Hard to Impress

“Can you guarantee to fix my tooth in one appointment?” the woman on the telephone asked.

“I never guarantee anything without seeing the tooth first, but I do help most people get out of trouble in one appointment,” I said.

“I don’t ever want to have to come back again,” the woman said.

“Okay,” I said.

“Which type of x-rays do you use?” the woman asked.

“We get the big ones that go right around your head and show all your teeth and jaws, the orthopantomographs,” I said.

“What about bitewings?” the woman asked.

“We like to have the big OPT’s first because we get much more information with less radiation exposure that way. But if we need small x-rays for detail, we can always get them too,” I said.

“How will you tell if the tooth would be better off with a filling or an extraction?” the woman asked.

I spent another five minutes discussing the criteria for restorative versus extraction treatment planning. Every answer seemed to lead to another question.

“You know a lot about dentistry, and you ask intelligent questions,” I commented.

“I am a dentist myself,” the woman said.

“Wow. That’s great. Where do you work?” I asked.

“I don’t work as a dentist. I’m a medical secretary, I work in the London teaching hospitals,” the woman replied.

“Oh,” I said.

“I gave up dentistry five years ago, soon after I graduated. I didn’t like working on patients unless they were unconscious,” the woman said.

“Oh,” I said.

The woman, Anna, had heard about me from another of my clients, who recommended me. She booked an appointment for the following Monday.

“Welcome,” I said, when Anna arrived for her visit with her husband, Keith.

She shook my hand. My nurse offered various forms for Anna to complete. I checked her health history and other details.

“Would you like Keith to come with you into the treatment room?” I suggested.

“Oh, no. He can stay out here,” Anna said, indicating the lounge room.

“Okay,” I said, glancing at Keith. He seemed used to being referred to in the third person by Anna.

Anna settled into the dental chair, and we examined her mouth and teeth together as she looked in the hand mirror.

“It’s the lower right wisdom tooth; it probably needs to come out. I realized after I spoke with you last week,” she said.

I checked my charting and her large OPT x-ray, obtained that morning.

“I think you’re right,” I said. “Would you like to have it done today, after we’ve cleaned your teeth?”

“Yes, please. I don’t ever want to come back again.”

I numbed Anna’s lower jaw and gave her teeth a spring clean. I sat her up in the dental chair for a rinse.

I felt my nurse’s hand gently on my shoulder. I looked up. Ada pointed to a large brown spider in the corner of the treatment room.

I decided not to draw attention to the minibeast, and to deal with it after Anna had left the room.

Anna’s attention had been caught by Ada’s hand signals, and she turned her head.

“Oh, my God, you have a huge spider in your surgery!” she exclaimed.

The moment for silent monitoring had passed. I got up, calmly apprehended the spider in my gloved hands, crushed it, and wrapped it in the gloves and a plastic bag. I disposed of it in the outside bin. I asked God for karmic forgiveness.

I scrubbed up, gloved back up, and took Anna’s wisdom tooth out. It was painless, and took seconds.

Anna joined Keith in the lounge.

“It was amazing,” she said.

At last, I thought. She’s ready to acknowledge my superior skill, extensive training, and comforting chair side manner.

“She chased and caught the biggest spider I’ve ever seen. She was so brave. I could never have done that!” Anna said.

Keith smiled. I smiled. Anna apologized for any earlier abruptness. I suggested a routine annual recall to keep her smile in top condition.

Anna got out her diary and we confirmed a time.

Strangers on a Train

As the train lurched forward, the elderly woman moved backwards at the same speed, then forwards, and then to the ground. She was a tourist, or at least someone unfamiliar with the London Underground tube system. I could tell by how slowly she moved; she was still standing when the train took off. I was too far away to reach out to her.

The man with her, presumably her husband, helped her to her feet. He spoke an Asian language. I could not tell what he was saying, but the look of concern on his face spoke volumes. The woman, shaken, sat down in the seat next to his. His enquiries grew more agitated.

As the woman spoke, I noticed for the first time she had lost a front tooth. She certainly had all her teeth when she got on the train. I tend to notice these things. Now there was a gap where her upper right central incisor used to be. I looked at the passengers on either side of me and across the aisle. Every one was focused on the unfolding drama. No one was moving.

