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Patient refusing to see periodontist

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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2 Answers

Patients who refuse the treatment (or ignore referrals for treatment) that they need are especially tough. My thinking aligns with the new hygienist. A patient can sign refusals (or you can give them referrals) but they don’t stand up in court. A patient can refuse treatment but a licensed dental professionals cannot “agree to neglect.” By continuing to treat this patient giving them sub-standard care based on their oral condition can be seen as supervised neglect. The majority of the dentists I have worked for would dismiss the patient after so many refusals. They simply don’t want to put their (and my) license in jeopardy.
Whether you keep giving referrals really doesn’t matter much, the bigger issue is treating the patient in the first place. Again, this is a tough one because as a clinician it puts you between a rock and a hard place. It feels wrong to not provide needed treatment, but it also seems wrong to dismiss a patient because they can’t afford or just don’t want treatment. There’s just no good answer here, unfortunately. Basically I’m trying to say that while patients do have the right to refuse treatment, practices have an ethical responsibility to abide by the standard of care. We live in a sue-happy society and we don’t want our licenses jeopardized.

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As far as referrals go, at my office we like to reprint the origional and sometimes the DDS will redate and resign it, and we will scan it back into the pt’s file so we can have a record the we reiterated the need to go to perio. I will reprint that referral EVERY time so that the pt gets the message that this is serious. While I won’t talk about it the entire appt, but weather it’s a referral to OMFS for EXT decaying wisdom teeth or referral to PERIO it’s one of the first things I start talking about. “Now, John, we referred you to see a gum specialist back in 2015, have you gotten a chance to go?” I like to remind them it has been years (sometimes) since we first discussed this with them. I explain why it’s important to go there and why we, as a general practice, cannot do their treatment. And I let them know I am going to mention this EVERY time I see them until they get the message. I try to keep it short and simple an then I tell them “Now that I’ve said my piece I’m not going to mention it again this appt.” Take photos with the intraoral camera, show them their x-rays, use a mirror and show them how far the probe sinks down in their gums. I do this for people who refuse to see specialists, pts with cavities diagnosed a year ago that won’t commit to tx, pt’s that refuse to floss, pt’s that have night guards on their tx plan for bruxism but don’t want them. I have had a lot of succuss with pts following through, eventually. Persistance is key. And I document, document, document. Sometimes my notes will read “Origional perio referral from January 2015 reprinted, redated, and resigned, given to pt. Reiterated the need and urgency for pt to see perio ASAP for eval of 7+mm pocketing. DWP possible consequenses of not seeing specialist such as tooth loss. Pt acknowledged and voiced understanding of treatment needs and topics discussed today.” Again, I know that even signed refusals don’t hold up in court, but I feel what I adhere to is the best CYA measures if you have a DDS that doesn’t want to dismiss the pt.

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