Inside Dental Hygiene
June 2013
Volume 34, Issue 4

How the Dental Hygienist Can Bolster Your Bottom Line in Four Easy Steps

Encouraging patients to spend again takes an innovative approach

Roger P. Levin, DDS

Dentistry has changed dramatically in the past 5 years. The recent recession has altered how patients make decisions regarding recommended treatment and how dental practices need to manage their daily operations differently than prior to the recent economic downturn. These changes are affecting the role of the dental hygienist, which now must evolve in order for practices to remain productive and successful.

The Changing Dental Economy

In the last 12 months, the author of this article has lectured extensively on a subject he refers to as The 8 Permanent Game Changers in Dentistry, which includes the Great Recession and changes in consumer purchasing habits. Until 5 years ago, most consumers could be categorized as impulse shoppers. This meant that when these shoppers saw something they wanted, they typically made the purchase without a great deal of decision-making.

The depth and length of the recent recession changed that mentality. The impulse shopper is now gone and has been replaced by slower decision-makers. Similar to retail shoppers, many patients in the dental practice are now working through the same three questions when making decisions:

• Do I really want it?
• Do I want it now?
• Do I want to buy it here?

These questions have made it much more challenging for dental practices to persuade patients to accept recommended treatment. Since the onset of the economic downturn, practices have experienced more patients:

• Rejecting treatment.
• Delaying the start of treatment.
• Accepting partial treatment.
• Wanting to consult with other key decision-makers such as spouses.
• Checking financial capability to accept treatment.
• Canceling/not showing for appointments.1
• Reducing hygiene appointments to once a year or less.

These factors and others have resulted in 75% of dental practices experiencing production declining during the last 5 years, according to the Levin Group Data Center™. This lack of practice growth is forcing dentists to examine different business models to increase production. Unfortunately, a lack of business training and knowledge has prevented most dentists from returning to prerecession levels of high production. Declining production also means lower incomes and less retirement savings, which will delay reaching financial independence by 5 to 7 years.

The solution to meeting these challenges cannot be found in outdated business thinking. Simply doing more of the same will not solve the problem. Dentists have tried everything from new marketing activities to better communication skills, all of which can contribute to improved performance. However, these activities do not automatically motivate more patients to accept recommended treatment. This is where the dental hygienist can play a new role in the practice while continuing to provide quality preventive care.

The New Role of the Hygienist

Dental hygienists are respected professionals with years of clinical training. Millions of Americans see their hygienists once or twice a year. Given that the dental hygiene clinical procedure is typically not uncomfortable, patients arrive at the office, undergo hygiene treatment, and leave relatively happy. They enjoy the relationship they have with the hygienist and the opportunity to say hello to their dentist during the examination.

Until now, this has been the classic role of the dental hygienist. Just like retail consumers, dental patients are more cautious about spending money than in the past, which has made case acceptance much more difficult. For example, cosmetic dentistry production has dropped precipitously since the onset of the economic downturn. With most dental practices still struggling with declining production, dentists must consider managing differently, which includes giving hygienists a much larger role in the case presentation process.

The job description of the dental hygienist needs to change. In the past, the dental hygienist’s role focused exclusively on clinical activity and preventive care (and that will continue), but the new job description should include increasing practice production. In an era when 75% of dental practices have declined in production, every staff member should play the maximal role in increasing practice production. While each staff member’s job description should be evaluated as to how he or she can contribute to increasing practice production, dental hygienists have a unique opportunity to make a significant difference in the practice’s bottom line, especially because the dental hygienist spends more time with patients than anyone else in the office, including the dentist.

The following recommendations will reshape the role of dental hygienists and enable them to dramatically increase production:

• Lifetime follow-up. During the last 5 years, many patients appeared to have rejected treatment. To increase practice production, train dental hygienists to review unaccepted treatment with patients during each hygiene visit. This follow-up needs to be done subtly and politely, or the treatment that appears to be rejected will remain rejected permanently. Levin Group clients have found success with their hygienists reviewing unaccepted treatment with patients at 6 months, 12 months, 18 months, and longer. Eventually, many patients say “yes” and decide to move forward with previously rejected treatment. In some cases, patients were financially able to accept treatment, but lacked confidence in the current economy. In others, patients did not have the financial means due to job layoffs, reduced work hours, and other economic issues. Regardless of the reason for the initial rejection, it is now essential to train dental hygienists in the art of reviewing treatment presentations at each hygiene visit. This follow-up should not be done selectively or occasionally, but become a repeatable system and applied to every patient. This process is no different than a physician reviewing factors such as a patient’s smoking or weight during a yearly physical examination. At some point, many patients will lose weight or quit smoking. The same can now be true for the new role of the hygienist in the dental practice.

