Dianne Glasscoe Watterson, RDH, BS, MBA

Improving Clinical Outcomes

through Enhanced Communication
Educational Objectives

Upon completion of this course, the participant will be able to:

1. Recognize the importance good verbal skills in patient interaction.

2. Understand the cycle of communication.

3. Recognize barriers to communication with regard to patient care.

4. Implement new strategies for reducing disappointments.

5. Use effective analogies when discussing different aspects of dental treatment.

6. Respond effectively to treatment concerns.

7. Respond to patients that refuse radiographs or definitive treatment recommendations.

8. Understand the informed consent and informed refusal process.

In order to be successful in achieving positive treatment outcomes, the clinician needs two
things: excellent technical skill and excellent communication skill. This course discusses many
aspects of communication with our patients. The way in which we communicate with our
patients is important for many reasons. If the patient is unclear in his/her understanding, there
is a greater likelihood that necessary homecare instructions will not be followed. Clear
communication ensures that patients understand the advantages of proper care and the
consequences of refusing definitive care. The dental professional’s ability to communicate and
connect with the patient is an important consideration in helping patients achieve and maintain
optimum oral health.

Early Perceptions and the New Patient

A concept both simple and profound is this: it is a good thing when your patients like you. When
patients like you they are:

• Far more likely to be compliant with the homecare instructions you provide.

• Far less likely to break appointments or sue you.

• Far less likely to complain about your fee.

The reality is that people do not like going to visit the dentist. So it is our challenge to endear
ourselves to our patients in order to lessen the amount of dread they feel. It is difficult for some
clinicians to believe that patients will not automatically like them. You have to take the first step
to create a warm atmosphere and show them that you genuinely care in order for patients to like
you.

This is especially true for new patients that come into your practice. What is the average or
routine response of a business assistant when a new patient comes to the practice for the first
time? The greeting can be anything from a formal request to “sign in” all the way to total
indifference, even to the point of ignoring the patient.

If you want your practice to rise above the “average,” then it is up to you to break the ice with
these very special new patients. You get only one opportunity to make a good first impression.
Therefore, every new patient that comes into the practice should be greeted warmly with a smile
and a handshake. Business assistants are often the first people to interface with the new
patient. Business assistants should be anticipating the arrival of the new patient. When he or
she approaches the front desk, the assistant should rise from her seat, smile, extend her hand,
introduce herself and welcome the new patient warmly. This begins a positive thought process
with the patient that says, “I think I’m going to like this practice.”

When it is time to seat the patient in the clinical area, the patient should be greeted in the same
manner by either the hygienist or clinical assistant. Instead of just opening the door and
speaking the patient’s name, approach the patient with an outstretched hand and a smile and

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greet the patient warmly. “Hi, Mrs. Johnson. I’m Cathy, your assistant today. It’s good to meet
you. We’re all ready, so let’s head this way.” Such a greeting will set the stage for a positive
patient experience. For the doctors, if you feel that making that good first impression is
important, then you should be the one to invite the new patient back to the treatment area.
Having the doctor invite the new patient back does impress new patients positively if the doctor
extends a warm welcome by offering his/her hand and introducing himself or herself.

On introductions, it is preferable for the doctor to introduce him/herself by saying “I’m John
Smith” or “I’m Kim Turner” instead of “I’m Dr. Smith” or “I’m Dr. Turner.” This makes the doctor
appear less formal and intimidating, more approachable and down-to-earth.

There are two ways to express warmth and caring: through smiles and appropriate touch.
There may be days when you do not feel like smiling. Do it anyway. Make patients feel that you
are happy to see them. Make them feel like welcome guests in your home. Think of it like this:
if you knew someone was coming to visit you, and that person was bringing you money, would
you be looking forward to seeing that person? Every patient that comes through your office
door brings you money. Without patients, we have no practices.

Patients form perceptions about the quality of dentistry that is provided in an office. Generally,
they arrive at their conclusions based on two things, namely, the physical appearance of doctors
and staff members and how you make them feel. Dr. Harry Wong, a noted educational speaker,
says that as you are dressed, so shall you be perceived. And as you are perceived, so shall
you be treated. Always project the image that is in your best interest both professionally and
personally. Patients cannot judge doctors on the quality of their crown margins, nor can they be
sure if the hygienist removed all the calculus from their root surfaces. But they know if you’ve
made them feel special. Do you make them feel like just one more patient, or do you make
them feel special?

