Four-handed Dental Hygiene By Trisha E. O’Hehir, RDH, BS, Editorial Director, Hygienetown Magazine

 
Pictured above:
Eileen McQuade, RDH, BS, EF, is a part-time clinical
instructor at Northern Arizona University and is vice
president of Go To DDS in Flagstaff, Arizona.

by Trisha E. O’Hehir, RDH, BS Editorial Director

Mention “assisted hygiene” and you’ll find some hygienists who hate it and some who love it. Why such opposite reactions? After reading the Hygienetown.com message boards and talking to many hygienists who work with an assistant, I found two very different definitions of “assisted hygiene.” To some it’s an accelerated schedule with help from an assistant before and after the appointment, allowing the hygienist to focus on probing, instrumentation and oral hygiene instructions. Some of those who follow this approach often feel they are running from room to room, dealing with persistent neck and back problems, exhausted, and on the verge of burnout. An assistant might take over some of the duties, but does not “assist” them chairside. Sometimes these folks do it for a while, but then get burned out and “hate” assisted hygiene. They feel the quality of care is compromised, along with their ergonomics. It is hard to argue with them.

Those who love “assisted hygiene” are talking about a very different model. They practice four-handed dental hygiene. When discussing assisted hygiene, we must make the distinction between assisted and four-handed.

I asked several hygienists who have worked four-handed for many years, to share their insights, secrets and advice on this approach. According to the following hygienists, four-handed dental hygiene leads to higher-quality treatment, happier patients, less fatigued hygienists who stay in the profession longer and increased production. Incorporating four-handed dental hygiene was a smart career move for these hygienists.

HT: What is your experience working with a dental hygiene assistant? Dedicated four-handed approach, or an assistant who takes over some of your duties as you work out of one or two rooms?

Eileen McQuade, RDH, BS, EF: I’ve worked with assistants in a variety of scenarios, but I prefer to work with a dedicated dental hygiene assistant who works directly with me. This allows for the most efficient use of the RDH’s time and skills leading to excellent patient care, patient comfort and a noticeable increase in production. Working four-handed has increased my job satisfaction and makes my day more enjoyable.

Laura Mallery-Sayre, RDH, MS: I started with one assistant and two rooms and have worked with two rooms and two assistants for several years now. Our second dental hygienist also works with a dental hygiene assistant making three (hygiene assistants) in our practice. When one assistant goes down, we still have two to support both of us and we also have an expanded functions restorative assistant who is cross-trained and pitches in as well. To have only one dental hygiene assistant with an accelerated schedule and no backup is definitely not recommended.

Cynthia A. Chillock, RDH, EF: I have worked minimally with one assistant in two rooms on healthy patients or well-maintained perio patients. Most of my dental hygiene assistant experience is with a dedicated, four-handed approach whether it was working out of one room or two rooms.

Dave Bridges, RDH: I work out of one room, with one assistant – four-handed.

HT: How did you get into four-handed dental hygiene?

McQuade: After completing a post-graduate course in periodontal therapy, I was back in the office in the middle of performing SRP on a patient. He stopped me, after sucking down more than a little Peridex, blood and saliva, to ask, “Where’s your assistant? It doesn’t make sense that you try to do these advanced procedures without the same kind of help the dentist has! I feel like I get red carpet service in the doc’s chair, but in here I’m a second class citizen.”

Ouch, that hurt, but the patient was right. Why didn’t I have an assistant? When I whined to the doctor, he just looked at me and said “Don’t complain to me. If you think you need an assistant, figure it out and get one.” That’s just what I did and have never regretted it.

Mallery-Sayre: I developed an assisted dental hygiene program in my dental office in 1976 to meet the needs of an overwhelming patient load and it was one of the best career decisions that I ever made. Not only did my efficiency increase, the quality of my care to my patients was enhanced because I didn’t have to worry about running behind with my schedule. Fewer patients had to return for follow-up appointments and they greatly appreciated having someone there to continually suction and spray while being treated.

Top photo:
Working with Perioscopy,
Laura Mallery-Sayer, RDH, MS,
is assisted by Jonelle Pascubillo at
Dr. Frank Sayre’s office in Kailuna Kona, Hawaii.

Bottom photo:
Cynthia A. Chillock, RDH, EF,
works with assistant Patricia Bustamante.
Chillock currently works in the office of
Dr. Luis A. Cueva, Jr. in Tucson, Arizona.

HT: Did you resist the idea of working with an assistant in the beginning? What changed your mind?

Chillock: Absolutely! I resisted working with an assistant at first, but I also resisted the extra time I did not think I would need. What changed my mind was the fact that when I worked with the new assistant, I could see calculus that I would never have been able to see without that assistant. When I could see better, I found that I indeed needed the extra time to completely remove the deposits.

Bridges: Certainly not! I was the instigator. I realized that as my clinical duties expanded over time and became more and more intensive, I needed help to stay on time and prevent stress and burn out. I knew I couldn’t achieve certain procedures to my satisfaction without help. From another perspective, we’re now advised to have someone with us in the room whilst treating patients. Particularly, as a male hygienist, I felt vulnerable on this score so working with a nurse (dental assistants in the UK are called nurses) solved this problem.

HT: What surprises did you find when you started working with an assistant?

McQuade: I was surprised to find I could do more procedures with an assistant, and still stay on schedule. I also didn’t realize how much the patients would appreciate an assistant to make their visits more comfortable and enjoyable. Also, the battle with cross contamination became almost a non-issue thanks to another pair of hands.

