Doctor disagrees with hygienists: Conservative approach derails attempt to provide care

June 18, 2016
Doctor's conservative approach to patient care at odds with what dental hygienists recommend.


Dear Dianne,

I have been practicing dental hygiene for seven years, and I work with another dental hygienist who has six years of experience. We have a good periodontal assessment and treatment protocol in our office, and both of us agree about how to diagnose and treatment plan the various severities of periodontal disease.

We know when to perform a full-mouth debridement and when to go straight to scaling and root planing. We are diligent about performing full-mouth periodontal charting and x-rays, and we feel confident telling patients what type of cleaning they need prior to the doctor's exam: The choices range from a prophy, to selective scaling and root planing with a one-month recall, to full-mouth scaling and root planing followed by periodontal maintenance.

The problem we are having is with an associate doctor in our practice. She often disagrees with our assessment. After we have discussed the periodontal condition with the patient, the dentist will say that she got a different periodontal reading and doesn't see any bone loss on the x-rays. Then she will say that definitive therapy is unnecessary. We only recommend scaling and root planing for patients with probing depths of 5 mm or greater, and the majority of these patients have not had any care for several years and complain that their gums are bleeding and sensitive.

I have tried to talk to her, but she says she is worried about her license. My coworker and I are baffled that she would question our hygiene skills and even suggest that we are overdiagnosing periodontal disease. Many people in the office have had problems with this doctor. I've come to the conclusion that maybe she should be seeing the patients first since she always seems to have a different treatment recommendation than the other hygienist and I have.

I have one other question: Does there have to be radiographic bone loss in order to correctly diagnose periodontal disease warranting scaling and root planing? Please help, as I just do not understand!

Florida RDH

Dear Florida,

Yours is not the typical periodontal diagnosis problem I hear about. Most of the time, hygienists write to me to say that a doctor is diagnosing periodontal problems where they do not exist. In your case, the problem is a doctor who is so conservative that she prefers to delay definitive treatment until the disease has progressed to more significant pocketing-such as greater than 6 mm. Sheesh!

When you say the doctor is "worried about her license," I assume the doctor is afraid of being charged with overdiagnosing periodontal problems. That is a problem in some offices. If you look at disciplinary actions on most state board websites, overdiagnosis of periodontal disease is one of the more common infractions. Every profession has its share of dishonest people, including dentistry.

One of my colleagues is a consultant with a major insurance provider, and he tells me that fraudulent periodontal reporting is one of the insurance provider's top concerns. This is why many benefit providers now require radiographic bone loss in order to approve benefits. After all, you can't root plane roots that are covered by bone. Because of overdiagnoses made by dishonest clinicians, getting approval of benefits is more difficult for everyone. Periodontal charting is not enough to satisfy the insurance companies since they know how easy it is to inflate the readings.

I consider 5 mm with bleeding to be a sign of periodontal activity, and so do most insurance companies. However, bone loss is not always evident on radiographs, especially buccal or lingual. One way to "build your case" for the insurance company is to insert your periodontal probe in the site with bone loss and take a picture with your intraoral camera. Then submit the picture with the preauthorization. The earlier periodontal problems are intercepted and treated, the better the treatment outcomes. Therefore, we should expect better clinical results in treating a 5-6 mm pocket versus a 7-8 mm pocket. It seems to me that your office needs calibration since this doctor is not clinically on the same page with the hygienists. It would be advantageous to have a training session in which all doctors and hygienists come together to discuss protocol for the assessment and diagnosis of periodontitis and gingivitis.

I learned a long time ago that the more conservative doctors prefer to be the ones to make the decisions regarding treatment, so what I recommend is that you change your protocol. Here's what I mean: You gather the data, and when you find out the patient has some periodontal activity, you simply tell the patient, "Mrs. Jones, according to your x-rays and what I see in your mouth, there appear to be some problems that I need to bring to the doctor's attention."

Don't tell the patient she has periodontal disease. Instead, bring it to the doctor's attention and let the doctor make the call about definitive therapy. Present what you discovered in the assessment. Make sure you've performed a six-point periodontal charting with all numbers recorded, and show the doctor your findings. Be sure to document everything in the patient narrative. If the doctor decides that the patient does not need definitive periodontal debridement, document that in the patient chart. Never write your opinion-just stick to the facts.

Although I am confident that you are conscientious and competent, I would advise you to not take it personally if the doctor disagrees with your assessment of needed care. All doctors develop treatment philosophies; some are conservative about treatment planning, and some are more proactive.

I once worked with an off-the-chart conservative doctor, and I had to learn to accept the fact that he had a right to make diagnosis calls, even if I didn't agree with him sometimes. I distinctly remember a patient with a huge cracked amalgam. I told the patient about the problem and showed it to him with a mirror. I also shared that the doctor would probably recommend a crown for that tooth. Not only did the doctor not recommend a crown, but he also used one of his favorite sayings: "I believe we can get another 100 miles out of this tooth without crowning it," which meant he preferred to patch it up. He was the boss, and it was his decision to treat his patients according to what he felt was in their best interest. Incidentally, this ultraconservative doctor was the best boss I ever had!

My last comment is related to discussing your differences in diagnoses with coworkers since you mentioned that "many people" in the office share your frustration. Cut this doctor some slack and work toward understanding why she tends to be conservative in treatment planning. Sometimes, the conservative road is the best road to travel.

All the best,


DIANNE GLASSCOE WATTERSON, RDH, BS, MBA, is an awards winning speaker, author, and consultant. She has published hundreds of articles, numerous textbook chapters, an instructional video on instrument sharpening, and two books. For information about upcoming speaking engagements or products, visit her website Dianne may be contacted at (336)472-3515 or by email [email protected].