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Is Your Periodontal Policy Putting You at Risk

by Wendy Briggs

Periodontal care has become a serious liability risk for dental practices.

This one serious untreated condition is responsible for more lawyers ruining more dentists’ lives than any other…

I am often asked to review practices and highlight areas of opportunity. An area that is almost always predictably low is periodontal services. Prior to the review, each doctor is asked what their ideal periodontal services ratio would be for their patients. The numbers provided usually range from 25%-50% of their patient base. These are patients that in the doctor’s perspective should be receiving periodontal therapy in one way or another including periodontal maintenance.

Also sadly predictable is the dentist’s shock and alarm at the realization that even though they feel 25% of their patients should be enrolled in periodontal therapy, only 1%-2% actually are. Currently the highest I have seen in a review is 3.7%.

Did you know that more than 50 percent of all malpractice cases against dentists are due to undiagnosed periodontal disease, which are considered instances of supervised neglect?

What should the periodontal services ratio be?

I agree with the leading experts in our profession who recommend that 20-30% of your patients should be receiving periodontal therapy. Unfortunately, this is far from the reality that we see.

I believe that as a hygienist, we are responsible for maximizing 3 different roles during our hygiene appointments. We are a preventive therapist, a periodontal therapist and the patient treatment advocate.

Of these three roles, the periodontal therapist role is alarmingly underrepresented. According to Dentistry IQ, only three percent of dental production in the US is provided under the 4000 codes. As hygienists it is our role and responsibility to educate our patients on the health of their mouth and to advocate for the treatment that they need – including periodontal services.

Did you know that more than 50 percent of all malpractice cases against dentists are due to undiagnosed periodontal disease, which are considered instances of supervised neglect?

Most dentists aren’t sure what they should do in these situations, especially when it comes to malpractice.

Here are their most common questions:

Who is liable?

Do patients have the right to refuse care? Do I make them sign a waiver? 

What is informed consent?

If you have a patient whom you determine should have periodontal therapy, and they elect not to have it, that’s their prerogative. However, you are at risk of significant liability if you don’t fully educate the patient on the consequences of rejecting treatment and carefully document those occurrences. Many professional liability claims include allegations of lack of informed consent. Most are patient claims of, “I would have made a different choice had I known what would happen.”

Informed consent is a discussion between dentist and patient where the dentist is educating the patient about a diagnosis, the nature of the recommended treatment, any alternative treatment options, and then the benefits, risks, and consequences of each one of those.

As part of our role as a periodontal therapist, we can add to that discussion. We often see patients feel more comfortable expressing concerns with staff.

Keep in mind: The more expensive and complicated the treatment, the more information we should be giving the patient and the more time they should have to make the decision. Giving this information in technical language often makes things worse. We need to work hard to simplify our language and use words that patients can understand. Confused patients become paralyzed and can’t move forward, which is often what happens with periodontal therapy.

If a patient doesn’t give consent for treatment, they’re invoking their right to refuse treatment. However, there’s a subtle difference between the “right to refuse treatment” and the “right to sufficient information to refuse treatment,” so let’s talk about informed refusal. If the patient foregoes treatment, they really need to know the consequences.

For instance, if a patient refuses to have an infected tooth removed, they need to know about the potential for more pain, bone loss, and even a possible life-threatening infection. In the event of their refusing treatment – I cannot stress enough the need to…

Document, Document, Document

If they continue to refuse, especially when their refusal jeopardizes their health, the best course of action may be a dismissal. Patients have the right to refuse treatment, but patients cannot consent to substandard care. Supervised neglect can occur when dentists don’t act on symptoms that show signs of needing treatment. This occurs often in hygiene, when we don’t act on symptoms of periodontal infection – or when we allow refusal to go on for too long.

It’s reasonable to place patients in a holding pattern for a period of time, especially during something like a job change, but you should continue talking about the benefits of treatment and the consequences of avoiding it. Then, if they persist in turning down treatment and force you to provide substandard care, you may have to let them go as patients.

Document, Document, Document

In one real-life example, Dr. Dennis Miller was sued for neglect by long time patient, Harry Berkowitz, who regularly saw Dr. Miller and received proper treatment. When Dr. Miller recommended a root canal, Berkowitz sought a second opinion and during that second opinion was told that he had severe periodontal disease which claimed most of his upper teeth.

In his defense, Dr. Miller said he brought this to Mr. Berkowitz’s attention numerous times over the years and offered a number of treatment options, but that Berkowitz declined repeatedly because of the expense. The case was settled for $200,000 because of a lack of documentation.

Remember, you can’t let patients consent to substandard care. The doctor would have been fine if he’d dismissed the patient rather than continuing to treat him for 20 years in the face of continued refusal of treatment.

Most dentists don’t realize that there is a distinction between “informed consent” and “informed refusal.” You already know that a patient must provide “informed consent” before you can treat them. And you also know that the same patient may “refuse” your recommendations as well. From a normal, rational human perspective this is just common sense. But the legal world rarely operates on “common sense.” The facts are as follows….

1. You MUST document informed consent properly. You must document How the patient was informed, What information they were given and offer Proof of their “informed consent”

2. You MUST document informed refusal properly. You must document How the patient was informed, What information they were given and offer Proof of their “informed refusal”

3. If your patient continues to refuse care, especially when their refusal jeopardizes their health, the best course of action may be a dismissal of the patient.

I created a periodontal brochure that I use with all my patients and our clients are using with their patients. At each visit, I am able to document the date and where their health currently stands. A copy of this goes home with the patient, and we have fully documented everything in the patient’s record as well. Another high level strategy that we teach is to send a letter to the patient’s physician alerting them of the infection present in the mouth. This letter is used in combination with the periodontal brochure; the documentation in the record meets the criteria listed above.

You can download a copy of the brochure I use at www.WendysPerioBrochure.com

Wendy Briggs is the co-founder of The Team Training Institute. She is a registered Dental Hygienist with more than 25 years of experience. For the last 15 years she has taken her unique skills in doubling hygiene production directly to the practices. She has consulted with more than 3,718 dental practices in 12 countries. Hygiene is her passion … and exploding productivity, case acceptance, and profits are her areas of expertise.

If you have a specific question or hygiene-related topic you would like Wendy to address, please contact her at be.theprofitabledentist.com/hygiene-help.

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