Very Dental: Is the Hygiene Model Broken with Dr. Jason Smithson

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[00:01:19] This is a production of the Very Dental Podcast Network. This is the Very Dental Podcast. Welcome to the Very Dental Podcast, where you'll find entertaining and relevant conversations with visionaries, clinicians, and your friends in the dental space. Now, here's your host, Dr. Alan Mead.

[00:01:48] Very Dental people, welcome to another episode of the Very Dental Podcast. I'm your host, Dr. Alan Mead. Joining me again, he might be one of the Tom Hankses of the Very Dental Podcast because he's been on so many times. Welcome back, Dr. Jason Smithson. Jason, how are you doing? Hi, Alan. I'm good. How are you? I'm good. I'm good. So, I see that you're traveling around and teaching a lot still. Is that still happening? All that stuff is the same old? I'm stateside pretty much at Spear now. Okay.

[00:02:16] So, I'm there. When am I there next? February. You're there quite often. Like, more often than I... You're there several times a year, I'm guessing. Is that right? Like five. Yeah. Well, we now have four classes. So, we have a posterior resin class. We have an anterior resin class, which is basically class four in resin veneer. And then we have the weird... It's not called weird and wonderful, but that's what I call it. I like it. It's like the peg last, or the diastole discolored wear, blah, blah, blah.

[00:02:45] And then I have a new class, which you don't even know about, which is the aging tooth. So, we do three teeth. One is young and bleached and with loads of... You'd like it. Loads of incisal opalescence and texture. Okay. And then one's middle-aged with a little bit of wear and a few effects. And then there's a fun one, which looks kind of weird, which is the elderly tooth, which has got like an orange wear facet on the incisal edge, a crack line, a clasp. Nice! You can see it smelling. That's cool. That's very cool.

[00:03:14] It kind of... Like, people sit... I've done it a few times in Australia and in the UK, and people are like, am I ever going to do that? But, yeah, but when you need to do it, you need to know how. But also, even if you're not doing it, it's like you're actually kind of... This is something that we see, but we maybe don't register as like... It's literally just understanding that this is how teeth age. That's interesting. That would be worth it in itself, probably.

[00:03:41] It's a cool class. It's kind of a super master... It's an art class, really. Sure, sure. Arts and crafts, we love it. Hey, that's what we're doing at Spear this year. We got Spear Summit as well. Yeah. In March? I think so, yeah. And then I've got some stuff. I'm doing some stuff in Australia and obviously in Europe. So, yeah, that's me currently, and I haven't... Well, and we have the office three days a week. Okay, okay. I have my legal practice, but other than that, I'm pretty laid back. I'm not doing much.

[00:04:10] That's good. That's great. We'll talk about that in a little while. Okay, so you and I were having this conversation that I find completely fascinating because I'm struggling right now because I'm trying to find a hygienist. My three-day week hygienist is leaving. She found a job closer to home, and so I'm looking to fill her spot, and it's a struggle.

[00:04:32] There's not a ton of people lining up for the job, and the bottom line is these folks are being paid a lot more than they were before COVID. COVID thinned out the number of hygienists that were working. Everything is more expensive in the dental office, so it's hard, but I'm having a hard time finding a hygienist. I'm working on it.

[00:04:52] But what's interesting is you and I were talking about that, and there are very distinct differences between how dental hygiene is run and is seen by patients in where you live and where I am. So, in the United States, everyone sees the dental hygienist. Everyone needs their teeth cleaned, and whether you're healthy or you're a perio patient or whatever, it isn't necessarily the way you are brought into the office, but in a lot of offices it is.

[00:05:19] And you're basically the hygienist is everyone sees the hygienist healthy to perio, and you are kind of seen on recall in hygiene. That's how we keep track of patients. And so, what patients are used to in a lot of ways is we get to spend an hour with a nice lady who is gentle and polishes our teeth and shows us how to floss and brush and takes x-rays.

[00:05:44] And then we see the doctor for a minute or so, and that's what seeing the dentist is in the United States unless you need work done. That's like we have this recall system that in – I mean overwhelmingly, obviously there are specialty offices that are not like that and, you know. But for the most part, that's like the general thing. And patients – I have found patients really value having their teeth polished more than the dentist coming in to look at their teeth or talk with them about their – you know.

[00:06:09] And what's funny to me is how – I mean I see healthy patients every six months, and I see patients that are less healthy, sometimes three- and four-month recall. But a lot of times I see patients that have issues at every six months too. It sort of doesn't make any – we're not really – in other words, as you mentioned earlier off the recording, it's not really therapy per se for those people. It's just kind of a checkup and a nice little polish.

[00:06:36] Now, you're telling me they handle things quite differently in the UK. I kind of want to hear how – how does hygiene work there? Yeah. So, well, I'm going to come off as being a bit offensive here, but I think in the States you're putting the cart before the horse. Oh, totally. Totally.

