I have been practicing dental hygiene for almost 24 years. Recently I saw an elderly patient, who is in his 70's, with moderate generalized periodontitis. He is aware that he has gum disease and has even had several rounds of scaling and root planing in the last 15 years. His current dental insurance only covers preventive and does not offer any periodontal coverage. He has asked me to do a prophylaxis since he cannot afford to do scaling and root planing. Would I be putting my license on the line by doing so, even if he signed a scaling and root planing refusal form? He acknowledges his need for periodontal treatment but feels that at least a prophylaxis would help. Would I be abandoning him by refusing to do a prophy?
Every dental hygienist has encountered some version of this scenario. I am not an attorney so I am not giving a legal opinion on your question, but I will share insight on how I have successfully handled this situation.
The economic impact of a periodontal disease to overall health is something very likely your 70-year-old patient hasn’t fully considered. His objection is financial, yet United Concordia recently released data from their client base confirming that treatment of active disease in the mouth reduces medical costs for treatment of chronic diseases. I don’t know if your patient has any chronic diseases, but the principal that treatment of active infection can save additional costs can be applied across the board, because even if your patient lost teeth as a result of non-treatment; replacement would be costly. United confirms the annual health care cost savings due to effective treatment a of periodontal disease is 40% for patients with diabetes, 10% for patients with heart disease, and 40% for those having suffered a stroke. This savings was derived by comparing those who treated periodontal disease versus those who did not. If you want more specifics on their data, do an internet search for “periodontal treatment lowers cost”.
First and foremost, I would compassionately discuss the health-care saving potential for this patient. Second, I would inquire as to how long he thinks it would take to “budget” the cost of periodontal treatment into his own budget. See if you can agree upon a plan. If he states that it would take a year to budget enough for the fees associated with periodontal treatment, offer to provide a prophylaxis twice during that interim but be clear that this is not to treat infection, but rather to carefully monitor his condition and provide preventive care for teeth not yet impacted by periodontal disease. My caution would be to provide a coronal prophylaxis only and not try to squeeze "incomplete SRP" into that visit, as you want to proceed with complete biofilm debridement site by site to effectively treat infection.
Should your patient decide that he is never going to proceed with periodontal treatment, obviously this would constitute a collaboration with your dentist to collectively decide how to proceed. I do not have a “one size fits all” approach to this situation as individual patient circumstances vary greatly. That said, I would consider suggesting the patient find a dental practice that better suits his values should you find yourself at an impasse with any patient regarding treatment recommendations and the ability to provide standard of care treatment. I view this as a commitment to the integrity of the care you provide more so than protection of your license. As always, accurate documentation is your best defense.