Saturday, 16 March 2013

Lack of Wisdom

It is said that the corrective for those who wallow around in nostalgia—as it can't quite be right to call it—for previous centuries, such as I indulged in somewhat in my last post, is a single word: dentistry. See, it has just worked for you, hasn't it?

When, in conversation, one offers this remedy for—admittedly mostly harmless—self-indulgence, one's interlocutor will often be seen to wince, as if recalling some procedure, whether recent or further back in the past, and imagining its being carried out with a pair of rusty pliers or a hand drill, at any rate without effective anaesthetic, save possibly for a generous slug of alcohol. But anaesthesia and refined implements seem, in some ways, peripheral boons of modern dental practice. To get to the heart of what distinguishes modern practice from that of the vast majority of earlier centuries one has to consider organisms beyond the reach of our unaided senses: bacteria.

A few weeks ago I was conscious of both discomfort and tenderness around my upper left wisdom tooth. It wasn't much and certainly it did not deserve to be called pain, but it was constant and irritating. I had, before the symptoms appeared, finally got around to registering with a new dentist for the first time in several years, our previous, excellent, one having retired. She had taught me about the best practices of oral hygiene and, in consequence, during the years in her care, I had needed few fillings—some of them merely replacing work done in childhood—and not a great deal of specialist cleaning and polishing.

These had been the best years of dental health to date and this dentist's thorough care had also seen both our children through some awkward moments, including orthodontics. Perhaps I had been living complacently off the legacy of those years; certainly I had latterly been concentrating my health efforts on combatting lymphoma—for whatever reason, including no doubt an element of base fear, I had not very actively been seeking out a new dentist. Almost coincidentally then with the arrival of the new disturbance mentioned above I had entrusted the wellbeing of my teeth to a practice operating out of an old bank building about 30 minutes' walk from home. 

When I started fishing around the niggling gum with my tongue and then, the next morning, with my finger, I was aware of a palpable spot. Doing what comes naturally I pressed it and it burst, yielding the simple sense of satisfaction familiar to many of us from awkward adolescence onwards. Why was I, then, surprised to find, on withdrawing finger from gob, that there was a mixture of blood and pus on it—not much, but this was an entirely new experience and enough to be unsettling

Rather surprisingly I managed to obtain an appointment next day with my GP, who looked at the now subdued eruption at the back of the gum and said that it looked like a spot that was on its way to healing. However she entered the crucial caveat that she was not a dentist and was glad to know that I had an appointment with one just a few weeks away. She prescribed a generous course of antibiotic, metronidazole, to be taken in the event that the spot reasserted itself along with discomfort. She also warned me against drinking alcohol while on the antibiotic, as that would make me feel very unwell, the pills being engineered to combat anaerobic bacteria, the nasties that do not cavort and multiply openly in the caverns of the mouth but which lurk in the secret places above the teeth , biding their time until an opportunity arises for them to feast and multiply, typically when a tooth, or part of it, dies (say as a result of caries) or there has been a breach of the gum's defences. 

The placebo effect of seeing a professional worked for a while and the spot endured, but in a milder, less assertive, form. As a result I waited until the appointment with the dentist before discussing the matter with anyone again, and just kept the unopened pack of antibiotics as a sort of talisman in my rucksack. 

Registering with a new practice means that one's first task before sitting down in that high-tech, tremendously comfortable but simultaneously unsettling, chair is to fill out a medical history questionnaire. Most questions I can still answer in the negative—about heart disease, kidney trouble or stomach ulcers, say—but sooner or later I would get to that spot on the paper where I would have to confess all: the rare lymphoma and its treatment. Fortunately, my understanding of the disease has developed to the point where I can be quite succinct about what it involves, while the questions posed themselves provided some handy hooks for concise communication. 

When I was finally ushered into the room with THAT chair with the BIG light and THOSE implements—the white plastic cup of pink mouthwash, that fount of respite from all the probing and prodding that would ensue, already on the side tray—there was another opportunity to explain something of WM to someone who had never heard of it before and this—no disrespect intended—was not a rookie practitioner. 

A rookie cop, or at least a fictional and dramatic representation of one.
One possible origin of the word is that it is a corruption of "recruit".

Wookie – quite different, although you can presumably find rookie Wookies

It really is odd how proud one can feel expounding the basics of this rare disease to someone to whom it is unfamiliar. The thought that came to me writing this was that maybe evangelists feel a similar rush of blood to the brain, a flood of energy to the organs of communication. It has been a strange perk of being significantly unwell, to be sure, this urge to spread the word. 

