By Dianne D. Glasscoe
I have been out of hygiene school for slightly more than a year. I was fortunate to land a position with a doctor who is about five years from retiring. He is a wonderful boss, and his practice is full of loyal, long-term patients. The previous hygienist worked here for 25 years. As you can imagine, she built up very loyal and committed relationships with her patients. It was very hard for me to adjust.
The biggest problem I have is that the doctor doesn't seem to know how to diagnose periodontal disease. I have identified periodontal pocketing that was not previously charted, but the doctor always wants to "watch" the problem. He seems reluctant to tell patients that there is periodontal disease activity in their mouths. As a result, I'm trying to do deep scaling in a prophy appointment. Often, I feel the patient would be better served by being anesthetized (which hygienists cannot do here) so I can scale more thoroughly.
I really like my job here, and I'm beginning to feel that I'm part of the practice "family." However, it distresses me to feel that I am not doing the best I can for my patients. One thing I want to avoid is creating the perception that I am a "know-it-all" hygienist, but the lack of a periodontal protocol frustrates me every single day.
Can you tell me how to approach my boss about this without offending him? Can you give me some pointers on how to set up some kind of system for identifying and treating the periodontal disease that seems rampant in this practice?
Prophy Queen of NC
Dear Prophy Queen,
Actually, you have identified three problems in your practice:
• Uncharted, undiagnosed periodontal disease in the patient base
• A doctor who doesn't know how or is unwilling to inform patients of existing disease
• No set protocol on how to address and treat periodontal cases.
Let's look at each issue separately and then set a course of action.
According to The Dentalaw Group, a dental malpractice resource center, failure to diagnose periodontal disease is one of the leading causes of dental malpractice litigation. Here's how it can happen. Mrs. Jones is a long-standing patient of Dr. Niceperson. She has never been told there are any periodontal problems in her mouth, and she is faithful with her six-month recare appointments.
While Dr. Niceperson is on vacation, Mrs. Jones breaks a tooth. She goes to see Dr. Straighttalker for her emergency. When he looks in her mouth and probes the tissue around the broken tooth, he finds a 7 mm periodontal defect. He tells her that she will need to see a periodontist. The periodontist performs a periodontal exam and informs Mrs. Jones that she has periodontal disease, and that treatment will cost $4,000. Needless to say, she is upset and frustrated that this disease had never been identified and has been allowed to progress to this advanced stage. She files a complaint with the state board of dental examiners and files a lawsuit against Dr. Niceperson to pay for pain and suffering and the cost of treatment. This is the usual scenario.
Here's a true-life case, as reported by The Dentalaw Group. The plaintiff was 45 years old and had been under the continuous care of his general dentist from 1975 until 1995. He was compliant and diligent about his oral hygiene and followed all dental advice given by the defendant. When he needed restorations, he had them done. When he needed a root canal, he had it done. When he was told he needed a bridge, he had it done. The plaintiff developed periodontal disease that progressed until some of his teeth had no bony support.
The plaintiff was never told about the onset or progression of periodontal disease until he visited a different dentist for a "second opinion," at which time he was told to "run, don't walk, to the periodontist." The plaintiff lost teeth and required four quadrants of periodontal surgery and expensive crown-and-bridge restorations.
The case settled during a mandatory pre-trial mediation conference for $125,000.
So you see, failure to diagnose is a serious problem.
The second problem is that the doctor either doesn't know how or is unwilling to inform patients of existing problems. The former hygienist may be partly to blame if she failed to identify pocketing and call it to the doctor's attention. Many hygienists get in a comfortable "rut" seeing the same patients over and over throughout the years. She or he may go through a whole day and never pick up a probe, not realizing that tissue that looks deceptively healthy on the surface is masking underlying periodontal disease. Many doctors are so busy with the restorative end of their practices that they also do not bother to probe, even during an initial examination.
Even if the doctor identifies pocketing, she or he may be unsure how to classify the disease. Many doctors are unfamiliar with the 1995 or 1999 American Academy of Periodontology Classifications. For an excellent review of the AAP classifications, read an article by Dr. Gary C. Armitage on the association's Web site (www.perio.org; click on "publications;" then click on "position papers." The article is titled, "Development of a Classification System for Periodontal Diseases and Conditions.")
The 1995 classification system is the one most often used. The point is that using a classification system helps you and the doctor clearly identify the level and severity of disease. I highly recommend that all new patients be examined and classified according to their needs.
Another problem is that some doctors have a hard time breaking the bad news to patients. These same doctors will often use verbiage that does not adequately identify the problem. Here are three examples:
• The minimizer — "Mrs. Jones, it looks like you have a little gum problem that we need to attend to." No explanation is made of bleeding, pocket depths, quadrant scalings, or fees. The problem has been minimized in the minds of patients, and they don't understand why a little problem will take five appointments and $800 to correct.
• The unrealistic — "Mrs. Jones, you have a lot of build-up on your teeth, and you will need to come in four times to get your teeth cleaned." Periodontal therapy is called a cleaning, which denotes a simple procedure to a patient. There is no mention of disease or infection. I can just imagine what thoughts could be going through this patient's mind: "Four visits to get my teeth cleaned — ridiculous! They're just after my money!" It's little wonder these patients often break appointments. They haven't been convinced that there is anything wrong.
• The intellectual — "Mrs. Jones, I have found that there is periodontal destruction present with readings from 4 - 7mm. The alveolar breakdown will eventually lead to tooth mobility. We will attempt a therapeutic, non-surgical approach for resolution of this problem." After the doctor leaves the room, the patient turns to the assistant and says, "What did he say?" This doctor has not learned to communicate on the patient's level by using words that are easily understood. From the patient's standpoint, the doctor was speaking in a foreign language.
Doctors need to learn to call periodontal disease exactly what it is — namely, a chronic inflammatory disease that destroys bone and other supporting structures around the teeth. If left untreated, the disease causes the teeth to become loose and is a frequent contributor to bad breath and bleeding gums.
The third problem you have identified is lack of a periodontal treatment protocol. It is essential to have a written guideline that defines how the treatment will progress, how many appointments will be needed, and what the fee will be. I feel the fee should reflect the skill and expertise needed to treat the disease. Therefore, a Class IV periodontal case would be more costly than a Class II case. Here is a suggested template — "Patient Case Classification System" (page 61).
The doctor needs to understand that not having a bona fide periodontal treatment program is costing big bucks, as the periodontal treatment you are currently doing is being billed out as a prophy. There is a difference between periodontal therapy and a prophylaxis.
It takes three things to have a successful periodontal treatment program in any dental practice. First, it takes a periodontal treatment protocol. Second, it takes a motivated enthusiastic hygienist who enjoys the challenges and rewards of treating periodontal disease. And third, it takes a motivated, astute doctor who knows how to identify and classify disease. Your challenge is to approach your boss with this information and bring him up to current standards.
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 Lexington, N.C. To contact Glasscoe for speaking or consulting, call (336) 472-3515, fax (336) 472-5567, or email [email protected]. Visit her Web site at www.professionaldentalmgmt.com.