"I’m a dentist," I found myself saying. "Can anyone see this lady’s missing tooth?"

I put a reassuring hand on the woman’s arm, the universal language of comfort. Several passengers rallied.

"Found it!" one of them cried, pointing to an intact, long rooted tooth on the floor of the carriage.

"Has anyone got a clean plastic bag or tissue?" I asked.

"I have a bag," a man offered, handing over his Sainsbury’s shopping carrier.

In the ultimate form of recycling, I inserted my hand into the bag and used it as a glove. I picked up the tooth by its crown, being careful not to disturb its chances of replantation by handling it by the root. I mimed mouth opening to the woman passenger. I wiped the root with the saliva in her mouth, and replaced it, the right way round, in its socket.

"You need to see a dentist," I said, frustrated by my lack of language skills. But her husband nodded, and I hoped they would seek and find aftercare.

"Thank you, every one," I said as I sat back down.

The carriage, almost mystically, lapsed back into silence. I sensed a change in atmosphere, concern for the woman injured, and a feeling of connection with each other in her cause.

When it came to my stop, I waved goodbye to the woman and her husband. They looked up as I got off.

"Take care," I said.

I reported the incident to the station staff before leaving. They took down some details.

"We will follow up," they assured me.

As anonymously as I had entered the transport system, I left. But for those brief minutes in which I had done everything I could to save the unfortunate woman’s tooth, I had experienced a little bit of truth in the phrase, ‘A stranger is just a friend you haven’t met yet.’

A Tooth for a Tooth

“He thought I was looking at his girlfriend the wrong way, so he headbutted me,” Alec said.

“Were you?” I asked.

“He was drunk,” Alec said.

“How is he now?” I asked.

“Sober,” Alec said, “And he’s agreed to pay for the damages.”

I took Alec through to the treatment room, and we examined the cracked tooth in the front of his upper jaw. The injury occurred a week ago on a night out at the pub. Now Alec’s central incisor did not respond to cold. It was tender when I tapped it. It had changed to a grey green colour. Over half the crown had disappeared, leaving a diagonal, jagged edge.

“The tooth has died, I’m afraid,” I said.

“I don’t want to lose it,” Alec said.

“If we try to save it, it will need a root filling, a post-core, and a crown,” I said.

Alec and I discussed all the alternatives, from doing nothing (free, but disfiguring, unhealthy and uncomfortable), to taking the tooth out and replacing it with an implant (expensive, intrusive and only as a last resort).

“This will be the most expensive pint of beer my mate ever drank,” Alec said as he scheduled his first appointment to begin restoring his tooth.

“Better than having you press charges for assault,” I commented.

“I think that’s why he’s so happy to pay for the work,” Alec said.

At his next appointment, Alec arrived with his friend.

“Joe’s come with me today to pay for my treatment,” he said.

Joe produced a credit card and settled the account. I sensed tension between Joe and Alec, a mountain of unexpressed feeling between them, perhaps?

“How are you feeling, Joe?” I asked.

“Pretty stupid and sorry,” Joe said.

“Promise me you won’t make a habit of this. It’s harmful, distressing, and costly,” I said.

“I know. I don’t normally,” Joe said. “I’d just had a bit too much to drink, that’s all. When I drink I’m not the same person.”

“He’s a great mate, really,” Alec said.

“Ah. Might be a good time to reconsider the value of a wild night out. But if you find you need help to drink less, there are plenty of lovely folk out there to help you. I’ll get you some numbers,” I said.

Alec looked approving. Joe looked contrite. I handed Joe the telephone numbers of agencies more experienced in these matters than myself.

After several visits, Alec’s tooth was beautifully restored. With the help of my dental laboratory, who examined Alec in person to confirm the shade selection and improve the detailing on his crown, Alec now had a tooth that matched the rest of his smile perfectly.

“Invisible mending,” he said, smiling at himself in the mirror for the first time since his injury had occurred.

I rang Alec some time later to see how he was getting on.

“I don’t see Joe that often these days, to tell the truth,” he said.

“Oh,” I said, “And what about you? How are you and your tooth doing?”

