Refusing periodontal scaling

Dear Dianne:

I work in a general practice with a majority of blue-collar factory workers. The dental IQ is very low here, and often people only come in when they are in pain. Almost every day, we see patients that need periodontal therapy but refuse to submit to anything more than a "cleaning."

I feel very uncomfortable and stressed trying to help these people when I know they need more than a prophy. The doctor expects me to do the best I can within the time frame given, but I often run out of time before I am finished treating the patient. As you might guess, I run behind schedule more often than not.

Is there some kind of form we should be having our patients sign when they refuse periodontal scaling? Can you give me some guidance on how I can better communicate with these patients?
Overwhelmed in Oregon

Dear Overwhelmed:

Hygienists in many areas of the country feel the dilemma you present. In fact, I see this as a problem that is likely to worsen if the national economic situation does not improve. Here in North Carolina, we have been hit especially hard by textile and furniture jobs going to other countries where labor is cheap. Since the inception of NAFTA, we have lost more than 250 companies and over 50,000 jobs in North Carolina alone! When people lose their company-sponsored dental benefits because of job layoffs, they suddenly feel they can't go to the dentist unless they are in pain. Dentistry comes far down the list of necessities, behind housing, food, transportation, clothing, and medical bills. Several of my client offices are feeling the effects of a softening economy. What a sad state of affairs!

However, loss of dental benefits is only one of the many reasons why patients refuse to have definitive periodontal therapy. Some of those patients are afraid of pain. Unpleasant images appear in patients' minds when they are told that they need the roots of their teeth cleaned or scraped. They equate periodontal therapy with some painful surgical procedure. Others balk at treatment because of time constraints, especially when they are told they will have to come in for multiple appointments. For others, the trust factor is missing. Since periodontal disease is not usually painful and can progress virtually unnoticed by the patient, some will be unconvinced when you inform them of disease.

I can identify with your dilemma. Many years ago, I worked in a practice like the one you are describing. Here are some of the comments I remember:

• "My brother had his teeth cleaned one time, and all the enamel fell off."
• "I'm going to lose my teeth anyway, so why bother?"
• "My momma and daddy both wear plates, and they are doing just fine."
• "I'm just going to wait until they all come out so I can get a set that won't get cavities."
• "I just bought a new satellite dish, so I can't afford to get my teeth fixed."
• "The last girl ripped up my gums so badly that I hurt for two weeks. That's why I didn't come back."
• "I really don't have time for this."

The challenge for you is to raise the dental IQ of patients you are privileged to treat. It is no small task when you work in an area that is saturated with people who have periodontal disease. The verbiage you use is extremely important in motivating patients to accept care. Also, the approach you use will differ, depending upon whether the patient is a patient of record or a new patient.

Here are some sample comments I might use with a new patient after the doctor and I have discovered periodontal disease and the need for treatment:

"Mrs. Jones, have you ever heard of pyorrhea? It is a bacterial infection in your gums that attacks the bone around your teeth. If left untreated, the bone deteriorates so much that the teeth get loose. Most people are unaware that this disease is present, because it is usually not painful until the later stages of the disease.

"A regular cleaning will not help you. In fact, it could cause quite a bit of discomfort. This disease is treatable though, so I think we will be able to help you. The disease itself is not inherited, but sometimes the tendency can be present in families. The good news is that periodontal disease is usually slow-moving and quite treatable. We are here to help you keep your teeth for as long as you need them!

"The deposits (called tartar) that have built up on the root surfaces of your teeth are quite hard and tenacious. These deposits are like a coral reef in the ocean where marine life hides and lives. All kinds of nasty bacteria live and hide in and around this tartar. Our therapy will involve getting rid of all those deposits, thereby eliminating hiding places and breeding grounds for bacteria. During the course of our therapy, we will make sure you will not experience discomfort or pain.

"Throughout the course of our therapy, I will ask you to do some things concerning your home care that you haven't done in the past. If you will do what I ask of you, our chances of success are great.

"Periodontal disease is a little like diabetes, in that we don't use the word 'cured.' We attempt to bring the disease under control and stop the progression of bone loss. With treatment, many people are able to stop the disease and thereby save their teeth. Each patient is different. Some get better results than do others. If we find that your gums are not responding to our treatment, it may be necessary to refer you to a gum specialist, called a periodontist, for further treatment."

Each presentation to the patient should center on your own sensitivity to the patient's needs, level of understanding, and willingness to proceed with treatment. Visual aids, such as an intraoral camera, are helpful in getting the point across.

