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A new threat to dental hygiene in Germany

Learn ways the update to the periodontal classification guidelines could make being a hygienist even more complicated.

As most dental professionals agree, it was time for an update to the periodontal classification and grading system. We got this update in 2017.

However, the incorporation of this update could be a threat to dental hygiene in Germany.

Firstly, the new classification system uses many factors in a diagnosis. This helps us improve the treatment of periodontal disease.

It also gives us a more systemic view of how periodontal disease functions.

Since change seems to come at a much slower pace in Europe than in the U.S., it’s not surprising that after three years, it still has not been adopted in Germany.

However, starting on 1 July 2021, the German dental community will officially adopt the new classification system. It will also include insurance coverage for supportive therapies.

According to reports, this integration is a “win-win” for patients and dentists.

So, why would such a promising development be a threat to dental hygiene in Germany?

How the threat to dental hygiene started

Dental hygiene has always enjoyed a love-hate relationship with the German dental community. When American hygienists first came over and started practicing, they were periodontal specialists.

However, as the German dental community is so typically resistant to change, this didn’t last long. The hygienists got push-back from dentists who felt intimidated by their training and felt undercut financially.

So, they enacted laws to slow the expansion of dental hygiene. One of the most notable ways was establishing and backing a preceptorship program for dental assistants. This was the initial threat to dental hygiene.

A concession made

Nevertheless, the dental community saw the benefits of having a professionally trained dental auxiliary on board to maintain the health of their patients.

So, they had to devise a system of “dental hygiene” that would still allow them to benefit financially, somehow. Thus was born the system of teaching dental assistants to clean teeth.

This was a win-win for the dentists and the assistants, right? Dentists could provide cleanings for their patients, and dental assistants could up-skill with the backing of the dentists.

This training system gained momentum and support. It is now what the dental community in Germany understands dental hygienists to be, up-skilled dental assistants.

How dental assistants up-skill to dental hygienists

The dental assistants can up-skill in different ways. Some dentists train their assistants themselves. Some take weekend courses.

They later earn the title of “Zahnmedizinische/r Prophylaxeassistent/in (ZMP)” and eventually “Dentalhygieniker/in (DH)” after completing a set amount of study hours.

We understand this system in the U.S. as preceptorship.

See the article Dental hygiene preceptorship – more harm than good?

The ‘dental hygiene’ programs do help the assistants to appreciate the need to treat perio disease. However, they often leave them ill-prepared to do so.

Ultimately, the goal of this system of “dental hygiene” is to clean teeth and not to maintain periodontal health. A lot of perio disease goes untreated or under-treated.

Unfortunately, some patients don’t learn of the consequences of under-treatment until it is too late.

The current periodontal disease treatment paradigm

Who legally can perform non-surgical periodontal treatment has always been a gray area in Germany. Some practices openly allow hygienists to treat perio non-surgically. Others only allow it as treatment by the dentist.

Therefore, supervision is not even an issue here. The main issues are delegation and billing.

For example, periodontal charting (PA Befund), scaling and root planing (PA Behandlung) and periodontal maintenances (UPT) are dentist procedures.

As a result, they may or may not be delegable. Insurance companies cover and reimburse these procedures well. Therefore, dentists could view any work by a hygienist as eating into their profits. This view is another threat to dental hygiene.

The state practice acts dictate periodontal treatment protocols

Who can do what procedure depends on each state’s practice act, much like in the U.S. Most perio treatments are not delegable. The reasoning is that: dental assistants are not trained to do any subgingival therapy anyway.

So, why would they ever need permission to check a perio pocket?

German-trained hygienists are, basically, dental assistants with expanded duties. The duties are where the confusion lies.

The way this works is: the ZMP/DH cleans the teeth (usually supra). Then, the dentist will check any signs of periodontal disease during the following dental exam.

Therefore, it is not uncommon to see patients on a 12-month cleaning schedule and a 6-month exam schedule. The dentist checks the periodontal condition using a PSR (PSI in Germany) probe.

The periodontal health is also assessed against the amount of supra deposits visible from 22-27 (33-43 FDI). The dentist may or may not work out a plan to treat the condition.

The reality is that dentists spend a lot of time putting out restorative fires. Periodontal issues are secondary at best, and the treatments are often sub-standard.

The new AAP and EFP classification protocols in Germany

The new periodontal classification system starts July 1st. This will dictate changes in clinical practice and diagnoses.

As each state tries to figure out how to incorporate the changes into their practice acts, foreign-trained dental hygienists must keep alert. Each state has its own rules.

For example, the Bavarian dental chamber released initial guidelines about how the adoption of the updated perio classification guidelines affects its allied personnel.

You can download the PDF with the guidelines below. (German language only)



The delegable duties, starting July 1st, are on the first page. They include, radiographs, Oral Hygiene Instruction incl. disclosing and supragingival polishing.

They also include “supra- and subgingival deposit removal”. This is where things get confusing.

The second page makes clear what procedures are not delegable. These include: the diagnosis of periodontal disease, professional explanations about the treatment options, as well as the maintenance of periodontal conditions.

Further clarification necessary

All of this left dental hygienists – both foreign-trained and German-trained – scratching their heads.

Dr. Manfred Kinner sought to explain what the implications of the changes will be in the article, “Die PZR hat Zukunft” (loosely translated ‘professional dental cleanings have a future – German language only’)

Die PZR hat Zukunft


Dr. Kinner basically restated what appears in the previously mentioned article. Nonetheless, he did provide a bit more clarity about new procedure codes and why certain ones can only be billed by a dentist.

He mentioned periodontal maintenances (UPT) as being one of those procedures. What exactly is “subgingival deposit removal” if not a periodontal maintenance?

As he explains, this new code (UPT) can only be performed by a dentist and is not delegable.

It seems that the Bavarian board heard back from many practitioners and sought to allay fears in the post “Delegierbare Leistungen bei PZR und PAR-Behandlung”.

This post mentions that allied professionals may remove subgingival deposits non-surgically.

What these rules mean for hygienists

There are some forward-thinking dentists in Germany who value a well-trained dental hygienist in their practice. These dentists will undoubtedly go to bat for their hygienists in the face of any new challenges.

How this works in practice remains to be seen.

For example, there are more billable supportive procedures for dentists with the new guidelines. The new codes give dentists broader benefits from periodontal treatment reimbursements.

Assigning them strictly to dentists prevents splitting the reimbursements with hygienists.

Routine supra-gingival cleanings can be performed by the dental assistants. This may decrease the patient base to support a hygienist.

Again, a win for both the dentist and the assistant. The dentist pays a fraction of the dental hygienists’ salary, the assistant gets more autonomy, and the patients are none the wiser.

Hence, another threat to dental hygiene.

Signs your job could be in danger

Since the laws in Germany protect the employee, getting fired is less of a fear. However, the employer could make it so uncomfortable for you, that you choose to leave yourself.

In other words, they could push you out.

What does that look like in practice? The first indication is the hiring of a ZMP or a dental assistant to do the cleanings. They would slowly have patients assigned to them while still working as an assistant.

Eventually, your patients could be funneled toward the dental assistant. This may be seen with immediate follow-up procedures or at the recall appointments. This would compete with your schedule, thus making it hard to fill.

If your schedule can’t be filled, they could make the case that they can no longer keep you on staff.

There are other, less obvious things to undermine your job security. Since you cannot be fired for trivial matters, you could be framed.

Another way to make you uncomfortable is to highlight your faults. The more faults you have, the easier it could be to make a case that you are a poor fit for the position.

What the future holds for dental hygiene in Germany

Since so many practices have benefitted from some form of dental hygiene in Germany. It is hard to imagine that the profession will be eradicated completely.

It is not hard to imagine, that the earnings of a hygienist in Germany will continue to be challenged.

If this is your concern, there are offices around Europe that are in great need of a well-trained hygienist and who are willing to pay top-dollar for one.

You just have to look around.

See the post Find Your Dream International Dental Hygienist Jobs

Photo by on Unsplash

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