[00:06:54] Because, like, the whole concept of having a dental examination by a professional like a dentist who is qualified to do that is that the dentist does the exam of the soft tissues, the hard tissues, the periodontium, and if you're lucky, the masticatory system. And then makes a diagnosis or diagnoses, multiple, and then makes recommendations for treatment, right? Okay.

[00:07:22] So, certainly in my office and for the main part in Europe, certainly in the UK, what happens is the patient will come and see the dentist on a recall interval that is defined by the dentist at the previous appointment. And we'll come to that in a minute if you want.

[00:07:44] And that recall could be three-monthly, could be six-monthly, could be yearly, could be two-yearly, depending on your risk for decay, for periodontal disease, for tooth wear. And we put all those parameters together and come up with a risk profile.

[00:08:03] And if somebody's got raging periodontal disease and perhaps they've got fairly complex reconstruction and perhaps they've got high caries risk and maybe some wear, they might be seen every three-monthly. And for patients, for example, my wife is a good example. She has had ortho. She has zero wear. She has zero periodontal disease. Good attachment. And not one tooth in her head is filled.

[00:08:32] So, she's on two-yearly recalls. Yeah, she is. Yeah. In fact, she could probably be on 10-yearly recalls. Right, right. Exactly. Yeah. So, basically, the recall is on the basis of relative risk and need. You do get the odd patient that's probably like my wife that says, I want to come every six months. Okay, fine. And then when they see the dentist, the dentist makes recommendations for hygiene.

[00:08:57] Now, for example, my wife would not see the hygienist, period, because she has virtually zero plaques, soft tissue, soft plaque scores or DI debris index. She has zero bleeding index. Mm-hmm. She has no hard deposits on her teeth.

[00:09:20] So, like, why would she need to see the hygienist for the hygienist to spin a profi cup around some healthy teeth? All they're doing is removing a little bit of enamel, really. Yeah, potentially.

[00:09:34] But on the flip, somebody who, certainly in our office, somebody who had BPE codes three and four and had a six-point pocket chart and had probing depths and bleeding on probing, they would not be allowed in our office to see the hygienist just for a profi. Mm-hmm.

[00:09:59] They would have to see the hygienist for something therapeutic, i.e. scaling and routine. Scaling and routine. Yeah, yeah, exactly. And then there are different kind of patients. I guess that's what it's called in the U.S., right? Sure, yep, yep. We don't really go like that. It's just like, oh, you need to go and see the hygienist for an hour. Okay. But it's a therapeutic appointment. It's not so funny because I think there's a lot of – if there's American dentists listening,

[00:10:28] I'm assuming, from what I understand, that is just the exact opposite of how we do things. Everyone sees the hygienist. And then some people need – Yeah, but why? It's like scheduling somebody in to see a restorative dentist and everybody has a fissure sealant or something like that. It just doesn't make sense. It is sort of like that. But you ask why. You know, and you even said the answer earlier offline. Why? It's because insurance. It's an insurance-driven problem.

[00:10:56] It's not driven by the need for therapy. And I'm sure that American hygienists would say, of course everyone needs to see a hygienist because that's kind of what they've always done. But the reality is, is like, is a prophy therapy? I don't think you have to be protectionist about it as a hygienist because firstly – I've got two points here.

[00:11:17] Firstly, if somebody doesn't need to see you, you could, if you're a glass half-empty person, look at it as, oh, I lost a patient. Right? But in reality, what it means is you've got extra time to see a patient who has need more.

[00:11:38] So, for example, if I see a patient and they've got, I don't know, five, six, seven-millimeter pockets bleeding on probing, blah, blah, blah, and we're treating them non-surgically because some people need to be treated surgically and then they would see the dentist or periodontist for that. But we're treating them non-surgically, then I might say, well, okay, we need to back up here. Yeah, you need to see the hygienist for an hour, but I'm going to schedule two one-hour appointments because she's going to need to give you local.

[00:12:08] She's going to need to work on you perhaps quadrant by quadrant. And they may even get three one-hour appointments. And if I had my hygiene book rammed full of profis, she doesn't have time to do that. Exactly. So, actually, it's better for the hygienist as well. Yeah. In the United States, though, I'm going to just stop you. In the United States, there are entire offices. There are entire DSOs based on the fact that you crank through these people and you can charge X amount for the appointment.

[00:12:37] And that feeds your restorative book. And it's like – it's a very – I mean the idea being if a dentist sees you in – You restorative book. I'm not sure that's true. I mean – My other point, by the way, my other point, by the way, is a question of value.

[00:13:24] It doesn't take long before they kind of – every time. It doesn't take long before they start to regard it as a cosmetic procedure like having their hair cut. A hundred percent. That's exactly right. Yeah. Yeah. Whereas, if the husband goes in – and it's usually the husband – and I tell him, okay, you need to see the hygienist for two one-hour appointments because you've got periodontal disease and we need to fix that. We need to stabilize you. And then I'm going to want you to come back and see me in three months and to have a look at how you're getting on.