The Four Facets of One-on-One Communication

One of the foremost speakers and writers on the topic of communication today is Dr. Nido
Qubein. Dr. Qubein is a past President of the National Speaker Association and current
President of High Point University. He has written many books about communication. How to
be a Great Communicator is a popular best-seller. In this book, Dr. Qubein posits that there are
four facets to one-on-one communication. Let’s look at each of those and apply the precepts to
the dental world.

The first facet is this - the message must be conveyed. Your mental dialect must be translated
into the mental dialect of your hearer. In other words, we should use words that patients
understand and avoid dental jargon. It is preferable to use terms such as gums (instead of
gingiva), tartar (instead of calculus), and pus (rather than purulent drainage).

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The second facet of one-on-one communication is this - the message must be received. You do
not know if you have conveyed your message until you have made sure the person has
received it. How can you do that? A good way is to say this, “Tell me, what are your thoughts
about that?” Or, “How do you feel about that? Does this seem like something you could do at
home?” It is advisable to avoid using the question, “Do you understand?” Or, “Does that make
sense?” Either of those statements could make a patient feel stupid if indeed he does not
understand or something really does not make sense to him.

The third facet of one-on-one communication is this - there must be a response. You must let
your hearer know clearly and courteously what you expect. It is advisable not to use “you”
statements, such as, “You’re not brushing well in this area.” You statements tend to make
people defensive. For example, you observed that the patient it is not performing adequate oral
hygiene at home. This could be his third quadrant scaling appointment, and he doesn’t look like
he’s brushed since his last visit. This scenario can arouse some pretty strong feelings of
indignation in the mind of the dental hygienist who is working her fingers to the bone to help this
patient. How might you help this patient without using a rude or offensive language, like “You’re
wasting my time and your money”? Remember to focus on the behavior, and avoid “you”
statements. “Mr. Smith, I’ve noticed consistently when you come in to see me there is a lot of
soft debris and food on your teeth. Now if these teeth aren’t kept clean during this treatment
phase, we can expect a much poorer result than if they were kept clean. Let’s work on this
together to see if we can improve the situation.”

The fourth facet of one-on-one communication is this - each message must be understood. The
cycle of communication is not complete until you understand the person with whom you are
seeking to communicate. You may not agree with your patient, and your patient may not agree
with you. But you must have an understanding of the patient’s point of view.

Empathy and understanding are important. For example, sometimes patients neglect
professional care for an extended time for various reasons. When the patient does return, often
there are extensive problems that go beyond basic care. Instead of chastising or berating a
patient for his lapse in care, the empathetic dental professional will encourage the patient by
saying, “I’m sorry you had to get what seems like bad news today. The good news is that we
can repair your teeth and get you back in good shape again. We’re here to help you in any way
we can.”

Barriers to Communication
There are two different kinds of barriers to communication: environmental and attitudinal. Let’s
look at each type of barrier.

Environmental Barriers

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Environmental barriers to communication include such things as loud or inappropriate music,
noise from other office areas, interruptions, and pain.

Interestingly, DENTSPLY® did a survey of 700 people and asked this question: “Have you ever
broken a dental appointment or cancelled at the last minute, and if so, why?” What they found
was very interesting. They found one in ten people had cancelled or broken a dental
appointment because of fear of the injection. If you as a dental professional deliver a
consistently painful injection to your patients, it is very likely that there will be patient retention
problems in the practice. You need to learn to give easy, pain free injections.

Please do not hurt your patients in any of three ways: physically, emotionally, or financially. We
understand physical pain, and all of us inflict some physical pain by their very nature of our
work. However, when your patient expresses pain in some manner, such as a flinch, a jerk, or a
grunt, you should immediately acknowledge the patient’s expression of pain and say, “Oh, did
that hurt? I’m sorry; I didn’t mean to hurt you.” The worst thing you can do if your patient
expresses pain is to ignore it. Always remember that if you do not apologize, the patient will
remember until the day he dies that you hurt him and did not apologize. If you apologize, most
likely, your patient will forgive you.

