Cerberus and Teeth

 Crossing the river Styx gets one into the bowels of hell. The guardian is Cerberus the multi-headed dog. As I went to my quarterly dental hygienist visit I was reminded of Dante's Inferno. Led by Virgil, Dante manages to see the sufferings of those in the various levels of Hell. What Dante left out, at the truly lowest level of Hell is the Dental Hygienist. 

These torturers of humans take forks and picks and dig into your flesh while telling you what a poor job of flossing you have done. Failure to floss is the greatest of mortal sins that humans commit, and as the Hygienist digs into nerves, seeing if she can extract blood from her victim, she again warns you of improper flossing. 

In today's pandemic world, all of this is done with her most protective garments, face masks, plastic shields, vacuum pumps. The noise level is extreme and she mumble her warnings into you unprotected face.

She then tells you what other services she can perform like a fluoride mouth wash, a herbal wash. more X-rays, teeth whitening. It is the equivalent of a used car salesperson in Hell.

I can appreciate the need but the gross lack of human kindness, the attitude that the patients, albeit a customer, is some form of sinner deserving of bodily punishment and personal humiliation, mostly due to improper flossing, is unbearable.

The dentist is nothing compared to this harridan of dental care. Dante would really have had included them had hey been there at the beginning of the 14th century!

Dentists and a General: Not the Military Kind

Dentists are in a world of their own. In the US at least they have no connection to Medicare nor is a Dental Plan unlimited if one has such.

Frances Woolley, one of my favorite Canadian observers of the world, reflects on what is not just a Canadian issue but perhaps a worldwide one, namely the expanding procedures in the world of dental care[1]. She opines on the use of general anesthesia for extractions. I most heartily agree with her conclusion but for a different reason. A general anesthesia, a “General”, is always a high risk procedure. However it does allow the practitioner to add to the fee charged for a nominal increase in costs, namely what may be administered. A local such as lidocaine or a related anesthetic numbs the pain, yet the patient does endure the procedure.

 However as an old rule of thumb, a patient takes one month’s time to recover from a one hour General. That means that for a thirty minute extraction under a General you are not quite yourself for two weeks or more. For a Local you are back somewhat in 24 hours of less. The Local allows you to experience the process and putatively experience it and expunge it. The General is a suppressed experience that somehow requires a longer psychological recovery. That is why people who have a four hour General for say a prostatectomy take a long period to “feel themselves” again. Just what the process is I have no idea.

Now for dentists in general. Often one heard in Medical School that you can examine any part of the patient’s body except the teeth! There are people who handle that and in almost all cases they are dentists. A physician can do eyes, brains, toes, skin, intestines and the list goes on, but “no teeth”. I often wondered why? The answer in my humble opinion is that the handling of teeth is still somewhat stuck in the late Middle Ages. It is a craft, and part art.

You see, when God made man, or woman for that matter, but with women he corrected for a few mistakes in the first model, they live longer, but God assumed that these creatures would not live that longer than the first few batches out the gate. Thus God designed teeth to last say 30 to at most 40 years, slowly falling out along the way. Then along came physicians extending life spans, despite attempts to keep it low by using tobacco and the like. God’s current plan on shortening life span seems to be obesity so we will have to see how that plays out. But back to teeth. They were poorly designed. Like a 1957 Chevy chrome front bumper. Good to look at in the showroom but by the second or third year rotting away! Then along came the dentists, tear out the old bumper and attach a new one. Then keep that process up a bit but as anyone remembers the 57 Chevy lasted no more than 5 years because the engine or floor boars went as well.

Now back to Frances. She observes:

And if it makes having a tooth extracted less unpleasant, what's the harm? Well, the harm may be to your brain. General anesthesia may increase the chance of post-operative cognitive decline. This article using Taiwanese administrative data found a link between dementia and a history of surgery under general anesthetic. On the other hand, this study found no differences between patients receiving a general anesthetic and those receiving epidurals in terms of cognitive functioning three months post-surgery - although patients receiving an epidural had better surgical, as well as better short-term cognitive, outcomes. Many surgical procedures can be performed either with an epidural or under a general anesthetic. It is hard to find any study suggesting that general anesthesia produces superior results in cases where local anesthetic is a viable option. This study finds that general and local anesthetics produces similar outcomes, but local is cheaper. This one found that epidurals produced better patient outcomes than general anesthetics, and this one also comes down in favour of the local option. This leaves aside the 40 percent risk of post-operative nausea and vomiting after having a general anesthetic. Perhaps one day we'll see the Canadian dental association issuing guidelines on the use of general anesthesia. Insurance companies might step up and only reimburse the cost of general anesthesia in exceptional circumstances.

