The Toothache Cure

Chapter  1

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It should have been a day like any other. It had started as such, with the usual routine on the clinic: the usual staff, and the same kinds of patients presenting with complaints of the same nature needing to be taken care of. There had been no reason at all at the beginning to suppose that it would progress any differently from any other day, and yet, by the end, it was the day that changed everything.

There was a cluster of a trying kind that morning. That’s the term the medics use for the incidental bunching up of groups of patients who are all presenting with the same sort of problems or complaints, and they crop up surprisingly often, as much in dentistry as in any other discipline. There might be repeated problems with cobalt/chrome dentures, for example, appliances rarely seen in the ordinary course of events; or difficulties with opening the jaw, or pain issuing from the same quadrant in every patient. But on that particular morning there seemed a preponderance of people disenchanted with their appearance.

A rather morose young man set the pace. Blonde haired, with a pleasant but rather shambling appearance, he wandered into the surgery wearing an untidy suit and carelessly knotted tie, carrying every kind of personal office accessory he could handle without having to resort to the use of a hand-cart. He dumped his lap-top on the chair on the corner, followed by his blackberry, i-pad and i-phone, and some kind of personal music player – it could have been an mp3 player, Gwyneth didn’t know what all the latest gadgets were – plus a set of ear-plugs with about a yard of attendant springy wiring which he stuffed into a side pocket as he came striding away from his accoutrements to fling himself into the dental chair.

Good morning, Mr. Little, Gwyneth said in welcome, noting that he did return her greeting, even though it was only done slightly; I am Miss Kimberley. Have you been to this Dental Hospital before?

The young man shook his head.

I see. Well, from his referring letter, it would seem that your dentist has sent you because you are not happy with the condition of your teeth.

"I’m not happy with my teeth, the young man corrected her, moodily twiddling his thumbs, which were resting on his lap. He looked as though he didn’t know what to do with his hands without a device to hold on to. I hate my teeth. I mean I really hate them.  They’ve always held me back in life, and now they’re so bad they’re just spoiling everything. They make me really miserable."

Oh, dear. How so? How are your teeth affecting you so badly, Mr. Little?

"They’re stopping me from advancing myself. I’ve been trying to improve my position in work for ages, but they’re completely holding me back. I’ve got to advance myself in life, I’ve simply got to. I’m applying for all the promotions I can get, everything I can go for, trying to better myself – I’ve simply got to get on. But I’m not getting anywhere. I can’t get anywhere without perfect teeth. Without perfect teeth, it’s all just a waste of time. Mine are awful. They won’t do at all."

Can you tell me what specific problems you are having with them? Is it difficulty in saying certain words? Or with your speech in general? Or trouble with eating? Anything of that kind?

No, it’s the way they look that’s no good.

Have other people said anything to you about their appearance? Commented about your smile, for instance?

No. He spoke almost absently, staring gloomily down at his feet.

So nobody has told you they don’t like the way your teeth look?

No. The young man became irritated all of a sudden. Look, why are you asking me all these questions? Just get on and do me some treatment! I’ve told you what needs sorting out. Of course nobody has told me they don’t like my teeth. Who’s going to come out with something like that to my face? People aren’t that rude. Nobody in their right mind is actually going to say it. But that won’t stop them judging me by them.

Well, I make the enquiry because I want to know if this is a self-assessment you are giving me, or if it is endorsed by someone else’s opinion, Gwyneth explained. It would appear to me from what you are saying that you would like an improvement in the main appearance of your smile, and that there is nothing else wrong at present.

Don’t say it like that! he exclaimed indignantly, swivelling round in the chair and facing Gwyneth at last. "You’ve got to understand, this isn’t a matter of ‘just,’ this is really serious. Everything hinges on my appearance. It’s vital for me to look as good as I possibly can for my interviews."

Gwyneth resisted the impulse to suggest he start with a tidy suit and a more cheerful countenance. Instead, she offered to take a look at his mouth. The young man acquiesced, and sat back so she could recline the chair.

There was really nothing out of the ordinary in there. His smile line was more a grimace, but it was an ordinary kind of smile, and his gums were pink and healthy, nothing to comment on there: no asymmetry, no deviations, mid-line where it ought to be: average cleanliness, well maintained by his dentist, no fillings needed. A slight rotation of one lateral incisor was apparent, but his occlusion was normal. No orthodontist would agree to try and improve a minor discrepancy of that nature.

