EP61: What to Do When a Patient Declines Perio Treatment

In today’s episode of the Double Your Production Podcast, Dr. John and Wendy Briggs are discussing the all-too-common problem of patients declining perio. They’re sharing a tragic story of a practice where providers couldn’t agree on this issue.

In this conversation, you’ll learn how to talk about this disease with patients, how to present the treatment needed, and the system to make sure the patient, hygienist, and doctor are all happy and moving toward optimal health.

Listen now:

Welcome to the Double Your Production Podcast with the team training institute, the one place designed for dentists and their staff who want to grow their practices by following in the footsteps of those that have done it or in the trenches know exactly what you're going through. And now your leaders, the stars of the podcast, Dr. John Meis and Wendy Briggs.

Hey, everybody, this is Dr. John Meis with Wendy Briggs and The Team Training Institute. We are so excited to tackle one of the toughest topics in dentistry. We see it all the time in our lectures and in conversations and meetings, in the hallway, and on social media. So, Wendy, you saw something recently on social media, do you want to kind of give us an idea of what the topic is?

Yeah, you bet. We do see this a lot, as you mentioned. And it's one of the most common questions our coaches get asked as well when we're walking practices through systems for improving periodontal therapy. I'm going to remind our listeners we focus on creating world-class hygiene departments, right?

And we focus on preventive therapists, periodontal therapists, and the role of a patient treatment advocate. And the periodontal therapist's role is really challenging because there's so many, I guess, philosophies out there. There's so much misinformation out there. There's a lot of gray area, if you will. And it's not always black and white. So here's the scenario. a dentist posted on a dental group on social media and said, "I fired a hygienist today. And this hygienist was a great provider, did a lot of things well, and we were aligned on just about everything, but this one thing. And it ended up causing so much conflict that that one thing was the deal-breaker ."

And no, we can't tell you what her name is because I know y'all thinking, "Oh, that just sounds pretty good [laughter]."

So the one thing was that you just were not aligned on their philosophies, the periodontal therapy. So what to do with the patient who declines perio? Do we dismiss? Is it all or nothing? What liability exists for the doctor and the practice? Don't patients have a right to refuse care? All of these are very, very common questions.

And sadly, it's kind of turning out that I've seen this before, where the doctor claims to their philosophy, the hygienist is worried about their own license, and are they at risk if they practice supervised neglect? And how to handle that patient that declines periotherapy. This is not a very uncommon scenario. It happens a lot. I would say it happens every day in private practice.

Yeah, yep. And so a little disclaimer here. Neither Wendy or I are attorneys. We're not giving legal advice. We are not your malpractice carrier. So they may have an opinion on how you manage situations like this. But what we really wanted to do is, because that's a common situation, talk through a common sense approach on what makes sense from a patient perspective and therefore a patient experience perspective and what makes sense from a clinician perspective as far as living to your values and living to your clinical philosophies and avoiding messy patient disagreements. How's that?

Yeah, that's great. And I would say let's talk from a couple of different perspectives. You mentioned the patient perspective. Obviously, there's a couple of things that our clients, the members that we work with, the practices that we're directly coaching, we spend a lot of time on our process for informing the patient initially about what's going on. When we see early warning signs of infection there's a five-step process that we teach.

And a lot of that is simplified and boiled down into a systematic process, right, because one doctor might have three hygienists and, obviously, as we look at the performance of those providers, you could have one that's a superstar with perio and then you have others that it's a struggle. And, in many practices when we first are onboarding and we look at the data, almost every single practice that we onboard, perio is a struggle.

And I think it's because of some of the things that we talked about. "So much gray area, we really don't have the systematic process." So, without getting into too much detail about what that five-step process is - that may be another topic for another time; Certainly, we have a training on our member website that goes into that in detail - I would say that once hygienists embrace and utilize that five-step process, the first thing that we noticed is, these disagreements happen far less frequently.


All right. So, that's probably the first thing, is making sure that the conversations we're having with patients really help guide them to a place of understanding that this is a diagnosis of a disease and it's not just an upsell. Sometimes I feel like, at the end of the conversation the patient feels like, they're at a carwash, do they want the basic or the supreme?

Yeah, exactly. Exactly.