We inflict emotional pain when we make our patients feel stupid or incompetent. Doctors, this is
especially true for you. Never ever say anything that could be construed as disparaging about
the patient’s field of employment or even a lack of employment. Avoid white hot topic items
such as politics or religion. Doctors and hygienists have to be careful to avoid the “mother hen”
syndrome. It never helps when we sound as if we are fussing at our patient.

Interestingly, we do not cause financial pain with our fee. Financial pain is caused when we
unpleasantly surprise a patient at the front desk with a fee he or she was not expecting. So
always make sure patients understand their financial obligations before dental work is
commenced.

Another excellent way to build rapport with your patient after extensive dentistry is a post-
treatment phone call. It takes only a few seconds to pick up the phone and dial the patient’s
number. “Hello Mrs.

Smith. This is Dianne, the hygienist that saw you today. I’m just calling to check on you before I
go home to make sure everything is OK.” You may also use this time to remind the patient about
a particular instruction that you gave him or her. The point is that you cared enough to pick up
the phone and call the patient. Your expression of caring helps to build rapport. Remember, it’s
a good thing when your patients like you.

Attitudinal Barriers

Attitudinal barriers can also present communication challenges. These barriers include:

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 • Personal problems – Sometimes our patients come for their dental visit carrying a heavy
load of personal problems that may affect their ability to connect with us. We may
misinterpret their mood or feel the patient is aloof. On occasion, patients may share
their personal problems with us, primarily because they see us as more than their
caregiver. They see us as their friend.
• Illness – When patients keep their dental appointments even when they don’t feel well,
we should limit our communication to the most basic and important issues. To attempt to
engage a patient that is not feeling well in a discussion concerning elective dentistry is
not prudent.

• Perceived low treatment value – If we do not give our patients good value for either their
money or their third-party benefits, they will not regard our treatment as highly valuable
and important. Patients are not stupid. Offices that are geared toward high volume do
not project high quality treatment.

• Insufficient time – Dental professionals need the proper amount of time to deliver high-
quality care. If the patient is late for his appointment, it is advisable to seat the patient
and prioritize what is most important for that day. Use this verbiage: “We’re glad you
made it. We were worried about you. Let’s get as much done as we can with the time
we have left.”

• Prior bad experiences – Some patients have had very negative treatment experiences in
the past and have come to fear all dental professionals. It is your challenge to treat such
phobic patients with care and compassion and help them overcome their fear.

• Negative relationships – Patients that have had prior negative relationships with dental
professionals may bring those same feelings of negativity into a different practice.
Overcome this communication barrier by “killing them with kindness.”

Reducing Broken or Cancelled Appointments through Improved

Communication
There are two different kinds of barriers to communication: environmental and attitudinal. Let’s
look at each type of barrier.

Open time in the schedule is a big problem in some offices. While there is no way to completely
eliminate broken appointments, there are some good strategies that we can implement in our
practices to reduce and control disappointments. Two key strategies are (1) using correct
verbiage, and (2) being proactive in identifying potential offenders.

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Ineffective Communication

Part of the problem is that we use ineffective communication at times. Let’s start with the
phrases “cleaning and checkup” and “recall appointment.” It would be advisable for us to
remove these phrases from our professional vocabulary. Both phrases make the work seem
trite and trivializes what happens in the hygiene operatory. “Recall” is a word that auto makers
use when their products are defective and require repairs. Instead, let’s attach more importance
to hygiene appointments by calling those visits “preventive care,” “professional care,” or even
“continuing care.” Also, let’s stop “booking” appointments and start “reserving time” in our
schedule. For the periodontal maintenance patient, let’s stop using the term “maintenance” and
call those visits “disease control” visits.

Disrespecting the Patient’s Time

Another reason for broken and cancelled appointments is disrespect for patients’ time. If we
want patients to respect our time, we must respect their time. For dental hygienists, chronically
running behind schedule can happen because of having to wait an excessive amount of time for
the doctor to examine the patient. When the hygienist waits until she is finished before
summoning the doctor, the hygienist is perpetuating the problem. It is rare when a doctor can
come immediately upon being summoned. Usually, the doctor is engaged in treating a patient
and needs to find an appropriate time in which to leave his patient to examine a hygiene patient.
The solution for this problem is to implement an interrupted check system. The hygienist should
seat the patient, take any necessary x-rays, do the tour of the mouth, and then summon the
doctor. The doctor will have anywhere from 20 to 30 minutes to come and do the exam. When
the doctor steps in the doorway, the hygienist should immediately tell the patient that the doctor
will now be doing the exam. As soon as the doctor is finished, the hygienist will complete the
preventive care appointment.

