Ep. 45: Getting Serious About Your Hygiene Department, Part 1
The hygiene department is one of the biggest weaknesses for most dental practices. Even if you think you’re hygiene department is doing pretty well, you may be losing patients and underperforming more than you think. So in this week’s episode, Jeff lays out how to determine your actual performance and where you should be if you were truly maximizing hygiene production.
Topics:
:11 – Evaluating your true hygiene performance
12:18 – What should your expected revenue be?
21:21 – How HMOs and PPOs affect this
Links:
Hygiene Formula spreadsheet - https://www.mgeonline.com/hygieneformula
Compare fees - https://feelookup.com
The MGE New Patient Workshop - https://www.newpatients.net
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Questions From This Episode
How can you tell if your hygiene department is actually underperforming?
Not by how busy it feels or by total hygiene revenue, those can look healthy while hiding a real problem. The real indicator is your hygiene compliance percentage: how many recall visits you're actually seeing compared to how many you potentially could be seeing based on your total patient base. A practice can have full schedules, happy hygienists, and solid production, and still be capturing under a third of its real recall potential.
What's the hygiene formula, and how do you calculate your true recall potential?
Take your total unique patient charts over the last five years, multiply by two for two recalls a year, then subtract a conservative 40 percent for attrition. Divide that number by the weeks your practice is open, then by how many patients a hygienist sees in a day, and you get your potential weekly hygiene days. Comparing that to your actual recall volume over the last few months reveals your real compliance percentage, which is often far lower than practices assume.
What impact do PPOs and HMOs have on hygiene department profitability?
A significant one. Since hygiene has very low material costs, the hygienist's salary is the main expense, and that salary stays fixed whether they're seeing full-fee patients or heavily discounted PPO and HMO patients. In one real example, normal fees produced about 1,300 dollars a day per hygienist versus 672 dollars a day at PPO rates, roughly a 50 percent difference, which can push hygiene salary costs from around 30 percent of revenue up to 60 or 70 percent.
Why does hygiene tend to have a much higher profit margin than restorative work?
Because hygiene carries almost no material cost. There's no crown, no implant, no lab fee, just inexpensive prophy paste and low-cost digital X-rays. Once the hygienist's salary is covered, nearly everything else collected is profit, which makes a fully compliant hygiene department one of the highest-margin parts of a practice.
Roughly what percentage of patients does a practice typically retain, and why does that number matter so much?
The hygiene formula conservatively assumes a practice loses about 40 percent of patients over a five year window, though practices with genuine retention efforts in place should be losing well under 20 percent. That gap matters because most of a practice's real recall potential is sitting in patients who are still recoverable but simply aren't being called back in, not in patients who are permanently gone.
Episode Transcript
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For general dentists, we all know that building a strong hygiene department is desirable and important, so why does it remain such a persistent problem? I'd actually rank an underperforming hygiene department as one of the two leading weaknesses in a dentist's business model, the other being case acceptance.
The average doctor genuinely wants a great hygiene department. It can be a wonderful profit center, and more importantly, it's essential to actually fulfilling your practice's purpose. If that purpose is restoring health, function, and aesthetics, and maintaining that for your patients, you're going to struggle to do that if you're not seeing them regularly. How else are you catching small problems before they become big ones? That's precisely why a hygiene department matters, it's both needed and genuinely wanted, and yet it's still an area that consistently underperforms.
That's what I want to cover this week and next week, why hygiene departments underperform, and more importantly, the concrete steps you can take to fix it. This is a two part episode, there was simply too much ground to cover in one. This is part one. My name is Jeff Blumberg, and I'm your host.
Let's start with the two major reasons hygiene departments underperform, and they're actually fairly simple. First, the doctor or office manager doesn't realize the department is underperforming in the first place, they think it's going fine. Second, they may sense it's underperforming but genuinely don't know what to do about it.
Let's start with reason one, since before you can fix your hygiene department, you first need an honest read on its actual condition. You might not think it's underperforming. Maybe it's busy, you have a solid periodontal program running, very few cancellations or no-shows, five or six days of hygiene, two hygienists you're genuinely happy with, and production that feels satisfactory. That's great, but this is exactly where you can miss the forest for the trees.
Production, or hygiene revenue, is really a side benefit of a healthy hygiene department. The actual measure of whether your hygiene department is working is whether it's consistently growing, because sustained growth means you're actually retaining patients. That's the critical distinction: revenue alone doesn't tell you this, since revenue can come from plenty of sources, a productive periodontal program, a lot of new patients coming through hygiene, without telling you how many existing patients are actually staying active on recall. That recall retention number is the real measure of hygiene department health.