• The 4 Hygiene Factors™. This is a method developed by Levin Group for training hygienists to become more active in the case presentation process.

The 4 Hygiene Factors

Identify. Hygienists should be trained to identify all potential need-based and elective treatment for hygiene patients. An enormous opportunity exists in elective dentistry today to increase practice production. Levin Group has a target that 22% of practice production should be elective. When practices put in systems to reach this objective, they increase production, decrease dependence on insurance companies, and expand the number of services provided. In most practices, the amount of production coming from elective dentistry is 7% or lower. Learning to identify potential treatment with an understanding that it can always be overruled or changed by the dentist should be the first step in this new process.

Educate. Dentists only have a few minutes in a hygiene check to discuss potential treatment and educate patients. Hygienists, on the other hand, typically spend 40 to 60 minutes with each patient. This allows ample time to educate patients about potential treatment, answer questions, and serve as a resource for patients about any treatment-related concerns. This type of attention creates value for patients and confidence that the treatment will benefit them.

Motivate. Dentists have a limited amount of time during the hygiene check to interact with patients. A well-trained dental hygienist has both the time and the ability to persuade patients to move forward with potential treatment. Motivated patients accept more treatment, and slower decision-makers will increase their decision-making speed proportional to the amount of motivation they receive.

Close. It is now time for the dental hygienist to close the case. This includes a simple, benefit-based description of the recommendation, including fees, financing options, scheduling, and the statement that the dentist will, of course, need to confirm the findings and recommendations. When the dentist walks into the room, the dental hygienist has already accomplished most of the process. The dentist finalizes the diagnosis and treatment. Once again, training the hygienist is critical to present treatment with an understanding that the dentist will review all recommendations and make final decisions.

The 4 Hygiene Factors require the use of a specialized form of verbal communication called value-building scripting. The objective is not merely to inform patients, but rather to influence them in positive ways. While scripting traditionally focused on consistent messaging, its role has expanded to include psychological factors designed to create greater trust and loyalty to the practice. Dental hygienists need effective scripting to properly communicate all aspects of recommended treatment during each step in the process. Highly successful dental hygienists are viewed by patients as trusted advisers who are looking out for their best interests. Value-building scripting enables hygienists to successfully transition into this new role.

Scheduling dental hygiene patients. Dental hygienists need to play major roles in ensuring that 98% of their patients are scheduled at all times. Whether assigned to front desk staff or the dental hygiene team, it is critical that all hygiene patients schedule their next hygiene appointments before they leave the practice. In addition, any hygiene patient who is one day overdue should receive a phone call that day to schedule an appointment. If patients are not reached, the practice should institute a 9-week follow-up process, using phone calls, emails, and letters. This type of follow-up system prevents active patients from “falling through the cracks.”

Many practices have up to 20% of their hygiene patients overdue, which results in a large production loss and lack of referrals from these patients. The dental hygienist can be highly motivational, creating value for the hygiene appointment and encouraging patients to schedule while they are still in the office. This key team member can also play a role in encouraging referrals. The Levin Group target for referrals is for 40% to 60% of patients to refer at least one other patient each year. Most practices are well below 20%, missing significant opportunities to acquire new patients and increase practice production.

Homecare products. For many years, dentists have resisted selling products, rationalizing that it’s not worth the effort. However, ophthalmologists sell glasses, veterinarians offer medications, and dermatologists promote beauty products. Dentistry now needs to evolve to take advantage of this opportunity.

In an age of increased competition, providing homecare products is an excellent method for differentiating the practice and creating more value for patients. Product sales should be assigned to the dental hygienist. With proper scripting, many patients will prefer the convenience of making the purchase in the office, especially when reasonably priced. Practices can buy many products, such as power toothbrushes and dental water jets, at professional rates, leaving room for additional profit and increasing practice production. Every patient should receive a clear homecare plan that includes recommended products carried by the practice.


In the past, the dental hygienist’s main role was preventive care. In the new dental economy, the hygienist’s job description should be rewritten to include increasing practice production. Practices can no longer continue to operate as they did in the past. If they do, they will continue to struggle with production plateaus and declines.

Based on the time spent with patients, dental hygienists have the greatest opportunity to positively affect the practice’s ability to increase case acceptance. By reviewing unaccepted treatment during hygiene appointments, educating and motivating patients about potential treatment, scheduling their next appointments before they leave, and asking for referrals, dental hygienists are in the position to turn a struggling practice into a highly successful one.

With a well-trained dental hygienist following the principles outlined in this article, Levin Group estimates that production will increase at least 10% to 20%, capturing new treatment for the dentist and resulting in a larger volume of active patients.

Visit the Levin Group Resource Center at www.levingroup.com/gp.

About the Author

Roger P. Levin, DDS,
Chairman and CEO Levin Group Inc.
Owings Mills, Maryland

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