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Sitting in His Lap

Feb. 1, 2007
A Positive Approach to Periodontal Referrals

A Positive Approach to Periodontal Referrals

by Noel Kelsch, RDH

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When my daughter, Ma’rhya, was 14 she was treated for upper respiratory infections and asthma several times in a one-year period. It seemed like we spent more time in the doctor’s office than at home. Our trusted family doctor who had taken care of her for 12 years was perplexed as to what was causing this active child to suddenly have trouble walking into his office. School was out of the question as she grew weaker and weaker. Every day was a series of more tests, and Ma’rhya got paler each day. Though I had spent years prying teenagers out of bed in the morning, just getting Ma’rhya up and moving in the morning was a job that was literally impossible.

One afternoon I took her to our family doctor’s office. After examining her he asked us into his office. He sat down at my daughter’s level and talked to us both. He looked Ma’rhya directly in the eyes and touched her hand as he said, “Moe, you have a disease called Juvenile Ankylosing Spondylitis (JAS). It is very rare among teenagers. It is attacking you in a way I have never seen before. I do not have the special skills to treat this disease but I will find someone who can that we can both trust.”

The doctor went on to explain that the disease was attacking my daughter’s lungs and heart. As she slept, the pericardium, pleural sack, and surrounding rib cage were calcifying. This was the reason she was unable to breathe when she tried to get up in the morning. He explained in simple terms that there were doctors who went to school just to treat this disease. He told her he would find one of these doctors for her, then he asked her if she had any questions and answered her honestly.

He gave us the name of the referral doctor and a printout of information on the disease. He handed us one of his own business cards and said, “Please call me if you have any questions about anything. I am still your doctor and I will still be taking care of you.” The trust that had developed between my daughter and her doctor over 12 years of treatment was at its peak that day as the doctor demonstrated effective communication skills and his ability to refer my daughter in her best interest. His positive attitude went with us to the specialist’s office.

Referring a patient for treatment of periodontal disease is a complex task. In the past many negative connotations accompanied a periodontal referral. The attitude of all people involved in the referral process has a major influence in the patient’s response to the referral.

Working in a periodontal office, I have found that each time new patients sit in my chair, they bring with them the attitudes of the referring office, their friends, and families. R. Freeman, PhD, explained, “Two sets of attitudes exist - health-related and health-directed - and the dentist is the most salient referent. Principle components analysis demonstrated the dual nature of attitude, and suggested that family and friends were also influential ‘important others.’ This suggested clash exists between the lay and professional dental health perspectives. Clinicians should be aware that patients who are referred for consultations to their clinics arrive with their own strongly held attitudes and beliefs, appearing to value the advice of family as well as that of the dental health professional.”1 Patients are not just sitting in a chair and being diagnosed with a disease; they are also experiencing the words, expressions, and gestures of the referring doctor and his staff.

The referring office can send the patient with either a negative or positive outlook on the referral process. This can greatly affect treatment acceptance and patient compliance. R.J. Snoad, DMD, explained, “The act and manner of referrals to specialists is as important to a patient’s health as the treatment itself.”2 Stephen Weiner, clinical psychiatrist, explained, “This interaction is literally a transference of the dental professional’s personal bias or preconceived idea of the referral experience. This concept of transference can be conscious or subconscious on the practitioner’s part. It includes the mannerisms, words, tone, and information presented. This can be a positive or a negative bias. It can be actual or inferred in your speaking and mannerisms. Patients not only hear what you are saying, they comprehend what they read into what you are saying.”3

In many ways this concept is like Projective Identification (PI). PI is a psychological term that was first introduced by Melanie Klein, PhD, in 1946.4 It refers to a psychological process in which a person will project a thought or belief he or she has onto a second person. Then the second person behaves as though he or she is actually characterized by the thoughts or beliefs that have been projected. This is a process that both parties generally are not aware of. What is projected is most often an intolerable, painful, or dangerous idea or belief about the self that the first person cannot tolerate (i.e., “I have behaved wrongly”). Or it may be a valued or esteemed idea that is difficult for the first person to acknowledge for some reason.

PI is believed to be a very early or primitive psychological process and is one of the more primitive defense mechanisms. It is also thought to be the basis out of which more mature psychological processes like empathy and intuition are formed. The unconscious distortions of this process may affect the patient’s treatment, as well as interpersonal and intraprofessional relationships. I see the results of this behavior on a regular basis in the periodontal practice where I work.