Here's an example. Say you're an average practice adding 30 new patients a month, which is a common number, plenty of practices do more, some do less. That's 360 new patients a year. If you're retaining a solid 80 percent of them, that's 288 patients retained. Multiply that by two recall visits a year, since most patients need at least two, some need three or four, and you get 576 additional recall visits generated purely from that one year's worth of new patients.
If your practice is open 50 weeks a year, that's an average of 11.5 additional recall visits a week from just those new patients. If a hygienist sees 8 patients a day, that's 1.4 additional hygiene days a week added in a single year, purely from steady new patient growth with reasonable retention. Play that forward five years, and you've added 7.2 days of hygiene to whatever you started with. If you had 4 days of hygiene five years ago, you should now have roughly 11.2 days of hygiene from recall alone, before even counting periodontal therapy or new patient intake work also running through hygiene.
At that point you're realistically looking at 14 to 15 days of hygiene a week, which means 3 to 4 hygienists, and likely enough overall patient volume to justify an associate, all from a fairly average new patient number. I want you to sit with those numbers for a second, because based on what I actually see in practices, this is rarely the reality. What I typically see instead is an office with these kinds of underlying numbers struggling just to keep 4 days of hygiene full, new patients and periodontal therapy included.
So the first real step in building your hygiene department is a thorough but genuinely simple evaluation of what's actually happening in your practice. I'd recommend using what we call the hygiene formula, a spreadsheet where you fill in three numbers and it calculates the rest for you. Let me walk through how it works.
The first number you enter is total unique patient charts over the last five years. You might wonder why five years rather than the more common two-year active patient definition. That two-year window is largely a broker convention used in practice sales, it doesn't mean patients you haven't seen in three or four years have stopped considering you their dentist, most of those patients are genuinely still recoverable.
Let's use sample numbers, a practice that's seen 4,000 unique patients over the last five years, a fairly common figure. Multiply by two recalls per patient per year, giving you 8,000. Then subtract for attrition, and the formula uses a deliberately conservative 40 percent here, well above the under-20-percent loss rate you'd expect with genuine retention efforts in place, but conservative enough to account for five years of natural drift. Subtracting 40 percent from 8,000 leaves 4,800, your potential annual recall visits from that patient base.
Divide that by the weeks your practice is open, say 50 weeks a year, and you get roughly 96 potential weekly recall visits. Divide that by 8 patients per hygienist per day, and you get 12 potential days of hygiene a week, purely from recall, accounting for a full 40 percent attrition rate.
Once you have that potential number, you compare it against what you're actually producing. Enter your total recall appointments, three, four, and six month recalls and periodontal maintenance included, over the last four months. Here's a real example from a newer client: 510 recall appointments over four months, which annualizes to 1,530 a year, or about 31 a week. Divide 31 by the potential 96, and you get a hygiene compliance percentage of roughly 32 percent, under a third.
That's how a practice can genuinely believe things are going well, a busy hygienist, solid hygiene production, four to five days of hygiene, while actually operating at three to four times below their real potential. As long as the hygienist isn't sitting idle or sterilizing instruments with no patient in the chair, and you're paying them 50 to 60 dollars an hour regardless of who they're seeing, everything feels fine on the surface. That's the forest-for-the-trees problem.
This is also your genuine growth statistic, and I'll get further into tracking it next week. In this example, an office seeing 31 recalls a week against a potential 96 translates directly into real dollars. Using sample fees from a genuinely low cost of living area, Oklahoma City suburbs, specifically to avoid any argument that the numbers are inflated: an average periodic exam runs 58.50 dollars, four bitewings run 68.50 dollars, and an adult prophy runs 99 dollars, so a full visit with exam and X-rays runs about 226 dollars, and a prophy-only visit runs 99 dollars.
At 31 recalls a week, roughly 130 a month, split evenly between full visits and prophy-only visits, that's approximately 21,775 dollars a month, or about 261,000 dollars a year in recall revenue alone. A practice looking at that number, plus periodontal and new patient revenue on top, might reasonably think, we're doing over 300,000 dollars a year in hygiene, we're doing fine.
But look at what happens if that same office actually reached its full potential of 96 recalls a week, about 400 a month. At 8 patients a day, that's 50 days of hygiene a month, which at 17 working days a month means roughly 3 full-time hygienists just for recall, likely 4 total once periodontal and new patient hygiene work is factored in. Using those same average fees, 400 visits a month split evenly comes to about 65,000 dollars a month, or 780,000 dollars a year, in recall revenue alone, more than triple what the same practice was collecting at 32 percent compliance.
Hygiene also carries an exceptional profit margin compared to restorative work. A crown or an implant comes with a real material cost, the crown itself, the implant, the lab fee. Hygiene's main cost is the hygienist's own time and salary, since prophy paste is inexpensive and digital X-rays cost next to nothing. Once you're covering that salary, the margin on everything above it is substantial.