[00:13:54] And I say to his wife, actually, you're okay. You have no issues whatsoever. You don't need to see the hygienist, period. Then it looks more like a therapeutic procedure and the value is there. And therefore, the husband is more likely – if it is the husband – is more likely to go to the hygienist and get that treatment done because it's seen as therapeutic rather than – no disrespect to hairdressers. But it's not a health thing. No, but that's exactly right. The hairdresser analogy is almost perfect.

[00:14:24] The other thing is that it's being – the hygiene appointment is being prescribed by a doctor. In other words, you're talking about a situation where it's healthcare. We're talking about a situation where it's – I don't know what it is. I don't know exactly what you call it in the United States because it is so insurance-driven. And let's be honest. There are – people in the United States constantly say, I haven't been to the dentist because I don't have insurance. I haven't had insurance.

[00:14:47] And so the idea is that unless I can – unless I'm in a situation where I have someone helping me pay for it or just flat paying for it, I can't go to the dentist. And it sounds like – I mean, that obviously happens in the U.K. too. But they look at dentistry a little differently. If everyone isn't going to the hygienist – I know that sounds silly to say that, but in the United States, that's just what it is. Of course they go to the hygienist. And you're saying, well, some people are perfectly healthy and they don't need to go to the hygienist because there's a therapy involved with hygiene. This is not a big cohort, by the way.

[00:15:17] It's probably – in my office and my patients are pretty well looked after. It's probably only 10 percent, but it's 10 percent more than the average U.S. office. Tell me that – 10 percent of what? Say that again. Spell it out for me. I would say 10 percent of my patients don't have to go to the hygienist for hygiene care that is therapeutic, right?

[00:15:39] However – so I will have this conversation with that patient and I will say, listen, your gums are healthy, so you don't need to see the hygienist. And a lot of people say, thank you very much. Goodbye. But there is a cohort of perhaps that 10 percent that say, well, I want to see the hygienist. I got some staining and like I have to get the microscope down and boot it up to 12 mag to see the staining. But they can see it. Yep.

[00:16:05] So they may go to the hygienist and have airflow or something similar. We use silk and blah, blah, blah. But still, so they do see the hygienist. But – and then I will bluntly say to them, you appreciate this is a cosmetic procedure, right? Yeah. Okay, fine. And away you go. But even that creates value because from a business point of view, if you're offering somebody that is something that is a cosmetic procedure, then you can charge them more for it. So – Well, okay.

[00:16:33] So I want to ask you though about the UK and insurance. So in other words, it sounds to me like – I don't really know. I mean like you've got sort of a multiple tiered system there with regard to dentistry. I mean you've got the National Health Service stuff. Do they – is hygiene – from what you understand, do people that are sort of NHS dental patients, do they do hygiene on the regular like in the United States or not really? All right.

[00:17:02] So the setup in the UK is we have NHS, which is essentially government-provided healthcare. And the role of that is to – in inverted commas – secure oral health. Mm-hmm.

[00:17:33] So in the UK, in the UK, in the UK, in the UK, in the UK, in the UK, in the UK, in the UK, in the UK, in the UK, in the UK, in the UK. And then at the other side of the spectrum, you have people who are exclusively fee-for-service. Mm-hmm. Mm-hmm. In exactly the same way as the US. Mm-hmm. The patient comes, pays the bills directly to the practice. What you do is what you bill, and what you bill is what you get. Mm-hmm. Right? Financially. And I'm in that category now.

[00:18:03] I'm fee-for-service for everybody who walks through my door. Okay. And there are not that many practices in the UK that are like that, but it's increasing dramatically. And then you have the middle ground, which is most officers, and they're what are called mixed practices. So they offer treatment on the NHS, and then they perhaps have some fee-for-service patients. Mm-hmm.

[00:18:34] And they perhaps have some fee-for-service patients who pay through, I don't know if you have them in the US, cocapitation schemes, so you pay X amount per month. Per patient, yeah. It's an insurance. And then you get whatever for it. Yeah. Right. Yeah. And they're the majority. And it may be that they come in on the National Health Service, and they have some of their treatment done, fee-for-service, which is a little messy, to be honest.

[00:19:04] Yeah, I bet it is. I bet it is, yeah. And the people who are providing it will be the first to tell you it's a freaking nightmare to do that. Yeah. And that's why I got out of it quite a while ago, about 15, 20 years ago. Anyway, to get back to your original question, would they get hygiene treatment on the NHS? And the answer is probably not. Okay. I think there are some practices who need to be remembered in heaven who probably do provide that. Okay.

[00:19:30] But the vast majority probably will, the dentist will offer like a lower canine to canine scale and a bit of a buff around with a prophy in like less than three seconds, which I guess is some practices, a PPO type practice in the US. Mm-hmm. Mm-hmm. Which is quite clumsy.

[00:20:00] Yeah. But that's unfortunately how it works. That is, I got to say, it's fascinating. I didn't know when we were, when I set this up with you that we were going to come up, but it's like considering my situation with the hygienist, I'm just like, wow, it's a very different animal. Like we're, I mean, what I'm telling you about, you know, the majority of United States, that's not a surprise to you that I, that, that everyone, essentially everyone sees the hygienist. Is that right? Yeah.

