We all like to believe that we provide out patients with the high quality care. However, it is easy to get trapped into the “watch and wait” corner when we prejudge our patients or get used to a client refusing treatment. Meriam Webster  defines Benign Neglect as: an attitude or policy of ignoring an often delicate or undesirable situation that one is held to be responsible for dealing with. We call it the “nice guy” syndrome or “denying the truth” syndrome. Often this issue comes from lack of clarity with respect to who “owns the problem.
The first form of benign neglect begins when a new doctor comes into a practice and is faced with patients that have been seen by their “old” doctor for years. The new doctor sees the patient for a hygiene check and sees things like untreated periodontal disease or restorative treatment that is technically indicated but not complete. He or she knows that the best alternative would be to have the patient come back for a comprehensive exam and new treatment plan. The doctor thinks that if a new exam is suggested the patient will feel like all her or she is interested in is money. The patient is reappointed for hygiene and benign neglect sets in again. The patient is not offered an opportunity to understand their condition and a chance to take control of their own dental situation over fear of losing the patient. The office assumes the patient is either not interested in treatment, or cannot afford treatment.
It would be ideal if the new doctor and staff had a discussion about these types of patients and come to an agreement on how they will be handled in a team meeting. This can be a difficult situation, especially if the hygienist has a long standing relationship with the patient and the doctor and team are not on the same page with respect to the philosophy of the practice. However, the situation can be managed by spending just a few moments to ask a couple questions and listening. The conversation might go something like this:
Dr.: Mrs. Jones, Jane has noted that you have some increasing pocket depths on the lower left. It appears that they have been getting deeper over time. Were you aware of how the pockets are causing defects in the bone support for your teeth?
Mrs. Jones: Jane has pointed that out before but I did not want to deal with any added treatment due to the cost as our son was still living at home after graduating from college.
Dr.: Mrs. Jones I respect your situation. Hopefully he finds a job soon. However, it is my moral and professional responsibility to make sure you have all the information necessary to be able to make informed choices about managing your dental health. You determine the outcomes that you want. We are here to provide the care, skill and judgement to help you achieve your goals.
Mrs. Jones: Well, doctor I don’t want to lose more bone or lose any teeth. My son finally has found a job so I would consider doing something. How much will treatment cost?
Dr.: Mrs. Jones I will have Jane review with you the steps involved in getting your pockets under control and the time and fees involved. You have been a faithful client in this office for a long time. We thank you for that. It has been a long time since you had a comprehensive exam. Once we have your periodontal issues under control, I would like to provide you with a complimentary comprehensive exam just to make sure that there are no other issues we might be missing and to make sure we are doing all we can to help you be in total control of your dental health outcomes. Jane will help you from here. I look forward to seeing you soon.
In just a few minutes you have unmasked the elephant in the room of untreated disease. You have determined the reason and the patient’s level of interest. You have allowed the patient to take control of her dental condition. You have fulfilled your professional and moral responsibility to truthfully inform your patient about their dental condition.
What if Mrs. Jones still says no to treatment? All dentistry is optional so she is now responsible and in control. You have established her situation for the record. However, we would note her refusal in the record and her reason why. If she continued to refuse treatment we would ask her to sign a simple letter stating that she refuses treatment for the conditions specified in the letter and keep a copy in her patient file.
A complimentary exam is a great way to establish rapport with your patient. If further dental care is indicated she will feel she is in control. Once the word gets out about the experience of a comprehensive exam in your office and that you are not trying to “sell” dentistry, long term clients who know they have “let things go” will be expecting or asking for a new exam.
The benign neglect that shows up in a more mature practice is sneaky. Part of it comes from the doctor trying to be a nice person. Here is an example: You have to remove an upper bicuspid due to a root fracture. You know your patient’s wife is undergoing cancer treatment so you just dealt with the issue and do not discuss what might be done to replace the missing tooth. Now its two years later the wife is better but he has gotten used to no tooth. Now its eight years later and he is a trust office in your bank and every time you see him smile you see the missing tooth. He does not see the adjacent teeth shifting and the bone loss in the extraction site.
It is time for a conversation at the hygiene visit.
Dr.: Hi Jim. Jane has pointed out to me that your teeth are shifting more in the area where we had to remove that upper tooth that fractured several years ago and you are getting some deeper pocket readings due to food impaction around the adjacent teeth. Have you noticed any changes?
Jim: Yeah doc I have noticed more food getting stuck between the back teeth lately. That tooth has been gone so long I pretty much forgot about it. Would it be expensive to fix it so I do not have to use a toothpick after every meal?
Dr.: Jim, we have not done a comprehensive exam with you since well before you lost that tooth. I would be more comfortable in making suggestions about the options available to you for treatment if we take the time to look over your whole mouth. With the data we gather from a new exam I can develop a better long term master plan to help you take control of your dental health. Once we gather the data I will set aside time to review our findings and discuss the options and fees that are involved. Can you make time in your schedule for that?
Jim: OK doc. I will look at my schedule with Jane.
So what happens if Jim says no, he is fine the way things are? Remember, dentistry is optional. We have established with Jim that he is the person responsible and in control of his dental health. We have offered to work with him to define what options he might choose if he is interested in improving his situation. He can determine whether he chooses to consider the means we have available and is comfortable with the fees involved. We have met the moral and professional standards that allow us to sleep well at night.
Another area of concern in the mature practice is dealing with our long term clients who are elderly and losing the ability for self-care. Too often we pre-judge this group and tend to offer them a “quick fix” or “patch work” care” without taking time to listen to their concerns and educate them on the options available.
The truly elderly present some of the most difficult restorative challenges and challenges in periodontal and self-care. Often these clients are slower to respond to questions and slower to make decisions. However, a healthy mouth is a very real quality of life issue that should not be ignored. When we see a client in the beginning stages of decline we are obligated to make the extra time available to make the person aware of what we see. It is imperative that we establish the outcomes that the person is looking for over time. Then we need to honestly let the person know what they will have to do to reach their goal. For many it will simply entail additional visits with the hygiene department. For others it may involve significant dentistry. Just because a person is older we should not assume that they do not care about their teeth and smile and that they do not have the financial capacity to achieve the outcomes they want.
For those who are financially challenged this may be an opportunity to reward their long-term commitment to your practice with an individualized incentive program. For those who would benefit from four prophylaxis visits per year, consider offering the fourth visit free if they keep the first three visits. This sort of commitment to the well-being of your elder clients is a win – win. You gain a “missionary” for your practice and you also are less likely to have to be struggling to repair root caries on a second molar.
All of us will have patients who will choose to leave ideal dentistry undone. However, we can resolve the benign neglect issue by asking open ended, non-judgmental questions and listening to our patients. Avoid pre-judging patients whether old or new. Establish that the patient the person in control of the outcomes. We in the dental profession are there to provide care, skill and judgement. When we know the outcomes desired by the patient we can establish with the patient what a mutually acceptable means and acceptable fee will be to reach the defined goals.
 Miriam Webster Dictionary