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Tooth #13 – How the Light Gets In

October 2020 – (a note to clinical med-students)

Students, it’s been a minute since we shared a ‘small-bite’ beyond a link to a podcast or article. It’s been quite a year, and we ain’t done yet. We know your shifted rotations, licensing steps, (and M2021s, your residency-application process) all somersaulted last March. Thanks for understanding that our clinical-skills tips have adjusted as well. Here’s a new, mid-sized plate, if you don’t mind one also more personal ...

As a patient, no care-provider has known me longer or seen me with more frequency than my dentist. We met in the mid-‘90s, before some of you were born. He always palpates my lymph nodes, something my primary-care team of docs rarely do. He always starts a visit by asking about my life, any events or changes that could impact my health. As a patient, it helps to start with that; otherwise, I can forget big things from the tumbling surf of life-since-our-last-visit. A parent’s death. A personal cancer scare. Not sure why those are easier to forget when Present Illness takes the foreground, but they are.

When Dr. Lipps’ office had to close due to the pandemic (dentists not ‘essential’ per the Maryland Dept of Health) I worried he would just decide to retire. Late last summer when I cracked a tooth, he told me he was turning 70.

Before last Tuesday (Oct 13), the last time I saw him he was putting a crown on my cracked Tooth #13 – a first for me. While out for breakfast in Louisville, Kentucky for a niece’s wedding, I bit down and yelped. The diner was crowded and my family is huge, so only my sister Pauline heard me and grabbed my arm. “I think I just broke a tooth.” We couldn’t find it when I spit out my painful bite and dug around with our forks. That evening at the wedding reception, I was grateful for soft choices like falafel and hummus. Still danced like a fool, and tried to forget about it, but called Dr. Lipps after I flew home.

While I sat in his chair, he told me about his own dental cracks, including one at a wedding. “Part of the fun of growing older, Mary. You’ve taken such good care of your teeth, this must be harder to hear.”

I do floss, obsessively. Never had braces, or a root-canal, a crown or bridge or whatever else dentists like to do. Just fillings from youth, the metal replaced by white years ago. And I’ve worn a night-guard for years now, since he could see evidence that “you’re a clencher, not a grinder, at night.” But for years he’s told me, “No deep pockets, again. Keep it up! I’m giving you another A+.” (Getting an A+ at anything at my age is delightful.) So the crown process did shake me up a bit. I appreciated how he anticipated and normalized that for me.

(I’m a late-bloomer. Onset of menses, age 15. Meningitis, that ‘childhood’ disease, at age 41. Wisdom teeth, buried only inside my upper jaw, broke through at age 46, sideways; my only extractions to date.)

After he installed the crown last fall he said, “soon you won’t even notice it – be just like any other tooth.” That didn’t quite happen. I never quite forgot it was there. I planned to mention it when I saw him again on March 17, 2020.

Of course, his office shut down the Friday before, same as Georgetown’s campus. In May I got a mailed packet describing new equipment for cleaning and ventilation, their re-opening protocol (one patient at a time) and scheduling by triage – “people with ‘chronic periodontal disease’ first.” His wife would call everyone to schedule appointments. They asked that we patients be patient, to wait for her call. I waited, that tooth talking to me now and then, knowing I was not his most needy. I waited through June and July, and most of August.

Finally I reached out, and mentioned to his wife how something felt off. Not pain, but a kind of chronic salutation. She apologized for not contacting me before and found an open spot. October 13th, just after the long weekend, when I had a few staycation days planned. Dr. Lipps first asked about my Dad. “I see a note from a year ago, he’d gone into hospice?”

Right. Such a lot of year, packed into the past year. My father died in November, in Florida. My brothers and sisters and I are scattered over all time-zones. We all called his cell-phone, and his sister, our Aunt Teresa, played our messages at his bedside while he lay unconscious. A music therapist played Bach, sang a French song, ended with Chopin. At those sounds, Teresa told us his tremors stopped. During the night, he transitioned.

He’d wanted to be cremated and Pauline soon received the box of cinders. We were trying to find a time when all of us could fly to one place, maybe DC where he’d grown up? April of 2020, cherry-blossom time? Sounded perfect. (We finally held a kind of memorial via Zoom, on Father’s Day.)