Good schedule control involves having a business assistant who understands – at least in part –
clinical procedures and communicates well with clinicians. Doctors need a clear communication
tool to inform business assistants about the amount of time needed for procedures. Many
doctors run behind schedule on a consistent basis because they are not realistic about how
much time is actually needed for procedures. There is also the problem of where to schedule
emergency patients when the need arises. Occasionally, a procedure will not go well, and
additional time is used, often infringing on another patient’s schedule time. Undoubtedly, the
schedule is a major source of stress in many offices. When we do not schedule appropriately
and patients are kept waiting inordinately, they become frustrated, unhappy and feel
disrespected.

Unmotivated Staff Members

A third reason for broken or cancelled appointments is unmotivated staff members. It has to be
part of someone’s job description to keep the schedules full. When defined job descriptions are

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lacking at the business desk, the result is disorganization. A rather common situation is to have
two or more people at the business desk who have no defined responsibilities. The two most
important things that happen at the front desk are collections and scheduling, but nothing is
more important than the schedule. After all, if there are not patients in our dental chairs, there is
nothing to collect. In a one-doctor, two-hygienist office, there will be one business assistant who
is the financial coordinator and another business assistant who is the scheduling coordinator.
Both assistants will share some duties, like answering the telephone and helping with check-in
and check-out duties. However, each assistant has a primary duty, which is responsibility for
collections or scheduling. In a multi-doctor practice, there may be two scheduling coordinators
– one for hygiene and one for doctors. When organization is lacking at the front desk, often the
hygiene schedule goes unfilled. If there are openings in both the doctor and hygienist
schedules, the doctor schedule may take priority. However, keeping the hygiene schedule full is
just as important as keeping the doctor schedule full. A healthy, thriving hygiene department is
the best insurance for a healthy, thriving restorative department.

Holding Patients Responsible

A fourth reason for downtime in the schedule is that patients are not being held responsible for
their appointments. It is likely that there is not another profession that coddles its patients the
way we do in dentistry. The whole idea of the confirmation call seems silly at times. The subtle
message is “we’re not sure you are coming, so we need to confirm that you are really coming to
your dental appointment.”

What we need is a shift in our thinking. When patients give their permission to place their
names in our schedules, we should consider the appointment confirmed.

Did you know that it can be counterproductive to make confirmation phone calls? In a study that
looked at patient attitudes toward confirmation calls, the result was that one-third of patients
were actually annoyed by the call, one-third of patients stated that the call was very helpful, and
another third of patients were ambivalent about the call.

Either way, it is prudent to start holding our patients responsible for the time that they reserve in
our schedule. A good suggestion is to ask the patient if he or she would like to have a courtesy
reminder call. If the patient states yes, then we should expand the conversation to ask which
phone number would be the best number to call. Often we have a cell number, a work number,
and a home number. Business assistants can waste valuable time making calls to all three
numbers and leaving the same desperate-sounding message on each phone. If the patient
states that he does not need a reminder call, then the business assistant should thank the
patient for being dependable. The business assistant should make a note that no reminder call
will be necessary.

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Also, many offices use email and text messaging as a communication tool. Always ask patients
if they would like to be contacted for their appointment reminder in that fashion. Patients that
have to pay extra for texting may prefer not to be contacted in that manner.

It is important to understand that there are two classifications of people for whom it is
inappropriate to leave appointment reminder messages. The two classes of people are (1) the
new patient, and (2) people with a history of broken appointments. It is imperative someone
speak directly with these people. When a new patient calls, the business assistant gathers all
the pertinent information and schedules the appointment. Then the business assistant should
inform the patient that it will be necessary to speak with the patient directly within 48 hours of
the visit. The business assistant should ask the patient which number will be best to speak
directly with the patient. New patients are notorious for disappointing. So to reduce that
possibility, it is important to speak with the new patient directly, even if it means taking the
patient’s number home and calling after regular working hours.

