According to the ADA, independent dentists reported paying full-time dental hygienists $33.90 per hour in 2008.

Considering the current economic environment The Wealthy Dentist decided to conduct a survey asking dentists if they pay their hygienists an hourly wage or if compensation is based on commission.

It seems most dentists still pay their dental hygienists an hourly wage, but some feel paying on commission is more fair. Said one dentist, “Hygienists are worth their weight in gold!” Another dentist disagreed saying, “Practices couldn’t run without them, but the current economics barely breaks even at best … hygienists seem to think they are cash cows for the office and fail to recognize the support and facilities the utilize.”

It’s an interesting economic issue. Click on Play to hear more of what dentists say about paying hygienists –

How do you pay the hygienist in your practice?

Of the 20 fastest growing occupations in the US economy, half are related to healthcare.

Healthcare is experiencing rapid growth, due in large part to the aging of the baby-boom generation, which will require more medical care. As healthcare costs continue to rise, work is increasingly being delegated to lower paid workers in order to cut costs.

For example, tasks that were previously performed by dentists are now beginning to be performed by dental hygienists and dental assistants.

As dentists‘ workloads continue to increase from treating the aging boomer population, it is expected that the demand to hire more hygienists to perform preventive dental care will grow as dentists will want to spend more time working on more complex dental procedures.

There is also the growing situation of not enough dentists to provide adequate care in rural areas where hygienists are needed to fill in the gap. According to the Center for Rural Affairs, in 2007, approximately 15 percent of rural residents were 65 years of age or older, 25 percent greater than in the nation as a whole.

The U.S. population of those 65 or older is predicted to double by 2030, reaching 20 percent of the U.S. total population, and the fastest group age living in rural America are residents 85 and older.

The average median wage for dental hygienists is $32.81 hourly, $68,250 annually with the best employment opportunities following the population size of states. New York, Texas, California, Michigan and Florida employ the most dental hygienists.

See: Occupational Outlook Handbook, 2010-11 Edition — Dental Hygienists

“They get paid too much for what little they do,” complained a New York orthodontist paying his dental hygienist $27 per hour.

Another dentist – one paying $55 an hour – disagreed about the value of dental hygiene. "She's worth every penny. She makes me a fortune."

Read more about dental hygienists – Dentists: What do you pay your dental hygienists?

Another 11% have reduced the number of dental hygienists they employ, and 5% have cut compensation.

“Hygiene is the fuel that feeds the fire," said a California dentist.

How much hygienists are paid is an important dental management decision. "Upon doing a practice analysis, we found we overpaid our hygienist by $13,000," said one dentist. "We paid more in hourly plus benefits than we collected!"

“Our hygienist was paid salary and now she is paid hourly," said one doctor. Offered another, “Instead of any raises, we put our hygienists on a bonus system based on achieving a minimum daily production."

Here’s more of what dentists had to say on hygienists and tooth cleaning appointments:

• "Hygiene at our office, which has a dentist and a prosthodontist, has remained strong throughout this economy. We are very thankful." (Ohio prosthodontist)
• “We have not cut hours, but we have worked very hard at activating past due patients, with good success.” (General dentist)
• “We have at least two cancellations in hygiene daily. Most tell us to reschedule their dental cleaning later into the year. Other simply say they are not coming.” (Bermuda dentist)
• “Hygiene is the one aspect of the practice that hasn't shown lower numbers. I'm glad we instituted a good recall systems several years ago.” (Pennsylvania dentist)
• “We are seeing more no-shows, and some people are wanting to wait a year instead of 6 months for their next dentist cleaning.” (Dental hygenist)
• "If things slow down more, I will cut my dental hygentist days or time and do the dental hygiene myself.” (New York dentist)
• “They have to take on more responsibility.” (Massachusetts dentist)
• “We have a very periodontal oriented office. A lot of our patients are switching themselves to twice a year for teeth cleaning. They only want what the dental insurance will cover.” (Utah dental office worker)
• “The gross receipts were down about 1% last year, but the profits were slightly up.” (Pennsylvania dentist)

Read more about dental practice management: Dental Hygienists – How the Recession Affects the Dentist

Location is highly correlated with hourly base pay, with urban California hygienists being paid twice as much as their rural Southern counterparts.