Meanwhile in January, after a repeat mammogram and ultrasound, I needed a breast biopsy, my first. New adventures with a kind and caring radiologist and a technician, and stereotactic needles. Tried to practice mindfulness, but grateful for my night-guard.

Meanwhile we started hearing about an unusual virus hitting Wuhan, China. I’d already made travel arrangements to go to Kuala Lumpur, Malaysia in late February, to present at an international med-ed conference. Never been to Asia at all, or Hawaii en route – so excited. Then, so up in the air. Meanwhile, biopsy results, a relief. Dr. Simmonds, my gynecologist, left me a note in the online portal: “Benign!! YAY!!!!!”

Meanwhile the virus. Borders closed. Towns quarantined, toilet paper hoarded. Nursing home residents in Seattle with unusual eye infections. Italy, then Iran, hit hard. Mass graves. Americans trapped on cruise ships in Asia. Malaysia would be a virtual presentation, recorded Powerpoint. Made it as far as San Diego for my youngest niece’s 18th birthday March 3rd. Then Tom Hanks, infected. NBA, suspended. Hoya campus closure. (For how long? Shrugs all around.) Our SP Program, already short-staffed, would have to figure out a way to deliver ‘hands-on, in-person’ teaching and assessment while off-site and untouchable (or risk furloughs? no stress there).

Meanwhile around Memorial Weekend, 100,000 U.S. deaths from this spiked ball of proteins. Avoid interior or poorly ventilated spaces. Avoid close personal contact. Also high-touch surfaces. (Good description of the ILC.) Protracted uncertainty for both your classes -- would your on-site rotations begin in July? August? Later? Where would you be able to eat lunch? Would new M1s arrive on-site in early August? Would our SPs/PETAs be expected to have some special ‘COVID-immunity’ -- to work on-site at close personal contact, in interior spaces, with poor ventilation? But, how to teach physical exams over Zoom? My nightguard developed holes, whenever I managed to sleep.

Last week, 14 months post-crown: after empathizing about my Dad, Dr. Lipps said, “We’re due for routine x-rays.” I mentioned the extra mammography earlier this year. “Ah. We can wait.” He didn’t think my crown’s “talking” to me was of concern. “You’d be complaining of pain, have swollen glands, or face, gums would be red, maybe a fever.” Okay. Then his probe and mirror got to tooth 13.

The word “fistula” held other connotations for me. I understood it was a structural word, an abnormal channel, not specific to any one organ system. I hadn’t understood I could have one in my mouth. Or that chatty #13 could be swimming in infection, its surrounding bone destroyed during the COVID delay. (We had to take at least one x-ray.)

“I’m so sorry, Mary. Honestly, I’m surprised. If we’d talked on the phone and you described your symptoms, I would’ve said ‘no worries, no rush’.” I hadn’t characterized ‘pain’ or pressed for an earlier visit. (When I had meningitis, I also had no fever; it took the Kaiser E.D. almost 24 hours to do an LP.) He apologized a few times. “You did nothing wrong, okay? This is not because of anything you did or didn’t do.” He wrote copious notes to an endodontist with a 3-D scanner, underlined ‘call me.’ Not sure a root-canal would be feasible, or if we’d be talking extraction. “I know that’s hard to hear.”

Not really. I told Dr. Lipps I felt almost relieved there was something going on. I hadn’t wanted to jump the queue of anyone with “deep pockets.” Through his N95, his second mask and face-shield he said, “If this gets into your sinus we’re talking hospital, ENTs. Get the imaging soon.” He looked at my chart again. “You’ve had a tough year.” All I could think: Not really. Four friends’ mothers had died of COVID-19, with no family around. My 40-year-old cousin, a contractor, lost 6 weeks of work income, even though relatively asymptomatic. Our Standardized Patients and Physical Exam Teaching Associates, if healthy, still scramble to ensure Zoom income.

If only I could bottle my dentist’s genuine empathy, his repeated and sincere expressions of compassion and understanding. I would give a bottle to each of you to help us through this pandemic. And to the whole planet of human animals. (Other animals, I think they’re okay. But let’s save some for them.)

