Jeffrey C. Hoos, DMD, FAGD
Success in the private practice of dentistry is assured when the doctor finds the proper balance between three factors: art, science, and business.
This month's story begins with a patient calling from Florida in terrible pain and not knowing what to do. I know this patient very well, because she is my mother-in-law. For 27 years, she has been in my care and received whatever dentistry she needed at no charge. This is an important part of the story, because the dental care given was of the highest quality I could deliver without a concern about time and cost.
The history I got on the phone was: "My top left teeth are very sensitive to cold and only hurt me when cold water touches them or I am brushing my teeth. But, come to think of it, hot also bothers me. It never wakes me up, but the pain is terrible. The whole side of my face hurts. It really seems to hurt inbetween my teeth. When I use a toothpick, it really sets the pain off! Sometimes, when I chew, it hurts my back molars and my whole face hurts. The pain is really terrible, but something cold really sets it off!"
It would seem very clear to any dentist that the patient required the services of an endodontist. A few days later, after root canal treatment, my mother-in-law was feeling no better and, in fact, was feeling worse. The endodontist sent her to a periodontist. The periodontist saw her promptly and, after a complete set of X-rays, clinical exam, toothbrush instruction, bite adjustment, and then assuring her that things would get better, sent her home. Another desperate phone call from the patient followed, saying: "My pain is no better and becoming much worse! What do I do?"
The dentists who had seen my mother-in-law tried to provide the best care possible. For the first time, she had been made aware of the cost of dentistry. This certainly added to the equation of difficulty because, as she related to me, "Can you believe the root canal cost $900, and the periodontist did not do anything except look at me and he charged $800?" All I could say was that good dentistry is expensive and that she was lucky that her son-in-law was a dentist. Her reply was, "But they did not help me!"
When I finally had the opportunity to examine her, the clinical exam showed a very well-done root canal with no obvious pathology ... and two back molars that were ground out of occlusion! While she was in the chair, she had no pain. Banging on teeth, using cold, and clenching on a tooth sleuth could not create the problem. Then I remembered something that a "doctor of the mouth" told me: "Listen to your patients and they will tell you the diagnosis." I then said to my mother-in-law: "Tell me about your pain and be as detailed as possible." As she spoke, I kept trying to understand why it was so difficult to come up with a diagnosis and treatment. She was all over the place in her description of the problem. I could only imagine what the other dentists were going through, as I spent an hour discussing the problem with her. She finally asked for a toothbrush, and when she gingerly put it on the inside of her upper left teeth, she grabbed her face and let out a scream of clear distress. "That is the pain I am having! Please take out my teeth!" I decided to see if I could numb away the pain. After giving her some lidocaine, we tried the toothbrush test again and the pain returned. The light went off in my head. Clearly it was not her teeth giving her the pain!
My conclusion: This was not a dental problem, because we had done all the "dental things." Three of us had given it our best shot, and no one hit the target. What was left? She certainly was not making up the pain, so I changed my hat from dentist to "mouth doctor." Many of you probably have already arrived at the possible diagnosis of Tic Douloureux. After a conversation with a neurologist and two 100 mg pills of Tegretal, the pain was all but gone and I was being touted as a "dental genius" by my mother-in-law. "What were those other guys thinking?" she said. "They even charged me and they were no help at all!"
What is the real story? I really listened to the patient, but only because I had all the time in the world. Other professionals had ruled out other potential dental-related causes of the pain. The endodontist had treated and ruled out any pulp problems, and the periodontist ruled out any supporting structural problems. I was the lucky one to see the patient last ... and to have the time to really listen to the patient tell me what was wrong.
Jeffrey C. Hoos, DMD, FAGD, is president of the Giraffe Society: "Professionals willing to stick their necks out." His seminars focus on "Balancing: The Art, Science, & Business of Dentistry." Contact him by email at firstname.lastname@example.org or visit his Web site at www.dentalexplorations.com.