Help! A time in clinic when I wasn't sure what to do next...

A few weeks ago I had a patient referred with what was described as ten out of ten pain. Periodontal disease very infrequently causes acute pain (I would estimate approx 1-2% of my cases present with pain) and so immediately I was thinking about other possible clinical explanations.?

I conducted a full periodontal examination and it was clear that while the patient was certainly a periodontitis patient (stage 4 grade C), the clinical presentation, the patient description and history of pain didn’t marry up with the reported symptoms. The patient’s story kept changing, they were laughing and joking and tolerated the periodontal exam quite well. I became even more concerned that once the consultation was done the patient asked if I could prescribe something stronger for the constant and excruciating pain that they were experiencing. At this point I was worried that the patient may be exhibiting drug seeking behaviour but this was something that I had very little experience in and to be honest I wasn’t 100% sure what to do!?

I decided to tell the patient that the most important step was to debride their teeth under anaesthetic (removing the most likely causative factor - dental plaque) and that I would squeeze them in tomorrow to start their treatment - in the meantime they could continue to take their current pain relief medication (panadol and ibuprofen) The patient was happy with this plan, thanked me and left. (NB without paying for the consult because apparently they had forgotten their card).

40 minutes later we received a call from the referring dentists office explaining that they had just been abused by the patient who was demanding that they prescribe stronger pain medication and that I had told them that “it was the worst periodontal disease I had ever seen in my career”.? I apologised to the receptionist who had borne the brunt of the abuse - applauded her for her excellent management of the patient and assured her that I would deal with it. Problem was, now I was really out of ideas. As I mentioned I have almost no experience with drug seeking behaviour and I wasn’t even sure I wasn’t just being a jerk and keeping a patient in pain from a comfortable nights sleep!!So, I phoned a friend. In this case I my incredibly intelligent and competent wife who has extensive experience with this sort of thing having worked across private, public and even within correctional facilities.?

She gave me the following excellent advice:?

• Tell the patient I would write them a referral to their GP who could assess the pain better within the context of their current experience and the medication that had already been taken long term.?
• Request a pain management plan from the GP. This would provide more comprehensive pain relief in case treatment was delayed.

With this new plan I called the patient and firstly checked to make sure they were ok - they seemed fine, no anger, aggression or frustration toward me (always the way - the poor support staff cop all the abuse). I then explained my (wife’s) plan - They said they were very happy with course of action proposed and expressed gratitude at my call. So after writing the letter to the GP, checking the national prescribing database (patient had been prescribed oxycodone two weeks ago that they hadn’t mentioned at any point), calling the referrer (to assure them the patient had been managed and to inform them of the plan for their records), writing a clinical note to document my clinical decision making and messaging my wife to thank her for her help I was done. Phew!?

Now, I am posting this not to provide clinical advice but rather to show that at times even specialists need to phone a friend or colleague, ask for advice or admit to the patient they don’t know what comes next. There have been times I have had to do this for clinical periodontal problems/presentation as well (my actual specialty!) and times where I have told the patient that I would like to get a second opinion for them when I am not 100% certain of a particular course of action. My experience is that this builds even more trust with patients as they know and feel like I have their best interest at heart (which I do) and results in me being able to provide them with even more information allowing them to make an informed choice as to the next step.

Clinical dentistry is a team sport. Never be ashamed to ask for help! For anyone out there that needs advice you are always welcome to message or email me!?

PS - Patient presented two weeks later for their first treatment appointment, hadn’t seen their GP, hadn’t taken any additional meds, was very friendly and grateful through completion of their initial periodontal treatment and settled their account with no issues.?