The saint and her teeth

SAINT APOLLONIA WAS born in the 2nd century AD. She was one of a group of virgin martyrs who was killed in 249 AD during an uprising against the Christians in the Egyptian city of Alexandria. Prior to being murdered, she was tortured by having her teeth pulled out and damaged. Since then she has been regarded as the patron saint of dentistry and those suffering from toothache and other dental problems.

St Apollonia by M Landy

When I was a dental student back in the early 1980s, I did some research with a view to writing an article about Apollonia for the dental school’s journal. While carrying out my investigations, I came across an article (I cannot remember where) which described a sacred relic, one of Saint Apollonia’s teeth, which is held in a church somewhere in northern France. I cannot recall where this tooth resides, but I have not forgotten something that was written about relics in general in that article. That is, according to the writer, one of the miraculous properties of sacred relics is that they can self-replicate.

Since working on that unfinished article, I have hardly given Saint Apollonia a moment’s consideration until today when we visited an exhibition based around the works of the German artist Lucas Cranach the Elder (1472-1553). This wonderful exhibition is being held at Compton Verney, a fine old house built 1714 in Warwickshire and set in gardens very capably designed by Lancelot ‘Capability’ Brown (c1716-1783), until the 3rd of January 2021.

One of the rooms of the exhibition is devoted to works of art inspired by Lucas Cranach the Elder. Two such works by Pablo Picasso are on display alongside various other fabulous modern artworks by slightly less well-known artists. One of these pieces is a mechanised sculpture by Michael Landy (born 1963). This was inspired by the depiction of St Apollonia in a painting by Cranach which is held in London’s National Gallery. In Cranach’s work, Apollonia, dressed in a long, pleated dress coloured red, stands beside St Genevieve (martyred in what is now France), dressed in green.

Landy has created a wooden sculpture, a three-dimensional version of what appears in Cranach’s painting. In the latter, Apollonia is depicted with her hands clasped together around the long handles of a pair of pliers whose beaks are wrapped around an extracted tooth. Landy’s three-dimensional version, which is about twelve feet high, looks remarkably similar to Cranach’s. A foot pedal is attached to the sculpture by a cable. When a viewer presses the pedal, Apollonia’s hands move the pliers towards her mouth and then fall back again. It appears as if she has just pulled out her tooth. I wonder what Cranach would have thought about this rather gory adaptation of his original image.

You have now been warned. If you are a dental phobic and happen to visit this marvellous exhibition, do not, I repeat, do not press that pedal beside Landy’s sculpture. Also, try not to miss visiting this superbly curated show.

What? No gloves!

DENTISTS ARE FRONT-LINE workers, risking their lives for you. We put our fingers in people’s mouths and risk inhaling their expired breath and droplets of saliva and infected material. This has been the case ever since the start of human endeavours to resolve problems related to dental and oral pathology. I began hands-on dentistry in 1977 during the second year of my course in dental surgery undertaken at University College Hospital Dental School (‘UCHDS’). I qualified in early 1982 and worked in general practice until September 2017.

BLOG GLOVE Silvi_1024

At UCHDS we never wore gloves or masks while treating patients. The exception was for extractions that required minor oral surgery (cutting the gum etc.) when we were required to wear disposable latex gloves. For extraction that only needed forceps (‘dental pliers’) and elevators (wedge-like instruments), gloves were not required, but we did wash our hands between patients. When using the dental drill, we were required to wear safety googles over our eyes. What I have just described was what was considered correct practice at one of Britain’s leading dental schools. In those days, as in the future, any patient we treated was capable of harbouring nasty pathogens that could cause diseases such as tuberculosis, herpes, hepatitis B (and other forms of this virus), mycobacteria, fungi, and rarer diseases, all of which could have proved very detrimental to the clinician or his or her assistant.

The first practice I worked in was rightly considered to be one of the most ethical in the area. Once again, gloves and masks were not worn. Patients rinsed from a proper glass that was washed between appointments before being re-used. Instruments that had been used on a patient were placed in a bath of Savlon disinfectant for a while until they were needed again. All needles and local anaesthetic cartridges were single use only. At lunchtime and at the end of the day, all our metal instruments were sterilised in a hot air steriliser. It was not every practice that bothered to do this.  Horrified? Well, you might well be if you are old enough to have had dental treatment in the UK before the second half of the 1980s.

