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Hygienetown: Why Dentists and Hygienists Clash

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Hygienetown: Why Dentists and Hygienists Clash

And what can be done about it

The working relationship between general dentists and hygienists is at a breaking point in many practices across the United States. A Townie recently posed a question on a Dentaltown message board that opened the floodgates: What are the biggest sources of stress between dentists and hygienists today?

The responses were raw, candid, and eye-opening. They paint a picture of a profession grappling with shifting power dynamics, broken economic models, and cultural mismatches that threaten team cohesion and patient care. Hygienists in the thread repeatedly emphasized the importance of respect for clinical judgment, predictable pay (to avoid no-show volatility), and timely doctor exams. As one hygienist put it, “Recognize us as producers and educators, not just ‘cleaners’.”

The perio protocol problem
The single most repeated flashpoint in the thread was the lack of clarity and agreement on how periodontal disease should be managed in general practice. Dentists lament hygienists who avoid recommending scaling and root planing (SRPs) out of fear of offending patients, while others complain about bloody prophies being passed off as “maintenance.” Some dentists have stopped performing SRPs altogether, opting instead to refer patients to periodontists and avoid the internal drama that these cases often create.

One user put it bluntly: “Dentists and hygienists are not even speaking the same clinical language when it comes to perio. But periodontists and hygienists? They’re aligned. Why? Because they both live and breathe it.”

Dentists voiced frustration, but hygienists countered that a healthy periodontium must precede restorative work. “Restorative is futile without periodontal stability,” one said, pressing for complete charting and documented criteria before major work. Another added a practical guardrail: “If more than 1 hour is needed, it is not a prophy.”

The solution, many agree, lies in written, codeveloped protocols that set clear expectations on probing, staging, SRP indications, and referral thresholds. But very few offices take the time to do this. As a result, there is daily misalignment, patient confusion, and rising tension.

Wage inflation meets PPO reimbursement
Hygienists, particularly since the COVID-19 pandemic, are commanding higher wages than ever. In many urban markets, $65 to $100 an hour is not uncommon. Meanwhile, insurance reimbursements haven’t kept up. Dentists feel squeezed between staffing costs and stagnant production numbers.

“I had to raise everyone’s pay after one hygienist threatened to leave. That one comment cost me $20,000 a year,” one dentist shared.

At the heart of it is the contradiction many practice owners now face: They depend on hygiene to drive exams and restorative work, but often lose money on the hygiene itself. The math no longer works, especially for PPO-driven offices. Hygienists, however, pushed back, noting that in many cases they produce well above their hourly rate. One hygienist said she consistently produced four times her hourly rate, and in well-run offices, raises and bonuses came without ultimatums, which built loyalty and performance.

Hygienists also expressed mixed views on pay models: some prefer hourly pay to avoid the stress of no-shows potentially erasing a day’s paycheck; others like commission when it’s structured fairly and agreed upon upfront.

Some dentists are pushing back, eliminating the role of hygienists, switching to assisted hygiene models, or performing the cleanings themselves. But most admit it’s not sustainable at scale.

The hygiene labor market is broken
Frustration also surfaced over what some perceive as a “diva mentality” among newer hygienists, who they believe expect high salaries, minimal accountability, and flexible schedules. Others note the rise of hygienists leaving clinical practice entirely for temp work, education, or other roles.

The shortage is real, but some argue it’s not just about numbers. It’s about retention. “We don’t just need more hygienists,” one user wrote. “We need more who want to be in the chair five days a week and care about patient outcomes.”

There’s also tension between hygiene schools and private practice. Some feel hygiene instructors foster adversarial attitudes toward dentists, teaching students to view themselves as “patient advocates” who must police doctors and assistants. Whether fair or not, the perception alone is corroding trust.

One veteran hygienist pointed to surveys and local experience showing that many hygienists are transitioning out of clinical roles due to working conditions; churning out more graduates won’t help if they quickly exit the operatory.

Office culture: The invisible stressor
More than pay or protocols, the issue that kept bubbling up in this thread was culture: how teams communicate, resolve conflicts, and respect each other’s roles.

In practices with strong leadership, open dialogue, and aligned expectations, dentists and hygienists reported thriving relationships. However, in practices without those foundations, every disagreement over timing, diagnosis, and communication style became a power struggle.

One veteran hygienist said it best: “I’ve worked in great practices and toxic ones. The difference was never money; it was whether the dentist respected me and whether the team had each other’s backs.”

Is the hygiene-driven practice model failing?
Several dentists argued that the root of the problem isn’t hygienists at all, it’s the business model. Practices have become too dependent on hygiene for diagnosis, production, and patient retention. When hygienists leave or demand more, the whole operation teeters.

One solution repeatedly floated was to diversify marketing and scheduling to attract more patients in need of treatment, not just cleanings, such as emergencies, new patients with decay, and surgical consultations. “Stop relying on hygiene to drive production,” one dentist said. “Build your own diagnostic engine.”

Others took it further, suggesting that the general practice model needs to be split entirely: Either integrate hygiene under tight systems and leadership, or restructure around a leaner, fee-for-service, treatment-focused model.

Hygienists offered their own solutions: allocating sufficient time per patient, co-authoring the perio protocols, and establishing a clear pay model (hourly or commission) that aligns incentives. “Let’s compromise to find a workable solution.”

Conclusion: Is the rift fixable?
At the end of the thread, no one suggested there’s a magic fix. But some clear themes emerged: Clear perio protocols and regular team calibration reduce friction. Fair pay matters, but so do accountability and communication. Without strong leadership and culture, even the best systems will falter.

The PPO system continues to fuel unsustainable dynamics. Many dentists are considering radical restructuring, not out of spite, but as a means of survival. As one contributor put it, “You can’t blame people for negotiating their worth. But you also can’t run a business at a loss. We either fix the structure or brace for more exits, more burnout, and more tension.”

Dentists and hygienists alike agreed on one point: Neither group can succeed in isolation. Whether they clash or collaborate will depend on creating structures that honor the value of each role, because patients thrive only when the whole team does.
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