Thursday Troubleshooter: Dentist often disagrees with hygienist

This dental hygienist says the dentist she works with has trouble diagnosing hygiene. To make matters worse, the regional director of the DSO has blamed the RDH for the perio percentages dropping. What can she do?

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Nearly everyone has problems and concerns on the job, and sometimes you're just too close to a situation to solve something yourself. Share your concerns with Team Troubleshooter, and the experts will examine the issues and provide guidance. Send questions to megk@pennwell.com.

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QUESTION: After almost five years practicing hygiene, I have encountered a real dilemma in a DSO practice where I work. The dentist struggles to accurately diagnose hygiene. When a patient comes in for a comprehensive exam, I go in for a perio evaluation after the assistant is finished with her full mouth series of x-rays (FMX). I’ll tell the dentist my recommendation for a hygiene diagnosis, but she often disagrees. There have been a few cases of patients with radiographic evidence of bone loss, 5 mm pocketing with bleeding on probing (BOP), and clinical attachment loss, and I recommended scaling and root planing (SRP) to the dentist, but she came in after her exam and told me we’re going to do the D4346 gingivitis treatment. Meanwhile, when the regional director visited for her evaluation, she pointed the finger at me for our perio percentages dropping.

When the dentist told the director that when she recommends SRP and I tell her there is no bone loss and this is a gingivitis treatment based on the evidence, the director said, "There doesn't need to be bone loss to do an SRP,” and called it an "under the gun cleaning." I just about freaked! I had a patient in my chair so I couldn't explain everything about the criteria for each hygiene diagnosis. The conversation was left at, "We will have training soon," as if I’m the one who needs training! The director’s statement completely disregards everything I've been practicing my entire career. I spent the weekend researching so I would have evidence to bring to the meeting to support my statements. I printed out information from the ADA on the criteria for SRP, and it absolutely states there needs to be evidence of bone loss in order to root plane a tooth, which is obvious to hygienists. I plan to present this to the dentist. What's your feedback on all this?

ANSWER FROM AMBER AUGER, RDH, MPH, owner of Millennial Mentor:
I’m sorry you’re going through this. I was in a similar situation a few years ago where I felt disrespected, disregarded, and that my clinical judgement was being undermined. We are in a challenging spot as hygienists because we cannot legally diagnose. However, a healthy collaborative relationship with the dentist will allow hygienists’ roles to be optimized.

Regarding the misdiagnosis of periodontal needs, I would begin with speaking to the office manager. I would keep track of the specific cases and bring them to the office manager’s attention. In addition, I would reference articles to demonstrate the need for SRP and active bone loss at 5 mm pockets, reference science-based articles, and incorporate studies on supervised neglect. It is important to remember how you approach the conversation in regard to your tone and body language. In my experience, you should come from a place of concern for the overall health of patients and protection of the practice.

Due to hygienists’ passionate nature for disease prevention, proper tissue management, and the protection of our patients, it is challenging to stay calm. Take a deep breath and remember to think before you speak. I recommend practicing what you plan to say prior to the meeting, and pick a time of day to speak with the dentist when the office manager can also attend and supervise to allow for the best results.

When we do not properly diagnose and treat periodontal disease, we’re providing supervised neglect. Supervised neglect is the number one reason for dental lawsuits. As a provider, the hygienist is also liable for proper classification of gingival disease and periodontal management. If the dentist isn't willing to have a respectful peer-to-peer conversation to align science-based recommendations, then you may need to look for another position.

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