Student Life - Association of Dental Groups Bursary Prize (My Schizophrenic Patient)

Back left to right: Sara Hurley, Chief Dental Officer, Mr David Worskett, Chair of the ADG and Rebecca Exley, Undergraduate ‘Professionalism’ winner. Front left to right: Ryan Howells, Undergraduate ‘Professionalism’ winner Alan Lyons, Undergraduate ‘Skill Mix’ winner, Danny James Watts, Undergraduate ‘Professionalism’ winner, Awais Ali, Undergraduate ‘Skill Mix’ winner and Jack Stanley, Undergraduate ‘Skill Mix’ winner.

Introduction

I recently received an award from the Association of Dental Groups for an essay I wrote on the topic of professionalism. It talked about an experience that I had with a Schizophrenic patient who underwent a psychotic dissociation during an extraction.

The Prize Organisation and evening

The Association of Dental Groups (ADG) is a trade association whose members are corporate dentistry providers and dentistry groups serving both private and NHS patients across the UK.

The presentation ceremony was held in March at the Huntarian museum in the Royal College of Surgeons. This was a lovely reception with drink and canapes followed by the presentations themselves. It was lovely to meet and socialise the other winners. I had to rush off fairly quickly at the end to the Waldorf Astoria Hotel just down the road in Aldwych as this also happened to be the evening of our dental dinner!

What actually happened with the patient?

(Excerpt from essay)

The point at which I truly appreciated what it meant to be a dental professional was during an afternoon Oral Surgery clinic in October 2015.

I had a busy session with three dental emergency patients booked. The first patients’ treatment was completed uneventfully. After discharging that gentleman I picked up the notes for my next patient. This lady had been seen by one of my undergraduate colleagues on the Dental Emergency Clinic that morning. However, she had not been treated for her presenting complaint (Pain lower left) as she was extremely agitated and distressed, she had refused to be treated by an undergraduate and was demanding treatment from one of the tutors. The student was able to examine her and elicit a history, the patient was cooperative enough to have a sectional DPT taken of the area in question. The subsequent diagnoses were periapical periodontitis UL4/LL8 and the treatment plan was - XLA LL8.

Consent had not been obtained and the patient had been asked to return in the afternoon for a discussion. Further consultation of the notes revealed that the patient had hebephrenic schizophrenia and was medicated with Risperidone. At this point I decided to go and talk to my tutor. He confirmed that this was a case which required sensitivity and care and we decided to work closely together.

Once the bay was prepared I went out to the waiting room to introduce myself to the patient and bring her and her partner into the clinic. I walked and conversed with the patient trying to gauge her level of anxiety and keep her calm.

Once the patient was in the chair I explained the proposed procedure including the risks/benefits and my tutor explained that the treatment would be carried out by myself under close supervision, the patient was happy with this arrangement. Throughout the consent procedure the patient was agitated but her capacity for consent was not in doubt as she could understand the information being given to her, weigh up the pros/cons and communicate her decision after having retained the information for a few minutes.

Once valid consent had been obtained I began to administer local anaesthetic. At this point the patients’ demeanor rapidly changed. - She was particularly vocal during the ID block despite my best efforts. I gave the patient some time to calm down and completed the long buccal injection. At this point the patient immediately went very quiet and began exhibiting severe facial tics, then dissociating into a transient psychotic episode brought on by the stress of the dental environment. The patient was non-responsive to aural stimuli and began laughing and crying in succession whilst trying to get up out of the chair. We ceased all active treatment and with the help of a carer, managed to calm the patient down.

Following this episode we decided that the patient had undergone a transient loss of capacity and felt it prudent to reaffirm consent for the procedure. They consented and asked to continue. With support and reassurance we were able to extract her tooth, although not without difficulty. She also required another extraction, the UL4 and was keen to get it taken out at the same time. However, the decision was taken to rebook her on a staff grade clinic where she could be treated by a consultant in a private room. This was explained to the patient, she accepted this and was rebooked for two weeks’ time.

What did I learn?

This was obviously a real shock to the system and it really taught me that even though we are dealing within the mouth that it is so important to consider the patient who is attached to that mouth! Often this can be the hardest part of our job; the patient factors, not the dental factors. I always try to consider my patients holistically and adapt my care as appropriate for their needs.

As for the essay prize itself, I can't recommend it enough to current students. It's a great opportunity to reflect on your own work and to brush up on some key skills such as ethics and law in dentistry, a topic all too often overlooked.

Thanks for reading guys,

Bye for now.