in diagnosis

Don’t just do something, sit there!

Last week we had an emergency patient. She left a message on the answering machine over the weekend because her tooth was “killing her.” The appointment went kind of like this:

patient: “The tooth really hurt all weekend long. I was ready to take it out myself with pliers!” (they always say this)

me: “Tell me more about ‘really hurt.’”

p: “Any time I drank anything cold it would give me these little zingers. Ice cream REALLY hurt. Also, I couldn’t really chew anything on it. All I really had to do was press on the tooth and it would get really sore. I look some ibuprofen but it didn’t really help.”

m: “Wow. That sounds really awful. How does the tooth feel now?”

p: “It feels better now. The gum is a little bit sore, but other than that it’s fine.”

So I did an exam and took a PA. The tooth had a small occlusal amalgam that was serviceable. The patient was a regular and never missed a preventive maintenance appointment. The radiograph was within normal limits. No widening of the pdl, no evidence of radiographic decay. I couldn’t elicit the patient’s chief complaint with hot, cold or a tooth sleuth. Percussion was negative. The palatal gingiva looked slightly irritated. So slightly that I may have been seeing things that weren’t there.

In short, I couldn’t find anything. The patient told me that she was in serious pain throughout the weekend, and I couldn’t find the source of her problem.

There’s something incredibly unsatisfying about that. Dentists are trained as diagnosticians and surgeons. We’re supposed to figure out what’s wrong and then fix it. The patient is looking me in the eye and telling me that she was really hurting and she wants me to a) tell her why it was hurting and b) make it so it doesn’t hurt again.

I did have a differential diagnosis list forming in my mind and I laid that out for her. She may have gotten some food impacted between a few teeth (e.g. “Did you eat any popcorn this weekend?).  That can be very painful, but it almost always resolves itself with some effort at hygiene or by just working its way out. Or maybe the patient accidentally bit on something hard (think olive pit, chicken bone) and didn’t really remember doing it.

Who hasn’t had some kind of transient tooth pain at one time or another? If the patient has a low pain tolerance, this kind of thing could account for it as easily as anything else.

The bottom line was that the patient wanted an answer. And I wanted to give it to her. But I had nothing. Zip. Nada. My training as a diagnostician gave me nothing to go on.

My training as a surgeon said “let’s do something!” Hey look, when patients present with a problem, I gotta fix it, right? And if I don’t, I look ineffectual.

Put that drill down, cowboy.

Everyone remembers the radiograph of the patient that had endo in every tooth on the upper. The patient kept having pain and the doc kept doing root canals. The moral of the story was that the patient suffered from severe, chronic sinusitis and ended up needing surgery for her sinuses, not her teeth. How do you think that dentist looked after a mouthful of root canals placed without solving the problem?

I’m here to tell you that there’s nothing wrong with a good, old fashioned “let’s wait and see.” So long as the patient is comfortable, what’s the rush? Let the patient know that you have some ideas about what may have been happening but you’re not sure. Let the patient know that you’re there for them and if it happens again, you want to see them right away.

John Kois says “the best dentistry is no dentistry.” Especially when working from a lame differential diagnosis.


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  1. Another saying is, “If the only tool you have is a hammer, everything looks like a nail.”

    Just because you’re a dentist, and just because the patient says he or she has a toothache, it doesn’t HAVE to be dental in origin.

    Toothaches can be symptoms of other problems like the sinus issue you mentioned. Other underlying causes of dental symptoms can include Trigeminal Neuralgia or even heart attack.

    Perhaps I’ll regale everyone (in my own blog post) with the story about a patient I had with a horrible toothache. He was writhing in pain in my chair. I could barely touch his mouth. Except it wasn’t a toothache. Thanks for the inspiration, Alan! :)

  2. “the best dentistry is no dentistry.” … LOVE THIS! It’s true though, it’s very natural to want to figure out what the problem is and it’s absolutely frustrating when you feel “stumped” by what the patient is telling you. I agree 100% though with your conclusion that forcing the issue and performing procedures that may very well be unnecessary could end up doing more harm than good.