Dental Hygiene— in an Orthodontic Practice? by Daniel Grob, DDS, MS, Editorial Director

A few months ago, Orthotown included an article by Miranda Valenzuela, who reviewed the rationale and treatment of managing white spot lesions in an orthodontic practice. This was just one of the duties and tasks assigned to Valenzuela, who is the dental hygienist in an orthodontic practice.

How many of you have a dental hygienist in your practice? I do—and she's been part of my staff for more than 15 years. My business partner once said that adding a hygienist to our payroll was the single largest productivity booster in our 28-year practice journey … even though she never once billed for routine hygiene services. How is that possible?

The story, from the beginning
Do you remember Dr. Ron Redmond's standing-room-only lecture at the AAO meeting in Denver several years ago? He declared that hiring an orthodontist to work as an associate with the senior orthodontist was a money-losing proposition. Redmond estimated the cost of having an associate at around $250,000 per year—and that's coming straight out of the senior doctor's salary.

Our business partnership learned that the hard way, years earlier, within the first six months of its existence. Shortly after we created our two-man practice, we realized that the camaraderie was great but the bottom line wasn't improving—in fact, it was declining.

Fortunately, some forward-thinking general dentists had built a space in their office just for specialists. We agreed to rent it by the day so we could build our own practice (and of course accept referrals from them). Business was great—within months we were a steady one-day-a-week practice, then two days, then three … all as the stepping stone to a freestanding location.

Not satisfied with just one satellite practice, we quickly directed our attention to starting a second satellite office, renting an unused space from a periodontist for one day per month.

One thing led to another, and within a couple of years we had turned a two-doctor, four-employee, one-office practice into a two-doctor, three-office practice. The key to our success—and our eventual sale—was the addition of a dental hygienist.

Hiring a hygienist wasn't a new concept … or even our idea! General dentists and periodontists have used dental hygienists in independent roles for a long time. So how did a hygienist turn into one of our most productive employees ever?

Free yourself to focus on productivity
The justification for hiring a dental hygienist wasn't because we needed someone to “clean teeth” or to perform hygiene functions, although periodontal charting and the like can be performed by a hygienist, of course. The goal was to utilize (with state regulations permitting) a licensed legal entity capable of managing and performing certain duties on patients that otherwise would require the presence of a dentist or orthodontist.

During good times, we had noticed that the limiting factor to what could've been a productive day was a column of patients who were ready to have their braces removed. Being old-fashioned, we felt like we should do it, even though the staff removed the appliances, took X-rays and got the patient ready for us to remove acrylic. (I know that many offices across the country have staff remove acrylic, and there are devices that are quite good and safe at this, but we still preferred to utilize handpieces.)

We discovered that hiring a hygienist helped us with those tasks that most orthodontists don't enjoy—namely, removing braces and checking retainers. Time- consuming, labor-intensive, nonproductive visits. Need I say more?

Oh, I know that many of you will rail about how your patients want you to do the work, and that they enjoy giving you the big hug at the end. Nice, but convince yourself to get over it! With hundreds of positive patient reviews over the years, I can count on one hand the ones that mentioned the orthodontist specifically. Most loved the location, hours and staff, the free coffee and, of course, their beautiful new smiles.

To increase productivity, we scheduled the hygienist in the office that had no doctor present, thereby operating under “direct supervision.” (In other words, on non-doctor days.) This allowed the two doctors to staff other offices for production while the debanding was occurring at the third office. Our hygienist did post-treatment conferences, reviewed instructions to the family dentist and generally used her patient skills to “wow” the patients. The orthodontists would review before-and-after photos and X-rays, coach her on the script for each patient at debanding, and write it in the chart at the visit before the “big day.”

Our hygienist wasn't content with just doing several debandings per day, so she quickly added other procedures that we felt comfortable with her doing, ethically and legally.

A return on investment in time
For instance, how many of you dread retainer checks? They typically go like this: The patient comes in wearing his retainer and is either happy or has a concern. If there's a minor shift, you—as the orthodontist, being proud of your work—offer to fix it for free or for a reduced fee, then tie up your schedule … again, taking time away from current or potential patients.

On the other hand, when the hygienist reviews the patient, she may ask how he's feeling, see if there are concerns and offer remedies for any relapse or retention. With good office protocol and procedures, these appointments can lead to production in minor retreatment, or diagnostic X-rays to check for third molars. (This is similar to the discussion of recurrent caries under crown margins in the dental office.) I can't tell you how many times I came to the office the next day to find study casts on the desk, and a note saying that the patient would like to do limited clear-aligner therapy to manage a relapse that was caused by poor retainer wear, bad habits or wear and tear.

There are certainly offices that have a similar workflow in place and depend on only well-trained assistants. But if you want to expand your workflow, hiring a great employee to whom you can delegate tasks is more profitable and less hassle than hiring an associate. In addition, getting your systems in place for delegation will force you to define your system for treatment—and this will come in very handy when you do start thinking about selling your practice.

I'm speaking from experience: The shortcomings and strengths of your practice come to the surface when you ask someone else to do the work. Dentists utilize hygienists to keep the appointment book full; maybe you should, too!