[00:20:25] I also think it's a bit of a, I never really worked it out in modern dentistry, right? Because I can understand, right, why historically from like the golden years of the 50s, 60s and the 70s, why a dentist would do something operative and then jump into a hygienist room and do a hygiene check and then go back and do something operative. Mm-hmm.

[00:20:52] And I get that and I could understand why you might work out of five or six ops or more, some people. Because historically our procedures were extractions and silver amalgams, right? So they were pretty quick procedures. Yeah. And also the local work quite slowly. So I guess what you would do, you know, in the 70s was bang in the light. Anesthetic, yep. Local. It's going to take a while.

[00:21:20] That would take about four years to work. Yeah. And then you would go and do your hygiene check, come back, the local was working, spin out your silver amalgam 20 minutes, and then go back and do another hygiene check. That makes sense, right? It does make sense. So I guess where that comes from. I guess I see where that came from. I'm sure that's where it comes from. I'm sure that's where it comes from. 100%, right? Yeah. Now, we've got local that works by the time you put the local in. Just about, yeah. The local is working if you put it in the right place, right?

[00:21:50] So you're not hanging around waiting for local. You've got, broadly speaking, most of us doing adhesive types. I know some people still do amalgam, and that's okay. But most of us are doing adhesive type procedures and crown preps and blah, blah, blah. All this stuff takes time. And it's definitely more technique sensitive too. I mean like sneaking out in the middle is a really hard game. Keep your eye on it. Yeah, exactly.

[00:22:20] So what was historically a filler for the time while you were waiting has now become a hindrance. Yeah. Because I guess it's a pain in the ass to jump out and do a hygiene check. Well, they always talk about it. You're in the middle of a crown prep. You know, you're halfway. You just built your core up. You've got the tissues where you want them. You're just doing a prep. I can imagine. I don't do it, so I can't come at this with any experience. But I can imagine, you know, oh, you've got to do a hygiene check now. Like when you've half done a crown prep, I'm like, oh, my God.

[00:22:49] They always talk about multitasking. They talk about multitasking. And the reality is that from what all the research says is you can't multitask. Multitasking is near impossible. It is you just switch your focus quickly. Well, the story is, you know, if you're switching your focus quickly, you got it. It takes a little time to get your focus back where you're going. That is real. And on some level, that's what you're doing when you're doing multiple things at once. And I mean, people may be – No, you're not.

[00:23:15] I mean, that is what – it isn't that you're doing two things at once is what I'm saying. You're doing one thing at a time and you have to switch. You can't do two things at a time. Have you read a book called Deep Work? Yeah. Yeah, yeah. I forget the guy's name. So he talks about that, right? This guy knows what he's talking about. I forget the author now. He's written several books along these lines. I'll find – I'll put it in the show notes. Cal – Cal – Yeah, it is Cal something. It's – Cal – it'll come to me. Oh, it's Cal Newport.

[00:23:44] Cal Newport. Here we go. I'll put it in the show notes too. If anybody's listening by now. Yeah. If we haven't lost – He talks about that and it's impossible to focus on more than one thing at once effectively. Exactly. Yep. Yep. And since I read that, which is about three years ago, I've stopped trying to multitask.

[00:24:08] And what I find is I get more tasks done in less time and to a higher standard. When I used to think I was king of the hill, I could do ten things at once. I couldn't. And I was younger now. I'm like geriatric now. I can barely walk and talk at the same time.

[00:24:25] So, you know, I honestly don't think you could focus on a good quality crown prep or even a rapid crown prep if you weren't that bothered about the quality and do a hygiene check. I just don't think it's doable. I think if you did – if you had some time motion person sit down and do a study on it, which would be really interesting. Yeah. I bet you you would be less effective jumping up doing hygiene checks.

[00:24:52] Well, and the other thing is when you think about it, okay, let's just say a hygiene check on a patient that's been in my office for a while. You know, there's chit-chat. But if you've got like – if you've got an emergency patient in one chair and you're doing a crown preparation, you're doing some other procedure and you've got this – that hygiene check gets short time. That hygiene check is like, you know, I'm not seeing that much or whatever.

[00:25:16] You're not – literally, you're not looking at the – you're not doing the recall exam the same way on different people depending on what you've got going on. Well, actually, I think if you look at it, they're all getting short time, right? Yeah, probably. Let's say you have a patient who committed to doing, I don't know, some veneers or a bridge or something like that or an implant, something relatively high ticket. Mm-hmm. And halfway through it, the dentist jumps out to do a hygiene check and you've got to sit there and wait?

[00:25:46] Yeah. How do you feel? That's a good question. It's a good question. That would be like going out for an anniversary dinner with your wife to a really fancy restaurant. Yeah. And then, you know, after the appetizer, all the waiters just go and have their lunch break. Yeah. I'm going to tell you, in the United States, that's – We've got to do our lunch. Bye. Yeah. How would you feel? What would be your reaction?

