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Volume 25 , Issue 5
September/October 2005


Guest Editorial: Please, Just a Cleaning

Bryan Stahl


PMID: 16250564

It had the making of a great day at the office. It must have been 10 years ago, and as an eager, young dentist, I loved having these two patients booked for new patient exams. The fact that they were in their “golden years” was encouraging for production, considering their failing restorations and periodontal disease (I bet you all can relate). These people were nice enough. The problem began when an intraoral examination of the wife revealed a lesion easily the size of a golf ball on the left dorsum of her tongue. I was amazed she could swallow, breathe, talk, or masticate, but she seemed perfectly at ease with this lesion. Frankly, I was unable to identify it, but it looked like a hemangioma in color and consistency. I performed my usual charting and diagnosis, including a full-mouth radiographic series. I needed to work gingerly around this lesion, but was able to complete the initial diagnostic tests. The patient’s maxillary fixed partial denture (roundhouse) was very poorly constructed and needed to be replaced as a result of caries, poor esthetics, etc. Oh, that would be good for production and the bank account! Forget the fact that this nice lady only agreed to an examination in order to have her teeth cleaned.

My mind searched for a way to discuss the dilemma I felt I was facing; rendering treatment this patient demanded without first considering this lesion. I used every technique I knew possible to gently broach my concern and advise her that it would be prudent to seek the opinion of an oral surgeon for a consultation. She told me it did not make any difference whether this thing was on her tongue or not, and she would be dead soon anyway. I was actually very concerned about this lesion rupturing and bleeding, perhaps when I was preparing her teeth prior to replacing her restorative dentistry. I could just imagine it: her son-in-law is a malpractice attorney, I am cross-examined as to why I proceeded with treatment knowing full well there was this “elephant in the room” in the form of a huge vascular lesion/tumor. Was I just interested in profiting from redoing her failing dentistry? Quite frankly, dental school never prepared me for a situation like this. We ended our new patient experience with her doggedly stating nothing would be done with the thing on her tongue and she would not be taking my suggestion of having an oral surgeon take a look.

Perhaps to my relief, it was not long after this appointment that I got the request to transfer her radiographs. To this I complied. The soul searching began. Did I say the wrong thing, do the wrong thing? Guilt seems to be a big factor for me as a dentist. Thankfully this has lessened as the years have gone by, but it still can play mind games with me. At the end of the day, I feel I did what was in her best interest. I truly was concerned about her health, not just production and income. Needless to say, she probably would never have let me touch her restorations since they “felt fine” to her. Perhaps I need more training on how to sell cases, how to improve my consultations, how to discuss esthetic value with patients.

As dental professionals we are obligated to fully inform patients of their health status regardless of what we think or guess their response may be. Our duty comes before a predictable resistance from patients. We would not expect a cardiologist to not inform us of our blocked arteries and the consequences of them to our health simply because we don’t want to hear it or have to deal with the threat to our health. Obviously we have no control over a patient’s response to what we advise in our professional judgment, but that still does not get us off the hook. The burden is ours to advise as society has clearly outlined in many ways including laws, dental practice acts, etc. Clearly professionals are held to a higher standard than nonprofessionals and it seems to me that is how it should be. We must continue to do what is right for patients and our profession regardless of the consequences.

So much for a great day at the office. It seems I did everything possible to help this lady. She seems to have had a slight case of denial, but I informed her. And when I die, it will be with my conscience intact. In retrospect, maybe I did have a great day at the office.


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