“My new tooth is about to become a celebrity. My band is headlining this summer at that music festival I told you about,” Alec said.

“Well done,” I said, laughing. “I shall look out for you and your tooth in the line-up.”

A Fairy Tale

“You’ll be wearing a Tooth Fairy costume and handing out leaflets at Sainsbury’s,” Stuart, my Practice Manager and marketing maestro announced. He looked a little anxious about pimping his girlfriend - sending me out on the streets, scantily clad, to promote Gentle Dental Harrow.

The kind, cuddly Tooth Fairy, known for exchanging money for baby teeth, was my professional alter ego. Stuart, at six foot two inches in height and over fifteen stone in weight, had been known to scare small children visiting Gentle Dental on nursery school excursions. I think of him as a gentle giant, but he did not qualify to dress up in Tooth Fairy tutu and tights.

“When?” I asked.

“Today,” Stuart said.

I looked over at my work experience student. In university interview practice I emphasized the importance of physical projection in selling oneself. “Teeth, tits, tush,” I signaled as shorthand for smiling and standing tall and proud. Now it was my turn.

I wriggled into my turquoise lycra and netting costume, adjusted my padded breasts (artificial), my padded behind (natural) and my Tooth Fairy wings (totally natural, of course).

“You look gorgeous,” Stuart encouraged, despite his misgivings.

He took photos. He handed me our remaining ‘Two for One’ Smile Care Visit promotional leaflets. He helped me adjust my wings.

Outside Sainsbury’s, my work experience student and I distributed leaflets to willing shoppers, extolling the virtues of Gentle Dental Harrow to anyone who would listen. It was the morning shift, with elders arriving by taxi to do their weekly shop and mothers with preschool children in pushchairs.

However striking or inappropriate my costume, in fact, because of my striking and inappropriate costume, I was a hit with children in pushchairs. Kids found me clever, likeable, funny and charming. I chatted with their parents and shared tiny teeth tooth brushing tips. I smiled and flirted. Time flew.

Half an hour into our marketing initiative, a store employee came up to us.

“I’m going to have to ask you to leave,” she said.

“Why?” I asked.

“This is Sainsbury’s. You’re not allowed to do this here,” she said.

“Are you the manager?” I asked.

“No” she said.

“I’d like to speak to the manager,” I said.

“He’s in a meeting,” she said.

“I’ll wait,” I said.

We continued to hand out leaflets.

“We’re probably not on store property or land out here. I’d like clarity before I move on,” I said.

My work experience student looked nervous.

An elderly woman approached us.

“You’re asking to get raped in an outfit like that,” she said.

I didn’t hand her a leaflet. I glanced at my young colleague who was handing leaflets to more courteous and curious bystanders.

“We’re almost out of leaflets,” I said.

My work experience student looked relieved.

Three fit builders invited me into the back of their white van. I declined their thoughtful offer. I had work to do.

I carried on handing out leaflets.

Two uniformed male police officers approached. My heart sank. Had the elderly woman made a complaint? Had the store employee called in the big boys?

“What’s going on here?” the shaven headed officer asked.

“We’re promoting our dental practice, Gentle Dental,” I said.

“Nice name,” the officer with the cropped red hair said.

“We have a special interest in people who are terrified of the dentist,” I said.

“I’m sure we’d all come and see you if you’re dressed like that,” the first officer said.

“I can’t dress like this at work for health and safety reasons. My Tooth Fairy wings get in the way,” I said.

“That’s a shame,” the first officer said.

“Our sergeant could do with you,” the second officer said.

“He’s complaining of toothache and he hates the dentist,” the first officer agreed.

“I’d love to see him,” I said, handing them a leaflet.

We returned to work, triumphant and exhausted.

“That was great,” my student said.

“I’m never doing that again,” I said.

“You both did brilliantly,” Stuart said.

The next day we heard from the suffering sergeant at our local police station. We saw him the same morning and safely and lovingly restored him to health and serenity.

Our work experience student, unscathed by her adventures with the Gentle Dental Tooth Fairy, went on to study dentistry at Guy’s Hospital.

Stuart posted photos of me in my Tooth Fairy costume, teeth, tits, tush and all, on the Internet. My initial embarrassment has long since given way to gratitude, affection and pride. 

