EXPECTATIONS OF WAGES

KNOW WHAT YOU ARE WORTH AND BELIEVE IN WHAT YOU ARE WORTH

LISA DOWST-MAYO, RDH

I consider myself someone who tries to stay up-to-date with the changes in dentistry. I read my RDH magazine monthly as well as other dental publications. I have noticed how easy it is to find articles concerning almost every clinical aspect of dental hygiene, but it's difficult to find articles offering financial advice. Recently, I was offered a new job at a general dentist's office. I was really excited about this office; it was a great opportunity to work for a wonderful doctor. My new employer asked me what I expected to be paid during our interview, and I quickly realized I wasn't exactly sure. I was new to the area and not exactly sure what the "going rate" was.

I went home and thought about that conversation, and it prompted me to start doing a little research online. My searches yielded little advice specifically related to dental hygiene pay and production. Some general statistics were helpful, but nothing concrete or very useful in answering my future employer's question, "What do you expect to be paid?" That's how this article originated for me; I want to offer helpful advice to other dental hygienists who, like me, are not exactly sure what they should be getting paid.

Let's face it, dentistry is a business. Dentists are very aware of this since, in most circumstances, they are the business owners. Hygienists tend to spend a lot of time learning about the advances for patient care and techniques, but sometimes don't give the same focus and thought to what they should be getting paid for those services.

Like most of you, I have had mixed experiences when it comes to pay throughout my career. I have worked for very honest, caring, and fair dentists who made sure my family and I were provided for financially. They made good on all their promises for pay raises and bonuses. They were OK with my taking time off for family emergencies or commitments and made working for them a pleasurable and relaxed experience.

I have also had those not-so-great experiences. I worked for one dentist who promised bonuses, pay raises, and advancement, then did not make good on any of those verbal promises one year later. Dental hygienists as a whole are very caring, trusting, patient-oriented, empathetic people. When our employers make verbal promises to us we tend to trust and believe in them; I know I did. Unfortunately, in the "real world," not all business owners are as honest and fair as we would like to believe they are.

Hygienists are sometimes fearful to ask for written contracts as new hires. With the downturn of the economy, dental hygiene positions are scarcer than they used to be, so no one wants to lose out on an opportunity. There are not many other professions where a written contract/agreement is not part of the hiring process; so I am not sure why dentistry sometimes operates this way. My advice, based on my previous experience, is to always get everything in writing.

As with other professions in America, experienced workers are competing for the same jobs as new grads. Like it or not, new grads will often work for less money until they gain the experience it takes to advance their pay scale. It has been noted in multiple issues of Time magazine over the last couple of years, even job seekers with higher degrees such as MBAs are having to take entry-level positions in companies. Corporate America does not have the money to pay high-executive salaries like they used to.^3,4,13 Dentistry is no different.

Our profession is centered on the principles of community service and health, individual patient care, and delivering preventive services. These qualities in a profession are rare and should be appreciated and valued. Throughout my years of dental hygiene, I have met many colleagues who are timid about asking for raises in their workplace or asking to be paid what they feel they are worth. Dental hygienists provide a service in a dental office that no other professional can provide. Our licenses allow us to deliver very specific services that a registered dental assistant or front office personnel cannot deliver. Most dentists do not want to do their own prophies or scaling/root planing. Their time is better spent in higher-dollar restorative procedures and not in lower-dollar preventive services. Unless dentists want to be doing 10 prophies a day instead of crown and bridge procedures, they have to employ dental hygienists. So, if we are such a necessity in the survival of a dental practice, why do so many hygienists think they should not be paid fairly for their specialized skills?

When trying to determine a fair wage in our profession, many hygienists are left feeling confused and nervous. They will ask for a specific salary or hourly figure based on what they have heard is the going rate in their area. I did that same thing, as previously mentioned. But I then posed the question to myself, "Who decides this going rate?" Where did that figure come from? Despite all of my research, I still cannot answer that question; but I did find a way to calculate my worth to my employer.

Throughout my years as an RDH, I have also met hygienists who say they are afraid of asking their employers for a certain wage or a raise for fear of being fired or having their hours reduced. A dentist who would cut back your hours or make you clock out when you are not seeing patients because you are a "high-dollar-employee" may not be the person you want to work for long term. That sort of environment can be stressful and harmful to your motivation.