And they don't have clarity on the fact that they've just been diagnosed with a serious disease that can potentially cause life-threatening consequences if we do nothing.

And every year the research is getting more clarity on just how impactful it is on general health. So, this is not a-- this is not a tooth or gum disease only. It's a systemic disease, affects the entire body, and it does affect conditions that can be life-threatening.

Yeah, absolutely. So, that's thing one. Obviously, we teach a five-step process to really help the patient understand what it is we're asking them to do. And so with many practices, this whole problem goes away once that's fixed, right?

When you go from, "you need a deep cleaning", to a five-step process that informs the patient of the consequences of not treating it, for instance. When you have a process that's in place, now you have patients that are not confused, and they are in the place of making a more informed decision.

Right. Absolutely right. But even then, even then there are those situations where you go all the way through those five steps and the patient still says, "Nah, just give me the free one. I just want the regular cleaning. I just want the one that insurance covers. Give me the healthy cleaning." Right?

And so, how do you handle those patients? And like you mentioned, we're going to talk from the patient's perspective, but also from the doctor's perspective, right? Because, in many practices, the doctors certainly want some production out of that appointment, obviously, as a business owner. We don't want the patient leaving doing nothing. So, I think that's probably where some of this comes from.


And there is a little bit of a power struggle. And I do think as well, in today's world, we're getting conflicting information. Maybe not, completely accurate, information is floating in the marketplace. So that's kind of some of the things that we wanted to discuss today.

Sure. So, when you have that situation where you've made the recommendation and the patient does not want to move forward with that treatment but they want something done. And, what you mentioned is, the typical, they just want the regular cleaning that they have always had. This may be a new patient or an existing patient. I find it amusing that dentists seem to think that the incidents of periodontal disease is higher in the general public than it is in their practice.

But I'm not sure that's really true, particularly early-disease. Anyway, so, when they've decided that they don't want to do the treatment, now we've got a couple of choices, right? So now we can move forward and give the patient what they want. We can dismiss the patient. We can refer the patient. Any other options?

That's really it. We in the middle, right? We're not going to give them exactly what they want. We're not going to dismiss the patient. But I think, what we found is, there is room to meet in the middle. We started this off with a conversation. And that's ultimately what led to the firing of these hygienists was the unwillingness to do the prophy and give the patient exactly what they wanted because they thought their license was at risk. And they've been told--

Because the procedure was going to be coded, particularly, correct?

Yes - so that's where the biggest disagreement was. The doctor was saying just do the prophy, give the patient what they want. And the hygienist, from a principle standpoint, didn't feel right about that because of the language in the codes, right? So I think from the patient's perspective, what we often hear is, especially the new patient-- they might have come in on a $59 offer or some type of coupon offer.

And they can't help but feel like oh, now I need this $1,000 treatment. It's a bait and switch. And they come in wanting what they want. And when they're told no they can't have it, that's not a very good way to start the relationship. What are some other things patients-- what else do we hear from patients?

Well, from patients, often in their experiences in healthcare, they feel like they're not given the information and given the ability to make their own choice. And they hate that. They want to understand and they want to make their own choices based on their own situation and their own values. And they hate it when decisions are thrust upon them by people who maybe don't have the same values or the same financial limitations that they have.

Right. Exactly. So let's kind of talk through real quick. There is the option to just give the patient what they want and do the prophy. That's always an option. And that's what this doctor really wanted to do. And we teach and we know how important it is, that convenience to the patient is such an important thing. We know patient experience is important. We know the emotional connection is important.

And if we're saying no, we really are failing the patient in those areas, right? And then you mentioned, the other thing was to refer the patient to a periodontist. And that's always an option. If they're not willing to accept the care that we provide here, that's always an option. And it's a good option especially if we're worried about liability, right, because that covers the doctor in that regard. And that was really this hygienist's concern is their license being at risk. So that was another option. And then the other option we talked about was meeting them in the middle.

But let's hold off on that for a second. Let's talk through what liabilities you've heard. Because you and I have kind of heard some different things. And I think this is why there's some disconnect. You said you recently heard a lecturer on this issue. And then hygienists, there's a lot of chatter on the hygiene boards about what is acceptable and what's not as well.

