Practice News

Patients often ask me, “What is new?” Well here is the latest:

If you would like to order The Charm Carver click here.

If you would like to order “Doctor, Be Well” click here.

Click here to read an excerpt from The Charm Carver.

Click here to read an excerpt that you will not find elsewhere from Doctor, Be Well

Below, for your enjoyment, you will find a selection of our practice newsletters.

Autumn 2013 (2)

Autumn 2013

  In your mind take an egg, crack it into two perfect halves, discard the contents and one half of the shell.  In the other, peel out the membrane, wash and dry the inside and take a hard, dry cheese, like parmesan, melt it so that it runs and pour a coating in the shell that is about 1/16th of an inch thick and let it come to room temperature.  The cheese will stick to the inside of the shell and be hard enough that you can’t easily get it off.  But if you have a small, sharp instrument, maybe shaped like a fingernail, and a lot of patience, you could methodically scrape all the cheese out of the shell and, most important, not crack the shell in the process.

Dentistry is so mechanized today that routine removal of decay takes just a few seconds using what is known as a ‘slow speed’ handpiece.  But there are times when the gentlest touch with a slow speed transmits too much force and so cannot be used.  In these cases, as a rule, it’s often best to take out the tooth because if it is ‘eggshell thin,’ it may not hold up after it’s restored. There are exceptions though.  These special cases are among those that I call, “strange, rare, and peculiar,” a term used in homeopathic medicine. Here there is a chance to save the tooth and avoid the need for an implant, a fixed bridge, a removable partial denture or an empty space.  The requirements are: (1) enough tooth to withstand the careful scraping away of the decay, (2) a patient willing to risk a time consuming, tedious procedure with no guarantees of a successful outcome, and (3) a dentist game for a serious challenge of skill, patience, tactile perception, and sustained, focused attention.  If the ‘eggshell’ breaks, the ‘game’ is over and even after the tooth is restored it will never be 100% strong.  But if the three conditions are met, the game is on.

Having passed the milestone marking 30 years in practice I find it thrilling to put care, skill, and judgment to just these kinds of challenges.  They offer a feeling of fulfillment: from the sense of accomplishing a difficult feat and from the gratitude of the patient.  Here is what this patient, whose reconstructed tooth I have illustrated on the cover, had to say:

“Thank you so much for fixing this tooth; I’m so grateful!  I know I let things go for too long and I thought, “Well, I messed up, I’m going to lose this tooth.”  So the fact that you were able to save it even being so badly broken down gives me hope in my life.  It’s strange, but it’s like if even this could be redeemed, what else in my life might be possible?”    -D.F.

 

I am mentoring a young dentist about the importance of finding fulfillment in work.  I counseled her that happiness comes and goes in almost random ways: a case works out well or a patient is pleased and I feel happy; a case doesn’t work out well or a patient is not pleased and I am unhappy. We can only do our best and that best comes from perfecting the skills needed to do good work, the judgment to evaluate and solve different kinds of clinical problems, and always remembering that our work is inside the body of and attached to the emotions of a patient who is trusting us with their care.  By uniting our care, skill, and judgment we raise the bar and function on a higher level. I wrote about this in my second book, The Charm Carver, in the final chapter, entitled, “Gazing Out.”

 

Thank you for your continued presence in my practice and for continuing to send me your family, friends, and colleagues.  As you might guess from all I have said and notwithstanding my 30 year practice anniversary I’m not retiring any time soon!

 

Be Well,

Gazing Out (from The Charm Carver)

And now the sun sets to the south; the days are cold, and I find myself yearning.  Not for the warmth of another summer, and not for the thrill of a still distant shore: for I have lost my taste for these.  I yearn for what will come tomorrow, knowing I am ready.

My vessel will be empty soon and melt into the ground.  I’ve heard that our bones make the grasses grow strong, and I rest contentedly in this, that I will help the grasses.

My love will live a little longer, held in the hearts of those I’ve embraced.  And I rest contentedly in this, that love survives the Great Divide.

