Breaking the bad news

Dear Dianne, A dentist in our town recently died. He practiced for 45 years and never employed a hygienist.

Nov 1st, 2006

Dear Dianne,

A dentist in our town recently died. He practiced for 45 years and never employed a hygienist. He worked out of a small office with two chairs and only one assistant who worked at the front desk and at chairside. This dentist was quite a charismatic person and well-liked around town. He had a large and loyal patient base.

After his death, many of his patients started coming to the office where I work. Almost every one of his former patients we have seen has periodontal disease. It appears that this doctor never scaled subgingivally! These are patients who received regular care from him for a long period of time.

The dilemma for us is that when we tell these patients they need periodontal treatment, they view us with suspicion. Several have commented, “Dr. XXX never told me anything like that, and I went to him for years!” It makes me feel bad that they might think we are lying to them, possibly for financial gain.

Do you have any suggestions on how we can break the bad news to patients like this who have been receiving substandard care elsewhere, without disparaging the previous clinician?
Caught in a Dilemma

Dear Caught,

I’m glad you wrote about this situation, because I’m certain many of your peers across the country have experienced a similar scenario.

Failure to diagnose periodontal disease is No. 5 in the top ten reasons dentists are sued, according to Dr. Crystal Baxter, a prosthodontist and expert witness and consultant in more than 300 lawsuits against dental professionals. She states that in the majority of these cases there were no current radiographs or periodontal chartings. Many of the cases she reviewed were in practices that never employed a hygienist.

There is a problem with the periodontal identification process in some practices. When hygienists are forced to work with inadequate time, one of the first things to go is periodontal charting. This is especially true if no one is designated to record periodontal chartings. The time needed to do a six-point probing and recording solo is 10 to 12 minutes. In contrast, when an assistant records probings as they are called out, it takes only three to five minutes. When charting is not performed regularly, periodontal disease can go on unnoticed for months, even years.

Since I brought up the issue of probing, every adult patient in the practice should have a six-point probing with all numbers recorded, even those below 4mm, at least once a year. The reason that all numbers should be recorded is that if the chart is ever called into question in a court of law, a periodontal charting with only a few numbers scattered here and there looks like an incomplete charting to a jury. In the eyes of a jury, the rule is: If it was not recorded in the chart, it did not happen. I would use this same logic to build a case against the PSR method of probing. It is incomplete at best and should only be used as a screening device.

In the situation you describe, the dentist obviously did not practice preventive care according to the current standards of care. Since periodontal disease can go unnoticed by patients for years, his patients have been completely unaware of their problems. Although the original dentist passed way, he could still be sued. His patients placed their trust in him to take care of their dental needs, and he did not do that. This is called “supervised neglect.” The risk for him now is that some patient will sue him after learning the truth about the periodontal disease that has existed for a considerable amount of time.

It is unproductive and unethical to disparage another health-care provider, especially since the substandard care is in the past. Your challenge is to help these patients achieve and maintain good oral health by giving them the appropriate care they need now. You have to help them understand that they

have an active disease that requires more than just a “flick and polish” to become healthy again.

Let’s set forth a strategy that you and your colleagues can use when circumstances like this arise. I call it the “red flag” strategy. Before we delve into the specifics, let’s dream of the ideal scenario.

In a faraway land called “Dental Hygiene Utopia,” new adult patients see the doctor first, have their complete examination with necessary radiographs, and have the diagnosis explained to them. The patient understands and accepts the treatment recommendations. When the patient comes to the hygiene department, the roadmap has already been developed, and the hygienist is ready to begin therapy. What a beautiful dream, but dreams rarely come true.

Let’s assume that new patients are first scheduled in the hygiene department in your practice. A new patient is seated in your chair. You complete all the necessary preliminary functions - introductions, medical history review, blood pressure screening, intraoral and extraoral assessments, and radiographs. Next, you pick up your periodontal probe and begin charting. (Hopefully you have an assistant to record probings.) You see some significant subgingival deposits on the radiographs, and some bleeding upon probing. Now is the time to “raise the red flag.”

You say, “Mrs. Jones, have you noticed this area bleeding when you brush?” A little more probing, then, “Have you noticed this area being inflamed?” Now is the perfect time to engage the intraoral camera so the patient can see exactly what you see in her mouth. In the absence of an intraoral camera, pointing out calculus and/or bone loss on an X-ray is recommended.

All you are doing is calling attention to the obvious.

Then lay down your probe and say, “Mrs. Jones, according to what I see in your mouth and on these X-rays, there appears to be some problems with your gums and bone around some of your teeth, and before I proceed any further, I need the doctor to have a look.”

You have raised the red flag.

Then you leave the operatory to inform the doctor about your findings (out of the patient’s hearing range) and request a brief doctor examination. Most likely, you have interrupted the doctor with his/her patient, so an extensive exam should not be expected at this point.

When the doctor enters the room, introduce the patient to the doctor. The doctor will sit down, look at the X-rays, and perform a cursory exam. Then he/she should say, “Mrs. Jones, from what I see in your mouth and on these X-rays, you have periodontal disease. This is a chronic infection in your gums, and over time, it destroys what supports your teeth - the gums and bone. Your teeth are like fence posts. As long as the earth around those posts is strong and firm, the posts stand nice and straight. But if the earth around the posts deteriorates, the posts get loose. That’s what happens in the mouth. The disease in your mouth is destroying what supports your teeth. The good news is we know how to get this disease under control, usually in a non-surgical manner.”

Painting word pictures with analogies will help patients understand the disease process. Another good analogy is the way termites undermine the foundation of a building.

At this point, the patient may make any number of comments, such as, “No one has ever told me this before,” or “Dr. XXX never told me this.”

This comment really says, “I’m not sure I trust you,” which is a natural reaction for a first visit. One visit is seldom sufficient to build a bond of trust between a patient and clinician. You should not take offense when a patient makes this observation.

Instead, a good reply is, “Really? Well, we’re very glad you’re here today, because it’s obvious there have been some changes since your last visit.” The point is, all you know is what you see today. Whatever happened in the past regarding care is not your concern. Your concern is getting the patient back to good health.

Patients are not stupid. If a patient has been receiving substandard care, let him/her figure that out when he/she sees the difference in his/her former care compared with the care you deliver.

If the patient protests that all he/she wants is a “cleaning,” the “infected wound” analogy works well. “Mrs. Jones, if you had an infected gash on your arm, would a Band-Aid help it heal? Infections have to be treated appropriately, and a mere cleaning is inappropriate for your condition. That would be like putting a Band-Aid on an infected wound. ‘Cleanings’ are appropriate for people with healthy gums, and yours are not. But the good news is that we know how to get your gums healthy again, and that is with the right treatment.”

Your challenge is to help the patient build a bridge of understanding in her mind between a mere cleaning and treating an active infection. But what if the patient refuses your treatment recommendation for definitive periodontal treatment? That’s next month’s column. Stay tuned.

I hope these tips will help you improve your protocol when you deal with patients who have received substandard care. Stick to what you see today, and focus on what is needed to help the patient return to a measure of good oral health.
Best wishes, Dianne

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.

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