And this is patient base you already have. Practices routinely spend significant time and money acquiring new patients, which is worthwhile, but spend very little effort actually retaining the patients they already have. Bringing existing patients back into active recall costs relatively little compared to new patient acquisition, and the profit margin on that recovered production is excellent. Going from 1.5 hygienists to potentially 4, along with the resulting periodontal treatment and referral-driven new patients that additional traffic generates, is likely more volume than a single solo doctor could keep up with alone, which is exactly the kind of growth that eventually justifies bringing on an associate. This, genuinely, is the key to sustained practice growth.
So the first thing to do if you want to build your hygiene department is honestly evaluate where you currently stand. If your compliance percentage comes back in the 30s, 40s, 50s, even 60s, your hygiene department likely isn't nearly as healthy as it feels, and you're losing a meaningful number of patients through the back door as fast as you're bringing new ones in the front. In the example we walked through, the gap between current and potential production works out to roughly 500,000 dollars a year in lost revenue.
Here's a way to think about the stakes: imagine two otherwise identical practices, each collecting a million dollars a year total, both for sale. One collects 261,000 dollars from hygiene, with the doctor personally producing the other roughly 740,000 dollars. The other collects 780,000 dollars from hygiene, meaning the doctor is only personally producing about 220,000 dollars, which, given that much hygiene traffic, would functionally mean the doctor is barely doing any restorative work at all, essentially just checking hygiene patients. Which practice would you rather buy for a million dollars? I'd take the one with substantial hygiene volume every time, since that reflects real, sustained patient traffic flowing through the practice.
This recall compliance number is your genuine growth statistic, the foundation of recurring practice revenue. That's the first step before taking any action to build your hygiene department, which I'll cover in next week's episode: get an honest read on exactly where you stand right now.
One more important consideration before we wrap up: PPO and HMO participation. If your practice carries a heavy HMO load, you're likely charging next to nothing for hygiene visits. I recently evaluated a practice for a client with significant HMO and PPO participation, and the average fee they were actually collecting for a standard adult prophy code was 38 dollars, in an area where the average hygienist salary runs over 40 dollars an hour. That practice was losing money bringing certain patients in the door. With heavy HMO participation specifically, building out your hygiene department this way simply doesn't work, you'll lose money doing it.
PPOs specifically are worth examining closely too, since heavy PPO participation quietly destroys hygiene profitability and pushes practices toward strange workaround solutions trying to recover margin. Using the same Oklahoma City example: a hygienist seeing 8 patients a day at full fee, half full visits and half prophy-only, produces about 1,300 dollars a day. I also pulled MetLife's published fee data for that same zip code from their site, feelookup.com, an exam paid at 27 dollars, bitewings at 31 dollars, and a prophy at 55 dollars, a full visit worth 113 dollars against the area's normal 226 dollar fee, essentially a 50 percent write-off.
At MetLife rates, that same hygienist's daily production drops to about 672 dollars instead of 1,300, while their salary, typically 38.40 to 47.80 dollars an hour in that market, stays exactly the same regardless. At full fee, hygiene salary costs typically run about 29 to 37 percent of revenue. Running primarily PPO patients, that can climb to 57 to 70 percent of revenue, which makes genuine profitability extremely difficult to sustain.
If you're seeing heavy PPO infiltration, part of building a genuinely strong hygiene department is looking seriously at reducing that participation over time. Done correctly, dropping a PPO typically costs you around 30 percent of the patients in that specific plan, real patient traffic, but often little to no actual revenue, since the higher full fee on remaining patients tends to offset the smaller patient count. If you're doing three PPO crowns at 800 dollars each, that's 2,400 dollars. Drop the plan, lose one of those three patients, and two crowns at your full 1,400 dollar fee comes to 2,800 dollars, more revenue from less volume, lower material cost, and no lab fee pressure to boot.
We cover this in much more depth at the MGE New Patient Workshop if you want to dig further into it, link on the episode page. I know this was a numbers-heavy episode, but the core takeaway is simple: the first step is evaluating your hygiene department's actual health. Download the spreadsheet, enter three numbers, and you'll get a real, honest picture of where you currently stand.
I'd genuinely love to hear from you if you have feedback or questions, you can always reach me directly at jeffb@mgeonline.com. Next week, assuming you've worked through your own numbers, we'll get into the concrete action steps: the fundamentals for building a genuinely strong hygiene department, and specific steps to start growing it, retaining more patients, and recovering the ones who've quietly fallen off the schedule.
That's everything for this week, I appreciate you listening, and I hope this was useful. If you want more information about MGE, call 800-640-1140 or visit us online at mgeonline.com. I'll see you at next week's episode, where we'll get into the action steps. Have a great week.