But of all I learned from Simon, it now comes down to this—what will become of the fruits of my work?  “Only a third,” he told me one day, “will any person ever see.”  And I asked him about this, and he answered, saying, “Ah, Madeline!

Long have you watched me carving at stones, but close as you watch, you can perceive just a third of my fruits.   For effort always splits in threes, one part sits here on the bench, one part rises up to heaven, yet the last contains the chance to live on out beyond our days.

For we are but as vessels filled with just an outbreath of heaven.  But heaven must as well inhale and soon the spirit, briefly ours, must return from whence it came.  From this we gain the spark of life and heaven gains a spirit now that’s filled with newer flavors.  And when my life is over any spirit that remains is like a drop of ocean spray returning to the sea.  For spirit is an ocean, and we are not the fish, but drops to mix and mingle; dissolved and uncontained.

And yet if I collect myself—my body focused on my task, my mind in quiet openness, my heart preparing to receive—then the forces that forge all the gems; the rubies and the diamonds, the emeralds and the pearls; work to form a gem in me—a soul that can endure.

But if I work halfhearted, or partially distracted, or carve a form in carelessness then nothing will be crystallized.  Instead my precious third just merely dissipates as heat, warming up a chilly world from which I’ll fade without a trace. 

For we can forge a heavenly gem—never to melt in the endless ocean; forever to endure, forever to remain.”

Now I sit as the sun goes down, my breath returning to the sea.  But I am content with the gem in my heart and thankful for Simon who showed me.  Now I sit as the sun goes down and winter calls my name.

 ©2005 D.Shuch

Winter 2014 (2)

Winter 2013-2014

 Sometimes it takes a new feeling or concept to make a thing of beauty. Like a flower arrangement when it seems unfinished until a final bloom is added or a redundant one taken away. So it can be in dentistry when a strange, rare, or peculiar variation in an otherwise routine case calls for a new vision of how best to restore it. When treating it in ‘the usual way’ would work but could never feel like, as my physics professor once intoned: “an elegant solution.” Though beauty in dentistry is most often associated with esthetics, here I am writing about the beauty of a course of care that, though technically difficult, perfectly blends with the circumstances of the patient and his or her situation.  This is a central theme in The Charm Carver.

JD came for help in turning his mouth around.  He’d had a high pressure career and his health had taken a back seat.  Now he was focused on getting healthy and he knew his mouth was a big part of his problem.  He had gum disease and had already lost nine back teeth and was about to lose five more.  He was going to need bone grafts and dental implants or a removable denture. But on the day of the planned extractions I re-evaluated his situation and between my earlier gum treatments and what JD had done every day on his own, his gums were better.  So much better that it raised the chance for a radically different treatment. If we could save a seemingly hopeless molar that had massive decay and more than half of its bone support lost, then we could rebuild his mouth without further extractions and with just one crown and a fixed bridge.  The treatment would cost thousands less but it would only work if this one tooth could be saved and it just didn’t seem possible. 

 It was a molar built like a three legged stool.  Years before it had had root canal therapy and a crown and now after gum disease had ravaged the gums, the ‘legs of the stool’ were no longer buried in the gum but were standing out, half exposed. Food and germs got trapped in the cage between the roots and these decayed from the inside out. Imagine a stool buried in sand up to the seat.  If cream cheese fell on the seat it would clean up easy.  But take away half the sand so the stool is like a beach house built high up on pilings and lodge the cream cheese between the legs of the stool…now imagine the ‘stool’ is ten times smaller than the fingers of your hand and you’ve got to clean this space out daily and it is located in the back of your mouth where you can barely see and hardly reach. By the time I cleaned the decay away the ‘seat of the stool’ was gone and all that remained were three little roots that, now apart from one another, were each a bit ‘wiggly’. I can’t think of a dentist who, seeing this, wouldn’t just extract these pieces. 

JD had developed the skills to clean around the roots of his teeth but this would be more difficult. He’d need to maneuver a water pick around this tooth from three different sides.  But even still, could these roots be made to serve as a foundation for a functioning molar? 