Many dentists refer to us as "team members." If we are to be supportive of our offices and our fellow team members, then we obviously have to be a team players. Clocking out when patients are not scheduled will not allow us to support our teams. When I am not with a patient, I am helping the assistants and the front desk with their daily activities, restocking rooms, working on recare lists, and calling patients to fill in the schedule. I help with ordering and budgeting of the hygiene department and researching new products to introduce to the office.

The hygienist is often the unofficial leader in the back office, so my advice is always to lead by example. It will increase your worth and position in your office. There are also multiple publications you can read that offer advice when asking for a raise, (see reference page).^7,10,11

PRODUCTION DOLLARS

Many dentists have either sought advice from dental consultants or signed with their services to help run their practices. I have listened to many consultants over the past 10 years. While they all have different views on how hygiene departments should be run, or how periodontal disease should be diagnosed and treated, one common thread throughout their recommendations is hygiene pay. Generally speaking, a hygienist should be paid about a third of what they produce. Total hygiene production should equate to about a third of the total office production.^8,14 Simple, right? When you know this fact, you can now mathematically come up with a specific wage that is fair.

On the flip side, you now know what a dentist expects from his/her hygienist. For a dentist to afford you, you have to be producing at a certain level. While dentistry is a profession centered on patient care, the cold hard truth is that dentistry is also a business. If the dentist is not making money, he/she cannot afford to keep you on staff.

I am shocked when I meet hygienists who have no idea what they produce, what the total office production is, or how their production affects the whole team. A hygienist colleague once told me, "We have a goal in our office. But I don't know what it is, and I don't care." My internal reaction was "What?"

How can you not care about your production goals? To me, that is a roundabout way of saying you don't really care about your practice, your fellow team members, your employer or your patients' level of care. Dentists cannot afford new equipment or offer their patients the latest technology in dentistry if they do not have the money to buy it. What we produce directly affects our patient care.

Here is what I have noticed about my production numbers through the years. That number is not just a description of what I am producing; it is a true reflection of my total patient care. With the experts in our field telling us 30 to 50% of hygiene production should be perio-related procedures, if I'm not hitting that percentage, then I am not treating all of my patients' active periodontal disease. If my numbers are not where they should be, it's not because I'm not "selling" enough dentistry; it's really because I am failing to meet the needs of the patients in my practice.

I never used to view dental hygiene as a "sales" profession, but I have learned that it kind of is. I know the word "selling" has a stigma in our profession, but hear me out. Throughout my years of practice, I learned something about "selling" dentistry. If I am doing my job correctly - the way I was taught in dental hygiene school - then my daily production sheet should read a certain way. There should be a certain percentage of prophies, perio procedures, and adjunct services such as take-home products and sealants.

Based on the trends in dentistry, somewhere between 50-70% of Americans have some sort of periodontal issue (from gingivitis to advanced periodontal disease),^{1, 2, 5, 9} 42% of children have/had dental decay,⁹ and 92% of adults have/had dental decay.⁹ If your production sheet does not reflect these established national rates, then you need to reexamine the way your office is identifying, diagnosing, and treating dental disease.

Here's an acronym I created for myself to help remind me each day what I am here to do for my patients - not "sell" them dentistry but P-R-E-V-E-N-T disease.

• Patient always comes first.
• Realize each patient's unique personality traits.
• Eyes, open my patients' eyes to their treatment needs.
• Value, create value for the patient of the needed service. If people see no value to a service, they will not pay for it. I have to create that value.
• Educate my patients in a way they need me to. Know their personality styles and develop verbal skills to talk to them in a way they can understand.
• Never assume anything about anyone. No judgments.
• Total office production will increase as a result of good patient care.

The bottom line to hygiene production in any office is this: Dentists should not expect their hygiene department to bring in a high profit. Between the overhead, supplies, hygiene salaries, and amount charged for preventive services, the dentist is lucky to break even or maybe profit slightly. The dentist truly rolls a high-dollar profit from the hygienist through restorative dollars that come from our chair. Through the hygienist's encouragement, identification of dental needs, and patient education, patients will increase acceptance of necessary restorative treatment. Offering same-day dental treatment or scheduling patients back on the dentist side while they are still in your chair can make a big difference. In my opinion, the dentist should not be the only one in the office concerned about production, collections, and dollars. The whole staff, including the hygienist, needs to be on board with office goals, especially while the economy continues to struggle.

There are multiple ways to pay hygienists, all of which come with pros and cons for the dentist, as well as the hygienist.^6,14 The sidebars in this article share some of the details about the payment options.