[00:26:15] In the United States, that is so normal that – I mean, I suspect – The waiters to go and have their lunch break. I mean, that's not normal, but in the dental office, it is very normal for someone to run out and do – I mean, you've got dentists that are doing multiple procedures on, you know, like operative procedures and hygiene checks, and that is normal. And, I mean, the story is – your point is like why should that be normal? Why should someone accept that? Like they're – they've made time in their day and you get – I don't know. That's a great – it's a great point.

[00:26:44] It's a great question. Honestly, I mean, I'm coming at this – I'm coming at this as an outsider and I'm coming at – I'm conscious that I'm coming at this with actually no experience of doing that. So, well, I've worked out of two ops before when I used to do NHS, so I have a little bit of experience of doing that, but not a lot. But all I can see is the data suggests that it's going to give you faster burnout for sure. I believe that.

[00:27:13] You're going to do a worse quality job slower. I have no data on it, but as a consumer, I would prefer if the person providing my care stayed in the same room from start to finish. That's just me. And I think most people would see it like that. And it looks to me like – and we don't have any clue on this, but it looks like it's less profitable.

[00:27:41] So, it just looks dumb to an outsider. I don't know. My guess is that for someone who's working within the confines of insurance in the United States, it does come down to the things that you can bill in a period of time, which is not – clearly that is not necessarily what's best for patient care necessarily or whatever. But I'm sure that's why we – that's why the United States kind of has built it to be like this. It's interesting. I get that. I get that. And probably we're not talking about that cohort.

[00:28:11] We're probably talking about the 40 percent to the right of the bell curve, right? Well, and there's an expectation of a certain level of service, and maybe that's what we're talking about. It's interesting. It's very interesting. I – you know, considering the fact – I guess going back to the whole concept that you're talking about hygiene as a therapy and I'm – in the way that – Hang on. Whoa. Let's stop. Isn't it? Yeah. Well, I'm going to argue that – I mean you said it yourself.

[00:28:40] In some ways, it's like a cosmetic. In the United States, I'm not sure that it's always – is a healthy patient getting a prophy? Is that therapeutic? I'm not sure. I'm not sure. I'm sure that I've just enraged a lot of hygienists in the United States, but I mean if – Why would you?

[00:28:56] Like if I was a hygienist and I'm spinning a prophybrush around somebody who's got code zero with no bleeding on probing and no debris indices and zero bleeding index, I would be bored out of my head. Oh, it is. It's terrible. It's terrible. Yeah, and the other thing is you've got an hour. You've got an hour. So you've got to fill that hour with something, right? And this is a very United States-based thing because that's – in a lot of cases when you're – They have an hour to do that, right?

[00:29:26] Oh, yeah. Oh, yeah, for sure. I mean and they're mad if they don't have an hour. That's the story. I mean they're mad. And mind you, there are some patients that are clearly – you've got an hour for a healthy patient and you've got an hour for a patient with disease for the most part. Yeah, that's dumb. It is dumb. It doesn't make any sense at all. See, in our office, like somebody who says – like you get the patient that drinks maybe – they have healthy gums but they drink coffee or they smoke.

[00:29:54] Well, probably not smoke because then their gums would be unlikely to be healthy. But maybe they drink a lot of coffee or wine or whatever. Coffee or wine or whatever. Exactly, yeah. Yeah. So maybe they're going to end up with airflow or something like that but not really any scaling. That's scheduled for 30 minutes. As well it should be. Yeah. And like somebody with active disease and deep pockets, as I said earlier, might have a couple of one-hour appointments. So it's appropriate timeframe.

[00:30:20] And if they've had treatment, active treatment, scaling, root plan, their recall is different than the recall for someone who's healthy with stain or whatever. Or perhaps they have fixed PROS or implants or something like that. Their recall interval would be more timely or less and their appointments would be longer. Yeah. I'm going to blame the model in the United States on basically insurance that most people get through work in some way.

[00:30:50] And like you said, the fact that amalgams didn't used to take very long. That's kind of what I'm – I almost – I don't know that. This is literally my guess. I would love to know if someone knows more about that. But our model is our model and people stick to it so hard. And I tend to think of if I wanted health, like basically overall health, I feel like your model would definitely work better. But I'm not convinced that all patients really want health. I think a lot of patients just want them to spin a prophyl brush. Isn't that what we're about, right? Well –

[00:31:20] I think your first statement like regarding the amalgam and stuff and the time between patients, I think that's correct because I was just thinking back to when I worked in the NHS, which is essentially like a low-end insurance. It's like a Medicaid here or something like that. Yeah. And amalgams and plastic dentures and crown of the month, that kind of thing. Like a long appointment, a ridiculously long appointment would be an hour. Yep. Yep.

[00:31:49] And it'd probably be a quad of amalgams in that, right? Yep. That would be a long one. Now, I commonly have patients in for morning. Mm-hmm. So – and, you know, I think a lot of dentists see patients for an hour, an hour and a half quite commonly who are doing quad composite work or stuff like that, you know, multiple crowns, which we didn't used to do. Mm-hmm. But, well, with the exception of a PROS office, let's say.

