I've been a dental hygienist for 15 years. For 12 years, I worked with a wonderful doctor who was kind, fair, considerate, and very ethical. His sudden, tragic death was devastating to everyone who knew him. His practice was eventually sold, and I found work in a different office during the transition.
My problem is that my current employer often diagnoses periodontal disease and recommends root planing/scaling without demonstrating pocket depths or bone loss. He has the idea that anything that measures 4 mm or more requires periodontal treatment. The doctor sees all new patients first for a comprehensive exam and X-rays. He determines the periodontal status and develops a treatment plan that includes restorative and preventive care. The scheduler follows the treatment plan. When the doctor prescribes periodontal treatment, the patient is scheduled on my schedule for root planing/scaling. Several times over the past year, I have had patients diagnosed with periodontal problems by the doctor when all I see is mild gingivitis. This puts me in a very difficult position, since the doctor has taken time to talk to the patient about periodontal problems. Patients believe they need definitive treatment. If I disagree, I make the doctor look bad. When I pretend to treat periodontal problems that do not exist, I feel bad.
I need my job, but I feel like I'm living a lie. The doctor is over-diagnosing, and I don't know what to do about it. After all, I'm not supposed to question his diagnoses. Can you help me figure this out?
Dear Feeling Bad,
It's easy to understand why you feel bad about your predicament. Ethical clinicians treat their patients the way they would want to be treated if the roles were reversed. You are a seasoned hygienist with enough experience to know whether or nor a patient has periodontal disease. The overriding factor is the patients. They put their trust in us to provide appropriate treatment, and when we over- or under-treat them on purpose, we violate that trust.
I have to wonder about what criteria the doctor is basing his diagnosis of active periodontal disease. Gingival bleeding and 4 mm sulci indicate gingivitis, not periodontal disease. How can you plane root surfaces that are not exposed through bone loss? Further, all gingivitis does not progress into periodontitis. While I understand that the pathogens that are associated with periodontitis begin their destructive work in shallow sulci, definitive periodontal treatment is not appropriate until definitive signs are present, such as bone loss evidenced through periodontal probing and radiographs. Treating disease that does not exist is like an unethical auto mechanic telling me I need repairs that are not really needed, just to extract more money from me.
Dental benefit carriers have tightened their criteria and often refuse to pay claims related to periodontal treatment when firm evidence from charting and radiographs is not present. The propensity for fraud is ever present. Some doctors even feel justified with inflating the diagnosis because benefits carriers have not kept pace with increasing costs associated with providing good dental care. Sometimes, this line of thinking lands doctors in hot water with dental boards or the law when their fraudulent deeds are uncovered.
And it's not just doctors. Hygienists have been known to inflate their treatment in order to pad their production numbers, especially if there is a bonus opportunity from exceeding a predefined production goal. I read a case about a hygienist convicted of Medicaid fraud when it was discovered she was inappropriately coding the treatment she was actually providing. The result was jail time, a significant fine, and probation.
Most state board Web sites publish disciplinary cases. In a recent case, a dentist treatment planned root planing and scaling for periodontitis. The report states:
"Neither the Respondent's clinical chart entries nor the radiographs provided by the patient supported Respondent's diagnosis of type II/III periodontal disease, treatment plan or the treatment performed. The Respondent directed his auxiliary staff [hygienist] to perform procedures that were not supported by clinical or radiographic documentation. The standard of care for dentists licensed to practice dentistry in [name of state] requires dentists to accurately diagnose periodontal disease and refrain from directing auxiliaries to perform scaling and root planing when the need for such is not supported by clinical and radiographic documentation."
The doctor was found to be in violation of the standard of care after the patient in question filed a complaint with the state board of dental examiners. There were two violations: 1) inappropriate diagnosis and treatment plan, and 2) billing the patient's insurance carrier. The result was the doctor's license was suspended (but immediately reinstated) with five years' probation, he must not violate any standards of care during the probationary period and will be subjected to board scrutiny of his records during that time, 100 hours of community dental service, completion of a mandatory ethics course, and reimbursement to the board for the costs of the investigation. Probably the worst consequence of all was that the board's disciplinary action against this dentist will be reported to the National Practitioner Data Bank (NPDB). Third-party payers monitor the NPDB, and when one of their provider's names shows up, this doctor is flagged and sometimes dropped as a provider. There can be long lasting negative consequences associated with state board disciplinary actions.
This discussion would not be complete without mentioning something I see fairly often in consulting, and that is patients with no up-to-date periodontal charting or radiographs. I read chart notes that mention "heavy bleeding/calculus" and sometimes pockets, but no definitive periodontal treatment is treatment planned. Sometimes patients get a prophy when periodontal disease IS present. Too many hygienists get caught up in the "run and gun" mode and miss that periodontal disease is present, primarily because they omit the full-mouth periodontal charting/recording. In my opinion, under-diagnosing is just as bad as over-diagnosing. My advice to you is to have a heart-to-heart talk with the doctor. Tell him that something is troubling you, and that the two of you do not seem to be on the same page regarding periodontal diagnosis. Be prepared to cite a specific patient's case where the diagnosis of periodontal disease was rendered but not supported by charting and radiographs. Tell the doctor you are concerned for him and that you wish to practice to the acceptable and current standards of care. Relate that you're only trying to intercept and solve this problem before it becomes something that could threaten both of your licenses.
Patients are not stupid! Unfortunately, there is a fair amount of mistrust in the general public regarding dentistry because of negative reports in the media. (Remember the "Reader's Digest" article a few years ago regarding over 20 different treatment plans a man received in over 20 different dental practices?) If you approach this discreetly and with concern, maybe the doctor will improve his diagnostic skills. I hope he will see that you are only trying to save him from a ton of trouble.
Dianne Glasscoe Watterson, RDH, BS, MBA, 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 www.professionaldentalmgmt.com.