Needle Phobia

Rita had a badly broken down tooth that was giving her pain. She knew she needed it out. She had come to her first appointment prepared for an extraction, with James, her boyfriend, for support. We agreed the tooth was too decayed to save and that an extraction would be wise, the sooner the better, before the pain and infection worsened.

Rita was relieved and grateful to find a dentist (me) willing to offer an emergency appointment and fix the problem. There was just one even bigger problem.

“I hate needles”, Rita said.

Rita was absolutely phobic about dental injections. At the age of 8 years, she had had an unexpectedly painful dental injection that had gone on for an excruciatingly long time. The dentist had continued despite her obvious shock and pain, and her mother had told her to “Get on with it”.

As an adult, Rita had all her previous dentistry carried out with general anaesthetic, where she could be ‘put to sleep’. We discussed all the options for treatment this time, weighing up the risks and benefits of each, including referral for similar support with sedation or general anaesthetic.

But Rita wanted her tooth out today. She had seen my website, and she wanted to improve her ability to receive dental care while conscious, an experience she trusted me to provide.

“Sure”, I said.

Rita, James, my nurse and myself, all trooped into the treatment room. Rita sat herself in the dental chair. She was literally shaking with fear. I deployed ‘Lambie’, one of the soft toys I use for just such occasions. With Rita holding Lambie tightly, my nurse patting Rita’s arm and James stroking her hair, I applied ‘magic jelly’, a topical anaesthetic gel to numb the gum before injection.

Building trust is a delicate and crucial process. Fear of prolonged or unexpected pain was a significant factor in Rita’s phobia. I asked Rita to indicate to me with a raised hand if she wanted me to stop, and promised to do so immediately, even if she just wanted to “rest, cough, swallow, or comment on the weather”.

I used the ‘tell, show, do’ technique to avoid surprises, informing and demonstrating to Rita at every stage what I was about to do. Some people prefer not to know or see what is being done for them, and that is respected. Other people like the reassurance of explanation and advance notice, and Rita clearly benefited from this.

Rita was encouraged to breathe, focus on wriggling her toes, and to feel a deepening relaxation spreading from her toes, up her legs, and throughout her body as she relaxed and breathed ever more deeply during her care.

Rita stopped shaking, and relaxed her rigid hold on Lambie. With the support of my team, I gently and slowly numbed Rita’s jaw with a local anaesthetic injection in her mouth. I spoke soothingly and hypnotically to Rita. The offending tooth was carefully delivered in two sections while James and my nurse held their posts supportively.

Once finished, I congratulated Rita and assured her that she would not miss the tooth at all, which we then examined carefully. Rita noticed how much bigger and more rotten it was than she had imagined. Rita also took the opportunity to look at and touch the anaesthetic needle, which she declared was much smaller and finer than she had thought. She was delighted to have coped so well with treatment, and said she now felt confident to have future treatment with local anaesthetic only, a great step forward in practical and emotional terms.

“I’m such a coward. I should have come much sooner”, Rita chastised herself.

I reminded Rita that her fear and avoidance was the result of the childhood trauma over which she had been powerless, not because of any weakness on her part, and that a phobia is a logical way to protect oneself until a sense of safety is assured.

Then I reminded Rita that she was not, in fact, afraid of needles. She looked at me, puzzled.

“A picture paints a thousand words”, I said, pointing to several beautifully wrought tattoos on her arms, silent tributes to her courage and determination.

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Please note that I have made changes to protect the identity of my client but this is a true story. I thank my client, who kindly consented to her story being shared. 

It's Complicated

“You need to have your wisdom teeth out. They’re deeply impacted and draining pus. I’ll refer you to the oral surgeons”, I said.

‘What does impacted mean?’ my client asked.

“It means they’re stuck. They haven’t got enough room to come through properly, you can’t clean them because they’re halfway under the gum, and you keep getting infections around them”, I said.

“They’re not bothering me. Why do I need to have them out?” my client asked.

“The infection is causing bone loss. If you leave them you could lose both the wisdom teeth and the teeth in front of them. And it’s causing halitosis,” I said tactfully.

“Halitosis?” my client asked.