A man presented in my office, his arms folded tightly across his chest. He plopped himself in my chair and said, “If this hurts, you will never see me again.” I asked him what he had been told about the procedure, and he told me a story that made me wonder how he found the courage to follow through on the referral. He had been told that we would be cutting his gums away and that the referring dentist had a family member who had been in pain since she had had this done 20 years ago. The patient said that the dentist referred as a last resort in the worst conditions, when a case was so bad the person would need all of his teeth extracted. My patient told me that he knew he was going to lose all his teeth, and that this was going to be a very painful procedure, and that he would have pain his whole life. This patient came in with his referring office sitting in his lap.

I explained to my new patient what we would do and how the process has changed over the years. I was honest about the minimal pain involved and gave him literature on the procedure, and demonstrated on a model what I would be doing. I gave him positive feedback on my experience when I had the procedure done myself. I then asked the patient for questions. I reassured him this was a disease that was treatable and that we would take whatever measures we could to save his teeth and improve his health. Like my daughter’s doctor, I reassured him that he could call anytime to address any questions he had. I gave him the space to express his feelings by concluding each thing we discussed with, “Do you have any questions?”

I addressed each question verbally and in writing, so that when he left he could read concrete information that related directly to what we found in his mouth. At the end of the appointment, I gave him a pamphlet on his disease and diagnosis and a paper on aftercare that included the office contact information.

Dr. Gregg Mitchell, a general practitioner in Moorpark, Calif., has a style and demeanor that works well for patients who need to be referred. Dr. Mitchell tells patients his clinical findings and explains the severity of their disease and the treatment choices. He states that when patients have a condition he is not able to treat, he has set up a referral specialist whom he trusts. He makes this a positive statement and uses the patient’s hobbies and occupation as a relation model.

One patient was a bricklayer, and Dr. Mitchell compared the bone to mortar. He said that if the mortar broke down, the brick would fall out, and that he would not want a baker to set his new brick, and that a periodontist was like a professional bricklayer. A periodontist has the training and expertise to help the foundation and arrest the disease breaking down the bone. He went on to say that a bricklayer understands foundation and new ways to lay brick, and that a periodontist has great understanding of the tooth foundation and the best way to repair it. He finished by saying that he would always be the patient’s dentist and to call if he had any questions. He realized the patient would hear horror stories of past perio experiences, but that periodontal treatment had changed drastically. He stated he had never had a single complaint about the office he was referring him to. He dispelled all the myths the patient would hear. His demeanor was positive and concluded with, “If my wife had this disease, this is what I would do for her.”

The words we say and the demeanor and gestures we display need to lead the patient to oral health. Some of the following things can help communicate a positive referral:

  • Put it in writing. Do not just give patients an appointment card. Give them something concrete that states the diagnosis, a copy of their referral letter, periodontal charting, and written information on the nature and severity of their disease.
  • Make positive statements about referral. Be aware of the demeanor and inference you project with gestures, movement, tone, and wording.
  • Help patients understand that being referred does not mean they will not come back to your office. Continue to have regular exams and recare appointments. Communicate these plans for recare to the referral office.
  • Dispel what friends and other professionals say before they say it.
  • References1 Freeman R, Linden G. Community Dent Health March 1995; 12(1)48-51.
    2 Weiner, S. PDH personal interview 5/9/2006.

    3 Snoad RJ, Eaton, KA, Furniss JS, Newman HN. Appraisal of a standardized periodontal referral proforma. Br Dent J 1999; 187:42-46.
    4 Klein M. Notes on some schizoid mechanisms. 1946. In Money - Kyrle R, Joseph B, O’Shaughnessy E, Segal H. (Eds.) (1984). The writings of Melanie Klein. Vol III. London: The Hogarth Press.
    Author’s note: My daughter, Ma’rhya, is now 23 years old. She made it through high school and is attending the University of Nebraska. Her husband, Chuck, is in the United States Air Force. They have had to move all over the United States. Throughout their moves Ma’rhya has consulted with her childhood physician. The special treatment she has received from this caring and compassionate professional has made dealing with her disease much easier. For more information on Juvenile Ankylosing Spondylitis, go to or Brandon Kelsch, RDH, is a freelance cartoonist, writer, and speaker. Noel’s cartoons can be seen in RDH magazine and her articles have been published in both dental and nursing trade magazines, as well as books. She has received many national awards including Colgate Bright Smiles Bright Futures, RDH/Sunstar Butler Award of Distinction, USA magazine Make a Difference Day award, President’s Service award, Foster Parent of the Year, and is a five-time winner of the Castroville (Calif.) Artichoke cook-off! Her family lives in Moorpark, Calif. She can be contacted at [email protected].