In summary, dental hygienists need to be aware that dentistry is a business and treat it as such. If you invest in your practices the way your employer does, everyone wins in the end. If you don't ask for a raise or fair salary, then why would anyone just give it to you?

In no way is this article intended to encourage dental hygienists to demand more pay from their employers or ask for unreasonable wages. This was written with the intention of helping others who, like me, are struggling to answer their employers' question of, "What do you expect to be paid?" The relationship between the dentist and hygienist is one the most valuable relationships in the dental office. This article is intended to help you and the dentist come to mutual agreement in pay. I also hope it helps open the door to that conversation, as it can be an uncomfortable one for you and your boss. My final advice is this: know what you are worth, believe in what you are worth, and then ask to be paid what you are worth. Good luck!

REFERENCES

1. Bonito AJ, Lux L, Lohr KN. "Impact of Local Adjuncts to Scaling and Root Planing in Periodontal Disease Therapy: A systematic Review." Journal of Periodontology. August 2005, 76(8):1227-1234.
2. Burt B. "Epidemiology of Periodontal Disease." Academy Report, Position Paper of the AAP. May 2005, 76(8): 1406-1413.
3. Caplan J. "The Six-Figure-Job Hunt." Time Magazine. December 11, 2008.
4. Caplan J. "Why MBA Means 'More Bitterness Ahead'." Time Magazine. October 23, 2008.
5. Eberhard J, Jepsen S, Jervoe-Storm PM, Needleman I, Worthington HV. "Full-Mouth Disinfection for the Treatment of Adult Chronic Periodontitis." Cochrane Review. October 2008. http://www.cochrane.org/reviews/en/ab004622.html.
6. Farmer T. "Getting Paid What You're Worth." RDH. http://www.rdhmag.com/index/display/article-display/117461/articles/rdh/volume-18/issue-6/feature/getting-paid-what-youre-worth.html.
7. Heathfield S. "How To Ask for a Pay Raise." Ask.com http://humanresources.about.com/od/salaryandbenefits/a/ask_raise.htm.
8. Miller K. "Dental Hygiene Compensation." RDH. October 1, 2006. http://www.dentistryiq.com/index/display/article-display/275662/articles/rdh/volume-26/issue-10/feature/dental-hygiene-compensation.html.
9. NIDRC. http://www.nidcr.nih.gov/.
10. Roth JD. "Five Tips for Asking for a Raise." Time Magazine. August 4, 2011.
11. News Core. "How To Prepare To Ask for a Raise." February 8, 2012. http://www.foxbusiness.com/personal-finance/2012/02/06/how-to-prepare-and-ask-for-raise/.
12. Sanburn J. "5 Tips To Help You Ask for a Raise." Time Moneyland. April 5, 2012.
13. Tahmincioglu E. "Working for Free: The Boom in Adult Interns." Time Magazine. April 12, 2012.
14. Waterson D. "Compensating Hygienists." Dental Economics. 2008. http://www.dentaleconomics.com/index/display/article-display/8257498922/articles/dental-economics/volume-101/issue-10/practice/compensating-hygienists.html.

HOURLY

When you are interviewing for a new position, be ready to answer the question, "What kind of pay are you looking for?" Be direct, offer a $3 to $5 dollar range, and then be ready to discuss why the dentist should pay you that amount.

Advantages
•Hygienist does not have to worry as much about production or scheduling.
•You earn the same amount whether you see one patient or 10 patients in a day.

Risks
•Falls to the dentist. If the hygiene book is not full or the hygienist is not hitting production goals, the dentist will lose money. The dentist will be paying more to the hygienist than he/she is bringing in.

SALARY

This is not a common approach to paying hygienists; most dentists will opt for hourly pay as opposed to salary. On salary, the dentist pays you a flat rate no matter how much or how little you produce.

Advantages
• Hygienist assumes little risk. If the hygiene schedule falls apart, the pay does not change.

Risks
• Risky for the dentist because if the hygiene schedule is empty, he/she is still paying a salary to the hygienist. The dentist loses money by paying a hygienist who is not seeing patients.

BASE HOURLY + COMMISSION

I'm surprised that more offices do not opt for this type of pay grade for dental hygienists. In my experience, it's a win-win for both the hygienist and the dentist. This pay scale comes with a certain hourly rate and a percentage of commission based on production. See chart below for an example.

