One hygienist’s perspective on scaling and root planing refusals
Once upon a time, Julie Whiteley, RDH, didn't want to continue treating a patient who had refused scaling and root planing. She no longer thinks that way.
Your patient presents with active periodontitis. Despite what you feel is an informative, educational approach to guide the patient toward the necessary treatment, your presentation is met with those six words that leave you staring into a cavernous hole with a furrowed brow. “I . . . just . . . want . . . the regular . . . cleaning.” You are on one side of that hole and your patient is on the other.
There was a time I felt so strongly that those on the other side of the hole needed to jump over it and accept the indicated treatment—or be referred elsewhere. Of course, in most states the diagnosis, treatment plan, and final decision is ultimately the responsibility of the dentist, but I can assure you that I was very uncomfortable with the idea of performing “just a cleaning” for a patient in an active disease state. Although I knew that patients had a right to refuse treatment, as a provider I had a responsibilitynot to perform a treatment that was not indicated for their disease status.
Good communication skills, relationship building, and trust can help to move patients over the hurdles that stand between them and needed treatment. After understanding their condition, the proposed treatment, and the implications that can come from nontreatment, most patients are ready to move forward. They understand the value and are ready to accept.
What about when we dutifully and thoroughly inform, but the patient refuses the recommended treatment? Are we really doing all we can to try to help by providing an ultimatum to accept the ideal treatment or seek care elsewhere? When we dictate acceptance to proposed treatment, we run the risk of losing patients’ trust and respect, even if they accept the treatment. Patients may feel pressured, which can increase their resistance level and decrease their commitment.
We may also lose the opportunity to help that patient, which is a core value in health care. Patients, when given the choice between periodontal therapy and a referral to seek treatment elsewhere, may not choose to follow up. That could mean they are not receiving any care. They no longer have the continuity of someone who understands their cases who is helping to educate and guide them toward treatment, because you are no longer an option. Whatever their potential barriers to care may be are still barriers that will likely not move on their own. This doesn’t sound like optimal care either. So what do we do?
Our reality is that we do not work in a perfect world where every situation has one clear and ideal answer. We work directly with people (a highly variable and very complex component) in a very intimate space. We are also working in a field where so many of the people we care for come with barriers around dental care—to name a few, finances, limited beliefs around insurance, low dental IQ, lack of trust, pain (be it real, perceived or anticipated), shame/feelings of being judged, and fear.
Sometimes barriers can be easy to recognize and address, while other times they run so deep that the patients themselves may not even be aware of what holds them back. Patients may have situations in their lives that greatly limit what they have the capacity to commit to at that point in time. Often, we may not be privy to the battles that our patients are fighting outside of the realm of the dental office. Some may not be able to grasp or justify how something that doesn’t hurt, or something that is “normal for them” (like bleeding gums) requires a treatment that may be costly and not covered fully by their insurance benefits. For others, the cost of dentistry may be a luxury they cannot afford.
The bottom line is that our clinical assessment reality and our desire to provide ideal treatment can be vastly different from the patient’s reality in terms of what they are ready for at that exact moment. We simply may not be able to reach the patient in one attempt.
Learning to build a bridge
Remember that hole where the disconnect between the provider and patient was one the patient needed to jump over? I now look at that hole as an opportunity for the patient and provider to build a bridge together. Building that bridge doesn’t always happen in one visit. I’ve learned that providing an alternative treatment (albeit not ideal, but thoroughly documented) may buy the time needed to continue to foster the trusting relationship, uncover barriers with solutions, and provide the customized education that can ultimately guide the patient toward better health. I learned that something can surely be a benefit to a patient over doing nothing, at least for the short term. It can buy you some time, and that time can result in a patient who understands and wants the treatment.
For those that may be wondering about supervised neglect, we are not neglecting the patient. We have done our part by performing thorough assessments. The dentist has diagnosed and communicated with the patient about the disease, and recommended treatment. There is thorough documentation. By refusing definitive ideal treatment, the patient bears the consequences of that decision.
The importance of communication and documentation
In those cases where you have a patient who is not ready for periodontal therapy and alternative treatment may be an agreed upon option, communication and documentation are key.
Informed refusal should be clearly communicated and signed by both the patient and the dentist. It should be clear that disease has been diagnosed, treatment options have been recommended, and the patient has refused treatment, despite being made aware of the risks and benefits. The patient is choosing not to treat the disease at this time. It also must be made clear (both verbally and in writing) that any other hygiene procedures performed will not address the disease, but the patient is requesting the alternative service in the interim. It should be documented that the condition will be re-evaluated and re-addressed at the next visit. I would recommend attempting to place the patient on a shorter recare interval. Lastly, thorough and detailed clinical notes are also important.
Other important points to consider:
- These refusal patients should account for only a small minority of your patient base. Perfecting good communication skills, understanding your patient’s goals and beliefs, along with using motivational interviewing techniques to help patients work past barriers to care are helpful areas to master.
- We cannot perform treatment that the patient does not consent to. If it is agreed (under the diagnosis/directive from the dentist) that an alternative treatment will be performed, we cannot do “covert” periodontal therapy and disguise it under another CDT code. The patient has refused the treatment and it is not ethical or legal to proceed.
- This may not be the appropriate approach for every patient who refuses, based on the severity of the disease and other factors that may be present. Further, I cannot think of a time in my career where this “alternative” treatment has gone on for a prolonged period of time. You may come to a place where you say, “We have done all we can and the patient philosophy does not line up with the practice philosophy and standard of care.” Again, the dentist/practice owner is responsible for the diagnosis, proposing treatment, and making the final decisions. As hygienists, whenever possible, it is best to align ourselves with practices that share our own philosophies and values.
As auxiliaries, we are under the direction of the dentist. We are, however, often the first to identify periodontal disease, and work closely with our patients. We can continue to add tremendous value to the offices where we work and to the patients entrusted to our care when we consider possible alternative solutions to problems we encounter. Trust and mutual understanding can take some time to build. We are attempting to guide patients to optimal health over the long term. It is not to say that this approach is ideal for every patient and/or every provider or office, but it gives some ideas to consider with our managing dentists as we strive to provide our patients with care, open communication, compassion, and some time to decide.
Julie Whiteley, BS, RDH, is certified in human resources. She holds degrees in business administration and dental hygiene and has worked extensively in both fields. She is on the faculty of Massachusetts College of Pharmacy and Health Sciences University in Boston. Julie bridges her knowledge and experience from business, clinical hygiene, and teaching to deliver information and programs that enhance dental practices. Contact her at firstname.lastname@example.org.