Thursday Troubleshooter: RDH very concerned about dentist's dismissal of oral lesion

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QUESTION: I recently saw a longtime patient of the practice for the first time. The patient is a heavy smoker. She had been seen by two other hygienists previously. In 2016, the hygienist noted a suspicious lesion on the lateral border of the tongue. The doctor referred her to an oral surgeon. It was subsequently noted in the chart that the patient told the hygienist that the oral surgeon wanted to remove and biopsy the lesion.

At the next recall, another hygienist noted the same lesion and wrote that the patient was going to see the oral surgeon to have it removed. I saw her at her next recall and the lesion was still there. The patient informed me that the oral surgeon told her he was "99% sure it was nothing." It didn't look like "nothing" to me, and I told her that with her history of smoking, she should have it biopsied.

I passed a note to the dentist when he came in for the exam, sure that he would strongly recommend that she have the lesion biopsied. Instead, when she repeated to him that the oral surgeon didn't think it was anything to be concerned with but that he wanted to "snip it off," he just laughed and said, "I'm sure you're real anxious to do that." He said nothing more about it, seemingly taking the patient's word that it was "nothing." He dismissed her and she left.

We have no paperwork from any oral surgeon to indicate what his findings were. The patient is a dental phobic. I fear she is avoiding having the lesion biopsied because of her fear of dentists. But I am most upset that the dentist brushed this off. I am worried sick that this could be cancer, and if anything happened to her, I would feel partially responsible that she didn't have this taken care of. But I don't know what to do. The patient will not be coming back for another six months.

ANSWER FROM JAN KELLER,Jan Keller and Associates:
What a dilemma! I recommend that you document, document, document, and follow through, follow through, follow through. I have several questions for you to consider:
• Has anyone contacted the oral surgeon from the first and second referral for his or her assessment and prescribed treatment?
• Have pictures of the lesion been taken and documented at each visit to your office?
• Has the oral surgeon communicated with your office what the patient’s decision was after her diagnosis and treatment plan? Receiving documentation from the oral surgeon is important to complete your practice’s documentation.
• Depending on the documentation, diagnosis, and treatment recommendation from the oral surgeon, has the dentist had a conversation with the patient as to how he or she can help the patient follow through with the recommendations?
• Have you helped the patient overcome whatever concerns or challenges she might have about receiving treatment? This is important for a better outcome.
• Has literature been passed on to the patient regarding other cases of oral cancer, what to look for, and what to do? Have you suggested she join a support group?
• Has anyone talked with this patient about other oral cancer patients who had successful outcomes, to help allay her fears? Eva Grayzel is a wonderful example. https://www.evagrayzel.com/about-eva

We know our patients delay treatment for several reasons, including money, time, and fear. In this case it appears the patient fears what she might be told. Does she understand the risks and the benefits of delaying treatment versus undergoing treatment?

To answer this question, I called upon three of my colleagues who have either personally experienced oral cancer or who have insight into liability issues for feedback and input. Linda Miles, cofounder of Oral Cancer Cause (OCC) suggests that you might want to have a private conversation with the doctor to allay any of your fears about the patient, and to ask why he has decided that the patient doesn’t need further care.

Oral cancer survivor Eva Grayzel asks, “Did the doctor see a lesion and dismiss it? Or did he not see a lesion any longer in the spot noted in the records? This hygienist needs to call the patient and tell her how she feels about the suspicious area. Then she needs to document what she said and wrote on the records so she is protected in a court of law. I am a firm believer in a standard of care for screenings in every office so that the dentist knows the quality of the screening by each hygienist. Also, if this hygienist feels like her experience and knowledge isn’t considered relevant and with thoughtfulness by the dentist, then she is in the wrong practice.”

Having a conversation with the doctor, following through with the oral surgeon, and understanding why the patient has not followed through is essential. Then, documenting your conversations and findings is also essential.

Roy Shelburne, DDS, agrees that it is necessary to document the patient’s disclosure that she saw an oral surgeon, and to keep a record of the oral surgeon’s findings. “If the patient’s story pans out and the lesion has not changed (there should be a photo of the lesion taken by this hygienist and the previous hygienists to document what they observed), then all is good. If the information does not corroborate, then another contact with the patient is indicated and another referral should be made.”

Dr. Shelburne agrees that you cannot make patients be compliant, and that documentation is important. If the patient is not compliant with the general dentist’s or oral surgeon’s recommendations, a piece of documentation that would be helpful is a “Decline of Treatment” form. This form states the benefits of following through with prescribed treatment, and the potential risks when patients choose not to follow through with recommended treatment. Dr. Shelburne said that when patients are confronted with having to sign something that states they decline treatment, many of them often reconsider.

As for you feeling “partially responsible,” by following the suggestions here, you can feel confident that you tried your best. Your patients are lucky to have you as their hygienist, and I hope they appreciate your concern for them.

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