Advantages
• Hygienist is more concerned about office production and goals. The hygienist is more like a "business owner" of the hygiene department and not just an employee. Hygienist is also more concerned about his/her schedule and keeping up with recare.
• Biggest advantage to the dentist is if your hygienist does not produce, then he/she doesn't lose money to high hygiene salaries. This type of pay scale motivates hygienists and forces awareness of production for the practice. Hygienists are encouraged to preappoint patients and be on top of recall.
• Most of the time, this pay scale will definitely work to the hygienist's favor, with higher pay earned by hard-working hygienists.

Risks
• If the office is in-network with many insurers or does a lot of "courtesy writeoffs," this can affect hygiene pay. If this is the case, then changing the base salary may be something to investigate.
• Another risk could be a hygienist getting "production-hungry." Everyone needs to make sure ethical dentistry is still a priority and patient care is not affected. The hygienist needs to be OK with pay fluctuations; some paychecks may be higher or lower than others depending on hygiene production. But, at the end of the month and certainly the year, it tends to all even out.

Suggestions
• Dentist could offer a better/or situation for a specific length of time for new hires. Hourly plus commission or a specific hourly pay for three to six months until the hygienist is better established in the practice and his/her recall is in effect.

I worked on this type of pay for years. My patients' well-being is always my top priority, and I would never compromise that for profit. This principle should hold true regardless if commission is being utilized. I could see where commission may cloud a person's judgment; but I hope that would never happen since we all took an oath in our dental programs to always do the greater good for our patients. I do not "sell" dentistry to my patients to roll a profit, nor do I think about my commission dollars during the day.

I advise patients on what they need and why, and then encourage them to proceed with the treatment my dentist recommends. I recommend electric toothbrushes and at-home products when necessary and not to increase my daily production sheet. I noticed, if I did my job the way I should, the money was always there.

Actually, I feel this commission structure keeps me more grounded and honest in my treatment recommendations with patients and motivated me to start same-day perio treatment. It also made me very aware of my production and where I was financially for the month. I had the pleasure of working for an extremely ethical and fair dentist who always made sure I was compensated well for my hard work. For example, when he went in-network with new insurance companies, he adjusted my base salary accordingly so I never made less money than he was previously paying me.

STRAIGHT COMMISSION

Usually equates to roughly 33% of total hygiene production.

Advantages
• Dentist is risk-free in this scenario; if the hygiene schedule is not full or hygienist does not produce, then the dentist does not have to pay for downtime.

Risks
• Risky for hygienist, especially in a new practice or a practice where recare protocols are not strong.
• With the current economy, the hygienist needs to be very careful when agreeing to this type of pay scale. You need to know what percentage of write-offs the office does. Are they in-network with insurance companies; are they out-of-network; do they take DMO plans or CHIP? You need to know what their fees are for procedures as this number will directly affect your pay.
• Hygienists still need to realize they are part of the team and should stay late or come in early to help with necessary tasks around the office. Some hygienists think if they are not seeing patients and not making money, why stay at the office? Be very careful of this type of attitude; it will affect your whole team and sometimes lead to tensions with fellow workers.

HOURLY PLUS BONUS SYSTEM

Bonus is a perk in this scenario and should not be expected as a consistent part of salary.

Example
Hygienists get a percentage of what they produce over their goal. The most common percentage is 10% to 20%.
Daily production goal = $1,000
Actual production = $1,350
$1,350 - $1,000 = $350
$350 x 15% = $52 bonus

Advantages
• Dentist rewards a high-producing hygienist without having to raise base pay.

Risks
• Bonus systems can get complicated and can be difficult to track.
• One can also utilize an office bonus system. Some dentists will calculate how much restorative revenue comes out of a hygiene chair (hygienist scheduling a patient for restorative treatment during routine recare) and give a percentage of that.

LISA DOWST-MAYO, RDH, graduated with highest honors from the Caruth School of Dental Hygiene at Baylor College of Dentistry in 2002. She is an active member of the American and Texas Dental Hygiene Associations and has held various leadership positions in her local components since she graduated. She has published articles in both Access and RDH magazines and lectures on dental lasers, contemporary periodontal therapies, and the dental treatment for patients with AD/HD. She currently resides in San Antonio with her husband and two young babies who keep her very busy. Lisa practices clinical dental hygiene at Dominion Dental Spa, the office of Dr. Tiffini Stratton, DDS.