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Medically Compromised Patients Professional Issues

From the trenches: Why use a blood pressure cuff?

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This case was submitted by Dr. Ron Kellen

Four months ago, I had a walk-in emergency, male patient, age 32, suffering from a “terrible toothache.” His medical questionnaire was clean except for “a bit of blood pressure, but no problem and no medications.” He was husky, maybe 10 pounds overweight, clearly in fear of the ‘dentist experience.’ He pointed to tooth 13, very carious and fractured off at mid crown. The patient indicated that it hurt a lot at the top of the tooth and that he wanted to extract the tooth. Upon examination, I could see other obvious decay and perio. However, no exposure, it is P + + +. Apical buccal pressure + + +. 14 and 12 are P ½+. He flatly rejected RCT etc. Clearly, it will be a surgical exo.

As is my habit, I grabbed my blood pressure cuff and found BP 182/112, P 86. I stopped and explained that the reading was above the safe limits, as defined by my licensing board [160/110] and why this was a safety issue. I also told the patient that it might be white coat syndrome so we would wait few minutes while we get an x-ray, then check the blood pressure again. We discussed the importance of seeing his physician for follow-up. Five minutes later, the blood pressure reading was 194/115.

I discussed the option of opening the pulp to drain plus the administration of antibiotics to stop his pain until we got his blood pressure under control. He totally rejected this alternative. In the meantime, he was getting more agitated and squirmy, starting to perspire; he wanted to wait five more minutes, at which time, the BP was 203/122, P 93. He again refused the open and drain plus antibiotic treatment approach and I referred him stat to hospital emergency.

As he got out of the chair and walked to the front desk, he was loud and furious: “Now I have to pay your bill and you’ve done absolutely nothing for me. This is a rip off.” At once, I told my front-desk assistant that there is no charge for the visit, and that he will be seeing another dentist. As he stormed out the front door, I let out a huge sigh of relief. No fee could be worth him having a stroke in the office.

Thanks to my checking BP, I had dodged the bullet. I was deeply concerned that he would just go to another dental office, not mark the blood pressure history; and be a walking time-bomb. I even phoned the Royal Canadian Dental Surgeons of Ontario (RCDSO) for advice. After discussion, the only answer was that it would be up to each individual dentist that the patient might visit as to how s/he evaluates the situation.

Critical Points To Help You Avoid The Bullet 

USE an “easy-and-quick” BP cuff frequently. The Omron one-piece wrist cuff is inexpensive, accurate and non-threatening.  Many of your patients will be impressed by your thorough care. Staff are also comfortable using it. 

 

1 Comment

  1. Larry Gaum November 5, 2013

    Well done Ron. Excellent decision and thank you for using and taking a BP. My sentiments exactly.

    Reply

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