After I qualified, I subscribed to the New England Journal of Medicine with a vague idea of keeping up to date with medical science. Most of the articles were beyond my comprehension. However, in the mid-1980s, I began noticing many articles were being published about t-cells (a kind of white blood cell). What I only realised later was that these were being published because of the arrival and proliferation of a new threat to health: HIV (‘AIDS’). This epidemic prompted a dramatic change in how dentists operated. Almost overnight, we were required to wear gloves; advised to wear masks; commanded to sterilise instruments before re-using them; giving disposable single-use paper or plastic mugs for patients to use for rinsing.

What amazes me is that during the 35 years that I worked as a dentist, I never heard of or read about more than a handful of patients who were infected following dental procedures. There have been some newspaper reports of patients contracting HIV after seeing a dentist, but in some of these cases the mode of transmission was other than from clinical procedure. Over the years, I attended several lectures on the latest developments in cross-infection control. After each of these, I always asked the lecturer whether there was any scientific evidence that showed whether cross-infection controls in dentistry significantly affected patient mortality. Not one of these academic clinicians could provide an answer. One of them said to me:

“That would make a very good topic for a PhD.”

Whether they make a difference or not, modern cross-infection protocols make both the patient and the clinical team feel safer. I hope that everyone will feel sufficiently safe to be treated now that the atmosphere is infiltrated with particles of the Covid-19 virus. The nature of this highly contagious airborne pathogen justifies the many advances in cross-infection control that the profession has made since HIV appeared on the scene and will require further refinements especially in the field of air purification.

When I think back to my days of providing dental treatment with my bare hands and uncovered face, I am amazed that I and most of my colleagues never succumbed to anything much worse than fatigue and frustration caused by awkward patients.

 

 

Tooth powder

tooth powder

 

When I was a child, I brushed my teeth with toothpaste. My parents did not use paste. Instead they used Calox Tooth Powder. A small amount of this was sprinkled into the palm of one hand and then mixed into a paste using the wettened bristles of a toothbrush. The resulting gritty paste was then used to brush the teeth. I have no idea why my parents used the powder, but made us use toothpaste.

Many decades later, this year, I visited the Indian city of Pondicherry, which was a colony of France until 1954. We stopped at a tea stall that in addition to providing tea also sold small packets of paan and chewing tobacco (not very good for oral health) and packets of ‘Gopal Toothpowder’. Seeing the latter reminded my of my parents and their use of Calox. I asked the vendor how the tooth powder is used. He opened his mouth and rubbed his finger along his teeth. In his opinion, no brush is required. I bought a couple of packets, but have not yet been adventurous enough to try to use their contents.

Head to toes

It's raining again_240

 

This patient of mine was a local school teacher. An educated person, you would imagine.

One rainy afternoon he sat on my dental chair. Then, I reclined it so that he was lying almost horizontal: his head and mouth at one end of the chair and his feet at least five and a half feet from his mouth. I administered the local anaesthetic, waited for anaesthesia to become established, and then repaired the teacher’s decayed molar tooth with a silver amalgam ‘filling’. When the procedure was over, the teacher left my surgery apparently quite content.

An hour or so later, the teacher returned to our practice and asked the receptionist to allow him to speak to me. He entered my surgery and pointed to a mark on one of his brown suede shoes.

“I believe that you must have dropped some of your chemicals on my shoe while you were treating me,” he said.

I looked at the mark and quickly realised that this fellow was hoping to be compensated, possibly for a sufficient to buy a new pair of shoes.

“Unlikely,” I replied, “while I was treating you, you were lying horizontally. Your mouth was a long way from your feet. If I had dropped something, it would not have fallen anywhere near your feet.”

“Mmmmh,” he replied.

“Furthermore,” I added, “it’s been raining heavily all afternoon. Maybe, you picked up that mark while walking along the wet streets.”

The teacher left, and I heard no more about the problem with his footwear. I was left thinking what an unintelligent man he was, and that somebody had qualified as being capable of teaching young people.

This won’t hurt a bit!

human fist

 

One of my dental colleagues, a very confident fellow and a competent operator, told me this true story many years ago.

One day, he had a nervous male patient, a well-built strong looking man. However, the patient was extremely anxious, as many dental patients often are. The patient needed to have root canal treatment and was convinced that he would experience much pain during the procedure. 

As my colleague prepared his local anaesthetic syringe, he said, trying to be reassuring:

“Don’t worry, sir, after I have given you this injection, the procedure won’t hurt a bit!”

The patient turned to my colleague brandishing his tightly clenched fist, and said:

“You’d better be right because this will certainly hurt you!”