I’m not sure what you think can be achieved for you, Mr. Little, Gwyneth said, when her examination was finished. As far as I’m concerned, you’re fine as you are. Everything in your mouth is perfectly healthy. The radiographs your dentist enclosed are up to date and show your teeth to be sound. You have no problems.

But I do have problems. I just told you. Didn’t you listen? They look terrible.

In what way are they terrible? Can you be specific?

They are an awful colour, just awful. And this front tooth here is twisted. I want them put right.

You have a slight twist on that tooth, yes, but it is not detrimental to either your appearance or your ability to function. And the colour of your teeth is well within the normal range of limits. If you feel so critical of yourself, you could approach a cosmetic dental surgeon for an improvement in the aesthetics; that would involve some bleaching and a veneer on that rotated tooth, if anyone would agree to do it. But I must advise you here and now that such a course will be quite costly, and I don’t think you will notice much change afterwards, not since you have such small irregularities in your general dentition and a tooth colour that’s already at the lighter end of the colour spectrum. I’m afraid we can’t agree to do this kind of treatment on the National Health Service for you, because it is not justified.

What do you mean, it’s ‘not justified?’ Mr. Little cried out again. I pay my National Insurance, the same as anybody else. Huge amounts of it, in fact. If I want something doing, you have to find me somebody to do it.

Only if it is necessary for your dental fitness. That is the extent of our remit.

I don’t believe you.

As you wish. I’m sorry, but it won’t change the facts.

Well, I want to see somebody else then.

I see no reason to call in a further opinion. Your own dentist could not agree to do what you are requesting himself, and I concur with his opinion. Your complaint is of a cosmetic nature, and for that you will have to see a cosmetic specialist and pay privately. This is not an NHS matter. I am afraid we cannot help you here at this hospital.

That’s disgusting, Mr. Little said, explosively. I shall make a complaint. Who do I see to make one?

If you ask at the desk outside, they will direct you to the Hospital Administrator.

Mr. Little leapt out of the chair and went over to his things. Then he seemed to have a change of heart. I don’t really want to complain, he said, rather abjectly. "I want to get my teeth done. I have to get promoted."

But why, Mr. Little? What is so important about promotion? It makes no difference to who you really are.

Oh yes it does, he muttered darkly. He stared broodingly into empty space for several seconds. It will make all the difference in the world, he went on softly, almost to himself.

Tell me, Mr. Little, Gwyneth ventured, "if you do go ahead and pay to get your teeth done, and if you still don’t get promoted for some reason, what then?" She was developing a few misgivings about this chap, and felt quietly thankful that he didn’t qualify for treatment in the hospital. Anyone who undertook treatment for him on these terms was going to be onto a hiding for nothing.

"Ah! But I will get promoted, Mr. Little asserted, gathering confidence at the thought. Once I get myself improved so everything about me is what it ought to be, I’ll be fine. He gestured towards his teeth petulantly. I think it’s disgusting that you won’t help me with these. I have a lot of things wrong with them, whatever you may say about it. I think I shall make a complaint after all."

He swept out without acknowledging Gwyneth’s farewell, and Gwyneth put his file aside to write up later. It would have to contain a concise and thorough summary, with no ambiguity and no doubt about the objectivity of her opinion. Depending on how long his anger lasted, Mr. Little’s next stop could well be with the hospital management, and if her account was going to be read by a complaints committee, she would rather wait to make a record of it until the heat of the moment had worn off.

She had seen a similar case a day earlier; one that had quietly caused uproar among the clinicians at the hospital, with the controversy still simmering at a lower level several years later, because a lot of anxious thought was still being given as to how the mismanagement of another such case could be avoided if it should present in the future. This other young man had been given major corrective surgery to his jaws because he had insisted a mismatch in their alignment was preventing him from playing his flute properly. The misalignment, which was quite severe, had been duly corrected. Unfortunately, he had found himself still unable to play his flute even after his surgery had been done; at which point it had become obvious to the clinicians that the real reason he couldn’t play his flute was because he was actually a rotten flute player; but once the prop he had been using for his psyche for so many years was taken away by the beautifully redemptive surgery he was given, he became psychiatrically disturbed, and had several breakdowns. He then re-presented to blame the clinicians and surgeons for the unsatisfactory outcome, full of distress about what had been done to him with no good effect. Senior staff had been seeing him on an almost monthly basis ever since, trying to appease his anger and beat a tactful forward pathway for him, an all but impossible task with a man who refused to accept that he was in any way damaged psychologically back at the start. Gwyneth had been just one of a succession of clinicians he had called in to see with some trifling complaint he simply couldn’t come to terms with, because he had no insight into the real nature of his problems.