[00:32:19] I'm talking about a regular office. We just didn't used to do that. Mm-hmm. So, well, I don't know. I mean, it's above my pay grade, but it's something to think about in terms of the way you run your office. It definitely is. And it's – you know, I don't want to drag you into the politics of, you know, the profession of dental hygiene and how it's relating to the profession of dentistry in the United States. But it is – it's become a challenge that it didn't used to be, per se.

[00:32:50] You know. We don't have that in the UK. Yeah. Generally not. Interesting. Well, but it sounds like because – because, well, first off, not everyone in your practice is going to see a hygienist. Your hygienist is seeing a certain kind of patient. And in the United States – Well, we do have something in the UK, which you probably don't have in the US, which is called direct access. Okay.

[00:33:12] So a patient can call the office and directly see the hygienist without seeing the dentist ever. Oh, my gosh. Okay. Interesting. Yeah. That doesn't really happen. But that's on the – that's on the hygienist insurance. And that's – the patient signs a disclaimer saying, you know, if you have – the hygienist like trained to recognize oral cancer and really dangerous stuff like that. Sure, sure.

[00:33:41] So – but they – you know, there's no accepting responsibility for, you know, caries or anything like that. Yeah, that's interesting because I know that there's a few states in the United States that allow hygienists to have an independent practice from a dentist. And I got to tell you that the availability is such that – I know Colorado is a state that – and there's very little of it because it's not – I mean, honestly, they have a similar overhead to a dental office.

[00:34:09] And so does that happen often in the UK? I do have – I'll be honest with you. Because we're a relatively expensive practice, I do have some patients who are either struggling financially or a bit cheap who go to a direct access hygienist that is not our office. Interesting. But – but for the hygienists who are listening, the direct access hygienist is actually very good.

[00:34:40] And I know that because my wife's been there because it's actually just around the corner from our house. Sure, sure. So it's more convenient for her to go there rather than drive 40 minutes to my office. So is that common all throughout the UK? Is that like – Yeah, yeah, yeah. That is so wild because in the United States it just doesn't – barely happens. It's like hygienists are in the dental office. This is all new to me. This is funny. I've been doing this for a while. I think I know that. But that's wild that there's a separate – you can go to a hygienist separate from a dentist in the UK.

[00:35:10] I did not know that. Yeah, yeah. Do people do that? I mean is that like – yeah, I need to go have my gums looked at. But I mean like it's wild. There's one in our town that runs six days a week with two hygienists and they run – it's not like it's – it's actually – my wife's been there. It's actually done to a good standard as far as I can see. My wife's a trained dental therapist so she knows. She knows what she's talking about, sure. Yeah, exactly. So she wouldn't just go anywhere.

[00:35:38] And they would refer someone to a dentist if they had dental problems, you know, like decay issues. So like we've had not a vast amount but a few referrals from them saying, you know, patients got a – I think the last one was a denture or, you know, they've got caries, blah, blah, blah. So it can work both ways. It is funny. I have surveyed people in the Facebook group and stuff and like there are – like you can kind of categorize the patients that come into an American dental office.

[00:36:05] And there's a decent percentage of them that never need anything. They come in for – you know, they're healthy patients. They've got healthy gums. They don't – like you're talking about your wife, you know, and it's like on some level – But there are patients who want to come every six months. Yeah, exactly. Which is fine, I guess, which is fine. But it's also like the point of it is to – I don't know. It is definitely the difference between a doctor and a – I don't know. It's very – it's an interesting topic. The ones with the caries and the mobilities and the – Yeah, they're fine. I'm fine. Yeah. I'll just go see the hygienists.

[00:36:42] It's nuts though because I guess I didn't realize that the delivery of this care was so separate in the UK compared to the United. And honestly, it makes sense. Honestly, if I were a hygienist, I think I'd rather work in the UK because you're treating your patients in a therapeutic – like on some level, it might just be checking the box in the United States for some healthy patient doesn't really need you. But they're showing up anyhow because that's just how we do it. That's an odd, odd thing that I didn't know about.

[00:37:08] Well, what happens – what happens in the U.S., right, if – like who does the perio indices? Is it like the pocket chart, the bleeding index, the debris index, and works out the risk? Is that the hygienist? The hygienist. The hygienist. And then the dentist comes in and they kind of decide what sort of – sort of treatment. Like if it were a new patient, someone that were new, it'd probably be – although I won't lie.

[00:37:32] Yeah, I probe – if it's a new patient in my chair, I'm going to do that and we're going to kind of – because you've got to figure out what kind of patient they are if you don't know them as a new patient. I think a lot of offices – Just stop there one moment. So a new patient will come in and see the hygienist first? Oh, in the United States? I think that's probably the most – okay. Listeners, if I'm wrong – Oh, my God. Listeners, if I'm wrong about this, I want to hear about it in the Very Dental Facebook group. But I would say the majority of new patients probably see the hygienist first with the dentist doing their exam same day.