Introductions and my little tutorial over, it was time to "relax" in the chair and for the tools of examination—that small mirror on a stick and an array of pointy things—to be deployed. There was enumeration of my teeth and their accumulated quirks to the nurse standing nearby with her checklist and there were two x-rays, my jaws clamping on those supremely intrusive gagging cardboardy-feeling devices that confine the invading rays to one side of the mouth and prevent the resulting images being hopelessly mixed and unreadable. 

It was time to mention that troubling spot to my new dentist. She examined the gum, which now felt even more rested than when the GP had seen it, and she perused the hot-off-the-press X-ray images. It appeared that the infection might have been a superficial one, possibly introduced by a shard of bran lodged temporarily between tooth and gum, as the images showed no obvious sign of a deeper problem, such as necrosis of the tooth or an abscess. The dentist advised me to monitor the suspect tooth and gum and to return if there were any concerns. 

Walking out of the surgery I again felt that lightness of step that always follows reassurance but after about a week the spot reasserted itself. I prodded it (I know, I know...) and once more it subsided, but after several turns of this sad little cycle, it was clearly time to go back to the dentist, who was available without much delay.  On this occasion she had a more solemn air about her and, on hearing my symptoms, announced that there was most likely an abscess nestled above the tooth, which was now nervy when tapped with a probe. The route of travel was one-way: extraction, the foundations of wisdom teeth being too gnarly for a root filling. However, to make sure, she would take another X-ray— a bigger one this time, which would show things in more detail. The next room was little more than a large cupboard, just spacious enough to contain me and the X-ray machine, on to whose head-high plate I now positioned my chin. 

Back in the room with THAT chair the latest image revealed the problem: the tooth was indeed infected, its roots having a greyed-out, shadowy appearance that distinguished them from the more opaque pinnings of my other gnashers. In my now rather lowered mood, it was a positive relief to hear that the job could be done within the week by the oral surgeon who visited the practice every fortnight. For now, my task was to upgrade the metronidazole prescribed some weeks earlier from lucky-charm status to deployment mode and to take alongside it a course of amoxicillin that would subdue the aerobic bacteria at large in my mouth.

It was good that I had a lunch appointment to look forward to and a pleasant walk to get there, on a crisp winter day conducive to contemplative strolling. The chemist's, with its glass shopfront—gold lettering on a black background, reassuringly traditional—was just along the parade from the dentist's, so I was soon armed with the new antibiotic. 

Yay! More pill action!

Conversation with a friend in an extremely quiet and unrushed local restaurant steered my mind away from brooding on what the week ahead would bring. We spent quite a while talking about the ins-and-outs of a legal battle which my friend has, on grounds of principle and in the interests of the health of local democracy, taken an active role. If you have ever wondered how it is that our communities are saddled with so many horrible, or just mediocre, buildings, examination of the issues this tenacious friend has been grappling with would be highly instructive. Consider a heady mix of the following: local councillors making a major planning decision along party lines on matters away from their immediate locality; a major transport infrastructure company in partnership with developers and architects of no obvious distinction; a national sporting institution flexing its economic and political muscle; a race for the bottom by powerful interests in pursuit of short-term benefits and at the expense of the amenity of local residents and, arguably, the best interests of the travelling public; labyrinthine strategic planning edicts whose true meaning lies not in natural English but which can only be interpreted by sages; a legal judgment, issued after eye-watering expense, that ignores the word "and" at a crucial point in one of those same edicts. There are those who mock theology and worship democracy, but the processes and rulings of supposedly accountable organisations can be as arcane, opaque and crushing as the edicts of any empurpled priesthood. Democracy, like the fabled Emperor, sometimes walks around in the buff. 



After a week of palpable, if faint, apprehension, I made my way back to the dentist's that used to be a bank, my brother kindly giving me a lift and then retiring gently to a nearby caf√© while I bowed to the inevitable. The wait to see the surgeon was only short, but I tried to take my mind off what lay ahead by leafing abstractedly through the pages of a local business directory that was on top of the pile of second-hand reading matter—jittery patients, for the distraction of—that lay on the table in the reception area. 

Summoned by the nurse, I was soon in one of THOSE chairs again, the wide screen on its moveable arm in front of me displaying this delightful scene:

Not a teaser from one of the Alien movies the large X-ray of my jaw and lower skull taken the previous week.
The culprit wisdom tooth is the last upper one on the right side of the image (my left).
The area around the roots is shadowy, unlikely the equivalent areas of the neighbouring teeth. This indicates  death in the roots, while the darker patch immediately above the roots is a small abscess. Oh dear...

The surgeon was full of reassurance—his calmness no doubt merely the apex of an iceberg of efficiency and experience—and, as a result, the reading on my personal trepidometer dropped by a few points. He explained what was on the screen in front of us and what might have led to this not-so-pretty pass. In the corner of my eye glinted the tools of his trade and I caught brief sight of something that, for a dental implement, was rather on the bulky side and resembled nutcrackers. I concluded that it was the business end of this item that would shortly be brought to bear on the offending molar. 