Read more: How much dental hygienists get paid

The California Dental Hygienists' Association (CDHA) recently issued a public warning to parents about the Halloween dangers of sour candies, many of which apparently as acidic as battery acid. The acid content of these candies can damage teeth even more than the sugar of traditional candies.

They also advise minimizing one's risk by rinsing with water after consuming sour candies. However, it's important not to brush your teeth immediately! The acid softens tooth enamel, and brushing soft enamel is likely to do more harm than good.

Read more

Watch the Video

Luring hygienists to a practice in rural Maine has proved challenging. Though there’s been a lot of interest in the ads they’ve posted, very few candidates are actually interested in the “downeast lifestyle” that Machias, Maine, offers.

Recruiting Hygienists from Across the State

So the Sparagas decided to try another hygienist recruitment strategy – and it’s proven to be surprisingly controversial. For $35, the State Bureau of Records gave them a mailing list of all licensed health care providers in the state of Maine.

Interestingly, roughly a third of the listed RDHs used their current office as their personal mailing address. As a result, the Sparagas received a few irate letters from dentists questioning the moral and ethical appropriateness of soliciting their hygienists. As one doctor wrote,

I feel compelled to write you today with a serious concern we have regarding a mailing each of our hygienists received from you (at our office address no less!) inviting them to join your team at Machias Dental.

Our reaction to this solicitation initially was to laugh at it, though as I thought more about it, my feelings went from amusement to outrage to bewilderment. This is not the way we “do things” in Maine, so where was this coming from? I know your reputation and the reputation of your practice is outstanding, so I’m confused as to why this type of mailing would make its way to our office. I can only assume this was an oversight mistake on your part. I suppose this can happen. But did hygienists at other dental offices in the state also receive this letter? I certainly hope not!

Please either respond to this email or call me to discuss this matter further. I would like to put my mind at ease that the collegial culture Maine dentists have traditionally enjoyed is not on the decline! I look forward to hearing from you soon.

The Doctor Defends His Strategy

Dr. Sparaga’s response was both diplomatic and sympathetic.

Thank you for your concerns about our recent mailing to all the hygienists in the state in our quest for a new hire. I’m sorry if you have taken this personally and it has offended you.

As we all know, it is most difficult to attract qualified personnel to live here, and we’ve resorted to a mass mailing to Maine RDH’s seeking someone looking for a change not only in jobs, but in lifestyle. With a practice in an underserved rural area, we do not have the luxury of putting an ad in the local paper, hoping to attract a provider, someone looking for a change.

The state considers the lists of practitioners, medical and dental, as public information, rather than personal. With the dental manpower shortage in the rural areas, the state bureau of records is most willing to give out the list of all their medical and dental personnel especially if it helps remedy the maldistribution of manpower toward these areas. I would suppose when considering the current access to care issue, it might be considered unethical to restrict such information. For whatever reason, it would appear that many of the RDH’s listed their dental office of employ as their contact address, instead of their personal residence. We could not tell whether these addresses were of their home or office. And of course, I assume that these healthcare professionals will judge for themselves whether our offer of new horizons is offensive to them. I would propose that the offer might mean more to them than a concern for collegiality amongst us dentists.

Thank you for understanding that a mass mailing was the only way we could reach out to Maine’s RDH’s and supply more healthcare manpower to this underserved area.

But in addition to the angry letters, they also received several excellent replies from remarkable candidates. The Sparagas are happily interviewing those RDHs now.

Jim Du Molin’s Two Cents

I am squarely on Dr. Sparaga’s side. There’s nothing wrong with a doctor who is looking to hire hygienist taking a state mailing list and sending out a letter. It is clear to me that there are no ethical issues here. The state mailing list is public information, and I’m not going to fault Dr. Sparaga for using all the resources available to him.