“Bad breath”, I rephrased helpfully.

“You’re saying I have bad breath?” my client asked, clearly mortified.

“A little,” I said, “And it will go once the wisdom teeth are out”.

“How soon can I see the oral surgeon?” my client asked.

I grabbed my letterhead and completed the referral before my client could change his mind. He had not wanted to come to the dentist. He had merely asked about his teeth for an opinion. Now he was lying back in the dental chair with a plastic apron around his neck.

It was an unusual end to a first date. I had invited Stuart over for dinner. We had known each other as friends for years and recently decided to get to know each other in a romantic way. Since I live over the shop, popping downstairs for a bit of after dinner dentistry had seemed easy and logical. Stuart had not seemed so sure, but my enthusiasm overrode his objections.

The oral surgeon agreed wholeheartedly that Stuart needed to have his wisdom teeth out.

“She’s taking good care of you", he said, nodding his head towards me at the consultation.

Five months after our first date, Stuart lay back in a hospital gown and asked the nurse to reassure him again that the surgery was needed. The nurse assured him that on the overburdened NHS they only offered procedures that were absolutely necessary and no more.

The next time I saw Stuart, on his return from the general anaesthetic recovery room, he was dribbling, groggy and euphoric from potent painkillers.

“Marry me,” he slurred.

Stuart, separated from his wife, was still legally married. Tempted though I was, I could not take his wonderful offer seriously, nor take advantage of a man under the influence.

“You’re high”, I said.

Stuart’s recovery was complicated by dry sockets (loss of the protective blood clots) and infection. I loaded him up with local anaesthetic, more painkillers, antibiotics, and dressed his sockets with sedative seaweed poultices. I fed him soup and porridge. I bought him six box sets of ‘The Sopranos’, the only method that seemed to provide distraction from his pain.

For two weeks, he hated me, his girlfriend, and, for better or for worse, his dentist. He withdrew his marriage proposal.

Fortunately, Stuart survived his ordeal, and so did our relationship. One year later, I diagnosed and extracted his daughter’s infected wisdom teeth, this time with Stuart at the helm, talking her through the procedure.

The responsibility of treating family members weighed heavily upon me. I maintained professional integrity by asking myself if my care for my clients was what I would want for my loved ones. And whether I offered the same treatment to loved family that I do for my clients. This situation passed the test.

Years later, Stuart and his daughter still appear to love me. When I think of their wisdom teeth, I think of their loss as my gain. In the process, I gained a little more wisdom myself.

MGDS - Joining the Dental Elite

The idea of doing the MGDS, the Diploma of Membership in General Dental Surgery of the Royal College of Surgeons of England occurred to me on maternity leave. I thought it would ‘keep me busy’ while I waited for my daughter’s arrival. I knew several colleagues who had started MGDS, but none who had successfully passed the rigorous exam. In fact, only about 300 dentists in the UK, less than 2% of the profession, held the post-graduate qualification.

I already held my dental degree, honours science degree (in oral microbiology), and the Diploma in General Dental Practice. I was experienced in learning and taking exams. How hard could it be?

I soon found out. I recall the post-natal period as a haze of sleep deprivation. Memories of night feeds mingle with journal reading. My maternity locum at Gentle Dental Harrow accepted a hospital training post. I returned to work four weeks after Amy’s birth. In between working, expressing milk, mothering, breastfeeding and sleeping, I studied for the first part of the exam, the theoretical paper. One year later, I passed.

The final clinical part of the Diploma beckoned. I read constantly. I was on a first name basis with the staff at the British Dental Association Information Centre. The practice administration systems were overhauled. Every treatment protocol was scrutinized for best practice, evidence base, conformity to currently accepted guidelines, techniques and materials used and laboratory specifications. Only the highest standards were acceptable.

Four patients (‘clients’, my preferred terminology, was not an industry standard, I realized) were invited for treatment to demonstrate my clinical skills. One was a housebound gentleman with schizophrenia who required new false teeth. Another was my dental technician who did his own laboratory work, beautiful gold crowns, inlays and onlays, if I do say so myself. Two others were my daughter’s nannies. Both had grown up in Eastern Europe and had multiple dental needs. I remember them holding Amy while I provided hygiene, fillings, root fillings, porcelain veneers, crowns and partial dentures. At regular intervals Amy would wriggle and scream. We would pause while I fed her, then return to work.