Patients with a history of disappointment cannot be trusted. The call to such a patient would go
thusly, “Hi Mrs. Jones, this is Mary at Dr. Smith’s office. I’m calling regarding your scheduled
time with Dr. Smith on Wednesday, May 5 at 10:00 AM. It is important that I speak with you
directly about this visit. Would you please be so kind as to return this call by tomorrow,
Tuesday, before noon? Our number is 123-4567. Thank you for your consideration.” I
recommend the call be made 48 hours in advance of the scheduled time. If the patient does not
return your call by the following day, then the patient should be contacted after hours. Some
business assistants may balk at the suggestion to take a patient’s number home with them and
call after hours. But a key question is this - is it better to exert a little more effort and speak with
a potential disappointer directly or to have an unhappy doctor or hygienist pacing the hallway?
Always remember that an idle doctor or hygienist means no production. Excessive downtime
could negatively impact everyone’s pay.

Patient Illness

A fifth reason that people cancel dental appointments is because of illness. If a patient calls and
relates that he or she is ill and will not be able to keep the scheduled appointment, the business
assistant should express regret and wish the patient well. Then the patient should receive a get
well soon card in the mail. If this was a hygiene patient, the hygienist should be the one to sign
the card and write a personal note, such as, “Hope you’re feeling better today.” If the patient
was truly ill, the card will be uplifting. If the patient was not ill and simply used illness as an
excuse to disappoint, we hope the card will make the patient feel guilty.

Financial Difficulties

Finally, another reason patients cancel their dental appointments is because of financial issues.
We should always make sure that the patient understands his or her financial obligation before

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treatment is commenced. Some options might be outside financing, doing phased dentistry, or
working with the patient personally to help him or her receive needed dentistry.

Communication Dilemmas – the Resistant X-Ray Patient

At the morning huddle, you notice that “Don” is on your schedule today. Looking at his chart,
you notice that Don has refused radiographs on the previous three previous preventive visits.
So you know ahead of time that it is likely he will resist x-rays again today. Don has had a
history of caries and his homecare is poor at best. As you seat Don in your chair, you say to
him, “I see it’s time for your x-rays today. Is that OK?” Big mistake! Never ever ask a patient’s
permission to take an x-ray you need. Your statement should be this, “Don, as the doctor has
requested, I’m going to take some necessary radiographs today.” Now if Don protests, then you
should explore the reasons why he is refusing radiographs again. But do not argue with the
patient.

When patients refuse necessary radiographs, the doctor must get involved. When the doctor
comes in and to do the exam, the doctor should ask to see Don’s x-rays. The hygienist would
say to the doctor that Don has once again of refused x-rays. This is the point where the doctor
intervenes. The doctor should then say to the patient, “Don what’s this about? You’re asking
me to take care of you without the tools that I need.” Then let the patient speak. Sometimes,
patients will acquiesce when the doctor brings up the issue. However, if the patient is still
resistant, the doctor should continue with this statement: “Keep in mind that the state of _____
mandates that I treat all my patients in a competent manner. I cannot do that without
radiographs. Up-to-date x-rays are an important part of the standard of care.” Depending on the
patient, the doctor may opt to give the patient one more opportunity. The doctor could say, “All
right, today we will forgo x-rays. However, please be prepared on your next visit. We must get
some up-to-date x-rays.” Then the Dr. should say to the hygienist, “Make sure that is recorded
in Don’s chart.”

Fast forward to Don’s next visit. Once again, he refuses radiographs. It is the doctor’s
responsibility to handle this matter. The doctor should do the exam and then say to the patient,
“I’ve enjoyed having you as my patient in the past. However, in the future I will be unable to see
you. The state of _____ mandates that I treat all my patients in a competent manner, and I
cannot do that without radiographs.” If the doctor feels uncomfortable having this conversation
with the patient face-to-face, then a certified letter should be sent to the patient dismissing him
from the practice, according to state board rules.

The central point of the matter is this: the patient’s refusal of needed radiographs impedes the
doctor’s ability to diagnose. Even if the patient signs a form stating that he or she refuses x-
rays, this could still become a “failure to diagnose case” in a court of law. There are
documented cases where patients refused needed radiographs, some pathology developed,
and the doctor was unable to diagnose the problem because of not having radiographs.
“Failure to diagnose” cases are invariably won by complainants. It is a serious matter.