I think that she may be understating the issue. I would avoid a General at all costs. Last time I remember was when I had my tonsils out. They used ether, yes I am that old. Then after they ripped out the little lymph organs from the back of your mouth, pumped your lungs with ether, and some ended up in your stomach, you awake and have emesis emptying the last of your stomach contents past the now ripped out organ! Thank God medicine has advanced. But dentists using a General should really be extremely cautious. It must be a last resort in my opinion and done only when emergency facilities are proximate.

The same risks apply for example to colonoscopies. One can use a General or a more controlled use of fentanyl and versed. Even that has risks and requires a good backup plan. Thus the general use of a General is in my opinion highly unadvisable and Frances makes a compelling argument worth note to all.

---

[1] http://worthwhile.typepad.com/worthwhile_canadian_initi/2018/03/its-time-to-blunt-dentists-incentives-to-use-general-anesthetics.html

Teeth

One of the interesting things about Medical School is that every part of the body is open for examination and treatment, except the teeth. "No teeth!" Teeth are the exclusive purview of that clan of practitioners called Dentists. They have their own "school" and they stick together like taffy on teeth.

Now along come a piece by Alan Alda and his experience with this clan. I can sympathize with him greatly. Alda states:

I’ve come to see my exchange with the dentist that day as something that happens frequently in life — a brief encounter that threatens a relationship’s delicate tissue; the tender frenum of friendship. I wasn’t looking for friendship that day, but at least I wanted the feeling that I was actually being seen by him. Even though his gaze was intense, I realized that as far as he was concerned I wasn’t really there — not as a person. If I was there at all, I was something on his checklist. He was speaking into the vague mist of interpersonal nothingness. That few minutes in his chair has become a symbol for me of really, really poor communication and of what causes it: not really seeing the other person. Since that day, I’ve spent a lot of time on two socially useful pursuits: figuring out how to be a little more engaged — and uncrooking my smile.

In my experience, one which has occupied the last year or so,  began on a much more friendly manner. A nice dentist suddenly sends a letter telling us he is no longer practicing. OK, so find another dentist. Then get told you need 14 crowns, 4 of which are implants!. For those counting that amounts to three semesters at Harvard, room, board and tuition. Fortunately grandson number one is off to WVU to study Civil Engineering so that was not as expensive. But upon asking the dentist, now one of several, I have a dental "team", what happened, I was told that it was the way they did dentistry 30-40 years ago. I then asked what if the same is true with what he does today? The answer was; "You won't live that long." So Alan had a smile problem, mine was, as I suspect would be his at this time, that any mistakes would go with me to the everlasting!

So what of dentists. We only spend a few tens of billion each year. Why s low you may ask for a total health care bill of $3 trillion! Insurance. Most people have none and those that do can only get reimbursed for a tiny amount each year. 

Teeth are important. A bad abscess can kill a person, a poorly inserted implant can lead to osteonecrosis and off goes the immune system. But dentists occupy a special place in our society. They treat us with at best lidocaine/procaine and in turn we sit there for hours with our mouth ajar while they are conversing as to what happened over the weekend and we can feel the drill, the extraction, or whatever, and I suspect the psychic damage can be significant.

Perhaps it is a result of my first dental visit. I believe it was 1949, a former Navy dentists who my father swore by, after all he was Navy all the way, and I sat there looking out his office onto Forest Avenue. Then he started the drill. I think a foot driven thing from some German camp. I instinctively let out a cry, then he slapped me across my cheek, and told me to sit still while he performed his torture. Somewhere there is an embedded limbic valence to this event! I think it is one of those things that get handed down genetically, some epigenetic modification, some methylation of a promoter somewhere in our DNA.

Thus if Alan has a smile problem, I have methylated DNA that turns on some abject terror reflex. I would rather have a 40 core prostate biopsy than a visit to the dentist. Yet as the good nuns told us, this is just another offering to make up for our sins. I wonder what dentists do to perform their penance? I dread to think! Thanks for the warning Alan, hope the smile thing works out!