To try and bridge the gap between the two professionals, Claire and Faye discuss referral pathways between hygienists and periodontal specialists, including how to go about them and how to feel confident doing it.
The power lecture topic for the next phase of Contemporary Hygienist study clubs is going to be about referral pathways to the periodontal specialist.
We want to bring periodontal specialists and hygienists/therapists together.
It seems fitting that we kick start that by choosing this topic for this month’s edition of the Contemporary Hygienist column.
It’s a topic that arises time and time again. When should we refer, how do we refer and who should we refer to.
Communication and conversation
If stabilising periodontal disease is a team effort, then, when necessary, we’ll need to work closely with a periodontal specialist. This is so we can achieve optimal health for patients who require that secondary level of care.
The British Society of Periodontology (BSP) guidelines states: ‘As with all treatment involving a team approach, the long-term success of a care pathway depends on good communication between clinician and patient. This is to ensure consistency of treatment objectives and appropriate follow up.’
But it’s not just good communication between clinician and patient that is essential. Establishing good communication lines between all relevant clinicians – both in house and out of house, will ultimately result in our patients receiving the best possible care.
Don’t be afraid to reach out to your nearest periodontist.
Give them a call or drop them an email introducing yourself and ask if there’s anything in particular they’d like to see in a referral.
Ask for their advice or opinion. We are yet to meet a private periodontist who would decline the opportunity to open up a new avenue of referrals.
Sometimes it just needs a conversation.
When to refer
The short answer to this is when you feel out of your depth.
You’ll find at different stages in your career you’ll feel more/less confident in what you think you can and can’t treat.
It’s widely regarded patients should have at least one failed course of NSPT before considering referral – particularly within the NHS pathway. But it’s not always the case.
Sometimes it’s as much a gut feeling as anything else. If you sense what you’re looking at has an aggressive nature, or you feel overwhelmed by where to start, or maybe your set up doesn’t allow the length of appointments you think you’ll need, then it’s ok to refer on.
That referral might not be to a periodontal specialist straight away. If there’s another more experienced hygienist or therapist in house, have a chat with them.
A different pair of eyes
This also applies if patients are struggling to engage with oral health advice too. Sometimes a different pair of eyes or a different way of describing something can make all the difference.
Contemporary Hygienist co-founder Faye often receives referrals from fellow colleagues struggling to engage patients. Remember referring sideways also falls into the ‘working as a team’ approach.
Following the S3/S4 guidelines is key when considering the right time to refer to on.
The guidelines are set out in a very clear step by step format, dictating what each treatment stage should entail. Only when patients graduate at each stage do we progress to the next.
When we re-evaluate at stage three and find non-responding sites, this is the time to consider if a referral would be beneficial (usually after a second round of sub PMPR).
Show this step-by-step guide to your patients when discussing their journey from active disease to stabilisation. It’s a good way to help them visualise the journey they’re about to embark on and see the different stages where other interventions may be required.
How to have the referral conversation
It’s best to lay this out in the initial phases.
It is much easier to explain that a referral may be necessary at some stage in their treatment plan than to try to have that conversation after the treatment has been unsuccessful.
It will also protect you should a litigation claim arise.
For patients to fully consent, they must be given all the information they need to make an informed choice.
To fail to mention that not all periodontal disease can be stabilised with NSPT, and that in some cases a specialist referral is required, would be remiss of us.
Mentioning this at the start can act as a motivational tool too.
We always tell our patients to expect the worst, but that we’re going to work as hard as we can to avoid it. In addition, the harder they work at home, the more likely we are to manage their disease in house.
The patient’s best interests
It’s never a nice feeling as a clinician to retrospectively have to tell a patient that the treatment hasn’t been as successful as we’d hoped and we need to refer on.
By openly having these conversations at the start and throughout the treatment keeps the possibility on the table. In addition, patients won’t see it as a failing.
It’s a bit like seeing a GP who tries different meds to manage an earache, but decides to refer on to ENT when it doesn’t resolve the problem.
This would be seen as referring up. As a patient I’d be grateful for their attention to detail.
Referring on to a specialist periodontist when we’ve reached the limits of what we can achieve, is also acting in a patients best interest and that is something we should celebrate.
We use the words ‘failed treatment’. But it’s worth pointing out here that having some non-responding sites does not mean failure.
Those sites may have reduced in depth, but to consider them stable they must be less than five millimetres with the absence of bleeding on probing.
Remember only around 70% of pockets will be stabilised after one round of NSPT and just under 85% after a second round.
That loosely means that around 15% of all sites you treat with 2 rounds of NSPT will never be granted ‘stable’ status and you may have to consider other interventions to manage them.
What if the patient declines?
As already discussed, it’s doesn’t matter what level the patient is at when they are referred or who you choose to refer to. It only matters that you recognised that another intervention was indicated and you acted on it.
If a patient declines that referral it’s OK too. Document the discussion and their choices and respect them.
It may not be a perfect scenario, but do what you can to slow down the disease progression and revisit the conversation again at an agreed interval.
The patient may well change their mind if your charts show a deterioration from one year to the next.
Steps you can take to make your referral pathway easier
- Visit the referral practice. This is something we highly recommend in order to get to know the team who will receive your referral and to meet the periodontal specialist you will be referring to
- Shadow the periodontal specialist for a day. It’s a worthwhile way to spend your day. You will really see what the specialist says to patients and what treatments they carry out. It means you can talk from experience when you discuss all the options with your patients. A patient will ask what a periodontal specialist will do differently to you. Therefore, it’s good to be prepared for that. You could go one step further, like Faye did, when she nursed for a periodontist for six months so she could see exactly what a periodontal specialist did in detail
- When getting to know your referral clinic, ask what information they require when you send the referral forms. The clinic may have their own they like clinicians to use. We have also created a referral form for our Contemporary Hygienist members to use. We have worked on our referral forms with periodontal specialists and oral surgeons, so it covers all bases they need know
- Go along with your patient to the initial consultation. This really does make for a teamwork approach as you discuss the proposed plan for lifelong care together as a unit.
Don’t feel disheartened
Most importantly, don’t ever see the referral as a failing. As well as this, never ever feel judged.
An experienced clinician who is used to receiving referrals will know what it takes to manage a complex periodontal case.
They will have nothing but praise for your skill in recognising that a referral was required.
They will also have had many failed/unsuccessful cases in their portfolio themselves. Even with the additional tools they have in their arsenal.
Not all disease responds to treatment and that’s the reality, so don’t feel disheartened.
Instead, feel proud that you did your best and somewhere along the line, you improved your patient’s health.
If you are a periodontal specialist who wants to work alongside our Contemporary Hygienist members/study clubs to close gaps and work closer together with clinicians in your area, please get in touch with Faye or Claire Louise.
Read previous Contemporary Hygienist columns
- Navigating pressure in an isolated job
- Establishing the hygiene department as a practice cornerstone.
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