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It is important to mention that some dental offices abuse radiographs. Blanket mandates, such
as every patient gets them once per year, are inappropriate. We should take x-rays based on
the patient needs. Patients differ in their needs. Our professional training teaches us to look for
risk factors presented by our patients and make judgments based on those risk factors when
deciding if radiographs are needed. The ADA has a document on its web site to guide dental
professionals as to the frequency of radiographs. (http://www.ada.org/sections/
scienceAndResearch/pdfs/topics_radiography_examinations.pdf)

If the doctor decides against dismissing a patient who refuses needed radiographs, the doctor is
assuming a huge potential liability risk. In any event, make sure the conversation with the
patient is well-documented in the patient narrative.

Patients have many reasons for refusing radiographs, such as discomfort, fear of radiation,
strong gag reflex, or finances. If inability to pay is the reason for the patient refusal, it is
suggested that the radiographs be taken at no charge to the patient rather than continuing to
treat the patient without updated radiographs. This would be the best alternative if the doctor
feels he or she cannot dismiss this patient from the practice.

As employees in dental practices, hygienists are not liable if patients refuse radiographs and the
doctor decides against dismissing the patient from the practice. Again, make sure all
conversations are well-documented in the patient narrative.

Communication Dilemma – the Resistant Periodontal Patient

Another of the more common communication dilemmas today is the periodontal patient who
refuses definitive care after the diagnosis of periodontal disease has been given. This problem
is present in every dental office in America. In some offices, it is a regular occurrence as more
and more patients lose their jobs along with dental benefits. Since periodontal conditions tend
to worsen over time, let’s talk about how to deal with patients who refuse definitive periodontal
care.

Let’s start with the new patient. Ideally, all new adult patients should be seen by the doctor first
for a comprehensive examination, which includes a full periodontal charting. The periodontal
charting would indicate what level of periodontal disease is present, and treatment can be
planned accordingly. In communicating the presence of disease to the patient, the doctor
should avoid statements like “You have a little gum problem.” Minimizing the problem of
periodontal disease makes it difficult for the patient to understand why she needs expensive,
definitive treatment beyond a prophylaxis. The doctor should be very clear and state, “You have
periodontal disease which is a chronic infection of the bone around your teeth. Over time, this
disease destroys the bone, and if it is not treated appropriately, you will lose teeth. The good
news is that we have very good success treating this problem non-surgically.” If the case is
advanced, a referral to a periodontist may be the best course of action.

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In many offices, new adult patients are scheduled in the hygiene department first. Hygienists
have excellent skills in gathering data and performing assessments. Hygienists are qualified to
perform all the necessary preliminary functions — introductions, medical history review, blood
pressure screening, intraoral and extra oral assessments, periodontal charting/recording,
charting of existing restorations, and radiographs.

As an example, let’s assume in your assessment that the new patient in your chair has Class III
periodontitis. You can see some significant subgingival deposits on the radiographs, and you
see bleeding upon probing. The best way to communicate the presence of disease is to engage
in a process of discovery with the patient. You say, “Mrs. Jones, have you noticed this particular
area bleeding when you brush?” After a little more probing, you say, “Have you noticed this area
being inflamed?”

Now is the perfect time to engage your intraoral camera to let the patient see exactly what you
are seeing in her mouth. In the absence of an intraoral camera, pointing out calculus and/or
bone loss on an X-ray is also recommended. All you are doing is calling attention to what you
are seeing in the patient’s mouth.

Then you lay down your probe and say, “Mrs. Jones, according to what I see in your mouth and
on these X-rays, there appears to be some problems with your gums and even the bone around
some of your teeth. Before I proceed any further, I need the doctor to come in and have a look.”
Then you would leave the operatory to go and inform the doctor about your findings (out of the
patient’s hearing) and request a brief doctor examination. An extensive exam should not be
expected at this point, since it is likely that the doctor is busy with his/her own restorative
patient.