The patient who followed Mr. Little was almost in the same category. Gwyneth could feel herself wilting as she listened to the middle-aged lady in front of her hysterically saying that she simply had to have something done so she could maintain her youth. The patient’s eyes were fixed on the nurse as she was talking, and she followed her complaint up with a resentful comment about how lucky young girls were to be able to wear such tight-fitting clothes these days. She carried on watching as the nurse left the room with a tray of instruments. The older woman’s jealousy over a younger generation free to enjoy openly choices in self-expression that had been unthinkable back in the days when she was a young woman was all too plain to see. What treatment could there possibly be for such discontent and disappointment in life? Gwyneth did her best to be gentle as she assured the lady that her desire, although understandable, was going to be impossible to meet. After inspecting the patient’s mouth, she commended her on her exemplary mouth care, and suggested she should think seriously about the wisdom of meddling with such a good set of teeth; and that perhaps she would be better off attending some women’s weekend workshops instead, and doing some ‘inner work’. Somewhat to her surprise, the patient didn’t instantly reject the suggestion with a knee-jerk reflexive reaction, as Gwyneth had half-expected she would. Instead, after some further explanation and discussion about accepting the inevitability of ageing, the woman was struck with the idea, and left the clinic reasonably satisfied, happy at having at least been heard and understood. Gwyneth quietly breathed a sigh of relief. One patient departing in high dudgeon was more than enough for one morning. This woman might well apply more histrionics at a workshop once she got there, but she might also gain some self-acceptance along the way. It was a possibility that was never going to be met by taking her on as a patient at the hospital. 

One of Gwyneth’s greatest professional difficulties, and one that she had been trying to accommodate for the whole of her working life, was that so many of the notions and thinking processes of the great British public just didn’t sit well with her. They never had; and the years she had spent toiling in primitive third world countries trying, often with limited success, to sort out ordinary dental emergencies in broken-down, badly equipped clinics, where none of the general population had much hope of having even their most basic needs in life met, let alone those of their teeth, had only served to entrench and intensify her opinions regarding pampered first world nationals.

This strange feeling she had, the one that prompted her to think that the British public’s day-to-day living requirements were so well satisfied that they felt compelled to delve and burrow and strive to dig up smaller and smaller problems to scrutinise and produce with a flourish with the expectation that they be treated as monumental issues was compounded by the fact that, for some strange reason she had never been able to fathom, everything and anything that was quietly fomenting in a person’s life seemed to bubble up to the surface the minute they sat in the dentist’s chair. It wasn’t just personalities and underlying hang-ups that popped up to surface when patients took their place there; entire philosophies and expectations, hopes and fears and all manner of unexpressed worries were immediately made manifest as well, and it was possible to tell a good deal about a person right at the start of a dental consultation, just by exchanging a few sentences with them. She now had very little sympathy for many of the patients who wound up gridlocked in the English dental hospital systems. She thought their heads were stuffed full of nonsense. But she couldn’t decide if this was because her way of thinking was now completely out of synch with general British consciousness which had moved on without her, or if western people really were so safely micro-managed in every respect, with each and every need cosseted and catered for, that their lives were truly getting smaller and smaller in the way it appeared. Many of the people she was daily coming across were so introspective, so self-obsessed and focussed on their own trivial minutiae they were in danger of disappearing up their own backsides.

The nurse brought in the next patient while Gwyneth flipped through his notes. He had been seen at the Dental Hospital a number of times with painful teeth that had been diagnosed as eroded, and he had been provided with several crowns and composite build-ups to repair the damage. He wasn’t due his check-up yet, so she guessed he was attending with a problem. She sighed quietly, and hoped his complaint was going to be about something rational.