A telephone support network sprang up in the study group I attended. One colleague remarked his wife and staff had threatened to leave him if he did not pass the exam. Another asked me if I thought we would pass.

"Of course we will. We wouldn’t be sitting this exam if we didn’t think we would", I replied.

We hauled ourselves to the finish line.

Gentle Dental Harrow was inspected. My loyal and longstanding staff were inspected. Two of my patients were inspected. I was inspected. I was quizzed on every aspect of my practice, patient care, treatment planning and general dentistry. The clinical exam process took place over two weeks.

Finally, at the Royal College itself, envelopes bearing results were distributed. As I read the words, "We have much pleasure in informing you…" I cried, laughed, and hugged my colleagues. All in my study support network passed, but only half the candidates overall.

I went on to co-author a series of papers on how to pass the exam, which was published in journal and book form by the Faculty of General Dental Practice (UK). I keep up to date in my profession with research, writing, reading, lectures and tutorials. Memories of the exam faded, but the ethic of excellence has thrived. Alongside my daily focus on the care of people with dental fears and phobias, I never forget my desire to provide the best quality work I can offer. I enjoy the confidence I feel and the results and trust I gain. Was my MGDS experience a worthwhile investment? Most definitely.

15 Minutes of Fame (By Proxy)

My mother decided that all four of her children would be doctors, and this was the message I received from an early age. My father was a psychiatrist and my mother worked as a nurse before parenting took over. Medicine was the only career path mentioned.

When I missed out on entry to medical school, my father said if I studied hard I could reapply in a year. There were no congratulations for getting into dental school, which felt like second prize, if it were a prize at all.

I failed my first year of dentistry. Undiagnosed ADHD? Poorly developed study skills? A distracting boyfriend (as my mother believed)? Or an unconscious wish not to follow in the family footsteps? Whatever the case, I repeated the part of the subject I failed (chemistry) and passed very creditably the second time around, particularly since I then went to all the lectures.

My parental ambitions for me lay in tatters, but by this time the miracle had occurred. I had fallen in love with dentistry, both the job and the profession. I loved the way my own previously aloof dentist treated me as a colleague from the moment I shared I was in dental school.  I thrived on tales of oral hygiene transformed and delighted in working with my hands. I spent the time I had aside from study to do voluntary assistance in the oral biology department, beginning a life long passion for research. And I took classes in karate and bicycle maintenance, ideal for improving my fitness, confidence and coordination.

By the time I graduated, I was one of the top students, winning scholarships and research prizes. I did an honours science degree in oral microbiology. In my first paid job, I was able to offer free dental care for my parents, who by now had started proudly telling friends and colleagues that their daughter was a dentist.

I settled in London and worked as an associate for some years before setting up my own practice in Harrow. I acquired both the diploma and memberships in general dental surgery from the esteemed Royal College of Surgeons in between gestating, lactating and rearing my daughter. I thanked God I wasn’t a doctor. I didn’t see how I could have worked and parented if I’d had the life of a busy GP or hospital doctor instead of the manageability of dental practice.

My dental school days carry distant memories of despairing tutors chastising me for spending too long talking to patients and not enough time doing ‘real work’ (drilling and filling). I’m grateful that today my real work involves a lot of chatting, or ‘quality conversations’ as the psychiatric profession calls it. I love getting to know my clients, and helping transform their lives for the better, not just their teeth. So maybe I have integrated my medical/psychiatric/nursing family culture after all.

And my siblings? My older brother became a doctor and a medical researcher. My twin sister became a doctor and later a psychiatrist. Both, like my father, became professors. My younger sister, a renegade, became a film producer with her own production company. My parents, in their own ways, loved us and were proud of us all.

Her offspring were not the only children exhorted to achieve by my mother. One of my dear school friends shared her wish to become a teacher with my mother, who then decried her lack of ambition and told her she must do law. Today Julia Gillard is the Prime Minister of Australia, my claim to 15 minutes of vicarious fame, and the living proof that my mother wasn’t always wrong.