[00:38:01] So the hygienist will do – go through and take radiographs and possibly probing depths and stuff like that. And then the dentist comes in and does an exam and they determine the stuff that way. Would the hygienist have done any scaling at that point? I don't know. But I will say this. Most patients that are new patients, I know this for a fact, they're pissed if they don't get their teeth cleaned the first time they see a new dentist. They want it.

[00:38:26] And the story is like – that's like going to a doctor and the doctor doesn't know your diagnosis. Well, we do that. We do that but in the opposite way. Like, for example, on Tuesday I've got a new patient coming in and that patient is coming a distance. And they've asked to see the hygienist. Now, I've never seen that patient. So all we did is we just scheduled them an hour on the proviso that if they need more hygiene, we'll tell them then and then. Yeah, yeah.

[00:38:56] I mean – They may end up booking an hour and not need anything but that was their call. Yeah. I prefer to see new patients first. And lately that's worked out really well except, yeah, you kind of have to know – the patient kind of has to know that they may not be seeing a hygienist that day. And there's some patients that are red hot mad about that because they look at dental care as having the nice lady spin a prophesy brush on their tooth. That's what they look at is dental care.

[00:39:24] And, oh, and I got to see that stupid dentist who's going to come and tell me. It's like the magic fairy dust, right? It is a little bit. It totally is. And I mean I'm not downplaying what hygienists do. But on some level, when you're seeing a healthy patient over and over again on a six-month recall, it is a little silly. But why do we do it? Because it's paid for by insurance to do that. It's kind of in the same way that – Hang on a minute. Like how does the insurance work?

[00:39:52] So if they didn't have the hygiene, could they use that money towards something else? They could. They absolutely could. Yes, the hygiene comes out of the sand pot. It is. It's stupid. They've got cavities all over the place and they're spending their money on hygiene. Oh, yeah. And they're going to – and honestly, they will definitely – okay, this is so funny. They'll look at the amount that they have knowing that they need treatment. But they want to reserve for that hygiene appointment. They want to reserve some before the end of the year. If they're working on it, I have this much per year.

[00:40:20] But I want to make sure I get my hygiene before the end of the year. I'm not kidding. That is a classic thing. Again, listeners in the United States, if I'm wrong about that, I want to hear about it in the Facebook group. I'm going to drag Jason into this because it's true. It is very – like I think it's funny that we're having this conversation. I've never had this conversation with you. But, yeah, totally. People look at hygiene as the value. Like especially – and it is. It is for some people. Like people who need the therapy, it totally is. But it is very backwards how we do it.

[00:40:48] It's kind of like having a budget to renovate your house and like the roof is falling in and the windows are broken. But, oh, we better wash the windows. Yes. Yes. It's a perfect analogy. It's a perfect analogy. So this all in the setting of the fact that I'm now looking for a hygienist. And I'm like – because – and we have this weird system where half or more of this hygienist work is going to be basically washing the windows.

[00:41:15] And that's what the patients kind of want because that's what we've set them up for on some level. Do you not think it might be the job of the dentist to lead out of this? It's for sure. It has to be. Now, I'm going to tell you why is my practice this way? Because the practice I bought was like this and that's what every practice is. So all of a sudden, if you're used to seeing it like that, that's the thing. You bought that practice some time ago and it was – I mean you're working with the scope and et cetera, et cetera.

[00:41:44] You're not doing 20-minute amalgams now, right? No, that's right. I'm not going to – It doesn't fit your business model at all? No, but neither. Just taking insurance and I do that. So I mean like my business model is a bit of a hodgepodge compared to yours. There's no doubt about that. But also I feel like the reality is that I think I like the way you guys do it a little better.

[00:42:09] It makes more sense and it feels more like healthcare instead of like doing your nails kind of thing. The other problem, right, is we have a regulator which is similar to estate boards. It's called the General Dental Council. And rather than run the state, they run the whole country. And they would take a view – if you had a complaint and you were seen to schedule a patient with a hygienist before a diagnosis was made

[00:42:40] and before a prescription for the hygiene was written because the dentist has to prescribe – In the UK, they can either come direct access – the patient can either come direct access to the hygienist whereby they don't have to have a prescription for the dentist. Right. But if the dentist is taking responsibility for that patient's care, the dentist has to prescribe the hygiene to the hygienist. In other words, they have to specify what the disease is. Is it gingivitis? Is it peridontitis?

[00:43:09] What is the level of a peridontitis? Where is it? They have to schedule – sorry, they have to specify what treatment the patient's going to have. They have to specify the recall interval. And they have to specify where the local's used and which local. Mm-hmm. Right? So if you had a complaint, you would be in the severe doo-doo with the GDC if they'd seen the hygienist first. Interesting.

[00:43:35] And we do have some patients come direct access, come see the hygienist, like the look of the practice, and go, oh, can I become a patient here? And that's kind of different. Mm-hmm. But if you were repeatedly seeing patients without a diagnosis, that wouldn't be – you know, that's reasonable, right? Yeah. No, it is. It is very reasonable. I get it. And what's really funny about – it's been a pet peeve of mine, and I'm probably guilty of it just because of the American system a little bit.

