-2 total, recalculate the compensation ratio, and subsidies can be reimbursed as they had in the past. (Your accountant, who already has the necessary information, can handle this.) This system rewards effort when calculated with or without benefits. Now, the more diligently and effectively our hygienist works, the greater her rewards, just like me.

Hygiene profit center

Central to some RDH-dentist disputes is the small to nonexistent profitability of many hygiene departments. We must improve this to satisfy the dentist and the hygienist. Our 25% productivity increase requires a minimally higher overhead. Most expenses, such as equipment, rent, insurance, utilities and other staff salaries, remain unchanged. The net is reduced only by the hygienist’s salary increase and a few pennies for supplies.

Requesting a salary enhancement without growing hygiene production is akin to asking dentists to reduce their paychecks to fund a hygienist’s raise. Refusing a salary increase can leave the hygienist feeling frustrated and powerless, but dentists may suffer lingering resentment regarding their reduced pay should the request be granted. However, our enhanced profits resulted in my enthusiastic support and commitment to the hygienist and her department. Nota bene: The more she makes, the more profitable the practice. It is in the dentist’s best interest to maximize hygiene salary.

All employees, including janitorial, must realize that their economic fate and personal happiness remain inextricably linked to overall office success. Mutual profitability enhances everyone’s pay and allows for improved work environments. In these ultracompetitive times, dentists must become savvy businesspeople who comprehend this foundational truth of free enterprise: Increased incentives yield amplified efforts that result in higher profits

Creating an office leader

Most dental staff members are honorable, hardworking people. However, I’ve found that the vast majority aren’t self-starters; they do as they’re told. Seasoned professionals realize how rare and delightful it is when a teammate takes ownership and fully buys into one’s practice. I was delighted to have even one such individual at any given time, until this system created opportunities for well-educated, hard-working hygienists to control their destinies. Once hygienists became respected leaders, I only had to stay out of their way.

Future projects they might spearhead among many other practice-enhancing, profit-building strategies include: implementing or enhancing a soft-tissue management system; establishing a hygiene-controlled tooth-whitening program; creating an in-office dispensary for electric brushes and fluoride supplements; or developing a halitosis center. Each project improves patient service while increasing hygiene production (and compensation), thus creating a sense of control and personal power vital to health and happiness.

Expanded hygiene

Let’s dream big! Expanded hygiene, featuring two dedicated rooms and a fulltime hygiene assistant, is the next logically progressive step to explosive hygiene and practice growth. Space limitations prohibit a detailed discussion of the topic, but let’s consider the benefits such a system provides. The hygienist’s chairside:

  • Performs room setups and breakdowns.
  • Sterilizes instruments.
  • Seats and dismisses patients.
  • Reviews medical histories.
  • Takes needed X-rays and images.
  • Polishes, flosses, and administers fluoride (state law allowing).
  • Reviews oral hygiene (including aids suggested by dentist or hygienist).
  • Schedules recare exams.
  • Assists with pocket charting, sealant placement and periodontal treatment.
An assistant performing all these fatiguing, low-productive tasks allows an RDH to treat 12 patients daily instead of the standard eight. With expanded hygiene, quality of care improves as each patient receives 80 minutes of staff attention where before, only 60 minutes were available. (Two staff members, each working eight-hour days, create 16 total hours for 12 patients, or 80 minutes per patient.)

Expanded hygiene also enhances practice income in two primary ways. First, seeing a dozen patients daily rather than eight creates an additional 50% increase in hygiene production, above and beyond the 25% garnered by switching to commission compensation. Second, the added care diagnosed from 20 supplementary weekly examinations (four per day for five days) or 1,000 per year (20 per week for 50 weeks) further enhances revenue and may singlehandedly eliminate the dreaded business problem.

The hygienist is less weary at day’s end when freed from many tedious and tiring tasks; she is allowed to focus on the unique skills her training and license permit, just like me. Before beginning expanded hygiene, each of my hygienists worried she’d become a “scaling machine.” After a week, none wanted to work without an assistant, just like me.

Implementing the above changes results in hygienists, dentists and patients being better served and rewarded. A triumvirate triumph is essential because if the needs of all parties aren’t met, none will achieve lasting fulfillment. But by intelligently working together, we all become more!

Author Bio
John Wilde After working through eight years of higher education, paying 100% of all costs, Dr. John A. Wilde spent his next two years in the U.S. Army Dental Corps before beginning a practice from scratch in Keokuk, Iowa. He was debt-free at 30 years old, owning his home and the practice he’d designed and built outright. He was financially able to retire at 40 and fully retired when he was 53. He has published six books and written more than 200 articles. Contact: 309-333-2865 or

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