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Underdiagnosing

What do you do if you have a pt that’s been coming to the same practice for 15 years with the same hygienist and now is with someone new due to scheduling conflict. The pt has mod sub buildup and slight boneloss on X-rays. Then you suggest to her she may need gum treatment in the future if this persists. The pt gets upset and tells me why hasn’t anyone else told me, has it changed since the last time? What am I to say or do? And the doctor tells me to be careful with what I say?



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2 Answers

I would explain to the patient that you are basing your treatment recommendations on what you see clinically today. I would then ask the patient about homecare: do they clean interdentally, how often do they brush, etc. Before you think the other hygienist has been underdiagnosing, take a look at previous radiographs and read through the chart notes. Was boneloss apparent before? Did the notes say subgingival calculus present? What were the probe depths? Bleeding? Without knowing these things, its hard to say if the previous hygienist was underdiagnosing or if its a homecare issue on the patient’s part. The patient may be slacking on homecare or could have had a health change (diabetes diagnosis, etc.) leading to a change in oral health. Patients don’t always remember what they have been told either, however if it’s not in the chart notes, legally speaking, it didn’t happen.
 
If there is evidence of boneloss and disease and its not mentioned in the chart notes, you did the right thing by going to your doctor and addressing your concerns. The doctor may have told you to be careful with what you say because if the patient realizes their treatment has been sub-par the patient can take legal action. Beyond the hygienist, this falls on the doctor’s shoulders, as they have been doing exams and underdiagnosing too. This is all a big assumption here, I’m not saying this is what’s actually happening, as its hard to tell without more info and seeing the patient myself.

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I agree with Kara’s comments. I would add that talking with the hygienist might be a good idea – get history on the patient that might have been inadvertently left out of the chart or clinical notes.

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