Unorthodox Periodontal Protocol

May 1, 2008
I have practiced dental hygiene for more than 20 years and have been employed at one office for more than 15 years.

Dear Dianne,

I have practiced dental hygiene for more than 20 years and have been employed at one office for more than 15 years. Four years ago, I accepted an additional part-time position to help bolster my finances. Both practices are similar in that they serve primarily blue-collar clientele. I consider the long-term position my primary position and the shorter term my secondary position.

I've always known that my long-time boss has "control" issues and rarely delegates anything. For example, he insists on making all of his own temporary crowns and uses his assistant only for suction, instrument/material passing, and clean up, even though she is qualified to perform many other procedures.

Now that I am employed in two offices, I am seeing two different levels of care being given to patients. In the secondary office, I'm expected to do a full periodontal charting every year, a full review of medical history every recall, a complete intraoral and head and neck cancer exam every recall, and create a treatment plan for scaling/root planing when signs of active periodontal disease are present.

The standards are less defined in my primary position. My primary employer and I have butted heads regarding periodontal treatment. When periodontal pockets exceed 5 mm, he treats the pockets in his operatory with a gingivectomy performed with an electro-surgery cauterizing unit, and his own root planing performed with a single posterior scaler. He rarely allows me to perform SRP by quadrant or even localized.

I know this a loaded question, but is his treatment method below the medico-legal standard of care for treating chronic periodontal diseases? I do not ask this question to punish him in any way, but I am concerned for my license and the care of the patients. Can you help me?

Dear Stacey,

I have been in dentistry since 1972, and never have I heard of anyone treating periodontal disease in the unorthodox manner you described.

I posted your question to several doctors, and here are a few of their replies:

  • "Apparently the doctor you are describing is a sad dysfunctional dentist story, bilking money with ridiculous treatment. I would suggest this hygienist seek employment elsewhere, and then blow the whistle on this incompetent."
  • "This clinician could be sued for malpractice."
  • "Put in cold steel and phenol, and you have 1925 dentistry. This is not good in my mind. Leaves a BIG defect and other nasty things… Better post-treatment esthetics IS important to most patients."
  • "The word "cowboy" comes to mind, in the bad connotation. I feel sorry for the dentist's patients, because they have no clue about the effectiveness of what he is doing or the ethics involved. Does this dentist ever refer to a periodontist?"
  • "It causes severe gingival recession. This practice is historical as far as I know."

The standard of care is defined as what other reasonable and prudent practitioners do in a similar circumstance. Furthermore, if a practitioner engages in care that is typically thought of as "specialty care," he or she must meet the same standard of care required of the specialist. Therefore, it is safe to say that routinely treating periodontitis with gingivectomies is outside the current standard of care.

I will comment on the doctor's lack of business acumen as well. Not delegating to his qualified chairside assistant is a wasteful use of her skills. Further, it is common knowledge that non-surgical treatment of periodontal disease is the most productive procedure a hygienist performs. If the doctor insists on doing all the periodontal treatment, he is underutilizing his well-trained hygienists. What is he thinking?

Business acumen aside, the most important issue at stake here is patient care. These are words of wisdom from Michael Rethman, a past president of the American Academy of Periodontology: "In my opinion, what"s described here does not jibe with the standard of care for mild to moderate chronic periodontitis. Ideally, highly competent ScRP ought to be attempted at each periodontitis site at least once and each site reassessed before considering more aggressive approaches. This is because despite the fact that shallow probing depths are generally nicer to have than deep probing depths, the fundamental goal of such therapy is to eliminate the cause of the infection (and keep it eliminated via self-care and maintenance). Most times, non-surgical approaches, especially when performed by experts (who may also be using the added advantage of perioscopy) followed by high-quality self-care and routine professional maintenance, will work just fine at such sites, despite whatever probing depths remain. Surgery generally makes the most sense when non-surgical approaches have failed to achieve health."

Dr. Rethman continues, "Gingivectomies are seldom appropriate other than for suprabony pocketing. Furthermore, gingivectomies are most often used to remove excess gingiva that is coronal to the cemento-enamel junction."

It would seem that the doctor's use of gingivectomy is based in some historical protocol. However, we are more knowledgeable today about effective treatments for periodontal disease than at any time in the past. Every clinician has the burden, by virtue of being licensed by his/her state licensing board, to stay current with treatment protocols. That is why continuing education is mandated throughout the country. Failure to stay current regarding treatment protocols results in an undesirable treatment outcome and a possible danger to the patient. The liability risk is high for the doctor if a patient ever decides to sue for malpractice related to his unorthodox treatment. As a hygienist, you are also at some theoretical risk, although I don't know of a situation similar to this when a hygienist has been sued.

At the other end of the spectrum are those clinicians who espouse new and emerging treatment protocols that are untested and largely unproven by unbiased sources. They also risk liability. When a new treatment is advertised as a "profit center" for the practice, I get an uneasy feeling. The goal of any "new" treatment modality should be to enhance/improve the care provided for those people who place their trust in us, not lighten their bank accounts. If a patient decides to sue a clinician for malpractice related to a treatment outcome involving "novel" treatment, the clinician could be charged with practicing outside the standard of care. It could be that the care delivered is not the currently accepted standard of care.

It is unfortunate that your employer has not stayed current and is treating unknowing patients with incorrect, unethical treatment that causes pain and results that are not esthetic. Whether you should continue to work in his practice will require some soul-searching. If I was in your position, I would probably leave.
Best wishes,

About the Author

Dianne Glasscoe-Watterson, 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-Watterson for speaking or consulting, call (301) 874-5240 or e-mail [email protected]. Visit her Web site at