Two missed diagnoses, two tough outcomes

Jun 16, 2010

Editor's note: Helaine Smith's column, The Mouth Physician, appears regularly on the DrBicuspid.com advice and opinion page, Second Opinion.

This past week I had two experiences that exemplify the need for our profession to think like mouth physicians. The stories speak for themselves, but I will describe the events and let you draw your own conclusions.

A remarkably youthful 86-year-old woman came in for her first dental appointment in my office. For years she went to another local dentist. He did not take anterior radiographs. This seems to be a common trend in my area, especially among the older dentists. About 13 months ago she developed pain above her maxillary lateral tooth. The dentist thought it was a perio issue and advised her to consult a periodontist.

The periodontist treated the area for infection, and when the symptoms did not resolve after one week, he referred her to an oral surgeon who biopsied the area. It turned out to be squamous cell carcinoma. The patient had three-quarters of her maxilla removed at a Boston hospital and an excellent maxillary prosthesis fabricated.

She told me she has trouble eating and is constantly dealing with mucus and watery eyes. She has dealt with depression due to the extensive surgery and devastation it has caused. She said it would have happened no matter what, but it should have been caught sooner.

She never drank, smoked, or had any high-risk behavior. Her remaining 14 mandibular teeth are in excellent condition with 3-mm pockets. Yes, she is 86.

The second event this week was told to me by an orthodontist who was asked by her patient to provide her husband with a second opinion. The man had been told he needed to have his four anterior mandibular teeth extracted because there was no bone, then to have a partial denture fabricated.

The orthodontist examined the area and did not notice any mobility. The patient repeated what the dentist had told him, that the area "is black on the film and I have no bone." The orthodontist's curiosity was piqued, so she took a film and noticed a huge cyst that took up the entire anterior mandible, running up each root of the anterior teeth. She referred the patient to an oral surgeon and is now awaiting the results.

I know it is easy to think teeth first and jump to the treatment plan. But it is important to step back and think big picture first rather than focusing only on teeth. As dentists, we are often the only people who can detect early carcinomas of the mouth, and it is our duty to do this for our patients.

Although it is not every day we see serious pathology, we need to keep this in mind during our differential diagnoses and examine our patients, not just their teeth.

Remember: We are mouth physicians, not tooth plumbers.

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