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Am I in the wrong? How to handle the situation

I had a patient who has been with this office for years and has had 5 mm pockets and bone loss and we have been treating it as a prophy. He hasn’t been seen in a year and came in with 5 and 6 mm pockets with bleeding. I suggested loc srp. Told the doctor and he said to do the 4346 code. Didn’t get a chance to tell him I don’t have enough time to do the 4346 because he was in treatment and dr told me to get started with cleaning. I did a pro. Told the doctor I did a prophy and didn’t go beneath the gum. He got angry and yelled at me as to why I would even think he needed a SRP. I said he has bone loss and 5 and 6 mm pockets with bleeding. The doctor says there is no bone loss. I said it’s everywhere I showed him the measuring tool and measured to from Cej to bone and it was 3 mm. I said it’s more the 1.8 mm which is normal bone loss. He said that what I was measuring was biological width and it’s not bone loss and asked where I got my information from and I said books. He said we’re not in school anymore we are in clinical. He said there was no bone loss because the crestal bone was intact which I thought was not. He also said for it to be called an srp there needs to be radiographic tarter, perio chart and bone loss or changes in bone. His previous x rays the doctor said looks the same so there is no bone loss. I said it has to be a lot of infection to show on the x ray. He said exactly. So no srp. Then tells the pt to come in 6 months. Then brings me in his office the next day with the other doctor partner saying I mistreated the patient because I didn’t do the 4346 and I am an employee they hired and if I didn’t want to do the work they will find someone else. I said I did not have enough time. And that I had told him this. The other doctor agreed that it was not an srp. I feel like I was being attacked and I feel like of course they would not admit the other is wrong. They then asked if I would do the srp if it was my dad in the same situation I said yes!!! He said well now I don’t know what to think, I think you lack education and knowledge. I don’t trust your education. Because you were completely wrong!! So wrong!! I don’t know what to do from here. I feel so hurt by what he said. And I still don’t agree with him. Am I in the wrong? Does there need to be crestal bone changes from one X-ray to the next? I saw 3 mm of bone loss and automatically thought perio. The doctors said gingivitis.



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1 Answer

I’m so sorry you have been treated this way! You are correct, in that when measuring from the alveolar crest to the CEJ, healthy tissue should measure 1.5-2 mm. More than that indicates bone loss. You are also right that bone loss doesn’t even become apparent on X-rays until its a loss of 30% or so. Biologic width is the natural distance between the base of the gingival sulcus (not CEJ) and the height of the alveolar bone, this is different than the bone level to the CEJ. It sounds to me like you know the difference between bone loss and biological width.
 
Without seeing the patient clinically or seeing the radiographs its hard for me to say definitively that you were right. From your description though, it sounds like you were. According to your description, the patient had active infection with bone loss. Regardless of previous radiographs, you treat what you see now, which is what you were doing. I’m not saying that changes in radiographs do or don’t matter but it sounds like the patient has been treated incorrectly, with a prophy, in the past.
 
The doctor is misinformed that there needs to be radiographic calculus in order for a patient to qualify for SRPs. The need for SRPs depends on tissue loss/destruction and active infection. Some SRP patients will present with radiographic calculus, but some won’t. Further, a patient with gingivitis could have radiographic calculus, does the doctor think that requires SRPs? I hope not!
 
The doctor is the boss, but there’s no need to demean you. The doctor’s disagreement in your judgement could and should have been communicated much better. It’s one thing to disagree and have a discussion, its another to attack you (or make you feel like you were attacked). If a doctor told me I “lacked education and knowledge,” that they didn’t “trust my education,” or anything along those lines, I wouldn’t be working for that doctor any more. No matter who is right or wrong in this situation, this is an issue. You do need to do what the doctor says because they have the ultimate say in diagnosis, but they should definitely consider your hygiene diagnosis because you are educated to recommend proper periodontal treatment.
 
Again, I cannot say definitively who is right or wrong, but what was said to you was not okay, which is the bigger issue here. I’m not trying to downplay the importance of proper treatment of the patient by any means, but being demeaned is just not okay. It sounds like they want an employee who just follows orders without any critical thinking skills. From here, you need to decide if you are okay with being treated like that. If you are, then let it go. If you aren’t, it may be time to start looking for a different office that shares your patient care standard. I wish you the best of luck!

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