To refer, or not to refer

April 1, 2004
I have been a dental hygienist in a general practice for the past 15 years. During that time, I've seen many changes in the way we treat periodontal disease.

by Dianne Glasscoe

Dear Dianne,

I have been a dental hygienist in a general practice for the past 15 years. During that time, I've seen many changes in the way we treat periodontal disease. Thin ultrasonic inserts, site-specific pocket therapies, and the use of medications give us much better treatment outcomes than in the past.

However, there are times when I feel my conservative treatment is not enough. My boss seems reluctant to make referrals to the periodontist. Sometimes I feel like I'm in over my head.

Another problem is that some patients with advanced periodontitis refuse to see the periodontist, even when we tell them that they could lose teeth otherwise.

My question is this: when is it appropriate to refer, and how should the patient be told?
Caught in the Middle

Dear Caught,

I'm glad you asked this question, because it gives me an opportunity to share information that will help you and many of your colleagues when trying to make a referral decision.

When I graduated from dental hygiene school in 1978, there was no such thing as "non-surgical periodontal therapy." When a new patient presented with periodontal disease, the first order of business was to refer to a periodontist before any restorative dentistry was done. Most periodontal patients were treated surgically. When they returned for the restorative phase, their oral tissues were healthier. However, root exposure and sensitivity (often lasting for years) were common. In those cases where the patient refused to see a specialist, we muddled through what was then called "gross scale/fine scale" protocol and got off as much as we could, often depending on how much pain the patient could tolerate. Subsequent dentistry was built on unhealthy and unstable foundations. Welcome to the 1980s!

However, somewhere in the early to mid 1980s, the phrase "soft tissue management" hit the periodontal treatment scene. That phrase was actually tendered by the Prodentec® people. I remember attending one of their seminars with my boss, and we implemented their program the following week in our practice. We concentrated on scaling in only one anesthetized quadrant — a novel idea at the time. Needless to say, the results were overwhelmingly favorable, and our periodontal patients were being helped in ways that we had never been able (in a general practice) to help them before.

When we first started this protocol, I remember the feeling of freedom at not having to worry about patient discomfort during the scaling procedure. I vividly remember feeling insecure and unsure of what my efforts would accomplish. However, those feelings quickly turned to confidence and professional satisfaction when patients returned and their tissues showed stark improvement. The patient could see and feel the difference! Nothing was more professionally gratifying than taking a patient from a state of disease to a state of good health! As a result of so many good outcomes, fewer periodontal referrals were made.

However, then as now, there are situations that call for the expertise of a specialist. I am not a periodontist (and don't play one on television). I know and understand that non-surgical therapy has its limits. While many patients will benefit greatly from non-surgical periodontal therapy, some patients have underlying systemic issues that will compromise a good treatment outcome. Other patients will have deep vertical pockets that may require an open procedure to gain access to calculus that resides there. Additionally, some patients continue to lose attachment and bone, no matter what you do. In my opinion, these patients should see a specialist. Of course, patient cooperation and compliance are also issues that could influence the decision to refer.

It has been debated whether bleeding on probing is the best prognosticator of successful treatment. However, bleeding on probing can vary widely. For example, Mrs. Jones has a 6 mm pocket at the mesial of #2 that bleeds profusely. You anesthetize the area and debride it thoroughly. Three months later, at her periodontal maintenance appointment, the probing is still 6 mm, but now there is only a small spot of blood. Has there been improvement? Certainly! With more time and continuing professional care, the bleeding may stop completely, but a small amount of bleeding upon probing does not necessitate a referral.

We must also take into account the amount of pressure exerted with the probe. Any clinician with a heavy-handed technique can cause bleeding. My favorite probes are the plastic ones with the little ball on the end.

We know periodontal disease is a bacterial infection that, over time, causes breakdown of the supporting ligament and bone. The primary etiological factors are periodontal pathogens, while calculus is a secondary factor. We strive to remove as much calculus as possible, but the fact remains that rarely, if ever, do we remove all of it. Further, we can get some great results with our therapy, even when we do not remove all the calculus. If we can get the pathogens under control with scaling, site-specific therapies, irrigation, medication, or whatever is deemed appropriate for the patient, we can get the disease under control — without surgery.

Your statement, "The doctor seems reluctant...," may just be a perception on your part. Certainly, when you, as a clinician, feel a referral is in the patient's best interest, the time to broach this subject is in a private conference between you and the doctor before the doctor examines the patient.

How is the best way to tell a patient that he or she needs to be seen by a periodontist? First, every patient who agrees to conservative periodontal treatment in the general practice should be informed: "Mrs. Jones, most of our patients get very good results with our non-surgical therapy. However, once in a while and for various reasons, the outcome is not as good as we hoped or expected. If you happen to be one of those few, we may recommend a referral to a periodontist for further treatment. At this point, we do not anticipate that will be necessary, but we want you to know it may be a possibility."

Patients have varying host immunities, and we have little ability to recognize or influence that.

For the existing patient who needs a referral because of a worsening periodontal condition, here is an effective comment: "Mr. Smith, from the periodontal exam I've conducted today, I am very concerned that the disease is active. I've identified some difficult areas of active infection. What that means is that you are continuing to lose support around the affected teeth. The doctor may recommend a referral to a specialist."

All you are doing is raising the "red flag" that something is not right. You would need to inform the doctor before he or she conducts the exam.

For the very reluctant/recalcitrant patient, a suggested comment would be: "Mr. Jones, the periodontal infection that we identified on previous visits seems to have gotten much worse since I last saw you. If we don't get you to a specialist, you are certain to lose some of these teeth. This is affecting not only your oral health but your general health as well. There are many serious issues here other than just losing a few teeth. If you were my dad, my husband, or my brother, I would insist you see a specialist. Your well-being is my concern, and I want to help you. Could you share your thoughts with me about this?"

I hope this information helps to clarify when a referral is appropriate. Just remember, patients can refuse anything — up to and including resuscitation. You cannot force a patient to accept a referral. If a patient refuses a referral to a specialist, make sure to document that refusal in the patient chart and have the patient sign it.

Finally, have a conference with your doctor about these issues. Find out the doctor's thoughts on referral, and work together as a team to provide your patients with the most appropriate and thorough care possible.
Best wishes,

Why is the doctor reluctant?

A doctor may seem reluctant to refer to the periodontist. I can only speculate, but there are several reasons why this happens:

• Once a patient is referred to the periodontist, the patient is never released back to the care of the general practitioner — a form of patient stealing.
• There is no periodontist within easy driving distance.
• The local periodontist does not provide documentation and updates about the patient to the referring doctor as treatment progresses.
• The specialist makes disparaging remarks about care or quality of dentistry received in the referring doctor's office, and the referring doctor learns of these remarks from returning patients.

Who needs the referral?

What are the primary reasons to refer to a periodontist? In a nutshell, these are the patients to refer:

• Any patient that continues to lose bone and/or attachment despite your treatment.
• Any patient needing bone regeneration procedures around teeth supporting bridgework.
• Any patient needing grafting procedures.
• Any patient with gingival overgrowth issues that do not resolve after the cause of the overgrowth has been addressed.
• Any patient with whom you do not feel comfortable treating for any reason.

Dianne D. Glasscoe, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe for speaking or consulting, call (301) 874-5240 or email [email protected]. Visit her Web site at