{ tooth & nail }  The lessons I learned from herpes

It seems all my complicated patients have appointments after 3 o’clock. Recently, it was one of those patients who taught me some important lessons about dentistry, and life.

office fairly regularly for more than a decade. On this day, his chief complaint was that his gums hurt and had in the last week gotten to the point he could not eat comfortably. Roger said he had a low grade fever, right around 100, and had been feeling generally “crummy.” He had gone to his physician the week prior because of some respiratory symptoms, and they put him on something he could not remember. The prescription, which he thought was a steroid, did not help him at all. Roger’s gingiva was bright red, swollen and painful to the touch throughout his entire mouth, and he had a large ulcer on the tip of his tongue. Without hesitation, I had decided Roger had primary herpetic gingivostomatitis. As I looked up the antiviral prescription I write for such situations, I be- gan to worry about the steroid or unknown prescription(s) making the infection worse or reacting with my prescription. A call to his physician would be a good idea, but I decided to talk to Roger some more to see if I could jog his memory on what he was taking.

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Roger said that, truthfully, his gums had been hurting and he had felt sick for almost a month; that, after a couple visits, nothing his physician had done for him made him feel any better. A month seemed too long for primary herpes. The ulcer also was not quite what I would expect. Did the physician think he was having an auto-immune reaction? I began to get a little nervous at this point,

6 focus | MAR/APR 2013 | ISSUE 2

t 3:15 on a Wednesday after- noon, I saw a patient I will call Roger: a 27-year-old male, married with a 3-year-old son, who has been coming to our

not knowing what the physician had done, and thoughts of more serious things popped in my head. So, I called a local oral surgeon and asked if they could work Roger in at the end of the day. I apologized to Roger: I told him I was not worried, and that I thought he was having a viral infection, but I wanted to rule some things out. He left around 4 o’clock for the surgeon’s office. I began to feel really silly, thinking, “Heck I just should have monitored him for a week and he would have gotten better. The surgeon will do just that and make me look bad, and Roger will be frustrated with me for sending him to an appointment he did not need.”

Two hours later I received a phone call on my way home from the oral surgeon who was still at his office. Can anyone guess, yet, what was really going on?

Things had not added up in the surgeon’s mind for herpes, so he had sent Roger for a complete blood count. The hematologist consulted with a pathologist and they called to say Roger had acute myeloid leukemia (AML) and that he had to go to the emergen- cy room that night for a biopsy to confirm and begin treatment. His white blood cell count was over 80,000 per mcL (normal ranging from 4,500 to 10,000, but some cases of AML are over 100,000). The situation was so bad that if untreated Roger could die within a week or two. Also, someone was worried that chemotherapy would kill so many white blood cells that the dead cells could clog up Roger’s vascular system (also known as hemostasis or “sludging” in the capillaries), which could kill him or damage

anything with fine capillaries (eyes, lungs, brain). He may require a procedure called leukopheresis prior to chemotherapy to clear out the white blood cells.

Roger was in the hospital for two weeks, dur- ing which he had aggressive chemotherapy that started less than 24 hours after I saw him. Tomorrow (four weeks after initial treatment), he has an appointment to discuss a bone marrow transplant.

What were the lessons I learned about being a dentist from my herpes diagnosis?

First, no matter how sure you are about something, you can be wrong. Had I gone with my diagnosis, Roger may have died or been at a greater risk of hemostasis. It was an awakening experience to realize what I al- most did. Physicians may make decisions like this every day; a dentist may make a decision like this once or twice. We all, as doctors, can forget how important a seemingly simple decision can be.

Second, thank God for specialists and educa- tion—the surgeon may have saved Roger’s life. Never forget that more education and higher training leads to a gifted group of people who are truly doctors and dentists capable of wonderful things. For those who advocate a less comprehensive education for providers, I refer them to Roger’s case.

Third, oral health really is important to total health, just as we want the public to believe. Oral signs and symptoms for diseases truly do manifest where you, as a dentist, can tell something is wrong, while physicians will