Patient resistance

One problem we are having in our practice is the number of patients who express resistance to having periodontal scaling and root planing.

Dear Dianne,

One problem we are having in our practice is the number of patients who express resistance to having periodontal scaling and root planing. We diagnose lots of periodontal disease. But when we tell the patients that they need periodontal treatment, they present all kinds of excuses why they cannot do that now. Most of the time, all they want is a prophy.

That presents a dilemma for us, because we know they need more than a prophy. What are we supposed to do when the patient refuses to have periodontal treatment?

Needing Help in Nevada

Dear Needing,

Your question is among the top five that I am asked to address in my lectures across the country. Therefore, I know this is a concern in many offices.

In my last column, I talked about the communication process with the new patients who present with periodontal disease and using analogies to help them understand what is actually happening in their mouths. The communication challenge for the clinician is helping patients bridge in their own minds the difference between a prophy and the treatment needed to address an active, chronic disease.

There are also trust issues with the new patient. We must understand that - just because we tell patients they have periodontal disease - they will not automatically believe us. Winning the trust of patients happens over time by treating them with care, appreciation, respect, and demonstrating those attributes through our delivery of excellent treatment.

If you have a significant number of patients who refuse to have periodontal therapy, there must be a problem with the communication process when talking with patients. Since I haven’t directly observed your communication with patients, I do not know for certain what is turning your patients away from accepting treatment.

Your approach may be too direct; you are dropping the bomb without any warning. Maybe you need to take a little more time, building the case for periodontal therapy through visual means and relating what you see in the patient’s mouth. Maybe you need to learn to use analogies to help patients understand the disease process better.

Why patients refuse

Even if you do everything right with communicating the problem and building the case for definitive therapy, there is, unfortunately, still a subset of patients who will refuse the needed treatment. Here are some of the reasons:

  • Financial constraints. Let’s be real. When people are struggling to pay for the daily necessities of life - such as food, housing, transportation, and medical care - dental needs can quickly be reduced to emergency or pain-only issues. Offering your patients outside financing, such as with CareCredit®, is one way some people can pay for their care. Another option, while not ideal, is simply spreading the care over weeks, even months so patients can attain needed care.
  • Fear. A DENTSPLY poll of 700 people found 1 in 10 cancelled an appointment due to fear of the injection. An ADA brochure on patient fears related to dental visits says more than 40 million people in the United States avoid dental care because of fear. You certainly must consider your patient’s comfort during and after dental procedures as a priority. If a phobic patient experiences pain on the first visit, the chances are strong the patient will not come back.
  • Inconvenience. Many patients are busy, stressed-out individuals with hectic schedules. The challenge for you is to show the patient that the consequences of untreated periodontal disease are greater than the recommended treatment.
  • Obstinance. Patience is needed with these patients.
  • Mistrust. Again, patience is needed to gain the individual’s trust.

The problem with dismissal

While it might seem logical to simply dismiss from the practice any patient who refuses the recommended treatment, please understand there is a ripple effect in those actions. If you dismiss a resistant husband, you’ll probably lose the wife and children as well. Dismissing patients also can create negative missionaries in the community, which is bad for the practice as well.

However, there are valid reasons to dismiss undesirable patients from time to time, such as a history of broken or cancelled appointments.

Patients have the right to refuse anything, up to and including resuscitation. Every competent adult - including you and me - has the right to have a say in what happens to our bodies. Sometimes, the best action is to bear with people for a while. The patient may reject treatment today, but on the next visit, the patient may be more inclined to proceed with recommended treatment.

The art of being tactful

I had a recalcitrant patient many years ago. He was a prominent man in town, and he and his wife were friends outside the office with our senior doctor and family. He had referred many good patients to our practice. He consistently refused definitive treatment, and every time he came in, I would document his refusal.

Finally, after about four years of refusals, he agreed to a periodontal referral. A letter from me to the periodontist outlined his treatment sequence with our practice over the past several years, as well as his consistent refusal of definitive treatment for advancing periodontal disease. I wanted the periodontist to know that we had not been “asleep at the switch.”

The point is we opted to be patient with him rather than compromise his relationship with our practice. If we had simply dismissed him, we would have lost his whole family, plus any future referrals he would make. His disease was diagnosed and well-documented, as was his refusal for treatment. This did not put our practice in a compromised position legally, as the patient was informed and simply refused our treatment recommendation until much later.

A likely scenario for a lawsuit relating to “failure to diagnose periodontal disease” is when the patient has not been informed about his or her advancing periodontal disease and finds out about it when a tooth becomes loose. Or the patient may break a tooth or lose a filling while the doctor is on vacation and sees another doctor in the interim. The interim doctor may discover periodontal disease that has gone undiagnosed in the original practice. That is a lawsuit waiting to happen. In the majority of these cases, there is no up-to-date charting and/or radiographs.

If you take the time to help your patient understand the disease process by using tact and good communication through analogies and visual means (without being overbearing or aggressive), the chances improve that you will be able to lead your patient into a treatment protocol that is appropriate. Whether or not to dismiss any patient who refuses treatment should be the doctor’s decision and should be judged on a case-by-case basis. RDH

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 dglasscoe@northstate.net. Visit her Web site at www.professionaldentalmgmt.com.

The Rejection Letter

Refusal of Treatment form

From a legal standpoint, if the patient rejects recommended treatment for diagnosed periodontal disease, you must thoroughly document that you have explained the advantages, disadvantages, risks, and alternatives (ADRA) related to the proposed treatment.

Then you must document the patient’s refusal for treatment and have the patient sign your documentation. Some practices use a separate “Refusal of Treatment” form. If the patient refuses to sign your documentation, the doctor should get involved. You simply write, “Patient refused to sign this document,” and along with your signature, the doctor (or another staff member) signs as a witness.

Most likely, a patient who refuses to sign should be dismissed from the practice.

A sample narrative for chart entry

Patient has moderate periodontal disease with bleeding and bone loss (see attached periodontal charting). Patient refuses recommended treatment of SRP. I have explained the consequences of non-treatment, and patient has stated he/she understands he/she could lose teeth and supporting structures around teeth.
Clinician signature _______________ Date_________
Patient signature _______________ Date_________

If the patient cites a reason for refusal, you can also include that in quotation marks.

On successive visits, you do not have to rewrite the whole narrative, but simply refer back to your previous entry. “Patient again refuses SRP. See entry on (Date).”

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