So clearly, there's an obligation to do a periodontal exam. If you're doing a comprehensive exam, periodontal exam is part of that. So clearly, that's an obligation. To document the results of that is certainly an obligation. To inform the patient that they have periodontal disease is certainly an obligation. To tell them how to treat it is an obligation.

I think telling them what happens if they don't treat is an obligation as well so I think those are really clear. And I think most dentists and most hygienists would all agree upon that set of things, that all those things have to be done and documented. And I think if you do all of those things, and document them, and document the patient's choice to not move forward, I think your litigation risk is probably pretty small, not zero. Anybody can sue anybody for anything at any time, but I think your risk is low, not zero, but low.

I agree. And I think most of the confusion from my experience on the hygiene side is some hygienists say, "If you do a prophy, that's supervised neglect," right, because prophy indicates health. And there actually was a case, there've been a few cases in recent years where hygienists are sued in addition to the doctors.

So their states were it's absolutely a must for hygienists to carry their own malpractice coverage. So as producers, as providers, they're trying to protect themselves, which I completely understand. And I think where most of the confusion-- what I see most of the confusion is coming in informed consent and informed refusal.

So let's just take a quick minute and talk about those definitions. And for these definitions, I went straight to the source. I reached out to a malpractice carrier, and I'm using their definition of informed consent. So informed consent is the discussion between the dentist and patient - you just mentioned this - where the dentist is educating the patient about the diagnosis, the nature of the recommended treatment, and any alternative treatment options, and then the benefits, risks, and consequences of each of those, right? So informed consent, that has to be done, okay.

And when we look at many of these liability claims, heaven forbid, we do end up in a court of law. A lot of these claims include allegations of lack of informed consent. So the patient claims that they would have made a different choice had they known the consequences or if they had known what would happen, okay. So that's one thing.

And then I think where we get confused is informed refusal, okay. So the definition of informed refusal we say, well, the patient has the right to choose their own path. Yes, they do. However, informed refusal states that patients cannot consent to substandard care. Supervised neglect can occur when dentists, A, don't act on symptoms that show signs of needing treatment, or when we don't act on symptoms or when we allow refusal to go on for too long, okay. So that's actually what informed refusal is. And that, I think, is what guides a lot of the confusion. So patients can't consent to substandard care, but that doesn't mean if they don't accept our treatment plan day one, we dismiss them.

Yeah, and so if the patient is under the impression that a prophy is going to solve their periodontal disease, right, that is substandard care. If they understand that they've chosen something that is incomplete in treating that care, I'm not sure that's the same thing.

Right. I agree a 100%. And so when I say let's meet in the middle, one of the solutions that teach is we put the patient in what we call a holding pattern. We cannot emphasize enough how important the records are. We have to document everything. You need informed consent, you need informed refusal even though we've been told having a patient sign a waiver or informed refusal doesn't hold up in a court of law, we still have to have that documentation, proof that we have discussed the disease and the consequences with the patient, right.

And that's why when we say a referral to a periodontist helps us because that's proof that we had a conversation and that a recommendation was made. If the patient doesn't go through to the periodontist, the dentist isn't held responsible for that. That was a choice the patient made. But we often, sometimes refer the patient without documenting it effectively. So that comes into the-- you have to document it and I think the people who run into legal issues with this almost uniformly would tell you that their documentation was incomplete, and that was part of what lead to the issue.

So I think if you do all the things that we've talked about and you document them, I think a reasonable person that would be in the jury or would be a judge, a reasonable person, would say, "Well, you did what you could. And they made their choice." As my mother would say, "They made their bed, now they have to lay in it."


I think that's what reasonable people would say. But there are unreasonable juries and unreasonable judges. And so that's why there's not zero risk.

Right. Right. And the other thing that we say is in my world, I would prefer not to do a [inaudible] on that patient that still needs periodontal therapy. We say you put them in a holding pattern, right? We've been in an airplane where the conditions weren't right to land. It may have been excess wind. It may have been turbulence. It may have been air traffic control issues where they put the plane in a holding pattern. But eventually, what has to happen? You have to land the plane. You can't put in a holding pattern forever.

It's coming down sooner or later.

That's right. So we put them in a holding pattern, and my preference is that we actually code out a 4255.

