From the trenches: How to “dodge the bullet” and make the right diagnosis?

This case was submitted by Dr. Ron Kellen 

This situation occurred about 20 years ago. My office was in a plaza, on the second floor, requiring 26 steps to access it, with no elevator.

At about 2 PM on a weekday, a 60-year-old male patient presented in our office as an emergency case with a terrible toothache. He pointed to his broken 35. On his medical questionnaire, he indicated that he had a little bit of high blood pressure and that he sometimes would get out of breath. He was taking medication once a day for blood pressure, but he didn’t know the name of the medication. Otherwise, “he was fine.” He looked a little gray and he walked slowly, but I could not see anything specific.

I had a “funny feeling,” which stirred up my suspicion about this patient. Something just didn’t “fit.” Something was “not right.”

He was clearly in real pain and rubbing his jaw. Tooth 35 was sheared off horizontally about 2 mm above the gum, looking like it had been left that way for a long time, with an old pulp exposure, clearly non-vital. Following a rapid brief exam, it was also percussion negative, buccal apex pressure negative, with no sign of inflammation, no mobility. A quick x-ray confirmed that it was not the tooth instigating the pain.  Additionally, the remaining upper and lower left-side teeth looked to be in good shape; there was no “second choice.” I went over his medical questionnaire again; however, he did not change any of his answers or add any info.

Then I got smart. I asked him if he was taking any painkillers, and he said yes, lots. So, I asked him to list what he was taking: Tylenol #1’s, Tylenol #3’s, or ibuprofen? He promptly waived his left hand at me like “cut the nonsense,” and said “they don’t work!” I quickly asked, “What does work?” He answered: “2 nitroglycerin tablets.” I quickly asked how many and when had he taken them? He answered: 2 at 10 that morning, 2 at noon, 1 at 1 pm and 2 when he reached the top of the stairs to our office. 

I immediately excused myself and called 911 from the next room. I returned to his operatory to put him on “fresh mountain air, to help his pain.” My chairside assistant (who had been in the room and had ‘read’ my signal) had gotten it ready for me to apply.  As we chatted and waited for the paramedics, I asked for his car keys, which he gave to me with some hesitation. I told him that it was not his tooth, but that it could be his heart. At first, he pooh-poohed that, BUT then he told me that he had checked himself out of a General Hospital at 6 am that morning because he was “feeling fine – they had been concerned about something with his heart, but that was just baloney.”

When the paramedics arrived, they confirmed my tentative diagnosis, but the patient refused to get on the stretcher. He insisted on walking down to the ambulance. The next day, I got a phone call from his daughter thanking me for saving his life.

IF I had listened to his expectations and/or if I had administered a local, he could well have died in my chair. Certainly that would also have happened, if I had attempted to extract his “simple easy little” broken tooth. 

Some patients will misrepresent or omit crucial information in order to get what they think they want or need. They CHOOSE to not be aware or concerned about certain things that are often extremely important. His clean medical questionnaire would not have been much help at an inquest. And I quake at the thought of the publicity that would have occurred if he had died in my dental chair, and the effect of that incident on my entire practice and life.

Critical Points To Help You Avoid The Bullet 

LISTEN TO YOUR SIXTH SENSE.

Question the slightest “trigger” or when “something is not right.” 

Pay close attention to your chairside assistant, if she signals you about a “concern” she senses about the patient.

You will NEVER BE SORRY for any extra time or care you take, especially when all too frequently, it saves you and your practice from big problems.