Thursday, the endodontist with the CB-CT scanner took one look and called #13 “a goner.” Dr. Simon took time to explain all the angles. (Kind of cool to move through your own jaw, even if the dark parts were pools of pus.) He nodded when I mentioned my night-guard. “Clenching, right, great way to crack a tooth, I’m afraid.”

I remembered reading a few weeks ago that dentists nationwide are seeing record numbers of tooth fractures due to stress – unconscious grinding and clenching. Doctors are seeing unprecedented hair loss, even auto-immune diseases like lupus, in 2020. I’d had a delay of care, but my tooth had cracked open in 2019, pre-pandemic, so my HPI started earlier …

While Dr. Simon described extraction and benefits of an implant versus a bridge, I remembered the tower of crises that had built up in Florida last year. My father’s hallucinations, and ever-more-unpredictable and frightening behaviors. Misdiagnosed until I was leaving for college, his Bipolarity with paranoid psychotic breaks was now complicated with Parkinson’s-like tremors, and daily, not episodic, delusions. Now he talked about buying a gun because of ‘spying neighbors.’ Now he actually took a “Huber” to the airport at midnight to meet his ‘soul-mate’ on route from Hawaii; mystifyingly, she never materialized. Yet he could talk cogently with each of us in the same conversation. The last time I spoke with him on the phone, he asked about my work with SPs. Then said the FBI would fly him to Boston where he’d have all his organs replaced. (He’d done a fellowship at Harvard the year I was in 1st-grade, and always called Cambridge the happiest year of his life. I was actually glad his delusions were taking him back there.) Around the country, my family understood this was not quite dementia, more his decades-long psychosis as he approached 91.

Yet he refused to move into assisted-living. Yet he could no longer live alone. Yet none of us had income that could cover an enticingly ‘comfortable’ environment of care for him. All in all, enough to turn jaws into a vise-grips during the night. After he fell once too many last summer, the hospitalists refused to release him to home. They arranged for hospice care in a nursing home, a few weeks before my oldest niece’s wedding in Louisville. Even before I got in to see Dr. Lipps about the crack, I flew down to Florida to see my father’s new digs. The stubbornest man on Earth finally had no choice. Once again I was grateful, as a non-clinical person, to have portrayed or written cases involving emotional lability, grateful for tools like redirection and rolling with resistance. All of that helps at the family-level, too.

The endodontist apologized that I would have to lose the tooth. I’m just glad we caught it before it progresses beyond my jaw. Picked up the Augmentin on my way home. Dr. Lipps called that night and suggested we meet briefly soon, to go through the options, their various costs and timelines. “Again, I’m sorry it got to this point.” I think both Dr. Lipps and Dr. Simon are more distressed than I am. Because of obsessive flossing and no deep pockets, they wouldn’t ‘expect’ it, from my records? Stuff happens. Maybe I’m overdue, in late-bloomer style. I just want the mess out of me. I hope tooth #13 will launch from my mouth very soon.

Yet their kindness is everything. What I’ll remember most about this strange week in a strange year after an already trying 2019: the emphatic concern and care from both my longtime dentist and new endodontist; the occasion to remember my gyn’s post-biopsy note, especially her “YAY!!!!”; and how all of them led me to remember that a chart note about “father into hospice care” was a critical point of relief. Hospice meant the beginning of an end for him that held dedicated care -- after decades of stress about him and from him, and surely inside him. That 2019 note in my dentist’s chart signified a gift. Trained, compassionate people would look after him, my whip-smart, crazy and incomparable Dad, and in his way, he accepted that care.

And I could finally take a bite of breakfast and feel my own pain. The crack is how the light gets in.*

Here’s to seeing through whatever cracks lie ahead, future doctors – well beyond these days of distancing and extreme uncertainty. But please have faith that the light is getting in!

Thanks for reading. All the best as you progress through your clinical experiences.

*Ring the bells that still can ring

Forget your perfect offering

There is a crack, a crack in everything

That’s how the light gets in. (Leonard Cohen)

Warm regards,

Mary D

(now a.k.a. "muffin, none the wiser")

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