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How Should I Encourage Follow-Through in a Noncompliant Patient?

What is the correct protocol for a patient who presented with a suspicious lesion and is at increased risk for oral cancer (long-time smoker) but who did not follow up with our referral to an oral surgeon for biopsy?

QUESTION: What is the correct protocol for a patient who presented with a suspicious lesion and is at increased risk for oral cancer (long-time
smoker) but who did not follow up with our referral to an oral surgeon for biopsy? I am concerned about his health, as well as my and the practice’s liability.

ANSWER: I am not an attorney but I can respond to this issue as a dental professional. Because liability varies by state, the following response should be reviewed by your practice’s attorney to ensure you are adhering to your state’s legal requirements.

I am assuming that this patient was a patient of record who presented for a recare appointment. Your record of the lesion should include the location; a description comprising size, color, shape, borders, and texture; and photographs of the suspicious lesion. The history of the lesion is also important: how long had it been there and had it changed in size or shape? Was pain noted? In addition, any possible causes, such as sharp cusps or trauma, should be included in the patient record. The patient’s responses to questions about the lesions should be documented, as well.

After the dentist examined the patient, observed and evaluated the lesion, and referred him to the oral surgeon for a biopsy, did the patient seem concerned about the lesion and receptive to this recommendation? At this point, I would invite the patient back to your office to re-evaluate the lesion at no additional charge. Re-evaluate and record all changes. Try to determine why he did not follow up on the dentist’s recommendation to see an oral surgeon. If it is cost, perhaps he can be referred to a dental school or public health setting. Then the dentist can emphasize the need for biopsy to make the diagnosis. Not all oral lesions are cancerous, but the diagnosis in this case cannot be made through visual inspection alone.

One week later, the dentist should send him a letter (certified, return receipt requested) documenting the two visits to your office and clearly explaining the fact that he is genuinely concerned about the patient’s health. Again, advise the patient that the follow-up appointment with the oral surgeon is critical to effective diagnosis and treatment. Offer the patient yet another opportunity to speak with you or the dentist to answer any questions he may have. Sometimes fear can interfere with clear thinking. Then advise the patient that it is his responsibility to follow your recommendation to have the lesion biopsied. A copy of this letter attached to the postal receipts should be placed in the patient’s record.

Be absolutely sure that you document everything in the patient record. If the patient says he will go to the oral surgeon in a couple of weeks, document the date and time he called the office, the name of the individual he spoke with, and exactly what he said. In 2 weeks, call him again to see if he scheduled the appointment. The dentist and dental hygienist should both have independent malpractice insurance policies. As a dental hygienist, you are a licensed professional and malpractice insurance is available through the American Dental Hygienists’ Association for a nominal cost. It is a worthy investment in yourself.

The Ask the Expert column features answers to your most pressing clinical questions provided by Dimensions of Dental Hygiene’s online panel of key opinion leaders, including: Jacqueline J. Freudenthal, RDH, MHE, on anesthesia; Nancy K. Mann, RDH, MSEd, on cultural competency; Claudia Turcotte, CDA, RDH, MSDH, MSOSH, on ergonomics; Van B. Haywood, DMD, and Erin S. Boyleston, RDH, MS, on esthetic dentistry; Michele Carr, RDH, MA, and Rachel Kearney, RDH, MS, on ethics and risk management; Durinda Mattana, RDH, MS, on fluoride use; Kandis V. Garland, RDH, MS, on infection control; Mary Kaye Scaramucci, RDH, MS, on instrument sharpening; Stacy A. Matsuda, RDH, BS, MS, on instrumentation; Karen Davis, RDH, BSDH, on insurance coding; Cynthia Stegeman, EdD, RDH, RD, LD, CDE, on nutrition; Olga A.C. Ibsen, RDH, MS, on oral pathology; Jessica Y. Lee, DDS, MPH, PhD, on pediatric dentistry; Bryan J. Frantz, DMD, MS, and Timothy J. Hempton, DDS, on periodontal therapy; Ann Eshenaur Spolarich, RDH, PhD, on pharmacology; and Caren M. Barnes, RDH, MS, on polishing. Log on to to submit your question.

From Dimensions of Dental Hygiene. February 2016;14(02):68.

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