Hygiene Mentor: When patients refuse periodontal treaatment
Question: What should I do when a patient says no to periodontal treatment? Should I just provide them with a standard prophy, despite their periodontal status?
Answer: This is an extremely common situation that we face as dental professionals. We must not allow insurance to dictate patient care; we must remain committed to doing what’s best for each patient. The CDC reports, “One in two men and one in three women 30 years or older had some level of periodontitis.”1 The American Academy of Periodontology (AAP) says that if a patient is periodontally involved, they should not be seen at the same frequency as a patient who has never had periodontal disease.2
Patients who are on a periodontal maintenance often struggle to stay on that frequency of recare when they’ve never experienced anything different than their traditional prophy. How does your service differ? Do you provide laser therapy, salivary testing, subgingival irrigation? This is a critical component to our service; why would a patient want to pay more and visit the office more frequently if they’re experiencing the same service?
I believe that we need to partner with patients to determine why they hesitate about treatment and then work our way backward to devise a plan that will support them in caring for their periodontal disease. I’ll walk through how to identify why, the statistics on liability around periodontal disease, and calibration among the team.
Identify the “why” with the patient
Often, a patient refuses treatment because they don’t fully understand the “why” behind what we recommend. I find that once patients are properly educated, it’s much easier to get them to say “yes.” Education should start the moment they’re in the chair, when we begin showing them evidence of their specific risks for oral disease.
An example of this is reviewing their medication and discussing the effects of xerostomia on their periodontium. By starting the appointment this way, they’re ready for the clinician to make patient-specific recommendations. Disclosing the patient and showing them the plaque that’s present is not only a motivational technique, but it also employs them to take responsibility for their biofilm burden.
I find this to be extremely powerful with a disclosing agent that timestamps the bacteria to show mature plaque versus newly formed plaque. Following the disclosing process, I typically use my air polisher to remove the bacteria and begin the appointment with probing. I start here because I need to determine the patient’s gingival track prior to treatment.
Today’s technology allows for multiple options, with voice dictation increasing patient engagement and involvement in charting. As the clinician calls out the information, such as bleeding, clinical attachment loss, and numbers greater than three, the patient is prompted to make the connection between the discomfort and the bleeding pockets with higher pocket depths.
All this actively involves the patient in the process of data collection to determine the level of disease being greater than that of a prophy. I show the patient the plaque, I allow them to hear and feel the periodontal exam, and I explain what’s happening at the systemic level. This provides all the evidence they need to understand why this is necessary.
From this point, I let them know I’ll work with the business team to send all the data to maximize insurance. When it comes to the financial aspect, I’m not involved. As a clinician, it’s my job to collect the data to support the dentist and the dental insurance to confirm the level of disease; however, my treatment recommendations of the nonsurgical will not change based on the insurance coverage.
I’ll continue to recommend the treatment the patient needs. I may modify the home-care recommendations and adjunctive agents I provide in addition to the periodontal therapy, but I refuse to let insurance dictate the care. I wouldn’t want a provider to provide me with less than the standard of care because my insurance didn’t cover. I would want to know my disease state.
Liability
Patients cannot agree to supervised neglect. Therefore, even the most thoughtfully written periodontal refusal form will not protect a dental professional in court. It’s critical to note that one of the most common reasons for dental lawsuits is failure to diagnose. Therefore, as a team, there needs to be a protocol for how long the patient will be treated in-office below the standard of care recommendation.3
I will say I do find this form to be very helpful as it serves as a motivator for the patient to say “yes.” I’ve had multiple patients agree to the therapy once I’ve told them it’s a liability for me to treat them at a lower level of care lower than what the disease requires.
The dental team approach
The entire team must be calibrated on how to treat periodontal disease. I know this sounds obvious; however, many times when I’m providing coaching, I find there’s a large discrepancy in how clinicians treat patients. When we know the common factors that inhibit the patient from saying “yes,” we must have a team approach to support them.
For example, the business team should be able to provide the patient with a pretreatment estimate or explanation of benefits (EOB) once the doctor has confirmed that periodontal therapy is needed. Providing same-day information shows the patient how aligned and organized the team is, and most importantly, how critical the treatment is.
The patient should not have the option to “call when they’re ready,” especially when we know the systemic health effects of untreated periodontal disease. When they leave with an appointment, this increases their compliance for the nonsurgical periodontal treatment. As a team, you must decide how many recares you’ll see the patient under the level of disease.
When we properly work with the patient to overcome their objections, whether that’s fear of time, pain, or cost, then we’re successful in leading that patient to a “yes.” We’re doing more than cleaning teeth; we’re providing potentially lifesaving blood pressure and oral cancer screenings. Therefore, I believe that dismissing the patient immediately at their first refusal is not the answer; however, treating them for years under the standard of care is also not the answer.
Education with compassion is a high driver of patient compliance, and I’ve never had a patient decline soft tissue therapy with my root-cause approach to education combined with the business team’s financial arrangements.
Editor's note: This article appeared in the January/February 2025 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.
References
1. About periodontal (gum) disease. Centers for Disease Control and Prevention. May 15, 2024. https://www.cdc.gov/oral-health/about/gum-periodontal-disease.html
2. Frequently asked questions on the 2018 classification of periodontal and peri-implant diseases and conditions. American Academy of Periodontology. 2019. https://www.perio.org/wp-content/uploads/2019/08/2017-World-Workshop-on-Disease-Classification-FAQs.pdf
3. Palmer W. The top reasons dentists are sued: malpractice stats and the most common mistakes dentists make. Berxi. July 24, 2024. https://www.berxi.com/resources/articles/dental-malpractice-stats/
