More columns from Dianne Watterson
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Informed Consent and Informed Refusal
By Dianne Glasscoe Watterson, RDH, BS, MBA
I’m having a hard time finding solid guidelines regarding when a periodontal patient should be referred to a periodontist from a general dental office. I’ve heard different guidelines, such as any pocket over 5 mm should be referred if there is no improvement, or if there is continued bleeding on probing following root planing and scaling. Should referrals be based on localized areas, on whether a patient falls in a particular periodontal classification, or both? The doctors I work with are very concerned about doing what’s best for patients, so I know I have their full support. But we really need to establish solid guidelines so we can rest assured that we’re giving our patients the best care possible. Can you provide guidance on this issue?
This is a great question. I don’t think it can be answered simply or with a standard mandate.
In September 2006, the AAP published an academy report titled “Guidelines for the Management of Patients with Periodontal Diseases.” The guidelines were intended to help clinicians identify early when patients are at the greatest risk and to understand when a referral is recommended. The foreword to the guidelines states, “a one-size-fits-all” approach to periodontal care does not exist. Additionally, the guidelines are not meant to override a clinician’s knowledge, skill level, or abilities. The paper divides patients into three levels.
Level 3: Patients who should be treated by a periodontist
Any patient with:
- Severe chronic periodontitis
- Furcation involvement
- Vertical/angular bony defect(s)
- Aggressive periodontitis (formerly known as juvenile, early-onset, or rapidly progressive periodontitis)
- Periodontal abscess and other acute periodontal conditions
- Significant root surface exposure and/or progressive gingival recession
- Peri-implant disease
- Any patient with periodontal diseases, regardless of severity, who the referring dentist prefers not to treat
Level 2: Patients who would likely benefit from comanagement by the referring dentist and the periodontist
Any patient with periodontitis who demonstrates at reevaluation or any dental examination any of the following risk factors/indicators known to contribute to the progression of periodontal diseases:
- Early onset of periodontal diseases (prior to the age of 35)
- Unresolved inflammation at any site (e.g., bleeding upon probing, pus, and/or redness)
- Pocket depths >5 mm
- Vertical bone defects
- Radiographic evidence of progressive bone loss
- Progressive tooth mobility
- Progressive attachment loss
- Anatomic gingival deformities
- Exposed root surfaces
- A deteriorating risk profile
Level 1: Patients who may benefit from comanagement by the referring dentist and the periodontist
Any patient with periodontal inflammation/infection and the following systemic conditions:
- Cardiovascular disease
- Chronic respiratory disease
- Any patient who is a candidate for the following therapies who might be exposed to risk from periodontal infection, including but not limited to the following treatments:
- Cancer therapy
- Cardiovascular surgery
- Joint-replacement surgery
- Organ transplantation
The AAP published a new statement in July 2011. Here’s the link: http://www.perio.org/resources-products/pdf/periodontal-therapy_statement.pdf
As a way to show gratitude for referring patients to them, I’ve presented several “gift” seminars for periodontists who hire me to give a complimentary continuing education course for all their referring dentists and hygienists. The common complaint I hear from those periodontists is that by the time a patient gets to their office, his or her mouth is a train wreck. They often say if they could have seen the patient earlier, more teeth could have been saved. I understand their frustration.
Obviously, the longer a patient goes without effective care, the more likely the person is to suffer tooth loss. Periodontists also have failures, even when the referral comes early in the disease process. In fact, there’s a new study published in the Journal of Clinical Periodontology titled “Tooth loss in periodontally treated patients. A long-term study of periodontal disease and root caries” that looks at tooth loss after definitive treatment. The news isn’t very encouraging.
The conclusion — “Previously treated patients at a specialist clinic for periodontology continued to lose teeth in spite of maintenance treatments at general practitioners and dental hygienists. The main reason for tooth loss was periodontal disease. Tooth loss was significantly more prevalent among smokers than nonsmokers.” (http://onlinelibrary.wiley.com/doi/10.1111/j.1600-051X.2011.01811.x/pdf)
That being said, there is another problem — generalists are reluctant to refer due to economic reasons. Some have complained that once a patient is referred, they never see him or her again. Still others are driven by money and are well aware that periodontal treatment is the most productive procedure for hygienists. It’s a sad commentary when patient care is compromised by the generalist’s reluctance to refer for monetary reasons.
The fact remains that referral doesn’t guarantee tooth preservation. We just can’t save them all. Some disease processes do not respond to anything the generalist or periodontist does, particularly if the disease process is genetically driven. Smoking and diabetes are serious risk factors that can compromise outcomes, even with the best of care.
In the clinical sense, I knew my limitations. I knew when a case was beyond my capabilities. Even when the pocket was not so deep, say 5 mm to 6 mm, if I didn’t achieve acceptable outcomes, I never hesitated to recommend referral. The biggest problem I encountered was patients who resisted going. Maybe it was because I practiced in a rural, blue-collar area where dental IQ was not very high. I can remember a few patients who knew that referral was a necessity if they wanted to keep their teeth. Even that argument did not always convince them.
People refuse referral for various reasons, including financial constraints, inconvenience, fear, and denial. One of my signature stories is about a particular patient who refused a periodontal referral. He was a very busy business executive. Financial limitation was not his issue, but rather the inconvenience of seeing a specialist. This patient always had an excuse (usually work related) as to why he could not carve out time to see a periodontist. For several reasons, dismissing him from the practice was simply not an option. The doctor and I were well aware of his deteriorating periodontal condition, which was documented in his patient notes and signed by him. Finally, I was successful in persuading him that if he didn’t go, he was going to lose his teeth. A letter to our local periodontist that outlined this patient’s deteriorating condition and his ongoing refusal for referral preceded this patient’s visit. I wanted the periodontist to know that we had not been “asleep at the wheel,” but that the patient had simply said “no” to referral.
We practice within the boundaries that patients are allowed to set. While it is important to recommend what we believe to be the best care (including specialist referral), we cannot force people to agree to our treatment recommendations. Every competent adult has a right to deny treatment. It’s called “informed refusal” and is a hot topic in legal circles. Anytime a patient refuses the treatment or referral recommendation, we make sure the refusal is well documented in the patient narrative and we have the patient sign it. If you are using digital records, use a separate “Refusal of Treatment” form that the patient can sign, and scan it into your system. Anyone wanting a sample refusal form can email me at firstname.lastname@example.org. RDH
All the best, Dianne
DIANNE GLASSCOE WATTERSON, RDH, BS, MBA, is a professional speaker, writer, and consultant to dental practices across the United States. Dianne’s new book, “The Consummate Dental Hygienist: Solutions for Challenging Workplace Issues,” is now available on her website. To contact her for speaking or consulting, call (301) 874-5240 or email dglass coe@ northstate.net. Visit her website at www.professionaldentalmgmt.com.
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