The first task was to swill chlorhexidine mouthwash around my mouth for a minute in order to reduce the bacterial population to acceptable levels for surgery. Hello Corsodyl, my old friend. I had lived with this harsh, taste-blunting, tooth-blackening stuff for some months when having chemo, so was used to it, if only as the lesser of two evils, the greater evil by far being the risk of oral infection that could lead to something more unmanageable.

Next came the anaesthetic: three jabs at points around the tooth. The last of these, as the surgeon explained, would cause me to lose the sense of my soft palate lifting when I swallowed and this lack of sensory feedback would deceive my conscious mind into thinking that I might choke and trigger the gagging reflex. This proved, at the time and now in retrospect, to be the most disquieting experience of the whole sequence of dental dramas. It was time to be objective and override the reflexes thrown up by what can be regarded—no doubt unfairly—as the lower parts of our nature: those primitive areas of our brains whose dogged dependability has supported our evolution and enables our current survival at times of danger. For a while it was an effort to control feelings of panic and tell myself that I could still swallow and was not going to choke on my own saliva. 

Once I was used to this new, mercifully temporary, reality, it was time for the tooth to go. With the surgeon's assurance that all I would now feel would be pressure, I lay back in the chair. He frustrated my efforts to catch sight of the bulky extracting implement by palming it like a conjuror as he brought it from the table to the doomed tooth. It felt as if some very efficient leverage was being applied to the tooth and there was none of the tugging of pliers in the sensations—muted as they were by lidocaine—that very briefly followed. There were cracking and crunching sounds in my head but, as dental interventions go, it was mercifully mild stuff. With two goes of this procedure the tooth was no longer a bodily fixture and was placed without a sound on the side table.

Then followed quite a bit of digging, poking and scraping around in the resulting hole, my mouth all the time being kept rather horribly dry with one of those small vacuum hoses that are part of the dental nurse's toolkit. As I marvelled at the ability of anyone, let alone someone highly trained and experienced and equipped with precision tools developed over several centuries, to carry out procedures in such a confined space without first removing my lower jaw, the surgeon made a single stitch across the wound with thread that would dissolve in a few weeks. This drew in the gum walls that had until a few minutes before surrounded the tooth, so that they would close towards each other and heal more neatly. 

When all was done, the surgeon showed me the no-longer-offending tooth, a couple of its roots being noticeably darker than their fellows and therefore necrotic. It looked so harmless…

Ta-daah!!

He also showed me a sad little red sac, which, sure enough, was what was left of the abscess that  had previously flourished unseen, if not entirely unfelt, in the hidden spaces above the dead tooth. Although it was emptied of its noxious payload and reduced to the size of a peppercorn, it was nevertheless shocking to realise that the abscess was an entity in its own right that had needed removal: not just a space that had needed draining, but something with micro-thin walls—a structure, for pity's sake. 

The surgeon advised me that I should, if need arose over the next ten days or so, wipe my nose rather than blow it, as air pressure while the wound was healing could force bacteria that should be confined to the mouth into the sinus above the wound and thence into the bloodstream, resulting in chronic, system-wide and possibly life-threatening infection. We would be back to the dark days of our ancestors, where otherwise healthy and active people could be brought down by inadequacies of oral and dental health, succumbing to catastrophic bacteraemia that we are able to keep at bay with regular brushing, flossing and a preposterously large range of toothpastes.

A particularly drastic method of tooth removal employed by our mediaeval forebears

Our whole lives are spent accommodating, as well as fighting off, the inconceivable multitude of microorganisms that swarm within our mortal frames, not to mention those that assail us from outside. Furthermore we now understand that some organisms are essential for our normal functioning, notably within our gut. It is hard to imagine another snippet of current biological knowledge more humbling than this. 

I am still getting used to the changed landscape in my mouth. The hole where the tooth was has sealed over, the stitching thread has gone and, I trust, the biodegradable gauze used to pack the wound has been, or is on its way to being, absorbed into my own fabric. Occasionally I bite the inside of my mouth on the left side as a result of the new alignment of teeth, but the overall result is good and life moves on. I have to acknowledge though that this battle of the bacteria may have been won, but that the little buggers will get me in the end—this version of me, at any rate…

The Revd John Polkinghorne, KBE, FRS (born 16 October 1930) is an English theoretical physicist, theologian, writer, and Anglican priest.
He wrote an interesting article about a possible understanding of the afterlife here: http://www.thirdwaymagazine.co.uk/editions/apr-2012-/features/physics-and--the-final-frontier.aspx
My old tutor, Simon Blackburn, does not agree: