Dear Dianne,
I have written to you in the past and always await your advice RDH magazine because the topics are so relevant to our everyday practical life.
My question to you is twofold. We have a puzzle in our office about scaling and root planing (SRP). My co-worker took on a recently retired hygienist and found that many of our patients needed SRP. The hard part is getting some patients to agree to treatment. These are long-term patients of the practice who have been repeatedly informed of the need for SRP and have declined time and time again.
Here’s the rub. My colleague told me that she once worked in a practice where they allowed a patient to forego scaling and root planing, and actually signed a “treatment refusal” form stating that she knew the risks of not receiving treatment. He also stated that he would not hold the hygienist or doctor responsible for any negative consequences. Then, when he lost teeth, he sued the practice and won!
My colleague contacted our state dental board and someone there informed her that failure to provide scaling and root planing to periodontal patients who need this service could result in legal action and loss of our hygiene licenses.
I’m very worried. Now my colleague refuses to treat patients diagnosed with periodontal disease and refuses scaling and root planing when treatment is scheduled.
I fully understand that SRP is the gold standard for the treatment of periodontal disease, and I fully agree that patients who have periodontal disease will benefit from the treatment. I’m just confused about our requirements regarding patients’ rights to do what they choose with their treatment.
I don’t want to lose my license or be negligent in any way by not treating a patient, but I believe there are exceptions to this. I have had patients who are fully aware of the extent of their disease and aware of the systemic effects their periodontal disease can have on them. However, I have been told by more than one patient that they cannot afford periodontal cleaning. They have to choose between paying their bills or getting dental treatment.
We also have a patient who is 91 years old and refuses treatment telling us she doesn’t “buy ripe bananas”, and we have a patient who has terminal cancer and chooses not to have treatment. I have spoken to hygienists at other practices who tell me that patients have the right to choose what they feel is best for them and it is not our place to force them to do something they don’t want to do. What are your feelings on this matter?
Also, we have a number of patients who have a fair amount of attachment loss, but no inflammation, bleeding, stone accumulation, or significant pocket depths. What is your opinion on scaling and root planing for these patients?
Western RDH
Dear Western,
Thanks for the good words! I always hope my columns are timely and helpful.
When a patient has documented evidence of chronic periodontitis (meaning bone loss and ongoing and worsening disease activity documented over time), the appropriate treatment is SRP. The diagnosis must be made by the doctor and the appropriate treatment discussed.
If a patient refuses definitive treatment, this refusal should be documented, along with the patient’s signature on a document stating that they understand the consequences of non-treatment. It is the physician’s decision whether to retain or dismiss the patient from the practice.
The safest course is to fire anyone who disagrees with the definitive treatment, but the “safest” is not always the most palatable. The reality is that most dentists today are unwilling to turn away patients. Social media has allowed and encouraged patients to post negative reviews that can do a lot of damage to a practice. The fact remains that the dentist is ultimately responsible and the hygienist as an employee should follow the instructions of the dentist-owner.
The information given to your colleague by a representative of the State Council is disturbing and, I believe, grossly incorrect. If a hygienist refuses to provide services that a patient has agreed to, the hygienist would likely lose their job. But if the patient refuses a particular recommended treatment, it would be considered unethical to try to force the patient to agree. The hygienist as an employee cannot dictate care. Can you even imagine a hygienist (or dentist) losing his/her license simply because a patient refused a certain treatment? That would be ridiculous.
What I want to know is where is the doctor? Is the doctor willing to let that hygiene dictate who he will or won’t see? I know some landlords are very non-confrontational, but this is extreme. The dentist-owner is supposed to direct his staff members. The dentist-owner has to step in at some point and take a stand. Is he willing to allow patients to remain in the practice when they refuse necessary care? If so, then the hygienist must offer an alternative treatment, and perhaps not the ideal treatment. For some patients, I believe it is best to refer them to a periodontist.
Patients have rights, but so do the practice owners. While a patient can legally refuse a treatment recommendation, a practice owner can legally remove a patient from the practice. I heard a lawyer make this statement: “Patients have more rights than responsibilities and dental professionals have more responsibilities than rights.” So true!
Informed refusal is a hot topic in legal circles today. All able-bodied adults have the right to have the final say on what happens to their bodies. I can refuse any treatment, even resuscitation. But I bear the consequences of this decision. If my doctor tells me I need an appendectomy and I refuse, and my appendicitis bursts and I almost die, is my doctor responsible? Of course not. He told me I needed the surgery and I refused.
The problem in many offices is that they do not want to involve patients in decision making, nor are they willing to involve patients. It’s the dentist’s way or the highway. The reality is that there are often alternative treatments, even short-term ones, that allow patients to make the right decision.
I heard author, speaker, and entrepreneur Steven J. Anderson say, “One of the greatest challenges for us in dentistry is learning how to balance the clinical ideal with the patient’s reality.” Wow, what a profound statement! The reality for many patients is that dentistry is a luxury they cannot afford. I believe there are increasing numbers of people who fall into this category. that, plus the fact that there is patient distrust of the dental profession due to a series of negative articles about overdiagnosis. Every profession has its bad apples.
The reality of your patient examples is that some people have overwhelming reasons not to have extensive treatment. There are exceptions to every rule.
Regarding your last question, I would assume that if the patient has no signs or symptoms of disease activity and has shown continued improvement over time, then the patient is stable. Inflammation would be a key indicator of activity. We must always be diligent in monitoring for signs of reinfection or disease recurrence.
The best,
Dianne
DIANNE GLASSCOE WATTERSON, MBA, RDH, is an award-winning author, speaker and consultant. He has published hundreds of articles, several textbook chapters, and three books. Her new DVD on instrument sharpening is now available on her website at wattersonspeaks.comin the “Products” tab. Visit her website for information on upcoming talks. Watterson can be reached at (336) 472-3515 or by email at [email protected].