So I find that that's how we can meet in the middle. We're going to give the patient something of what they want. We're not going to give them the free cleaning. We are going to do a 4255. Sometimes we say for the obstinate, adamant patients that are worried about a bait and switch, sometimes it may be necessary to take that 4255 price point down to equal a [inaudible], but we're still coding the 4255.

That's not necessary all the time. It's only necessary in really extreme circumstance. So in that regard, we're doing the 4255, and we're continuing to schedule that patient maybe three months, maybe four months, maybe six months, whatever they'll accept, out, and every time we touch them, we're educating them. We're going through the five steps again. We're giving them another opportunity to see the value and to say yes to the ideal optimal care.

And then we also say for doctors and hygienists who are leery, sit together, come together, come to a place of agreement on what's your time frame. When it says, "If we allow refusal to go on for too long," what does that mean? What does that look like to you? Some doctors, it might be 18 months. Some it might be 24 months. If they're not going to accept ideal care after 24 months, it may be time to have a dismissal conversation.

However, the dismissal conversation doesn't mean they're going to be dismissed, right? It's a conversation about why this may be the best path for them, but almost always, when we've sat down to have a dismissal conversation, we actually get the patient saying, "Oh, no, no. I didn't realize it was that big of a deal. I still want to be your patient. What do we need to do?"

Yes. And we've had this conversation today in the context of there was no restorative work that needed to be done, right? And so that's another complication and difficulty is if they've got restorative work that needs to be done. Do you do the restorative work in the areas of disease? Well, it gets even muddier, doesn't it?

Absolutely. We know that it's like rebuilding a house on a foundation with termites. Doesn't make a lot of sense. But the patients don't often see that.

No. So I think most people would provide minimal care if there is active periodontal disease and a refusal to treat on the restorative side. Provide minimal care until that has resolved. And anywhere along this path, referral to the periodontist can make sense. Anywhere along here.

But certainly, if they've been in a holding pattern for a period of time and are not moving forward, that's the time to continue to try to influence them, and maybe getting a periodontist involved will help influence them to move forward with the care that they really need so that they can maintain their general health better at least than they would be able to do with periodontal disease.

Right. And it's important to note too, part of our five step process is using the cameras, using very specific language when we're discussing and talking about the infection that's in their mouths. all of those things can dramatically transform patients' willingness to move forward, which is why it's so important.

And I know, Dr. John, occasionally we have offers for people to give our membership website a test drive, so why don't we do this? Why don't we add to the home page of the podcast a link where if people are interested in that-- because the five step process to increase case acceptance is one of the modules that we teach on our member website. For people listening today, if they're wanting that information, if they're wanting to see how we go about transforming patient acceptance when it comes to periodontal therapy, we will include a link to whatever offer we have going right now.

It changes frequently, so I'm not exactly sure what it is, but we'll come up with something amazing for our podcast listeners as a test run for our member website so that you could access those incredible resources. We've seen practices and hygienists dramatically transform case acceptance with those tools alone, so again, start there and then, having clarity and a real process for what to do if the patient says no thank you is really, I think, the way that we can avoid chaos. We shouldn't having to be firing team members over this, especially productive good team members.

No, that's true.

We should have a plan in place.

Yeah. It's just a sad story about the doctor and this hygienist, because probably there was a way to work this out that they could have come to an agreement on, and you hate to see that happen.

Yeah. Absolutely. And again, if you have a highly productive provider and you see eye to eye on just about everything, don't let this be the dealbreaker. Often it just requires a conversation and high level thinking and a willingness to meet in the middle and compromise in a way that everybody that feels good about, right? Because we don't want anybody's license to be at risk, and certainly the doctors don't want that for the hygienists, and the hygienists don't want that for the doctors either. So we find that there's a way to work through scenarios like this.

Yeah. For sure. All right. Did we cover it well, Wendy?

I think so. I think people hopefully will have some insights. I'll also link on our podcast home page a few articles that we've written about this subject, because it is such a hot topic. People really do struggle with this. So we'll provide some additional resources on our podcast home page, and to get to that, you just go to www.theteamtraininginstitute/podcast

All right. Awesome. Well, thanks, Wendy. Great job. And we'll see all the rest of you on the next episode of the W Dental Production podcast. Bye-bye, all.

Thanks everybody.

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