Where Do We Go from Here? What a Hygiene Career Looks Like in Group Practice

As they grow in popularity among clinicians at all stages of their careers, group practices and dental support organizations (DSOs) are offering new opportunities for dentists and their teams. We spoke to experts in the field about the effect this trend is having on the profession.

Katrina Sanders, MEd, BSDH, RDH, RF, a practicing dental hygienist, educator, and speaker, has seen a change in how practitioners view and approach patient care and hygiene. In the past, DSOs focused on maximizing patient insurance benefits by providing as many of them as possible with the meat-and-potatoes care they had come to expect. Some of today’s group practices and larger DSOs, however, are adopting new technologies and taking on such tasks as salivary diagnostic testing and the prescribing of probiotics. And, in the process, they are changing the face of hygiene education.

“We have seen a powerful influence in education and…[in] the expectations…within our profession to move patients away from the standard model [and toward]…looking at patients individually and developing unique care plans,” Sanders explains. “Sometimes, we need to integrate new products, procedures, technologies, and modalities to achieve that. So…born out of that is an interesting new wave of group practices.”

Sanders also sees these practices’ granting more autonomy to providers and making more resources available to them so that they can offer tailored, patient-centric care.

The attitude “used to be, ‘If we don’t have the product here in this office, or if corporate hasn’t thumbed up this new product/device/technology, then you don’t get to use it,” she observes, but “now they are starting to say, ‘if somebody wants a custom-made experience, let’s create that and empower our providers.’ So that’s been a neat shift.”

Belangie Perez-Torres, RDH, director of Hygiene Strategy & Operations at Aspen Dental Management, says that strong relationships with patients make collaborative care possible and that group organizations recognize that hygienists are instrumental in building the kind of relationships that motivate patients to get the care they need. “Collaborative care goes beyond…the…relationship between the doctor and hygienist,” she stresses. “It involves the patient in the co-assessment and codesign of their treatment plan to achieve oral health and overall health goals.”

Moreover, hygienists are more intentional in their questions. They are moving away from low-value inquiries about brushing and flossing frequency and asking about family history of gum disease and edentulism to fashion patient-appropriate plans. “If their parents had dentures before they were 50, that’s a concern,” she points out, because such a patient may be healthy today but at higher risk for future problems.

And technology facilitates fruitful conversations. For instance, she adds, patient management software improves the collection and organization of data, and having the information at hand helps patients and providers make the right decisions. “That’s where DSOs can be a differentiator because they recognize technology as a great investment, not just operationally but also clinically.”

Lori Hall, CDA, LDH, senior director of Hygiene Operations at Heartland Dental, says her company views hygienists as patient advocates as well as providers. At practices supported by Heartland Dental, the hygienist is the first clinician that patients see and the one who discusses medical history with them and relays that information to the dentist. “If they can make sure the doctor understands the things going on with the patient from the get-go, then the clinical team is going to take better care of their patients,” she says.

Technology is also essential to the changing role of hygienists. Many Heartland practices offer better patient care with lasers and intraoral scanners like the VELscope® Enhanced Oral Cancer Assessment System, which identifies areas of the mouth clinicians should examine more closely. “That’s a great thing” about this system, she adds, it “could save someone’s life.”

And yet, some of the basic skills hygienists learned in school, like measuring blood pressure, are coming back because hygienists know that the symptoms of hypertension and diabetes show up early in the mouth, so there is a renewed interest in detecting these conditions as soon as possible.

“Over the years, I’ve seen us start looking at patients…more holistic[ally],” Hall says. “We are on the front lines, catching these things and…help[ing] patients by referring them to their physicians.” She attributes some of these developments to a changing patient population, one that is more aware of the importance of oral health and familiar with the things being discussed in the operatory. And technology only enhances communication: “You might think that scanning would be just for Invisalign or ortho, but we can show patients so much with that, like malocclusion and the connection to perio. You can show someone the plaque,” she says. “From a patient-education standpoint, it’s amazing what it can do.”

Brandi Hooker Evans, MHE, RDH-ER, owner and president of Stellar Outcomes, thinks that group practices have allowed hygienists to shape their own careers as dental health providers. She isn’t sure whether that is because group practices have influenced the profession or because hygienists have begun to realize the significance of their role, but that realization, she believes, is crucial to today’s hygienists. Moreover, large organizations can afford to offer excellent benefits and give hygienists access to specialty dentistry, thus enriching their experience. Having that knowledge and those tools is very exciting: “If you are willing to be a team player and own your career by providing quality assessment and diagnosis, the level of disease in the population is such that you will…[earn] double, if not triple, [what] a typical hygienist [earns]. And if you are working with a bonus system, which many big corporate groups…[offer], you make considerably more money than [by] just clocking in and out.”

There is a caveat, however. If you only “pick and scratch” teeth in 40-minute, back-to-back appointments, or sometimes in a double-column model, that’s a quick path to burnout. Instead, Hooker Evans encourages hygienists to seek out the sweet spot where they can earn more while seeing fewer patients, delivering better care, and providing the comprehensive treatment each of them needs.

“You are less stressed, enjoying more one-on-one time with your patients, providing higher quality care—which is more profitable—and…liv[ing] a more comfortable life,” she says. Another aspect of working in a corporate setting is that you can provide pro bono care to those patients who cannot afford what they need because when overhead is lower, there is more room for philanthropy. “Most of us in the dental profession showed up hoping to help people. So, if we can help people in a more profound way day-to-day…become more profitable, and…have the capacity to donate service…the emotional satisfaction of that career increases exponentially.”

