By Dianne Watterson, RDH, BS, MBA
Six months ago I saw a patient for the first time. He was a longtime patient of the practice but had been seen every six months by the previous hygienist who had recently retired. The patient had severe periodontitis but chose not to treat it, preferring instead to come in every six months for a "cleaning." I used a prepolish for sensitivity, cleaned his teeth as best I could with ultrasonic and hand instruments, and polished and flossed. I also discussed his periodontal condition and noted that he did not want to treat it. The worst area was around tooth No. 31 with very little remaining bone and 10 mm-plus pockets. At that time, I recommended coming in every three months, which he agreed to do.
The patient returned three months later and saw another hygienist. She also recorded his periodontal condition in her notes.
Three months later the patient was back in my schedule. As he sat down in the chair, he told me that the last time I cleaned his teeth, he had to come back because I had given him an infection. The dentist had never mentioned this to me. I checked the notes that the dentist had written on that visit. The notes indicated that the patient had returned four days after I had seen him with a fistula and infection around tooth No. 31. The doctor recommended extracting the tooth.
I attempted to explain to the patient that I did not cause the infection, but that his entire mouth was infected with a disease he chose not to treat. I also told him that the dentist had recommended extraction of that tooth, which he had not done. He cut me off and stated that he didn't get an infection when the other hygienist cleaned his teeth. It was clear that he had no interest in hearing what I had to say, so I cleaned his teeth in silence, irrigated with chlorhexidine around tooth No. 31, and at the end of the appointment told him that I would schedule him with the other hygienist in three months.
Was it purely coincidental that this tooth became infected shortly after his visit with me, or is it possible that the cleaning itself triggered the infection? If so, how do I prevent something like this from happening again? I know that I am not able to get to the bottom of deep pockets-especially on a sensitive patient-with "just a cleaning." Personally, I would like to refuse to treat patients like this, but my employer will not allow me to refuse treatment.
Have you ever seen a hornet's nest? We usually "cut a wide berth" around hornets' nests, because we don't want to take a chance on stirring them up and getting stung by a mad hornet. I think what happened in your case is that you stirred up the hornet's nest in the infected pocket.
A deep, infected periodontal pocket is like a hornet's nest with lots of microbial activity. The microbes can be inoculated into the tissue by way of small wounds or breaks in the epithelium that often occur during instrumentation. The abscess that forms is a localized collection of pus formed by the disintegration of tissue. The abscess is the body's attempt to localize an infection and wall off the microorganisms so they cannot spread throughout the body. As the microorganisms destroy tissue, an increased supply of blood is rushed to the area, and it becomes red. The cells, bacteria, and dead tissue accumulate to form a clump of cream-colored liquid, called pus. The accumulating pus and the adjacent swollen, inflamed tissues cause pain by pressing against the nerves. Sometimes the abscess drains by itself by forming a fistula through the epithelium, which is what happened with this patient.
You did not give this patient an infection; he already had that. The difference is between "chronic" and "acute." He had a chronic infection that erupted into an acute episode after the infected area was instrumented. What happened is that visiting the infected area stirred up the microbes and increased the microbial activity at that time. Please note that periodontal abscesses can occur without instrumentation as well.
According to Lawrence Page, DDS, PhD, a periodontist in Ellicott City, Maryland, the patient described has an uncontrolled infectious disease-chronic periodontitis. Proper care should include identifying the pathogenic microorganisms and using the appropriate systemic antibiotics. He needs definitive periodontal therapy, possibly surgical and nonsurgical. This patient must practice exquisite home care including use of daily subgingival biofilm disruption and disinfection methods. Otherwise, he will continue to lose support.
It would be prudent to irrigate this patient postscaling with povidone iodine or perform the scaling with a mixture of povidone iodine and water to cool the tip while scaling (three parts water and one part povidone iodine). This would be the best way to head off issues like this in the future when you encounter patients with deep pockets. But this will help only temporarily if the patient refuses to get the definitive care he needs.
Please understand that this kind of thing is more common that you might think. The host immunity fluctuates, and the fact that the patient didn't get an acute episode with the other hygienist may point to inadequate instrumentation of the area or may be merely coincidental. All the same, I wouldn't lose one minute of sleep over this. You did the best you could in a bad situation. He needs to follow the doctor's advice and get this tooth out. We don't like to have dental funerals, but since the patient refuses periodontal therapy, he will be better off without No. 31.
I wonder what the patient has been told. Was he told he has "a little gum problem" by a dentist who wants to minimize the situation? Or has he been informed that he has a chronic infection-periodontitis-which will cause him to lose his teeth if he chooses not to treat it? Has he been told that he is ingesting the infection every day, which may lead to other systemic disease processes? Does the patient understand that chronic infections in the oral cavity can and do influence disease processes in other areas of the body?
While I understand that dismissing a patient from the practice is not pleasant, the doctor is assuming a serious liability risk by keeping this patient in his practice. Make sure that you and the dentist record the high level of infection and lack of interest in treatment by the patient. It is best to at least mention his infectious disease and likely disease progression at each appointment, even briefly, and record his response to protect from potential lawsuits. Record the patient's exact words in quotation marks. The disease is diagnosed, so this would not be a "failure to diagnose" case in the event of a lawsuit. However, we do live in a litigious society, and there have been "failure to treat" cases that question the level of care the patient received. Good documentation is imperative!
All the best,
DIANNE GLASSCOE WATTERSON, RDH, BS, MBA, is an award-winning speaker, author, and consultant. She has published hundreds of articles, numerous textbook chapters, an instructional video on instrument sharpening, and two books. For information about upcoming speaking engagements or products, visit her website at www.wattersonspeaks.com. Dianne may be contacted at (336)472-3515 or by email [email protected].