Paired Caring – What Patients Deserve
By Bill Purifoy
In last month’s Twelfth Night, our editor expressed his opinions on the topic of periodontal referrals. The question posed in the title of his article was whether periodontics was an area of “shared care or careless sharing”? Ouch!
From a periodontist’s perspective, Griff’s article raises several concerns. On the other hand, a critical self-evaluation may be warranted and beneficial. Many of the specific issues mentioned are valid. I’ll respond to his points, and offer a few of my own.
Griff is absolutely right. Periodontal disease happens! Even with the best preventive and maintenance therapy, inflammatory disease occurs and recurs. In addition to microbiologic factors, local anatomic features, occlusal relationships, smoking, genetic predisposition and numerous systemic conditions contribute to gingival and periodontal diseases. Blame or guilt do not have a place here. Periodontal diseases are comparable to other chronic conditions, e.g. hypertension, diabetes, and cardiovascular disease. Patients may be stable or unstable while under our care.
The Fort Worth periodontist Griff mentioned who frequently regarded referral patients as being his to keep was dead wrong in that behavior. Timely case reports/profess reports, shared recalls, and/or release back to a referring dentist are necessary responsibilities for all periodontists. On rare occasions a patient may refuse to return to a referring dentist. In this unfortunate situation, an open line of communication is needed between the referring dentist, the patient, and the periodontist. A periodontist can encourage a patient using positive dialog, but cannot force compliance. Patients have also been known to mislead us by reporting that they are alternating when they are not. Imagine that!
Patients who disappear right after seeing a periodontist, then resurface a few years later worse-off than ever, may do this for a couple of reasons. Some patients fail to complete recommended treatment and compensate for their discouragement or embarrassment by ceasing all professional care – usually until something hurts. Another possibility is that the periodontist misjudged the patient’s emotional readiness for comprehensive therapy and follow-up care. A patient who is apprehensive, has not seen a dentist regularly in the past, and who has “sensitive” teeth is not a good candidate for much surgery. This type of patient should have supportive therapy for an extended period of time to establish trust and to develop positive dental habits. Otherwise, some will get wounded and disappear.
I applaud Griff’s suggestion to provide initial preparation and caries control before referring the patient to a periodontist. This initiates the process of improving oral health, includes the GP in the process, and establishes some level of compliance before consideration of definitive therapy. There are excellent interim restorative materials available, and most offices can provide a satisfactory level of initial debridement and inflammation control. This is good dentistry and good sense.
I don’t really think the type of periodontal probe should be a source of contention. Variation in the diameter of a probe, the amount of probing force, and angulation are impossible to standardize in clinical practice. Don’t tell the insurance companies, but probing depth is only one small piece of the diagnostic puzzle. Bleeding, suppuration, tissue tone and color, mobility, radiographic alterations, furcation exposures, and a half-dozen other parameters should be considered when assessing a periodontal patient’s condition. Even intangibles such as an experienc3ed clinician’s instincts will guide the diagnostic and treatment planning process. Each parameter deserves consideration, but the significance of a specific probing measurement should not be overanalyzed.
“Refractive” breakdown in previously treated cases is more common than we would like. Griff’s statement that periodontists are slow or reluctant to resurgerize, or even to admit that their cases are breaking down, really hits home. It’s difficult to be the messenger of bad news. I like to be thought of as a nice guy. Perhaps the reason a periodontist is more likely to call a spade a spade when a patient has been in the GP’s recall, is that the bad news was already given to the patient when they were referred back to the periodontist. It is much easier to confirm an adverse condition rather than break the news of one. The blame should be squarely placed on the nature of the disease, rather than the provider of maintenance care.
Surgical retreatment is to be expected over time. In my practice, a group of 100 patients who had been in maintenance care for 25 years or more had to have surgical therapy an average of 2.8 times each. This translates to surgical retreatment every ten years or so on average. Patients who are informed of this on the front end tend to accept it better than those who weren’t educated on the nature of chronic periodontal disease. Again, the blame should be squarely placed on the nature of the disease, rather than the provider of maintenance care. This is how physicians deal with chronic disease. As dentist, we are often too hard on ourselves and each other.
Now here’s what I really think:
Interdisciplinary therapy elevates the quality of dental care for our patients. Paired caring can create awesome outcomes especially when using oral plastic surgery to enhance complex esthetic cases. If you don’t currently utilize a periodontist, find one you like and get to know them well. There is no doubt that you and your patients can benefit.
Communication is a two way street. The periodontist is just as interested in what the referring dentist is planning for the patient, as the referring dentist in what the periodontist plans to do. There is much greater case acceptance when a patient fully understands why he/she is being referred to a specialist, and when the periodontist is pre-equipped with pertinent information and records. Seven questions drive news gathering: who?, what?, when?, where?, why?, how?, and what’s next?. Patients, periodontists and referring dentists deserve answers to these questions. Let’s communicate with each other.
Strong relationships are the key to success in the referral process. The longer I practice the more I realize it! Relationships take lots of work, and it is a continual process. As with any close partnership, we must be sensitive to each other’s needs and do our best to meet them. When problems occur, they should be confronted quickly and without the stilted, clinical language of a professional letter. Personal dialog is best. For me, this doesn’t come easily, but as we all grow with experience, we can strive to do better. Many thanks to Griff for all of his articles and for having the courage to approach these touchy subjects.
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