A failure of mine

Just an incident that manifested today which I'll recount and add my thoughts afterwards:

A patient that was seen in emergency by a new graduate colleague about 6 months ago. The patient didn't speak English and the appointment was done through an interpreter service. The patient was complaining about pain in the second quadrant and the only tooth with an issue was the 27 which had a short root canal treatment but no periapical lesion. The diagnosis was difficult because there were multiple teeth tender to percussion and pain wasn't localised to the 27 tooth. Bitewings were taken and periapicals of the first and second quadrant.  No definitive diagnosis was made but, the patient was sent for extraction of the 27 but this didn't eventuate for some reason or another. Fast forward 6 months and the patient has been booked into see me for extraction of the 27 based off the previous referral. The patient says this tooth isn't sore but there is pain in the 4th quadrant. I note that all of his teeth are worn flat and he is literally clenching non stop in the chair. Multiple teeth are tender to percussion in all quadrants based off this I am fairly certain that bruxism is the cause of his pain. He says that the problem feels like the 43 and there is a large fracture that is causing his pain. I note a small enamel fracture on this incisal edge and reassure him that no, this isn't a problem. I counsel him on the supposed cause of his pain and strategies to reduce day bruxism. Fast forward about a month and the patient is back in the emergency clinic seeing a another younger colleague. I had been contacted by his daughter and organised the appointment and an OPG prior to his appointment as I knew the diagnosis had been tricky. I checked the OPG out of curiosity after the patient had left as I was busy with other jobs. To my surprise there was a massive, irregular radiolucency around the apices of the 44 and 43 and over the site of the mental nerve. I questioned my younger colleague about what he did for the patient and it eventuated that he had done a small filling on the 46 as the patient was insistent that the pain was coming from that tooth. I asked him if he had gotten any further diagnostic information such as pulp tests or periapicals and he said no. The three of us who had seen the patient reviewed the xray and mulled over our mistakes. The confusing aspect was that there was a large radiolucency around the mildly unrestored 43 and 44 teeth apices. My thoughts as to the diagnosis are either a pulpal origin due to a crack or trauma or some sort of expansive pathology involving the mental nerve. We will follow up on this case as soon as we are able to. 

The main theme of this series of unfortunate events is our lack of action in attaining more diagnostic information:

• The first dentist who saw him did a barrage of diagnostic tests with bitewings and periapicals as well as percussion tests and pulp tests. He is one who compensates for his lack of confidence by performing more investigations however the investigations he did just happened not to reveal the problem. Targeted diagnostic tests are appropriate the majority of the time, however, when the problem is not localised, broader scale investigations may allow you to have an overview of the issue to then target your investigations. Proceeding with irreversible treatment when you are minimally confident of a diagnosis is ill advised and waiting may allow the problem to become more obvious.
• My overconfidence in diagnosing the patient's problem based of history and 6 month old records was my undoing. I failed to test his dental condition adequately and so uncover the true nature of his problem. I saw unrestored and minimally restored teeth and assumed they were fine and didn't open my mind to the weirder and more wonderful things that dental pathology can produce. I accepted records that didn't explore the entire mouth in the process of making a full mouth diagnosis.
• The third dentist's mistake was assuming that patients can diagnose themselves. Trigeminal pain is fickle and we can never take their word on the source of their pain. Otherwise what is the point of our presence in the appointment? He had the benefit of the OPG showing the large lesion and ignored this still. He was confused as to the existence of the lesion because there was no apparent cause in the teeth it was radiographically associated with. The first dentist saw something he was confused by and took action he wasn't sure of. The third dentist saw something he was confused by and took no action to investigate. 

I don't know where this patient will end up but there is an important and humbling lesson to be learned here and I will certainly keep a more open mind in the future. It is important to draw these conclusions from our failures and rather than mull over our inadequacies, make a promise to ourselves that we will strive to not repeat the mistakes of the past.