However, if you just sit down and proceed to scale without taking some time to help your patient understand what is happening, chances are strong that the patient will be unwilling to proceed with more definitive treatment. For a patient of record, the conversation might go like this:

"Mr. Jones, have you noticed this bleeding around this tooth? I am seeing some changes since the last visit that indicate you have active periodontal infection present. I want the doctor to have a look at this before we proceed any further."

You have a "day of discovery." This raises the red flag that something is not right and draws attention to that fact. However, if you proceed to scale without informing the patient of the severity of his disease, how is the patient to know?

Several years ago, I remember a particular patient who came in every couple of years for his "cleaning." Each time, his periodontal condition had worsened from the previous visit, and I would try to convince him that he needed to have more definitive treatment. The last time I saw him, I sat the chair upright, and this was my speech:

"Mr. Smith, I've been telling you for several years that you have gum disease. From what I see today, the disease has been very active. You have an active infection in your gums that is likely affecting other parts of your body as well. We're running out of time to save your teeth, and if you were my dad or brother, I would insist that you see a periodontist. I feel like we're just putting a band-aid on a gaping wound here. You know I want to do anything I can to help you. If we are going to save your teeth, we need specialized help. Please share with me your feelings."

With my impassioned plea, he took a deep sigh and said, "Well, OK, if it's that important, I guess I better see to it." Finally, I had penetrated the ignorance barrier! Further, after his treatment, he thanked me for urging him on.

Another point I would like to stress is that you are not helping the practice's bottom line by doing prophys on people with periodontal disease. Periodontal patients require the utmost in skill and expertise from dental hygienists and should be charged appropriately.

Working in blue-collar practices with much periodontal disease is hard work, both emotionally and physically. You feel like you have to move a mountain with a spoon and sand bucket. However, the reality is that the professional rewards of helping some of these people achieve a high level of good oral health can be exhilarating and fun!

The fact of the matter is this; patients can refuse any type of treatment up to, and including, resuscitation. There will be some that have an impenetrable resistance barrier to definitive treatment, either with you or with the specialist. Many offices take a hard line on these people and dismiss them from the practice if they refuse treatment. With some patients, this might be the best approach. However, I've always felt that we are here to help people in any way we can within certain parameters, and some treatment is better than no treatment. I would not permit myself to "steal" from the next patient's time by trying to do everything I would normally do on a healthy patient, but rather do as much as possible with the allotted "prophy" time. Polishing can be omitted, as that procedure is the least important part of the visit. I would lean heavily on power scaling.

The key here is thorough documentation in the patient chart. Any conversations should be noted, especially patient refusals to accept periodontal treatment. Have the patient sign the chart. In offices that are paperless, the patient should be asked to sign a refusal document that is kept in a separate file.

However, please understand that a patient cannot give consent for a clinician to be negligent. The patient has a right to refuse treatment, but he or she cannot give permission for the clinician to engage in supervised neglect. In our litigious society, it is entirely possible that the patient will prevail in a negligence proceeding, even if a refusal of treatment was signed. I have heard of such cases, although I have no personal knowledge of such a suit. As with all sticky situations, each case demands common sense and sound judgment.

Best wishes,
Dianne

Another facet of discussion for this column is referral letters. Here is a sample letter that would precede this patient to the specialist (along with the full mouth series of radiographs):

Dear Dr. Periodontist,

This letter is to introduce our patient, Jack Smith, to your practice. Mr. Smith was first seen in our office in January 1995, as a new patient. He had gross hard and soft debris on his teeth with mild periodontitis. He refused to have periodontal scalings, stating that he only wanted his teeth "cleaned."

He did not return until March 1997 and was informed of existing periodontal disease. Again, he stated he did not want anything but a "cleaning."

His next visit was not until June 2001. We attempted to convince him of his need for more definitive treatment, as his condition was worsening. Again, he refused.

At his most recent visit, we were finally able to convince him that if he wished to save his teeth, he would need specialized care.

My perception is that he is quite fearful of pain. I sincerely believe you will be able to help him overcome his fears and save his teeth as well.

Thank you for your assistance with this patient, and we look forward to seeing him again after your treatment is complete.

Sincerely,
Dianne Glasscoe, RDH, BS

A periodontist would appreciate knowing a little of this patient's history. Additionally, this makes you look professional and competent. It prevents any misunderstanding, such as if a patient tells the periodontist he has had "regular" care in the past and can't understand why he now has gum disease.