My first dentist was Dr Herb Goldstein.  You have all benefitted from my exposure to him in two ways: because he inspired me to become a dentist and because he demonstrated to me, when I was six, that contrary to my experiences getting vaccinated by my pediatrician, an injection hurt a lot less if there is, in the doctor performing it, an intention not to hurt the patient (you can read about this in my first book, Doctor, Be Well, just find it on Amazon and ‘search’ for page ‘144’).  “Uncle Herby” practiced in a beach community near where I grew up and it was there that I first saw beach houses built up on stilts.  Perhaps it was this old connection between my dentist and these kinds of structures that the pieces fell into place that day as I stared through my dentist’s mirror and into JD’s mouth, trying to visualize a kind of dental restoration that I had not seen before nor even heard about in my thirty years in practice. 

The roots would each need a small support post, but I could not unite these three with a big filling and build the crown on top of that as the surface of the filling between the roots and against the gum could never be properly shaped, so the roots had to stay separate.   But as they were not parallel to one another it would have been impossible to get a crown to slip on and fit on top of them all, so first each root would need to be fitted with a small gold thimble, known as a ‘telescope coping’.  These could be cast to perfectly fit each root stump and would cover them right to the gumline—making it hard for the roots to further decay.  Also they could be cast to fit the angles that the roots made as they exited the gum while their tops could be made parallel to each other, so that a crown could be made to slip on and fit perfectly on top of them all.  Telescope copings are used when dental bridges need to cover many teeth that are far from being parallel; but to use this technique on non-parallel roots of a single, badly broken down tooth?  Unheard of! 

The tooth is working perfectly and JD couldn’t be happier. As for me, to the end of my days I will recall this strange, rare and peculiar fix as truly a thing of beauty.

Thank you for your continued presence in my practice and for your referrals of friends, family, and colleagues.

Be Well.

Spring 2014 (2)

 

Spring 2014

 In your mind imagine a cookie jar with a lid that fits the rim like a thimble fits a finger.  Filled with cookies, you realize, too late, you put the jar back in the cupboard with the lid off and that the jar fits the shelf with only a small amount of clearance—so you couldn’t easily shimmy the cover on while the jar sits on the shelf.  Also imagine the cupboard is old and that the cookie jar with its lid on props up the shelf above it and keeps all the stuff on that shelf from falling off.  So it’s important to get the lid back on the jar and it’s got to fit snugly—to keep the cookies fresh—and it also has to fit the underside of the upper shelf to hold it in place.  In real life you’d pull the cookie jar out, press the lid on and slide it onto its shelf while taking care that it also supports the shelf above it.  In real life it would be crazy to try to figure out how to get the lid back on the jar and support the upper shelf while not moving the jar out first.  But dentistry can be crazier than any problem with a cookie jar.

 When I started this series of “Strange, Rare, and Peculiar” newsletters I knew I’d be including this case but I wasn’t sure if I could convey what made it so difficult (and so interesting!) in terms a lay person could understand.  Before now I’ve not shared this case with more than a few dentists and even from them I have gotten puzzled looks that ask, “Why would you even try to come up with this kind of fix?” Even if you don’t grasp the whole thing, I hope you’ll gain a glimpse of what can go into solving a tough dental problem.  As far as answering the ‘why’ question, please see my last newsletter where I discussed the idea of ‘an elegant solution’.

 AP, a patient who now lives about 4 ½ hours away in West Virginia but eighteen years ago lived an hour away in Pennsylvania, came in with a problem: a fixed bridge had grown uncomfortable.  The front end of the bridge was supported by two premolars, then came the span that replaced a missing molar and the back end was supported by a small wisdom tooth.  The problem was that the glued connection holding the bridge onto the wisdom tooth had given way but the bridge was still firmly glued to the two premolars.  There are two common fixes to this: either break the glue seal on the two premolars and reglue the bridge—but this risks breaking or cracking either of the premolars, or cut the bridge off and remake it from scratch. 

