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When the doctor doesn’t make referrals…

One of my perio patients came in for her 3 month maintenance appointment. A 51 year old female with insulin dependent diabetes. I noticed a small black area on her tongue that had not been there previously. It was jet black, 2 x 2 mm, slightly raised. It was not consistent with the surrounding tissue. It actually looked like a piece of something burnt sitting on the side of her tongue. I thought that she should be referred to an oral surgeon immediately for a biopsy, but the doctor told her we would reevaluate at her next appointment. Am I over reacting? If it was on my tongue I would have made an appointment right away.

This same patient has severe perio: 9, 10, 11+ mm pockets, many mobile and drifting teeth. After completing the initial SRP, I asked the DDS about referring to perio. He said he didn’t think they would be able to help her. We are not helping her either! She has pockets that I cannot clean adequately. She has 3rd molars that make cleaning even more difficult. At this last appointment, I told her to look into seeing a periodontist to see if they have other options for her despite the doctor not wanting to refer her. Am I wrong? Even if they can’t do anything for her at least she will know she did everything she could.

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1 Answer

In my opinion, you are not over-reacting and you are not wrong! As you probably know, if a lesion does not clear-up within two weeks, it’s time for a referral for a biopsy. If the lesion is cancerous, waiting until the patient’s next appointment could be too late. Cancer can turn from stage 1 to stage 4 or worse, quickly. Unfortunately, I know this from experience. While not oral cancer, this happened to my dad. He was deemed cancer free, but started to have pain. The oncologist told him it was nothing and gave him vicodin for 3 months. At the 3 month mark the doctor said, well we have been “watching an inflammation.” We immediately went to a different doctor. The new doctor said this is not an “inflammation,” it is now stage 4 cancer (after comparing the CT scans). My father passed within months. I tell you this to assure you that, again, you are not over-reacting. In my mind it is neglect to “watch” a lesion. It is also the dentist’s duty to provide the patient with all treatment options (PARQ). Regarding a referral to a periodontist – it is not the dentist’s place to decide what a periodontist can or cannot do. Those pockets started as 5 or 6 mm and if the patient was referred then she may not be in the shape she is now. I refer to a periodontist for pockets over 6 mm because our instruments simply cannot adequately reach much deeper. Some may not agree, but I would have told the patient, that if it was me, I would see a periodontist and an oral surgeon even if the dentist doesn’t agree because I need to sleep at night! I would also chart like crazy exactly what the dentist is recommending or not, to cover your license. By not referring, your doctor is not only doing a disservice to the patients, but is setting himself up for a lawsuit. This situation makes me so sad because patients put their trust in healthcare professionals and to not make proper recommendations is so very wrong, morally and ethically. Frankly, I wouldn’t feel comfortable working for a dentist like that. This is a tough situation, do what you feel is right; as someone must stand up for the patients. I wish the best of luck to you!

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