Dental case study: Persistent gingival swelling

BACKGROUND

A 58-year-old retired teacher, Mrs L, attends the dental clinic complaining of painful swollen gums and bleeding. She is a smoker with a history of periodontal disease and has regular appointments with the practice hygienist.

Dr P examines the patient and notes swollen and inflamed gingiva that are very sore to touch, particularly in the lower left quadrant. Further examination also reveals swollen lymph nodes. Mrs L states that her gums have been increasingly sore for over a month and are making her feel generally unwell.

Dr P suspects periodontal infection. She prescribes a course of antibiotics and offers advice on oral hygiene. A follow-up appointment is booked.

Mrs L returns to the surgery a week later with no improvement. Dr P undertakes root surface debridement and scaling under local anaesthetic and further antibiotics are prescribed.

Two weeks later Mrs L returns to the surgery for an urgent appointment stating the pain in her mouth is keeping her awake at night. She also complains of related flu-like symptoms. Dr P discusses referral to a periodontal specialist but also advises that Mrs L see her GP, given the persistent severity of the pain in her gums after two courses of antibiotics and also her other, more general symptoms.

An urgent referral is sent via email the next morning to a periodontal specialist. In the attached letter Dr P outlines Mrs L’s clinical condition and states that she has also advised the patient to see her GP.

Three weeks later a letter of complaint is received at the surgery from Mrs L’s husband. It states that she has been admitted to hospital with a diagnosis of acute myeloid leukaemia. Mr L is angry that the practice did not pick up on the diagnosis sooner and refer his wife to hospital.

ANALYSIS/OUTCOME

Dr P contacts MDDUS for advice in replying to the complaint. A dento-legal adviser (DLA) reviews a draft letter of response.

Dr P addresses the letter to Mrs L to ensure patient confidentiality and states she can share this with her husband. Dr P first expresses her sympathy over the diagnosis and best wishes for a good recovery.

The letter then offers a brief summary of the care offered to Mrs L at each consultation, with dates and treatment/advice provided. Dr P explains that the majority of cases involving sore and swollen gums are periodontal in origin (e.g. gingivitis). Persistent or atypical symptoms can be cause for concern and clinical guidance calls for dentists to refer appropriately.

Dr P points out that given the persistent pain and bleeding and ineffectiveness of antibiotics she made an urgent referral for specialist care and also advised Mrs L to see her GP (recorded in the notes).

Mrs L responds briefly to say she is satisfied with the response, and she remains a patient at the practice.

KEY POINTS

• Be wary of persistent or atypical dental symptoms that may be oral manifestations of systemic disease.
• Record all treatment and referral decisions discussed with the patient.