 

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Your smile in my hands

People are naturally quite exacting about the appearance of their front teeth. Apart from self-esteem, people judge others by the state of the teeth in their smiles and while speaking. As a dentist, I was often challenged by my patients’ desires to have a smile which looked good.

man person face portrait

On one occasion, a young girl in her teens came to me with a loose denture, which she wore to replace a missing upper incisor. I suggested to her that she could get rid of the cumbersome dental prosthesis if I replaced her missing tooth with a barely invasive adhesive bridge attached to a tooth neighbouring the gap. She agreed, and the bridge was prepared. I fitted the new replacement tooth, which looked very realistic to me. Repeatedly, I asked the young girl whether she wanted have a look in a mirror to see the new tooth in place . Repeatedly, she refused, saying:

I’ll look at it when I get home.”

I never heard from her again. So, I can only assume that either she loved the bridge or she was so disappointed that she visited another dentist. I have come across this behaviour several times since then especially with patients who have been supplied with a denture bearing a complete set of teeth. However, most patients prefer to see what they are getting.

Many years later, I prepared two crowns (‘caps’) to restore a lady’s two upper central incisors, the most noticeable teeth in most people’s smiles. When the crowns arrived back from the laboratory, I removed the temporary crowns that had been protecting the prepared teeth. Then, without using cement (‘dental adhesive’) I placed the new crowns on the patient’s teeth so that she could say whether or not she approved of their shape and appearance. I noticed that the pocelain on the crowns had a pale greenish tinge. I looked up at my dental nurse. From her expression, I realised that she had also noticed the less than desirable dicolouration. I was fully prepared to sent the crowns back to the laboratory to have their colour improved when the patient exclaimed:

Oooh! These are lovely. They’re so beautiful. Oh, thank you, doctor!

Hearing this, and seeing the smile on her face, I felt that it would be foolish to have the crowns remade. So, I cemented them. She was a regular patient and never made any adverse comments about these crowns on subsequent visits to my surgery.

This only goes to show that there is no accounting for taste.

 

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Burger buns in Baldock: two for one

Shop

 

If, say, your dentist were to offer to take out two of your teeth for the price of one, and you  needed to have only one tooth extracted, would you be excited by this special offer? I bet you would not.

Supermarkets are always making offers such as buy one, get one free. Once, we needed four burger buns. We entered a branch of Tesco’s in Baldock (Hertfordshire, UK) and found that burger buns were sold in packets containing twelve buns. Reluctantly, as there were no smaller packs, we took one pack of twelve. As we were heading towards the check-out desks, a lady who worked for Tesco’s chased after us. She was carrying another pack of a dozen burger buns. She said:

You didn’t take these.”

We only want one pack,” I told her.

But you must take a second pack. There’s a special offer. Two for the price of one.”

I told her that we really did not need 24 burger buns; we only wanted four. As it was obvious that she was not going to take ‘no’ for an answer, we took the second pack of buns without any idea of what we were going to do with them. As far as I could see, we had simply helped Tesco empty their shelves of a perishable product, which if not sold would have had to be thrown away.

Another supermarket chain, tries to encourage purchases by offering the customer a free cup of coffee after paying for the goods. And if you have bought enough, a free newspaper is also on offer. These are nice gestures, but do they compensate for the higher than average prices of many of the goods on offer in their stores?

Parking in shopping centres can be costly. Some supermarkets have large car parks associated with them. They are often close to other shopping outlets, and charge a fee for parking. However, car owners who make a purchase in the supermarket are given a voucher that allows them to avoid paying for the parking.

Special offers are, of course, designed to attract sales. And, we as customers are often happy to take advantage of them. However, I still refuse to believe that many would go for a two for one offer on tooth extractions. But … maybe … I could tempt you to accept three extractions for the price of one!

 

It has its uses

Psychedelic headscarf_240

 

In the UK, unlike some countries in Europe, we have a fairly liberal attitude towards Moslem women covering their heads and faces to a greater or lesser extent. In the last dental practice where I worked until I retired, our patients came from all over the world. A not insignicant number of our female patients were Moslems who wore some kind of head covering. A few of them insisted on being treated by female dentists, but most of them did not mind seeing one of the male dentists.

One of my female Moslem patients came to the UK from a north African country. She always wore a loose-fitting headscarf, but did not cover up her face. One day, she needed to have a front (incisor) tooth removed. I explained to her that the situation was such that she would have be without any replacement for it for 24 hours – I cannot remember why. 

Will you be able to cope without that tooth for a day. The gap will show every time you speak or smile,” I said.

Picking up the end of the scarf she was wearing, she covered her mouth with it, and then said humorously:

This has its uses!

And with that comment, she allowed me to remove the troublesome tooth, and then left the surgery with her face covered. She looked like a typical Moslem woman wearing a face-covering. Nobody would have guessed that she was missing a front tooth.

