Balancing Previous Patient Experience with Appropriate Diagnosis

It's 4 p.m. and you have an athletic event for your son or daughter to get to at 5:30 p.m. In your morning meeting that day, your staff reported that the new patient seated in your chair called in.

“I have a cracked tooth with swelling into my neck and I know it needs to be pulled, just like the other ones,” your patient says.

You know that this type of patient does not fit your ideal comprehensive dental philosophy and you feel your gut groan just a bit as you begin the few steps that seem like they take a mile into the next operatory.

As you walk into the room, you find a well-groomed woman in her mid-50s. During the review of present illness interview, she reports that her lower right molar has been hurting for two months, but sometimes if feels like the second molar is hurting. The pain comes and goes throughout the day but does not bother her when she's sleeping.

She reports that her pain level varies from a 2 to a 6 and is near a 6 at the end of the day and after eating. She also says that the pain is always present to some level and throbs when it is most painful. On a pain drawing, she indicates that the pain extends into the preauricular area and down her neck into her right shoulder.

She has been divorced twice, once three years ago, and she is currently ending her second. Incidentally, she reports that she lost the teeth on her maxillary left side three years ago for similar pain – one at a time, after which each extraction and an endodontic procedure seemed to alleviate the pain until “another tooth cracked a few weeks later” over the course of a few months. Since she is now experiencing the same pain on the other side, she is certain she has another fractured tooth that needs to be extracted “just like the others.”

Medical history is benign except for left knee arthritis, for which she takes meloxicam 7.5 mg once a day when she feels she has knee pain. Her tooth pain seems to be “a little less” when she takes that medication, as well.

On cursory clinical and radiographic examination, you make the following observations:

• The mandibular right first molar has some minor stained buccal and lingual vertical cracks that do not appear to extend subgingivally.
• There is generalized recession and moderate horizontal bone loss with minimal gingival inflammation and no periodontal pockets greater than 3 mm.
• There is no non-physiologic mobility.
• There are moderate wear facets and maxillary central incisor attrition consistent with the patient's age.
• There is no apparent periapical pathology.
• There is no apparent condylar pathology or clinical joint noises.
• Load testing of the temporomandibular joints with a leaf gauge is unremarkable.
• There is no percussion sensitivity, no atypical cold sensitivity, no selective pressure sensitivity on the right molars using a Tooth Slooth. However, there is right masseter tenderness, which is similar to the pain that the patient has experienced within the past month (familiar pain).
• Taut bands of muscle are present in the right masseter body with pain that reproduces chief complaint, and the left masseter contains taut bands that are mildly tender to palpation. There is no appreciable swelling or signs of infection. When you inject approximately .5ml of 3% mepivacaine into the most painful taut bands in the right masseter, you eliminate the pain of chief complaint.

Therefore, your preliminary working diagnosis is myalgia of the masseters, subtype myofascial pain with referral (to the neck and pre-auricular region). You have ruled out the tooth as the source of the patient's chief complaint as the right masseter body. From the history, it is likely that the loss of the teeth on the other side of the mouth was also due to the same diagnosis and that the myalgia is exacerbated by the stress that the patient goes through during the divorce process. Unfortunately, the previous dentist had apparently misdiagnosed the patient's chief complaint as cracked tooth syndrome.

Obviously, the patient's thought process does not follow the same path as your diagnosis. Even though you have clearly proven through appropriate diagnostic testing that the patient is incorrect, she still insists that the problem is the tooth. From your training and expertise, you have learned that your diagnosis is far from complete and that much more time is needed to gather much more thorough information in order to develop an appropriate treatment plan and to rule out other contributing diagnoses.

These include – but are not limited to – sleep screening, complete joint examination, detailed muscle evaluation, diagnostic study models, photos, bite splint therapy, etc., which are part of the Spear esthetics, function, structure, biology (EFSB) system for comprehensive treatment planning.

After you explain this to the patient, she says, “Doc ... I just want to have the tooth pulled!”

What do you do? Clearly, the patient's philosophy does not match yours.

You have essentially three options:

1. Comply with the patient's request and extract the tooth
2. Refer the patient to an oral surgeon
3. Refuse to treat the patient

The answer requires an understanding and application of the American Dental Association's “Principles of Ethics and Code of Professional Conduct .” If you opt to comply with the patient's request to extract the tooth, the principle of “do no harm” certainly outweighs the concept of autonomy because you know that extracting a tooth for the wrong reason will leave the patient dentally crippled and that the pain will likely return after the patient's masticatory system returns to homeostasis, just like what likely has happened previously.

Since a patient cannot consent to malpractice, there is a real medicolegal concern for you, as well, should you extract the tooth. Therefore, on the grounds of non-maleficence and justice, option No. 3 becomes much more reasonable.

If you refer to an oral surgeon for extraction, then in a sense you are agreeing with the patient that the tooth should come out, which puts you in the same ethical predicament as the first option – unless you clearly state to the patient and oral surgeon that it is for a second opinion, which might be reasonable. However, this assumes that you are questioning your own diagnosis and may create a situation where the oral surgeon may fall into the trap that the dentist who extracted all of the teeth on the left side did, since you really have no way of knowing how far in depth the surgeon will go into the diagnosis.

Might your diagnosis be more thorough? The ethical principle of professionalism is at stake here because you really are only wanting the oral surgeon to confirm your diagnosis and to pass off a challenging patient. Is that fair to the oral surgeon in this case? Probably not. Therefore, the only logical option based on an ethical thought process is to refuse to treat the patient unless she is willing to accept your diagnosis and undergo recommended further diagnosis and appropriate treatment planning.

Ethically and from a risk management point of view, you have done your job – having triaged and made an appropriate preliminary diagnosis based on appropriate testing that ruled out infection and dentalgia and having offered an appropriate course of follow-up action for better diagnosis and treatment planning.

ADA ethical principles

Autonomy: The dentist has a duty to respect the patient's rights to self-determination. However, the dentist has a right to choose who he or she treats, and how, within accepted parameters.

Non-maleficence(“do no harm”): In the course of treatment, the dentist has a duty not to cause intentional harm to the patient that is outside the reasonably anticipated discomfort associated with appropriate treatment.

Beneficence: The dentist has a duty to act in the patient's best interest.

Justice: The dentist has a duty to treat people fairly and within the scope of practice defined by laws in the state of practice.

Veracity: The dentist has a duty to communicate truthfully with patients and with colleagues for the welfare and continuity of care for the patient.

Professionalism: The dentist has a duty to the profession to uphold the ideals of the profession.

References:

1. Schiffman E, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special interest Group. J Oral Facial Pain Headache. 2014 Winter; 28(1):6-27. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4478082/ Accessed June 17, 2019.
2. American Dental Association. Principles of Ethics & Code of Professional Conduct. November 2018. https://www.ada.org/~/media/ADA/Member%20Center/Ethics/Code_Of_Ethics_Book_With_Advisory_Opinions_Revised_to_November_2018.pdf?la=en Accessed June 17, 2019.

Kevin D. Huff, D.D.S., M.A.G.D., is a diplomate of the American Board of Orofacial Pain. He is a member of Spear Visiting Faculty, a moderator on the Spear Talk online forum and a contributor to Spear Digest.