When the doctor enters the room, introduce the patient to the doctor. Then the doctor will sit
down, look at the X-rays, and perform a cursory exam. The doctor should say, “Mrs. Jones, from
what I see in your mouth and on these X-rays, you have periodontal disease. It is a chronic
infection in your gums, and over time it destroys what supports your teeth, namely the gums and
bone. Your teeth are like fence posts in the ground. As long as the earth around those posts is
strong and firm, the posts will stand nice and straight. But if the earth around the posts
deteriorates or falls away, the posts get loose. That’s what happens in the mouth too. The
disease in your mouth is destroying what supports your teeth. The good news is we know how
to treat this disease and get it under control, usually in a nonsurgical manner.”

Helping the patient understand the disease process is critical to ushering the patient into the
definitive care he or she needs. Not only does the patient need to understand the disease, the
patient also has to own his disease before he is willing to agree to treatment.

However, even with excellent communication skills, some patients will continue to request a
“cleaning” rather than the definitive periodontal care that is needed. Sometimes patients do not
understand the disease process associated with periodontal disease. However, the standard of

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care for treating periodontal disease is definitive periodontal treatment, not a preventive
procedure like a prophy. One analogy that can be used when a patient requests a prophy but
needs periodontal care would be that a prophy would be like putting a Band-Aid over an infected
wound. We can further explain that treating a periodontal infection effectively involves a
different treatment than a prophy.

It is advantageous to avoid the phrase “deep cleaning” when speaking of periodontal treatment.
The phrase “deep cleaning” conjures up all kinds of unpleasant images in the mind of a nervous
patient. Carpet cleaners provide deep cleaning services. Dental hygienists and dentists
provide specialized periodontal care.

A wonderful analogy to help the patient understand the micro environment under the gum line is
that of a coral reef. For example, “Mrs. Smith, over time the root surfaces of your teeth have
been building up a hard calcified mineral. You may know it as tartar. This material is just like a
coral reef in the ocean. It’s very rough and bacteria love it. This tartar provides all kinds of
wonderful habitat for bacteria. So in our treatment, we remove all those hard tartar deposits and
thus remove the hiding places for the bacteria. Then your gums start to heal. With our good
care and the care you will be taught to do at home, your gums will get better and better. The
goal is to stop the breakdown of the bone around your teeth and return your gums back to a
healthy state.”

Clinical Ideal vs. Patient Reality

If the patient refuses the treatment recommendation for definitive care or a periodontal referral,
here are the possible options:
• Do nothing.

• Dismiss from the practice.

• Provide care at a reduced fee or complimentary.

• Provide an alternate treatment for the short term, not the ideal.

The first option of doing nothing is not a good choice, since we know that periodontal disease
continues to progress over time. Doing nothing risks the patient’s overall health, because
periodontal disease is known to affect other systems in the body.

The doctor always has the option to dismiss the patient from the practice. However, this may
seem to be a harsh and extreme way to deal with a resistant patient. Anytime a doctor
dismisses a patient from the practice, there is a ripple effect. The dismissed patient will, in all
probability, become a negative missionary in the community.

If financial issues are problematic, the doctor may decide to provide care at a reduced fee or
even complimentary. The practice should have several financial options available to patients to

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help patients obtain care, such as phasing the dentistry or using third-party lenders like
CareCredit®.

In some cases, it is appropriate to provide an alternate treatment that is meant to be a short-

term option only, such as a debridement with a power scaler. This is certainly better than doing
nothing. Please note that a prophylaxis is not an appropriate treatment for a patient with
periodontal disease. In dentistry, we must find a way to balance the clinical ideal with the
patient’s reality. In some cases, that may mean providing an alternate treatment for the short-
term, not the ideal treatment.

A good example would be if a patient came in with a broken tooth. After examination, the doctor
tells the patient that he needs a crown. The patient then asks how much it will cost. The doctor
then gives the patient the fee, to which the patient replies that he cannot afford to have a crown
done at that time. The patient may ask the doctor if there is anything else that can be done.
The doctor could offer to do a build-up or maybe even a pre-fabricated crown to buy the patient
some time, with the full explanation to the patient that the treatment being offered is not the
definitive treatment that is needed. It is not the ideal, only a short-term alternative. Most
doctors would not opt to dismiss such a patient from the practice. As with any treatment,
thorough documentation in the patient chart is a necessity.