 I saw that the reason the glue seal gave way was because her chewing produced forces that pulled up on the back end of the bridge. What AP needed was a modified design that contained a stress breaker on the back molar.  This allows biting-down forces to be supported by this back molar while keeping any lifting forces from pulling on the glue seal of the crown.  It is made by having a separate crown on the wisdom tooth that contains a depression, called a ‘rest seat,’ sculpted on it’s front end and having a horizontal finger-like projection, called a ‘rest,’ on the back end of the bridge that sits snugly in the seat. Biting pressure holds these structures tight against each other but if the back of the bridge lifts, the ‘stress’ is ‘broken’.

 Bridges with stress breakers must be glued in a strict sequence: the crown with the rest seat goes in first and then the bridge with the rest is fitted on top of that.  But here the bridge was already in place and while I could cut off the rear most crown in a way that would leave a gold stump that I could shape into a rest, placing a newly made crown onto the wisdom tooth and shoe-horning it under the rest seat creates the cookie jar on the shelf problem.  And trickier than figuring out how to get the new crown onto the wisdom tooth with the finger shaped rest in the way, was figuring out how to shape the rest and the wisdom tooth so that once I shimmied the crown under the rest, the crown would snugly fit both the tooth and the under-surface of the rest at the same time.  It’s like the lid needing to seal the cookie jar and hold up the shelf above it at the same time.  Sculpting the end of the bridge from the gold stump to make a rest would be tough to do. This is not a common procedure and I would have to find unusual dental drill bit shapes and find new angles of holding the drill to access the areas that I’d have to sculpt.  But separate from the issue of difficulty was the issue of possibility: did a geometry even exist that would allow for a crown with a stress breaker to be retrofitted under an existing rest?

 Crowns fit on teeth like thimbles fit on fingers—they slide on vertically, along what is called a ‘straight path of insertion’.  My earliest idea about how to retrofit the crown with a stress breaker involved a kind of ‘shimmy’.  I’d create just enough clearance for the front edge of the crown to clear the finger of the rest and then angle the crown onto the wisdom tooth.  This would be like using whatever slight clearance existed between the top of the cookie jar and the underside of the shelf to squeeze the lid into the space and then press it down onto the top of the jar.  The problem with this was that if I engineered the fix to work this way, there would end up being a gap between the underside of the rest and the rest seat just as soon as the crown was pressed down on to the tooth.  It called for an even stranger fix, one that involved a ‘rotational path of insertion’ for the crown.  This proved to be the key to making this fix work, although it raised the difficulty of doing it by a factor of ten.

 The key turned on shaping the underside of the rest, not in the conventional way—as a ‘finger’ with a fairly flat horizontal surface but more like the curve of a quarter-circle.  The rest seat on the crown was then made to fit this circular curve so when the crown went in, the pathway to getting the crown onto the wisdom tooth involved engaging this quarter circle and rotating the crown around this surface so that once the rest was fully in the rest seat, the crown was fully on the wisdom tooth at the exact same time.  It also involved shaping the stump of the wisdom tooth to allow for this rotational path of insertion and introducing some extra sculptural elements to add more friction to help hold the crown on.

 Repaired in this way, the bridge lasted eighteen years before there were problems in the premolars that required their loss and with them, the bridge.  The crown on the wisdom tooth still remains and is now part of the new fix that I’ve designed to replace AP’s missing teeth.

 Recently a young person asked me for career advice.  I said, “It’s simple:  do something that you enjoy working really hard at even if no one else ever sees or can appreciate what you’ve done.”

 Thank you for your continued presence in my practice and for your referrals of friends, family and colleagues.

 Be Well.

Summer 2014 (2)

Summer 2014

 When a tooth splits vertically—like a tree hit by lightening—there is nothing to be done except extract it and plan a replacement.  Occasionally though, in circumstances ‘strange, rare, and peculiar,’ there may be something to salvage.  The most frequent occasion of this rare circumstance is if the tooth has roots that spread like the legs of a three legged stool.  If the split cleaves off a single root and two are left intact, there may still be a chance to rebuild.  But it is unheard of when a tooth has only two roots and the split is between them.  But holding the belief that things may not always be as bad as they seem, sometimes a deeper look reveals an elegant solution.

