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When pain is not relieved

30 October 2019

Dr Brendan Clarnette recounts a valuable learning experience from a challenging patient

I would like to share a recent case where many of the risk management strategies I have learnt through Dental Protection, mentorship and experience all came together to turn what could have easily been an ugly situation into a case that I, and others, can learn from while still being able to sleep at night. This case highlights the importance of record keeping, good communication, consent, professionalism and teamwork.

I treated a 60-year-old female patient in an emergency appointment. Before I met her there were a few red flags that, in hindsight, I should have taken more seriously. Firstly, in our practice software I could see that she had attended our practice once, three years ago, and had seen another dentist who has since left the practice. In summary, the patient had been left with a note in her file to say that the dentist would not like to see this patient ever again.

Secondly, in the note for my upcoming appointment, our receptionist had left a message saying that the patient was quite pushy on the phone, asking to make sure that treatment would be done on the day. In the first of numerous instances of teamwork that helped immeasurably in this case, our receptionist has been trained to professionally but clearly tell emergency patients that treatment is not always possible at the same time as consultation, and had recorded this conversation with the patient.

Knowing these things, I went into the appointment with my guard up. I usually approach these patients with a “kill them with kindness” attitude and we actually got on quite well. She seemed a little eccentric but no more so than many of my patients. Then came the third red flag in our initial interaction, when she began a list of “poor treatment” she had received in the past and that this was the reason for her poor oral health. This is always a big red flag to take note of, as a patient who is saying this about other dentists is just as likely to add you to that list of dentists they complain about in future. Despite this, she did not seem unreasonable in our interaction and so I naively thought that perhaps these previous dentists had just not had great communication skills or gained true informed consent before performing what they themselves had probably considered compromised treatment.

The patient’s presenting complaint was with a freestanding 47 that had been giving pain for two weeks with the cold and when brushing her teeth. In her account, it did not cause pain at any other time but this pain was quite strong and sharp. Upon investigation, the 47 had deep buccal decay as well as an existing occlusal amalgam that had recurrent decay and a visible mesial crack line. It was not tender to percussion and cold produced a strong painful response but it did not linger. My working diagnosis was of reversible pulpitis, but due to the unknown depth of decay and crack, I was unsure if this was indeed reversible.

I took intraoral photographs and began to explain the situation to the patient, giving options of a large restoration or a crown. I laboured the point that we did not know how the tooth would respond to either of these treatments and the tooth may end up in more pain, which may result in the tooth needing root canal treatment. This conversation ended up taking 40 minutes and was quite circular. Importantly, my dental assistant is trained to record these conversations in our notes and she put her name to them too, providing a second person to corroborate any disputes. I feel this is an important element of the record keeping process. At the end of the appointment, the patient had not made up her mind and said she would call when she had done so.

The next day, the patient had booked in for a crown preparation. The preparation proceeded normally; there was deep decay and a visible crack, which I took intraoral photos of during the procedure. Nevertheless, I was hopeful that the tooth would survive without needing a root canal treatment. At the end of the appointment, I showed the photos to the patient and explained that these issues could result in needing a root canal treatment but that I was hopeful this would not be the case.

The next day, when our receptionist was doing follow up calls, this patient said that she was in a lot of pain. The receptionist tried to find the patient an appointment to investigate it as soon as possible. Despite reiterating that we would like to see her, she decided that she did not want to return until the crown was ready for insert. On insertion day, it was clear that the prepared tooth was suffering from irreversible pulpitis. I explained this and the patient became very angry and was not receptive to calm conversation. Eventually I gained consent for extirpation at no charge, with the intent to call the patient two days later once she was out of pain, so that we could have a suitable conversation about the situation.

Unfortunately, when I called the patient she was not in a better frame of mind and could not understand why she now needed root canal treatment or extraction, despite being warned multiple times previously. After this conversation it was clear that reasoning was not going to help either of us and so I offered to pay for her root canal treatment with our principal dentist. She agreed to this.

In a fantastic show of teamwork, my principal dentist completed her root canal treatment and cemented the final crown. At the end of this, the patient reported to the principal dentist that we were both lovely people and she thought that we were great. I didn’t see that coming.

Lessons learned

There are many things that were emphasised to me and that I learnt during this case, and I hope those reading can gain something from this too.

The first lesson is to always look out for those red flags. Fortunately, I had spent 40 minutes discussing the risks and warnings of my proposed treatment including possible requirement for RCT, and had documented this conversation in my clinical notes. Even though this didn’t prove to be that helpful in the end as far as my patient making a complaint, it made me feel like I had done everything possible, and certainly would have helped if the complaint was viewed by AHPRA. When you see the warning signs, think defensively. I should have used more defensive communication skills at the end of the preparation appointment. Instead of saying that I hoped that root canal treatment would not be needed I should have again emphasised this possibility, so that it was the last thing on the patient’s mind when she left.

One of the major takeaways is that you are never alone in a situation such as this and there are always other dentists and Dental Protection to call on for support. I called Dental Protection after my phone call with the patient and they were very supportive on the phone. We talked about my records and I was reassured that our record keeping was such that we could fight the case with the patient if it was to come to that. Record keeping is one of the most important risk management points to always keep in mind. Complete written notes with conversations summarised are very helpful. A picture says a thousand words and so having good intraoral camera photos is also extremely useful.

This case also highlights the importance of professionalism. Professionalism means putting the patient’s needs and desires above your own. In this case, I had to resist the personal urge to prove that I was right, that I had warned of this possibility and ‘win’ the argument. In reality, there would be no winner in that situation. In reality, it was better to just find a solution that the patient would be happy with. This is what professionalism means, to put others before yourself even when you do not feel it is fair. This allowed me to deal with the situation relatively quickly and put it behind me to be able to sleep well at night.

If I were not able to call on my team to support me during this case, it would not have ended so calmly. I am thankful that I have receptionists and assistants who are well aware of risk management strategies to deal with difficult patients. I am also thankful to have a principal dentist who is always happy to help. Always call on your team for support – including Dental Protection.

I was relieved to know that my record keeping would have helped me if the situation were to escalate, but I was more relieved to have my mental health intact, and deal with the situation quickly and sleep well at night.

The dentolegal perspective

Often, the best learning exercises come from situations where things don’t work out as planned:

1. Red flags are easy to recognise in the ‘retrospectoscope’. At other times we see them coming but just don’t pay them the attention they deserve. The learned lesson is not just the recognition but also the adaption of our approach and treatment and reacting to the risks identified.

2. Sometimes a minimalist approach, such as initial caries removal and temporisation for relief of pain instead of crown preparation, lessens the impact if this treatment does not proceed as expected.

3. Teamwork does make the workplace a safer environment for both our patients and us. It is particularly important when a patient is not happy or treatment does not go according to plan.

4. Receptionists often take the heat for the rest of the team, and a warning from your receptionist of possible trouble ahead can be priceless. Remember to thank them.

5. This case also highlights the benefit of photos. If ever there is disagreement on, say, shade or shape, or the possible presence of oral pathology or an adverse outcome such as an abraded or burnt lip, a photo can be a very important recording of events.

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