Registered dental hygienists are a scare resource. Given the realities of supply and demand, that means there will be competition for RDHs. If you’re a dentist and you need a hygienists, you will do whatever you can and pay whatever you need to in order to find a hygienist. It’s easier for dentists to raise their prices than function without a hygienist.

In addition, there are lots of reasons why RDHs (or anyone) might switch jobs. No matter how great a job is, sometimes people need a change of scenery. People are going to do what’s in their own self-interest. If you want loyalty, get a dog!

So to the doctor who complained, I would say, “If you’re taking care of your hygienists, then you have nothing to worry about.”

What do you think? Post your comments!

Four out of five dentists in a recent Wealthy Dentist survey report paying their dental hygienists a salary or base hourly wage rather than on commission. It’s an important economic consideration for any dentist.

When setting compensation structures or assigning available operatory space, it is useful to analyze the relative profitability of the individual producers in the practice. The chart below begins by analyzing one dentist’s profit on his two hygienists, Mary and Tim, after direct costs (labor and treatment supplies) but before general overhead costs such as rent and office administration.

Comparative Value of One Day’s Production

In the example, Mary is paid on commission (45% of production), whereas Tim is paid a flat daily salary of $288. At current production levels, the dentist realizes about the same amount of profit on each, $292 per day.

As production increases, Tim will become increasingly more profitable than Mary. The dentist’s profit on Mary will always be 36% of whatever amount she produces, as a result of the commission structure.

Measuring Profits

However, for each additional dollar that Tim produces, the dentist’s profit will be 87% – over twice as much! This is because once Tim’s salary is paid, there is no further labor cost for that day.

Suppose the dentist has a goal to increase profit in the practice by $1,000 per month, or $58 per day. Mary would have to produce an extra $161 ($58 divided by 36%) to generate the $58 profit; Tim would only have to produce an extra $67.

The majority of the practices that we see have a goal of increasing profit. For the most part, this means that production must increase. Clearly, the dentist in this situation wants to convert his hygiene department to a salaried basis. That way, the doctor will net more profit on each additional dollar produced.

The conversion from commission basis to salary basis, together with the setting of the higher goals, can be structured as a “Win-Win” situation that benefits both the hygienists and the dentist.

Let’s assume that the dentist has already determined that in order to meet the practice’s goals, hygiene production has to equal $962 per day. (We have repeatedly seen practices increase hygiene production from levels of $700 per day to $1,000 or more per day.)

An equitable, Win-Win compensation alternative that meets the dentist’s goal and motivates the hygienists could look like the following:

Step 1: Effective immediately, both hygienists are placed on salary at $288 per day.

Step 2: The new production goal is $962 per hygienist per day, with advanced training to be provided.

Step 3: When each hygienist achieves an average production level equal to the new goal for one month, then he or she will earn a one-time increase in base salary of $25 per day, for a total of $313.

Increasing Daily Hygiene Production to $962… plus:

Under this proposal, neither hygienist experiences a reduction in current income due to the conversion from commission to salary. However, they do obtain the potential for realizing significantly higher levels of income, and the doctor increases his or her profit by $200 per hygienist a day. This is achieved through a combination of advanced clinical training and a bonus system that motivates the entire office staff to achieve ever-higher levels of production.

Next week I’ll discuss the economic differences between hygienists and dental associates.

Step One: Preparing to Hire a Dental Hygienist

“The moment I take my hands out of my patient’s mouth, my income stops.” Almost every dentist comes to this realization at some point in his career. At this point, many dentists start to think about investing in gold mines in hope of achieving that long-sought-after dream of passive income.

Passive income comes, as we know, from applying capital in such a way that we can earn income from the labors of others. The communists in Russia called this “exploiting the masses” and the net result was that the Czar lost his head. In America we call it “capitalism,” and once again, many dentists have lost their heads over the concept of passive income.

In a dental practice, income is derived from the treatment of patients. Traditionally, this process begins with the new dentist performing all treatments personally.