Why People Refuse Definitive Care

There is a variety of reasons why patients do not consent to definitive periodontal care. Those
reasons include:

• Financial issues – the patient may feel your fee is too high, or he may not have the
financial resources to pay for the care he needs.

• Inconvenience – the patient may feel that numerous visits needed for periodontal care
will overwhelm his already-hectic work schedule.

• Fear – the patient may experience overwhelming fear of the pain associated with
treating his gums.
• Mistrust – the patient may feel that you have inflated the diagnosis, especially since
periodontal disease is typically painless.

It is challenging for the dental professional to first determine why the patient refuses definitive
periodontal care, and then to develop avenues to overcome those challenges. One of the top
reasons is financial issues. When people are struggling to pay for housing, transportation, food,
clothing and medicine, dental care might be restricted to emergency-only treatment. Other
reasons for refusing definitive treatment include fear, inconvenience, and mistrust. Some of our
patients have been through unpleasant experiences in other dental practices that have left them
scarred mentally toward any kind of dental treatment. Some of our patients are so busy with

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their work that they do not see how they can carve out time to address dental care. Other
patients mistrust us because we have not earned their trust over time with excellent patient
service.

Informed Consent and Informed Refusal

Whatever the reason for refusal of our treatment recommendations, we must understand that
patients do have the right of refusal. In fact, every competent adult has the right to have a “say”
in what happens to his or her body. The two legal precedents pertinent to our discussion are
“informed consent” and “informed refusal.” The healthcare provider should make it clear to the
patient that he or she is participating in a decision.

Informed consent is about a patient’s understanding and willingness to voluntarily agree to

proposed treatment after it has been explained in language the patient can understand. The
most important goal of informed consent is that the patient has an opportunity to be an informed
participant in his or her health care decisions. Informed consent may be either verbal or written.
It is generally accepted that complete informed consent includes a discussion of the following
elements:

1. A diagnosis and an explanation of the medical or dental condition that warrants the
proposed treatment.

2. An explanation of the purpose of the proposed treatment.

3. A description of the proposed treatment and the individual patient’s role and
responsibilities during and after treatment.

4. A discussion of the known risks and benefits of the proposed treatment.

5. An assessment of the likelihood that the proposed treatment will accomplish the desired
objectives. When discussing treatment outcomes it is important not to appear to
guarantee treatment outcomes to the patient. Remember that individual patients will
respond differently to treatment.

6. A presentation of alternative treatment options, if any, and the known risks and benefits
of these options.

7. A discussion of the prognosis if no treatment is provided.

8. A discussion of the actual costs associated with the proposed treatment.

9. Reinforcement of the individual’s right to refuse consent to the proposed treatment.

Patients often feel powerless. To encourage the patient’s voluntary consent, the

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 healthcare provider can make it clear to the patient that he or she is participating in a
decision, not merely signing a consent form.

Informed refusal is about patient’s refusal of all or a portion of the proposed treatment after the
recommended treatment, alternate treatment options, and likely consequences of declining
treatment have been explained to the patient in language that the patient can understand. A
patient has a legal right to refuse proposed medical or dental care.

When a condition has been diagnosed and a patient refuses the recommended treatment, the
patient should be asked to sign a “Refusal of Treatment” document. If the practice still uses
paper charts, the patient can be asked to sign the chart narrative or a separate document that
outlines the advantages, disadvantages, risks, and alternatives of treatment vs. non-treatment.
The patient’s signature verifies that the patient understands the consequences of non-treatment.
If the patient refuses recommended treatment on subsequent visits, the clinical notes do not
have to be re-written at each successive refusal. Instead, the clinician can note: “Patient again
refused periodontal treatment recommendation. See notes on (previous date where thorough
documentation exists). Signatures never expire, so it is not necessary to have the patient sign
again.

In Conclusion
Communication is a skill learned throughout life. From the moment we take our first breath, we
begin a lifetime of learning to communicate. Good communication skills are as important as
good clinical skills for all healthcare clinicians. The best communicators are those individuals
who have developed a keen sensitivity to the person/s with whom they are seeking to
communicate. Good communicators have learned to step out of their own preconceptions and
consider the thoughts and feelings of others. Be committed to a continual process of learning
and improving your own personal communication skills. The better communicator you become,
the more your patients will benefit from your efforts toward optimum oral health.

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