Mallery-Sayre: The biggest surprise of all in working with an assistant was how much fun I had during the day. I no longer face the stress of how I’m going to manage the schedule for the day if someone is late or has been lax in their home care. I enjoy my patients more; I feel even better about the quality of care that they receive from me; I have more time to spend with everyone, really concentrating on each patient’s individual needs; and I have another professional there to spend my day with. My assistants have all become friends of mine and we truly enjoy each other’s company. At the end of the day, the last patient receives the same quality of care that the first patient receives because I’m not exhausted anymore. I get out of work on time, have time to go for a workout before going home and have fallen in love with dental hygiene all over again.

Chillock: There have been so many surprises, it’s difficult to list them all. I was surprised at how much ergomonic retraining was needed if I ever expected to have enough room for the assistant to get in there and help me. It felt very frustrating at first, getting the combined choreography correct. Once I did make those changes, there was a greater impact on the reduction of head and neck pain than I anticipated. I also felt a different type of team feeling while treating patients with an assistant. It was also humbling to discover how much I could learn from that other team member when there was a great assistant sitting in that other chair, even though I had been CDA prior to dental hygiene.

Bridges: I was amazed and troubled at what I discovered I’d been missing for years! I found out where it’s impossible to get effectively without assistance. I discovered that having someone else meant I had a type of peer review. I like my nurse to feel valued and involved, so I’ll ask her how she thinks we’re doing on a particular patient. I’ll ask if she can see anything I might have missed. I found that I re-evaluated all my procedures and asked her how she thought we should work. What would make life better for us? What would make the patient’s experience better from her perspective?

HT: What is the most valuable aspect of working with a dental hygiene assistant?

McQuade: Working with a hygiene assistant makes the day run so much smoother and more predictably for everyone. The patients appreciate the red-carpet treatment they receive when there is an assistant and an RDH to answer questions and assist them through their dental appointment. The dentist benefits because a happy, satisfied patient completes more treatment and refers others to the practice. Also, it’s possible to do more treatment and treatment consultation when working with an assistant and still stay on schedule.

Mallery-Sayre: Working with an assistant has made my career in clinical dental hygiene and clinical research one of the greatest joys of my life. I love being a dental hygienist! Working four-handed has saved my body from constantly having to reach and torque to provide care on my own. My ergonomics are so much better with an assistant and it has made a huge difference in how my neck and back feel. Even working with one assistant, I spent enough time on my own with the patients to really feel the stress on my body. With two assistants, I am rarely without chairside help and my body posture has actually improved, eliminating my neck and back pain.

Chillock: I see value for the patient, hygienist, assistant and dentist. With assisted hygiene, patients are more comfortable during the hygiene procedures and can relax in the chair. I work more ergonomically, protecting my body and at the same time providing a higher quality service than working alone. Assistants feel empowered being part of the hygiene team and the dentist values the care and service provided to his/her patients, plus the increased production.

Bridges: The patient is the prime reason for having an assistant. For me, having an ally to share the day with and bounce ideas off and discuss/review stuff with is invaluable. The team gets the chance to experience and influence another part of the practice and the dentists know their patients are well cared for by happy and effective staff. I believe it’s important to see the benefits as qualitative and not just quantitative. It’s about a higher level of patient service, care and treatment efficacy, not just about profit. The former leads to the latter in any case.

HT: How do you pay for a dental hygiene assistant?

McQuade: The assistant’s salary comes from my production. It’s a win-win situation because hygiene production went up as soon as I started working with an assistant.

Mallery-Sayre: The hygienist’s production pays for the assistant. So, the hygienist truly pays for the hygiene assistant and that compensation is accounted for in the production goals for the day.

Chillock: In the past, I have paid the assistant completely, paid half the salary or reduced my salary to accommodate paying the assistant. Once I had a student doing a free externship in the office. The employer pays the assistant now. The increased hygiene production will more than pay for the assistant.

Bridges: The practice pays the salary of my dental nurse from the increased production in the hygiene department.

HT: What advice do you have for hygienists who would like to incorporate assisted hygiene into their practice?

McQuade: Make a written job description for the DH assistant position in your office. Include qualification, duties, hours and other responsibilities in the office. Before hiring the DH assistant, review the role of this new assistant with the entire team at a staff meeting. Allow for staff input and discussion on any concerns they may have with adding a “new person to the team.” With a positive attitude, cover how you will conduct the interview process and “welcome” the new person into the office.

Chillock: Get some extra training for you and your assistant from someone who has worked four-handed dental hygiene before. It will greatly reduce the time it takes to get through the learning curve and helps focus both hygienist and assistant on providing a better dental hygiene experience for the patient. In the long run, the cost of the additional training will save many dollars and hours and will reduce the frustration.

Mallery-Sayre: My advice for anyone who loves dental hygiene and wishes to sustain his or her career is to hire an assistant or two. The amount of increased revenue covers the cost of the assistant’s salary and it will change your life as a hygienist. I cannot imagine providing the type of periodontal therapy that I provide without their help.

Bridges: Without being too flippant – do it! You will not regret it.

HT: Four-handed dental hygiene has been a good career decision for these four hygienists. With the help of an assistant, they can provide high-quality care, enjoy their workdays and have increased production to pay for their assistants. To read more and ask these hygienists questions, please visit www.hygienetown.com, and search for “four-handed.” Four-handed dental hygiene may be the change you’re looking for to enjoy your career more and provide higher quality patient care.

Top photo:
Laura Mallery Sayer, RDH, MS, and assistant Jonelle Pascubillo practice four-handed hygiene.

Bottom photo:
David Bridges RDH, works with nurse Kate Cardon at Clarence House Dental Health Centre in Gloucester, Gloucestershire, UK.