Of course, there are also disadvantages to working in a group. Hooker Evans acknowledges that some have a culture of low-quality, high-volume care. However, she would encourage hygienists to “just say no” under such circumstances. Although she doesn’t judge hygienists who submit in those situations, she stresses that in 20 years as a hygienist, she hasn’t known anyone who feels happy, healthy, or whole in such a scenario.

“In our heart of hearts, as a hygiene community, we know that type of practice is not using our skills, knowledge, and license to the best of its ability,” Hooker Evans says, adding that adopting a whole-health approach to hygiene often outproduces high-volume patient rosters. “Having a quality conversation with the practice owners about our vision for the future and what we want to be as providers and what we want to see for our patients is critical to moving away from that corporate burnout.

Overall, Change Has Been Good for Hygienists

According to Sanders, many large group practices and DSOs have had a positive impact on the profession. Some host all-team meetings and annual educational sessions. A leadership mentality at the top fosters mentorship and the opportunity to elevate the level of care team members provide, often outside traditional hygiene. Without this, 2 hygienists at the same practice could be delivering vastly different patient experiences. By focusing on core values and recognizing “rock star” staff whose critical thinking and daily actions improve care, this kind of leader fosters excellence.

Sanders also appreciates that group practices tend to make a greater effort to treat periodontitis, which affects nearly half (47.2%)of adults between the ages of 30 and 79.¹ By contrast, the number of gum disease treatments are much lower at private practices. Unfortunately, some misinterpret this difference as overdiagnosis on the part of groups that are pushing hygienists to deliver more care than patients need. The irony, she says, is that group practices’ periodontal treatment percentages align more with what dental professionals know to be true about the prevalence of gum disease.

Perez-Torres believes that hygienists should champion new technology and patient care initiatives. Those who do, “at least in the group practice, tend to have more growth opportunities…. For example, they might become a trainer or grow into a clinical support role for hygienists, like a hygiene manager or director. We even have hygiene recruiters,” she points out.

What Does the Future Hold?

Perez-Torres says that our greater understanding of the connection between oral and overall health and the rapid growth of artificial intelligence will prove synergistic in terms of patient outcomes and, therefore, that the industry will seek hygienists who can train others in the use of new technology. Hygienists are often involved in product development, she notes, because their clinical experience bridges the gap between engineering and patient experience. And these trends allow for different career paths outside the operatory. “I’m seeing many more hygienists in DSOs in VP roles.… [At] Aspen Dental, we have two, and I’ve seen other DSOs promote many hygienists into leadership roles,” Perez-Torres says. “And I love that.”

Looking ahead, Sanders sees 3 critical developments:

1. The shortage of hygienists could push providers into a no-hygienist model. As hygienists leave the profession and clinicians try to fill empty roles with new graduates, Sanders envisions a future in which dentists clean their patients’ teeth or move hygienists to a double-column scenario, in which they treat 2 patients simultaneously and an assistant picks up the slack.
2. Hygienists will empower themselves. Sanders has seen many hygienists’ learning to provide myofunctional therapy, perform A1C and airway screenings, collect samples for salivary testing, and deliver nutritional diagnostics services. They want to become certified in Botox and dermal fillers, which she considers a viable option. Some are becoming anesthesiologists, numbing all patients at large group practices, while others are assisting periodontists during surgery. Some pursue mobile dentistry and administering care in nursing homes, rural areas, and Native American reservations. And still others may embrace telehealth and work independently.
3. Group practices will offer different services. Sanders thinks some will adopt a boutique-style or spa-like approach. Instead of serving everyone, they will see patients who want a particular type of care. These niche, branded practices can develop a standard operating procedure they can duplicate and franchise as demand dictates.

Sanders has been involved with group practices throughout her career, including working in one when she was just out of school. She learned a lot and enjoyed her time there and thus encourages clinicians to consider their options and remember that there is always a spectrum in terms of autonomy and benefits between a large group and a private practice and that the latter will always have its own culture and will focus on certain aspects of care.

“We are starting to see some really neat trends, with…these group practices…working to empower their providers and elevate patient health,” she says. “I’m excited to see what happens—as long as we keep our sights and our minds on elevating the health of our community first and foremost.”

Hall, too, is optimistic about the future of technology-driven roles but thinks that as long as hygienists are coming into the profession, there will be demand for them at dental practices. Hooker Evans is likewise enthusiastic. Among her coaching and continuing-education clients, she senses a hunger for more. The oral-systemic health connection, she says, has ignited interest in what hygienists do, among those who have been working with patients for 25 years as well as among new graduates.

She also sees the burnout model ending within the next five years. Owning one’s career leads to a desire for more education, a dedication to a higher level of care, and a better work ethic. The passion for this career is spreading like wildfire. “More and more people are saying this isn’t enough, and I want more…. That will make the next 5 and even 10 years look different…and the more [that] hygienists and dentists…hear this, the more excited everyone gets. It’s shifting the entire culture to more fulfillment and excitement. It makes me feel so hopeful.”

Reference

1. Periodontal disease. Centers for Disease Control and Prevention. Updated July 10, 2013. Accessed April 4, 2023. https://www.cdc.gov/oralhealth/conditions/periodontal-disease.html