The Angry Patient

Dear Dianne,

Recently I had a new patient in my chair. When I did my initial assessment and periodontal probing, I noted several areas of pocketing and generalized bleeding. He had had no care for several years, and he presented with moderate periodontal disease. I explained to the patient that he had periodontal disease and needed root planing and scaling to bring the disease under control. The patient seemed agitated and said that all he wanted was to get his teeth cleaned. When I explained that a “cleaning” was not the appropriate treatment for periodontal disease, he became angry. He jumped up from the chair, ripped his patient napkin off, stormed by the front desk, and declared, “I’m going to sue this practice!”

The front-desk assistants and I were shocked by his outburst! Now I’m left feeling like maybe I didn’t do something right. I’ve never had anything like this happen before, and I certainly do not want to be the reason for a patient lawsuit. Could this patient really sue us? What should I have done differently?
- Worried and wondering

Dear Worried,

Here in America, anybody can sue for almost anything. However, the success of any lawsuit brought against a dental professional is determined largely by the quality of the chart notes. I hope you thoroughly documented your findings and the patient’s response. I would advise you to use quotation marks when recording remarks the patient actually said. Certainly clinicians have the right to refuse to render inappropriate treatment.

However, let’s go back to the actual appointment. Your office protocol is typical of many offices that see new patients in the hygiene department first. I understand that the reason many doctors use this protocol is because hygienists are excellent at gathering data and performing assessments, but it is preferable for new, adult patients to see the doctor first for a thorough examination and periodontal charting.

The patient’s response may have been different had the pronouncement of periodontal disease come from the doctor instead of you. In the future, I would advise that you change your protocol for new patients and allow the doctor to deliver the diagnosis of periodontal disease. The best way to do that is to gather all of the necessary data, arrive at an initial periodontal classification, then have the doctor come in and confirm the assessments and co-diagnosis.

Obviously, this patient was upset that he didn’t get his teeth “cleaned” at the initial visit. With a new patient, there is no way to know for sure what the patient needs in terms of preventive care before an assessment is performed. Some new patients will need only a prophylaxis, but others will require more definitive care. Your business assistants should inform new patients who want to get their teeth cleaned on the first visit that there are several different levels of preventive care, and the level needed will be determined after the examination.

“Mrs. Jones, since we’ve never seen you before, I don’t know what level of preventive care you need. That will be determined after your examination. We tailor our treatment based on patient need.”

If a new patient needs periodontal therapy, I think it is wise for the hygienist to scale a limited area and use Code No. 4342 (root planing/scaling one to three teeth) on the first visit. By doing this, at least the patient feels he or she has had some scaling done.

Consider what you would have done if, instead of causing a scene, the patient had told you in a regretful way that he could not afford periodontal care right now. What would you have done under that circumstance? In that case, I would probably have done a full-mouth debridement with a power scaler and documented well that the patient declined definitive care for his periodontal condition. After all, some care is better than nothing.

This particular patient’s expectation was that he was to get his teeth “cleaned,” but his expectation was not met. However, his expectation was not reasonable, based on his periodontal condition. It is certainly not your fault that he had neglected his teeth over time to the point of developing periodontal disease.

Using appropriate analogies is a great way to help patients understand the disease process at work in their mouths. For example, you could have said: “If you had pneumonia and your physician wanted to treat you for a common cold, would you think something was wrong?” Or, “If you had an infected wound on your arm, would merely putting a Band-Aid^® on it make it get well? Doing a mere ‘cleaning’ on someone with periodontal disease would be like putting a bandage on an infected wound.”

Our world is not ideal, and sometimes in dentistry we have to provide less-than-ideal options for our patients. Consider the patient who has fractured a molar and needs a crown on the tooth. What would the doctor do if the patient states he simply cannot afford to have a crown done right now? Would the doctor send the patient away with no care? Probably not. The doctor would probably provide a less-than-ideal option, such as a temporary crown or a large restoration.

So, here are my suggestions:

1. Improve the communication between the business assistant and the new patient at the time the initial appointment is scheduled.
2. When periodontal disease is present, have the doctor come in and deliver the definitive diagnosis.
3. If the patient’s expectations are unreasonable, you may be able to adjust the expectations through good verbal skills. Use analogies to get the point across.
4. Patients are not to dictate care, but we have to operate within the boundaries they set. Patients do have a right to refuse care, just as we have a right not to render inappropriate care.
5. Remember that you can’t please everyone, but you can try.

About the Author

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 e-mail [email protected]. Visit her Web site at www.professionaldentalmgmt.com.