Eventually, as the practice grows, the dentist realizes that it pays to focus on providing more complex treatments which have a higher economic return for the time they take to perform. There is more bottom-line profit in crowns than in prophies, even though both are clinically necessary.

The next step is to hire someone to perform the prophies. At this point the dentist takes the first step toward becoming a full-fledged capitalist who is about to exploit the labor of another human being: a dental hygienist.

This capitalistic venture is really a two-step process. The first step is the application of capital to equip an operatory space with the tools and equipment necessary for the hygienist to perform the required treatments. This comes either from the dentist’s savings or from a capitalistic institution – the bank. In either case, this represents an investment of capital and a degree of risk.

At this point, the dentist has acquired one of the most important elements necessary in achieving passive income – an asset. The primary asset in every practice is operatory space. We measure this asset in terms of operatory days.

The concept that must be understood is the linking of capital assets (operatories) to time (the number of days you can use the asset) to generate income.

While this may seem very basic, it is amazing how few dentists ever fully utilize their asset of available operatory days to generate income.

Step two in the capitalistic process is to actually hire a hygienist… I’ll get to that next week, so stay tuned!

In this poll, we asked dentists:Do you support expanding the role of dental hygienists as independent practitioners?

Four out of five dentists don’t think hygienists should have greater independence. A full 81% of dentists responded, “No – many of these proposed changes would harm dental practices and offer patients a lower standard of care.” Only 19% replied, “Yes – Granting dental hygienists greater autonomy would improve access to care for patients across the country.”

The most significant factor in determining a dentist’s vote was geographic location. Rural dentists were four times more likely than their urban or suburban colleagues to support greater independence for hygienists. As rural areas are more likely to suffer from a shortage of dentists, it may be that rural dentists see hygienists as a way to improve access to care for rural patients.

Specialists were completely (100%) opposed to granting hygienists more independence. While most general dentists were in agreement, one in five general dentists (21%) did favor greater rights for dental hygienists. See the full survey results.

Here are some of the comments our dentists had to share:

Go to Dental School

• “If hygienists want to practice dentistry, go to dental school.” (suburban Illinois)
• “Hygienists would be great independent practitioners upon graduating dental or medical school.” (suburban Connecticut)

There’s No Replacement for a Dentist’s Supervision

• “Expanded roles would be great within a dental practice. It’s not a matter of money, but of complete and thorough care for all.” (urban Florida)
• “Expanding the role of hygienists MUST ensure that patients do not receive fragmented care.” (rural New Hampshire)

What About the Business Model?

• “The business model doesn’t make sense anyway… Hygienists generally do low-profit procedures; the overhead would kill them.” (urban Arkansas)
• “We have it in Colorado and it has had absolutely no impact. Hygienists are not the autonomous entrepreneurial sort.” (urban Colorado)
• “There is no money in prevention so these hygiene offices would go out of business.” (urban California)

Standards of Care Must Be Maintained

• “My concern is the insurance industry will find it easy to set up hygiene clinics that promote minimal care, not optimal.” (urban North Carolina)
• “Only a dentist can diagnose decay and periodontal disease.” (suburban Washington)
• “The mean reason that I need to do more surgery then would have been necessary is poor root planing by hygienists.” (Periodontist, urban Iowa)

In Defense of Dental Hygienists

• “It is us, hygienists, who have the potential to overlook dollar signs in our patients and do the right thing.” (Hygienist, suburban California)
• “I think that it would be great for hygienists to work on their own… in some cases they have a better eye for things than the doctor.” (Not a dentist, suburban Illinois)

Alaska Says It’s the Wave of the Future

• “Dentists have been trying to protect their turf by restricting or denying auxiliaries the ability to provide services… In Alaska, dental health aid therapists are working outside the regulation and licensing of dentistry. We need to wake up and be more receptive to auxiliaries doing portions of patient care and be in control of the education, licensing and regulation of these auxiliaries. It will happen with us or without us.” (suburban Alaska)

Read more comments or check out the full survey results. And feel free to post your own comments!