Mr. Brown proved to be a sedate, elderly gentleman who came in slowly behind the nurse and took his time getting seated, rinsing his mouth out and then removing his eye-glasses before turning his attention to Gwyneth. Gwyneth waited patiently until he was comfortably settled. There was nothing to be gained in pressuring him – elderly people progress very much at their own pace. 

Ah! Yes, Mr. Brown responded affably to her greeting and introduction, still dabbing at his mouth with a tissue, Miss Kimberley. I presume you simply choose to work under your maiden name, since I am told by the receptionist that you are, in fact, married. And you have returned from foreign parts, I hear. Working for a charity, too. How commendable. Tell me, did you enjoy working in the Sudan and the Yemen?

I got on well enough, thank you. And what can I do for you today, Mr. Brown? Gwyneth was still smiling, but she had become rather more clipped. This was a consultation about his teeth, not a social call, and she didn’t encourage personal questions. She regretted that she had not headed him off sooner with her own enquiries when he had first come in; and made a mental note to have a word with the receptionist later about fending off this kind of inquisitiveness.

Oh, yes. My teeth. Oh, well, dear, it’s the same old problem. No matter what they do for me here, it keeps cropping up again, sooner or later. Now I have a tooth here, do you see? This one, here. Can you see the one I mean? He pulled his lip aside to demonstrate a lower premolar displaying the kind of gingival recession typical in the elderly. The neck of the tooth just above the gum-line was notched and worn; another common finding in the elderly. If I just touch the tooth here, it feels sensitive. Here. Not here, or here. Just in this area here, the place I am indicating. And yet it is not sensitive to hot, or to cold, nor is it tender to pressure. I have myself tested the tooth with water of varying temperatures, and with food of different textures and toughness, all provided for me by my wife, and I have elicited no response from it in any other way than the one I have just given you. Now, isn’t that interesting?

He regarded her with a measure of triumph, as though expecting the new clinician to find his situation as intriguing and puzzling as he did. However, she did not.  He had sensitivity in exposed dentine, a condition endemic in older patients who still had their own teeth. What she needed to find out was the cause. She checked his medical and social history, and after updating his notes on the medication he took for hypertension and angina, asked if she could recline the chair a little so she could examine the tooth more closely.

Only a little, dear, if you don’t mind, Mr. Brown said. My heart condition does inconvenience me, and I cannot tolerate being laid flat.

A very little is all I need, Gwyneth assured him. It’s only so I don’t have to turn myself upside-down to look inside your mouth.

She adjusted the chair a bare six inches and still had to crick her neck, but she was able to examine his teeth carefully, finishing up with the one he had come in about.

This tooth was restored at your last visit, she said. And yet I see you have more erosion developing on the neck of the tooth between the filling and the gum. And not just in this tooth, either. There is active erosion still taking place all across your mouth. I presume you have been asked previously about your diet and cleaning methods, and have been given advice accordingly?

Mr. Brown nodded amicably. I have, he said. The last young man who treated me was most assiduous. He told me to avoid acid food, and I have followed his advice to the letter. I have even instructed my wife to test everything with litmus, to make sure she presents me with nothing detrimental.

Well, that may be a little extreme, Mr. Brown. You don’t need to limit yourself to such an extent. It’s only citrus and sour things like yoghourt and vinegar that may be damaging.

Mr. Brown held up his hand. No, no, dear, he said, say no more. I have established my routine, and my wife has accepted it. There is no problem.

Then I congratulate you on your conscientiousness, Mr. Brown.

He gravely inclined his head.

And as to your cleaning methods: I beg your pardon, but I must enquire. I’m not trying to teach you to suck eggs, I know you have been cleaning your teeth since before I was born; but something in your style of living is still causing an active problem here. Are you using a sensitive formula toothpaste and a softer brush, as was suggested? I see from the hygienist’s notes that she has advised you, as well.

I use the softer brush, dear, but I decline to use formula toothpastes. They are titanium based, and I deplore the use of heavy metals in cosmetic products.

There are herbal preparations...

I use nothing whatever that is commercially produced, he interrupted, with another wave of his hand. Such products are unnatural, even if they claim to be otherwise. Kitchen store-cupboard ingredients are what I limit myself to, as I have always done, and my mother before me.

