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Leaving behind calculus

I have a special needs pt that has extremely bad perio (9+ mm pockets), I did SRP on her, but 5 months later 2 bigger radio graphic pieces of calculus were left over and now there are smaller pieces of calc developing. This pt in general develops calc easily. It honestly took me 2 hours to do 1 half side perio maintenance today. when talking to the dentist about referring the pt out he wants to keep her here as much as possible. I feel so bad for the pt because I for one did a disservice to the pt for not doing a great SRP, but now I further think I am doing her a disservice by keeping her there. Myself and the dr sort of talked to her about going to the periodontist, but she if “comfortable” here, wants to stay, and doesnt understand what they will do differently. I am going to talk to the dr abut referring her out again but I dont know how to go about explaining it to the pt or talking to the dr about it. I am a new grad so any help would be great.

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2 Answers

I completely agree with you in that its a disservice to the patient to not refer her to a periodontist. Once periodontal pockets reach 6+ mm, there’s only so much our instruments can reach, no matter if you are a new or seasoned hygienist (in my opinion). This, unless you have a dental endoscope and can literally see into the pockets.
Please don’t think you did a poor job at treating her (SRP)! I say this not only because of instrument effectiveness with 9+ mm pockets, but also, how do you know those aren’t new calculus deposits since you last treated her? Unless post-treatment radiographs were taken to check for remaining deposits (which still aren’t 100% accurate because deposits need to be big enough to see radiographically, and X-rays only show in 2D) you can’t place all the blame on yourself.
When talking to the doctor about referring this patient, I would explain about instrument effectiveness and doing what’s right for the patient. If a referral isn’t given (regardless if the patient goes or not) and the patient loses teeth, there’s a possible law suit there. Not saying this patient (or caregiver) would sue, but its best to not take these kind of risks.
Addressing referring with the patient is tough enough, and especially so when they are a special needs patient. Does this patient come with a caregiver? I would explain the need to them in addition to explaining to the patient. When speaking with the patient, and explaining why going to a “special dentist” is important, keep it simple, and to the level of their understanding. Only the periodontist will know what treatment they are going to definitely recommend, so you can really only prepare the patient for the exam and diagnostics (radiographs, periochart, etc.) which is much like what the patient experiences at your office.
Lastly, I have to address the doctor “wanting to keep her within his practice.” This is not to the patient’s benefit, like I stated above. Sadly, some doctors don’t refer because they want to keep the production for themselves despite what’s best for the patient. This is not okay or ethical. Of course, I’m not sure if this is your doctor’s motive, but what if it were a suspicious lesion? Would the doctor not refer out for a biopsy? This could have life-threatening effects for the patient. It is important that you work for a doctor that shares your same patient care standard, this includes when to refer. Again, I’m not saying this is your doctor’s motive, but even if the patient doesn’t go to the periodontist, a referral should be given, if not only to protect your license.
It seems your gut is already telling you the right thing to do here, so listen to it! You can’t make this patient go to the periodontist, but explaining its what’s best for them, you can do. I would hope your doctor would be on board with doing what’s in the best interest for this patient. Best of luck to you, you got this!

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I was going to add a question about a similar situation that came up at work yesterday. We have a patient who has generalized 6-9mm pockets with bleeding. He comes every 3 months for perio maintenance and we have talked many times about a periodontist but he constantly refuses. A new hygienist to our office saw him yesterday and she was feeling like she was doing a disservice to him because she could not clean everything effectively in an hour appointment. She also was concerned because at her previous office they would refuse to see the patient if they refused to see a periodontist.
Our doctor wants to continue to see patients even if they refuse a periodontist and tells patients that we will just do the best we can here. This is very frustrating because then the patient doesn’t think it’s as important as it is!
Should we be giving this patient a referral at every appointment or is it ok to just do it once? (He has been given one and also signed a form acknowledging our discussions about his severe perio) Is it ok to keep seeing patients when they have active severe perio and refuse to do anything different about it?

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