[00:44:04] But like there's a lot of implicit diagnosis. Like it can't be implicit. It has to be explicit. It has to be written down. I mean like – well, like, okay. So, okay. This is a classic example. Someone does an exam, and they don't diagnose caries on the mesial occlusal of number 12. They diagnose a restoration that needs to be done on that. It's very – in other words, there's an implicit diagnosis that there's caries there. And so a dentist jumps straight to a restoration. I know that you've heard of that before. You've seen that.

[00:44:32] I mean it's just – it's one of these things where, well, yeah, he has decay here. We need to do a restoration X. And so there's an implicit diagnosis there, but it really needs to be explicit to come up with a treatment. But I think a lot of – like that takes time and thought. I do that a bit. Of course. I think everyone does. If I'm honest. Because dentistry is like – it's very repetitive. I mean there's only so many diagnoses that we see. It's not like – unless you're treating oral cancer, you just don't see that much. Like peri's root canal or peri.

[00:45:02] It makes perfect sense, but it should be explicit. And you're essentially saying, well, they can't really see the hygienist unless there's an explicit diagnosis of their periodontal condition. And I think we're sort of – sometimes we're guilty of that. And like I said, we go to the hygienist so we can see what kind of perio case they are. I'm like, well, that can probably work so long as the exam has worked into – but the reality is I get what you're saying. Like why is it assumed that they need the hygienist? Because that's the American system. Everyone needs to see the hygienist. It's just bizarre.

[00:45:32] It's just wild that it's so difficult. The other problem – because I've got a legal qualification, but it's not American. It's UK. But you've got a consent issue if a patient sits down, starts having a prophy, right? Without a diagnosis. Because you can't – by definition, you can't have informed consent without a diagnosis. Because otherwise, if you have no diagnosis, how would you explain the risk to the patient?

[00:46:02] And if you can't explain the risk to the patient, then you don't have informed consent. So – and I imagine that's the same in American law, I would think. I suspect on some of the – That's kind of a world over. That's a basic. But there's a little bit of this implicit diagnosis stuff going on there too. Because why do you go to a new dentist? Why do you want to see the hygienist at your new dentist's office first? Because I've always had cleanings and so I just need a cleaning.

[00:46:30] In England, you also have something called duty of care. So if you start treatment on somebody, you have to look after them. You can see a patient – like I could see a patient make a diagnosis of periodontal disease, for example. Give them a treatment plan with costings and they could decline that and go.

[00:46:59] And I have no duty of care because I've explained the problems. I've explained the risks of not having treatment and they've left by their choice. But if I start treatment, it's seen as beginning the treatment pathway. So I then have a duty of care to them. So by definition, I imagine if the hygienist was under your direction and they've started treatment,

[00:47:29] and then you suddenly say to them, oh, you've got raging perio and you need X, Y, Z. And they go, I can't afford that. My insurance doesn't cover it. Bye. Certainly in the UK, you could be criticized for that. I don't know about American law. But that might be something worth looking at. No, for sure. And I think there's a fair amount of – As patients become more litigation-oriented. Yeah, yeah.

[00:47:55] And I know that litigation seems to me – for my friends in the UK, it seems like maybe a bigger concern in a lot of cases than here. But your point is well taken. And the reality is I think we have a weakness in this whole – there's an implicit diagnosis where it should probably be explicit. I think that makes things a lot clearer. But, I mean, just in the same way that our whole insurance – you know, the water we swim in is sort of insurance-based,

[00:48:23] and there's so much opacity about what's going on. It got in medical and dental. That's a whole other story. But it's just interesting. This is an interesting conversation, honestly. I was not expecting it to go there. But it's kind of – I feel like there's discussion to be had here. What we should do is we should probably wrap up, and then I'm going to throw some of these questions into the Facebook group, and then we'll talk – we'll come back again. Because I know for a fact that, like, in the United States, your model makes so much sense. It's not my model, by the way.

[00:48:53] Well, I mean, you're saying the model that you're describing is so – I'm reasonably sure they do it in the rest of Europe like that. Do they do it in Canada like that? I don't know. I don't know. I don't know. I think we can find out, though. But, like – and maybe I'm wrong. In Australia, they do it in the same way. Okay. Maybe it's crazy, and I'm just the one guy that just doesn't understand how things are in the United States. But I don't think so. I think this is kind of how we do it in the United States. I'm going to go out on a limb here, but I think that model is only the U.S. Yeah.

[00:49:23] I think so, too. I think. I think. I could be very wrong. There's a lot of only in the U.S. going on nowadays. Let's be perfectly honest about this. Why should this be any different? Yeah. Okay. This was fascinating. We had another topic we're going to cover. I think we should cover it like many of the conversations Jason and I have. We probably need to do it on another podcast because we're going to go too long. So I'm just going to cut us off here.

[00:49:48] Jason, as always, it was great to have you on, and I'll drag you into these conversations in the Very Dental Facebook group. This was interesting. Thank you. Have a good week.