Gwyneth’s heart started sinking. She already knew what he was going to say he used: it was going to be either salt, or soot. They were the tried and tested formulae of bygone generations who managed to keep their teeth during the days of gas and extractions. And such materials were way too abrasive, especially now his gums were shrinking.

Well, Mr. Brown, she said, trying to keep her smile to the fore, and what did your mother use that worked so well that you have stuck with it?

Ah! Now, you’re going to be surprised to hear this, he said complacently, but salt or soot is very effective for good tooth cleaning. I bet you didn’t know that, did you? Mixed with a little cider vinegar or lemon juice, you know.

For the next five minutes, Gwyneth counselled him against the use of such a concoction when there was so much ongoing damage in plain view, but it was in vain. He upheld his own viewpoint in exactly the same way he held up his hand to stop her from remonstrating, and asked her to be a good girl and just do him another filling. She finally gave up talking, and repaired and extended the perfectly sound filling that was already in place, afterwards making a note in his records that his oral hygiene practice was at fault, and that he was declining to follow advice and instruction, with ongoing damage to his dentition as a result.

As he walked out, blissfully unaware of the frustration such bull-headedness caused in the dentists and hygienists trying to maintain the integrity of his mouth, Gwyneth recalled a young Welsh woman she had once seen, years previously, who had come in with red and swollen mucus membranes and every tooth in her head aching after using a popular bathroom cleaner called ‘Vim’ to clean her teeth. Gwyneth had almost screamed with horror at the sight. Vim was a very good cleaning product in its day: cheap, and readily available; but it was a scouring powder meant for bleaching and scrubbing enamel baths and sinks; it was never designed for mouth care, it was much too powerful. In response to Gwyneth’s distress and concern at the destruction being wrought by her cavalier misuse of a cleaning product, the young woman had smiled up at her and exclaimed with great satisfaction, Ah, but look, see, it fetches them up lovely!

Chapter  2

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The Sedgefield Marsh Dental Hospital and School was a part of the University Hospital of Lowton Beck. It was a separate, but integral part of the main hospital complex, constructed of stark black and white concrete and glass, and it stood four storeys high in its own plot with its own car-park. It was a busy place, providing dental services free of charge to its attending public as an incentive to get them to accept treatment from dental personnel who were still going through their training. A small access road divided the Dental Hospital and School from the much larger School of Medicine, and then continued to wind round and about the rest of the teaching complex, providing the necessary link between the main hospital, its annexed buildings, the halls of residence for nursing staff and students, the laboratories, and a number of extensive car-parks. The entire teaching hospital was of the post-sixties university era, sited conveniently alongside a motorway for ease of access and parking and avoidance of congestion; all of which demonstrated a greater concern for the general passing motorists than it did for its own patients and visitors, who had been charged since the day of its opening for the privilege of parking on-site there.

It was unremarkable except perhaps for its ugliness. It had been built on the cheap as a part of the British Government’s strategy for increasing the numbers of new graduates, and was intended to help reduce the perennial shortfall of clinical personnel within the National Health Service. It had been politically placed, with a glorious fanfare over the diplomatic and socio-economic implications of such decision-making, in Lowton Beck: a new town planned and developed amidst strong controversy on reclaimed low-lying wetlands close to the River Severn on the borders between Gloucestershire and Gwent, where it served the communities of both England and Wales.

Gwyneth’s return to the UK had been very recent after a number of years spent abroad. After a spell of soul-searching, she had applied for a position in the Conservation Department of the Dental Hospital at Lowton Beck, and, to her surprise, had been accepted as an Associate Practitioner there. It was a position attaching her to the teaching side, as opposed to the hospital side of the institution, even though her main duty was the treatment of patients with significant medical conditions or dental needs. Along with other practitioners, she kept the waiting lists down, thus taking some of the clinical pressure off the academic teaching staff. Occasionally she would be called on to supervise senior undergraduates in their training on the Conservation Clinic, and this was one part of the job she did actively enjoy. It was a likeable way to spend the time, getting to know the students as she gave them instruction and advice on the practical aspects of the restoration of teeth.

Perhaps, though, it had been a mistake to go back into a teaching hospital so relatively late in life. Perhaps she had been too long absent from the halls of academe. Those years spent in foreign lands had altered Gwyneth’s perceptions, her priorities and sense of purpose. And they had certainly