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Perio Referral

I’ve searched through several answers at this website and found one question like mine, but I have a few things to add. For all new patients at our practice the dentist and assistant sees the patient for an hour and then hygiene has an hour for cleaning (amazing, right!?) So I have an upcoming SRP patient who hasn’t been to a dentist in 35 years, has generalized 8mm pockets with massive radiographic calculus on every tooth surface including max anteriors. I work in a general practice and I expressed my concern to the dentist that our instruments aren’t effective after about 6mm and I’m afraid of burnishing and causing perio abcsesses. My dentist told me ‘you can do it, I have faith in you, just take xrays after and if you don’t get it off we’ll refer him’
She also said he is not the type who is likely to ever visit a periodontist so it’s either he sees us or does nothing at all.
I trust my dentist and her opinion, but this whole situation makes me a bit queasy! I know that even if a patient refuses a referral, the office is still liable for further problems.
I know I’m an idealist, I know the real world isn’t clinically black and white, and that a patient will just be getting a cleaning at the perio office before getting gum flap surgery so it might as well be here, I’m just afraid of how the dentist will view me as a hygienist after this. She told me if I was uncomfortable she’d just move it over to the other hygienist schedule, which doesn’t really fix the problem for me! I want this patient to get the care he deserves, just the thought of overworking my wrists and fingers to get off these mini boulders between his teeth and knowing I can’t reach the base of the pocket isn’t what I do. It’s like a patient coming in with a knife sticking out of his hand and telling him ‘we can probably pull it out and we’ll get it clean, but there may be shards in your skin that will cause more problems in the future’! I would rather we refer to a place where they have access to the full care than taking a chance on my skills alone.
Please tell me I’m overthinking this, that I’m totally wrong and life will work out! I’d rather feel wrong than feel sick over this anymore! I really value any advice! Thanks!

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2 Answers

Also I would like to add that I will support the dentist and do as she asks, I’m not planning a mutiny here, I’m feeling so discouraged right now is all and would love advice on moving forward.

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This is a tough one. My first question is, how does your dentist know this patient won’t follow through with a referral? Why not give the patient a referral, and depending on if they follow through or not, go from there? The patient should be given the choice before giving less than thorough care.
If the patient does not follow through with the referral, the old saying applies, “You can lead a horse to water, but you cannot make them drink.” In this case, if the patient will not see a periodontist, and you do move forward with SRP in your office, be sure to educate the patient like crazy why being treated by a periodontist is in their best interest (again). Then, chart like none other because if it isn’t in the chart notes, it didn’t happen, and this is a case where those chart notes may end up coming in handy if their are consequences with doing treatment in your office.
In the chart notes include things like how you explained and educated the patient on the need for a referral: your instruments cannot adequately reach the bottom of pockets the patient presents with which is why a referral was given to be treated by a periodontist, what happens if the tissue heals around a deposit because thorough debridement could not take place (infection, perio abscess, possible RCT and crown, or loss of tooth/teeth, etc.), basically, cover PARQ in extreme detail.
While it’s wonderful that your dentist has full faith in your abilities, I don’t think they are seeing the liability they are setting themselves and you up for. Again, this is where your extremely thorough chart notes come in. Also, I must point out that your dentists recommendation of “just take x-rays,” is not an accurate assessment of if deposits were thoroughly removed. Radiographs are 2D images, so only interproximally will you be able to see if large calculus was removed, and that’s if it’s dense enough to show up on radiographs. Radiographs do not show buccal/facial, or mesial deposits, nor will they show burnished calculus. Plus, there’s also the question of ALARA – were those radiographs really needed? Especially because they don’t paint a comprehensive picture?
Again, this is a tough one. It’s also a situation of being between a rock and hard spot because is just trying your best, even though you know instruments aren’t effective at cleaning that deep into pockets, and hoping you remove all deposits best, or is it actually a disservice to the patient? It’s an age old question of if some treatment is better than no treatment. I completely understand why this would have you feeling sick. Do what you are most comfortable with. You have to sleep at night knowing you did what you feel was right.

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