A precocious child

Sometimes it pays to keep your mouth shut at the dental surgery.

In the 1950s and early ’60s, our family dentist was a kindly German Jewish refugee called Dr Samuels. In those days, I learned later while I was studying dentistry, sugar used to be an ingredient of toothpaste made for use by children. I doubt that my mother provided us with children’s toothpaste, which she would have regarded as being gimmicky.

Dr Samuels had a very upmarket practice in London’s St John’s Wood. His waiting room floor was covered with thick pile oriental carpets and the reading matter was glossy journals such as Country Life.

The surgery, where Dr Samuels performed his dentistry, was old-fashioned. Instruments were kept on display in glass fronted metal cabinets. His x-ray machine looked antiquated even to my young, inexperienced eyes. So, did most of his other equipment, much of it made by the German Siemens company. One of my uncles, also a patient of Dr Samuels, once asked him if a museum might be interested in displaying this historic looking dental equipment. Samuels answer was that it was not quite old enough for a museum.

Dr Samuels drilled teeth with a cord driven dental handpiece. He told us that he had an air driven high speed dental drill, but he did not like it because it cut too fast in his opinion. So, having fillings in his surgery was quite a noisy and bumpy experience.

Dr Samuels was a gentle, kindly man, like a benevolent grandfather. He never frightened me.

At the end of an appointment, he used to reward me with a boiled sweet. I looked forward to receiving these. However, one day when I was about 8 or 9 years old and he offered me the sweet, I said to Dr Samuels: “No thank you. Sweets are filled with sugar and bad for my teeth.”

The price I paid for my precociousness was that he never again offered me a sweet at the end of my appointments with him. I should have kept my mouth shut and graciously accepted his kind but unhealthy gift.

A bit too far

Drill a bit,  not too far.

In the tooth is a nerve:

do not disturb it

 

DRILL 1

 

It would not have been fair to my patients if I had written what follows before I had retired from practising dentistry. If I had been one of my patients, I might have lost confidence in my dentist after reading this.

Before dental students are allowed to drill teeth on living patients, much training is required. A great deal of this is done using plastic teeth mounted in the jaws of the heads of a mannequin, known as a ‘phantom head’. The plastic teeth are held in the artificial jaws with metal screws. The screws fit into holes on the undersides of the teeth so that the crowns of the teeth appear intact. As a dental student, I spent many hours each week practicing cutting standardised cavities. The cavities had to be cut to very precise dimensions, which were neither to be exceeded nor the opposite. I recall that certain parts of the plastic teeth had to be cut to exactly two millimetres deep and much the same width. At first, I found this extremely difficult. Not only was I not yet used to using dental drills, but also the plastic cuts in an awkward way.

Eventually, the time arrived for a practical test. Unsupervised, we were required to cut one of the several cavities that we had been learning to prepare. Disaster struck. Within a few seconds of starting my tooth, I had cut too deep. The metal of the screw retaining the plastic tooth in the phantom head was staring me in the face. I called over the examiners. They studied the tooth carefully, and then one of them said to me:

“I think you have exposed the nerve, Mr Yamey.”

“We might be looking at a root treatment, here, don’t you think?” asked the other examiner.

I could not believe what I was hearing.

“I think we’re looking at a failure here,” I replied.

They agreed.

I spent another few weeks in the phantom head room, and retook the exam, which I passed with flying colours, you will be relieved to learn. Now, I was deemed ready to treat dental cavities on real teeth in real patients – under supervision, of course.

The first tooth that I had to work on had only a little decay. Nevertheless, after the intense training, which emphasised cutting teeth should be done as conservatively as possible, cutting only as little of healthy tooth tissue as was strictly necessary to retain the restoration (‘filling’), I approached my first ‘real’ tooth with much trepidation. After boring down to the two-millimetre depth that was ingrained in my mind, I could see nothing but healthy tooth – no sign of decay. I summoned the clinical teacher (the ‘demonstrator’). He looked at the tiny hole I had created with great care and laughed.

“You have not yet cut through the enamel. Keep going,” he said.

The enamel, for those who are uncertain about dental anatomy, is the outer covering of the part of the tooth that is visible in the mouth. Beneath it, is the dentine, and below that the dental pulp chamber, which contains nerves and blood vessels. Decay spreads much more rapidly through dentine than through enamel.

I looked at the demonstrator, and said:

“But in the phantom head room we were told never to go deeper than two millimetres.”

“Those were just plastic teeth,” the demonstrator replied, “forget all that.”

 

[Picture from “Der Zahnarzt in der Karikatur” by E Henrich]