Diagnostic acuity versus negligence

This is not a challenge to one’s diagnostic ability, but rather a narrative of one man’s astute diagnostic acumen versus a team of dentists who proved disastrously negligent over a period of years. The first was Dr. Bernard H. Poliak, who practiced general dentistry in Palm Springs, California, from 1946 until his death in 1996. Bernie was a superb dentist and numbered among his patients ex presidents of the United States and their wives, as well as CEOs of the nation’s leading industries, and many luminaries from the motion picture colony. Every one, from servant girl to president, was treated the same in his office. In addition to being a skilled restorative dentist, he did all the endodontics required by his patients. He was a life-long member of the American Association of Endodontists and attended every annual meeting. The story starts one New Year’s Eve when Dr. Poliak was called at his home by Ambassador Walter Annenberg. One of his guests, Miss Elizabeth Taylor, was suffering a terrible toothache. “Was there something Dr. Poliak could do for her?” “Let me speak to Miss Taylor, please. How severe do you believe the pain to be? That bad! Would you do something for me please? Would you please rinse some ice water around that side of your mouth and tell me what happens? You’re saying that the pain disappeared immediately? Now you’re saying the pain is slowly coming back? Would you please ask Ambassador Annenberg to bring you to my office at once? I’ll meet you there.” (Poliak BH, personal communication, September, 1975). At the office, Dr. Poliak used hot and cold testing to determine exactly which tooth was involved, radiographed the area, anesthetized the tooth, and removed the pulp. The next day Miss Taylor reported complete relief and graciously thanked Dr. Poliak for his efforts—simple testing and definitive treatment. On another occasion, Dr. Poliak was called upon to administer to another famous patient, Moss Hart, the distinguished American playwright. In this instance, Mrs. Hart (Kitty Carlisle), called Dr. Poliak at four o’clock in the morning reporting that Moss had an absolutely excruciating toothache, it had awakened him suddenly and he was pacing the floor, holding his left jaw in pain. “Does he have pain anywhere else?” “No, just his jaw!” “Tell him to quit pacing, to sit down, and I’ll be right there.” (Poliak BH, personal communication, September, 1975). At the Hart home he used the same simple test for advanced acute pulpalgia that he suggested to Elizabeth Taylor—ice water swished around the affected side. In this case there was no relief from the pain. Suspecting a heart attack, Dr. Poliak knew he had to get the patient to the hospital without frightening him. (There was no 911 at that time.) He said he wanted to “conduct some other tests there.” Mrs. Hart went out to get the car and Bernie conducted Mr. Hart out to the front lawn while he went on to turn his car around. Looking back he saw Hart fall to the ground. He rushed to him and started CPR, but it was too late. Moss Hart died on his front lawn. Here again, simple testing and astute knowledge led to a correct diagnosis—but too late! In marked contrast to Dr. Poliak’s abilities is the sad story of five dentists: one a general practitioner, one a board-qualified (but not boarded) prosthodontist, and three board-qualified (but not boarded) endodontists. The endodontists were all trained in the same graduate program. In this case, the patient, a woman trial lawyer, started with the general dentist for whom she soon developed a lack of confidence. She requested her full-mouth radiographs and transferred to the prosthodontist. Using these original films, which by now were over a year old, he outlined a restorative prescription that included root canal therapy, crowns, and bridges. His first action was to refer her to an endodontist with the request to retreat two canals in the lower left first molar. (Even the third canal appeared to have a questionable periradicular lesion.) He subsequently crowned the tooth. The endodontist did as he was requested, but both dentists ignored the peculiar bony lesion, glaringly apparent in the radiographs, immediately mesial to the molar and involving the premolar region. Over a period of years the prosthodontist continued his restoration, including a bridge that fell out twice. Finally, the lower left premolar lesion had grown to be noticeable by the patient, just swelling, mind you, but no pain, inflammatory redness, or loss of function. At this point the prosthodontist took his first radiograph of the region and referred the patient back to the original endodontist. This man was not in the office that day, but his partner examined the patient and recommended root canal treatment for the lower left second premolar in the center of the lesion. The patient was unhappy with the substitute endodontist and chose one of her own, closer to home. Once again, the third endodontist took a radiograph, declared the lesion a periapical abscess, and recommended a root canal filling, even though the JOURNAL OF ENDODONTICS Printed in U.S.A. Copyright © 2002 by The American Association of Endodontists VOL. 28, NO. 12, DECEMBER 2002