 FL, a patient who hales from Florida, is in her 80’s and leads a busy life.  A year ago she came in with a split two rooted tooth.  It had had root canal therapy years before but unfortunately had never had the crown that would have kept it from splitting.  Now the situation was grave.  The tooth held a key position, being one of the few remaining back teeth that kept her bite stable.  With its loss there would have been a need for a fixed bridge, an implant, or a removable partial denture.  Without one of these there would be too few back teeth to keep her front teeth from buckling, a condition called “bite collapse.” Without the ‘support pillars’ of back teeth to hold up the ‘roof’, chewing causes the front teeth to splay out through the lips and then the distance between the nose and chin diminishes when the teeth are drawn together.  The chance to properly chew is gone and the face develops long and deep furrows falsely attributed to age.

 When I examined my patient I saw that the split divided the tooth into fairly equal halves, but the segments were not equally loose.  Normally with the split of a two rooted tooth, the two formerly joined halves, now no longer enjoying the benefit of mutual buttressing; each becomes loose in equal measure.  In FL’s case a picture emerged that explained this strange discrepancy: the bone that anchored the outermost root was thin and a little bit frail, while the bone that anchored the innermost root was thick and wholly rigid.  The discrepancy created an unequal foundation: biting forces propagating to the inner root met robust resistance, while those ramifying to the outer root met with a bit of ‘give’.  It was then just a matter of time before the outer root sheared from the inner.

 Without three additional factors this still would have had no consequence, but as luck would have it, “the aces all lined up.” The root canal therapy, performed years before, had been successful in that there was no trace of infection on the well anchored root; the anatomy of the remaining root was such that despite the split there was a well defined edge to ‘collar’ with a crown; and most important of all—the pattern of her jaw movements while chewing, in concert with how this tooth aligned with its antagonist—what is known as, ‘the occlusion’, was modifiable, such that I could confidently design a new bite scheme that would eliminate most of the tipping forces that would otherwise doom a crown on this compromised tooth. 

 In your mind take a ripe nectarine, stem side down, and with a thin, sharp knife, make a horizontal cut at the level of the ‘equator,’ all the way around to the depth of the pit.  When the cut is finished firmly hold the lower half and, with a quick twist, ‘unscrew’ the top half exposing the pit.  If you grasp the pit and pull it straight up, the nectarine fibers resist; if you press the pit straight down it will feel well anchored in the flesh; only if you tip the pit from side to side will you be able to loosen it and pull it free.  It is the same with teeth: they are anchored like a nectarine pit and even if half of their support is gone, if you don’t tip them, they will not come out.

 This fix is not without risk and FL knows it. But however long it lasts it postpones any course of treatment sure to disrupt her busy life.  “I travel, I visit family; I’m always on the go.  I’ll just get used to chewing nuts on my other teeth instead of this one and I’ll be fine.”  Already it’s been a year and its working out great.

 Thank you for your continued presence in my practice and for continuing to send me your family, friends, and colleagues. 

  Be Well

Autumn 2014 (2)

Autumn 2014

  Teeth treated successfully with root canal therapy can last a lifetime.  As long as there is no trace of infection, there is no risk to health.  But root canal treated teeth are different than teeth that still hold their nerve and blood supply: they are more brittle and more prone to fracture.  Most fractured teeth can be reconstructed with some kind of post and a crown.  Some fractured teeth break in such a way that they can’t be restored and need to be extracted.  Yet on rare occasions there are badly broken teeth that can’t be restored but are still well worth keeping.

 FL, a patient in her 80’s who lives in Florida (and who was also featured in the Summer 2014 Strange, Rare, and Peculiar Newsletter), broke off her upper left canine.  It was previously treated with root canal therapy and had no sign of infection.  But the break was, as we say, “horizontal;” like a tree cut with a chainsaw, flush to the ground.

 Among the options we had for restoring this very visible part of her smile was to make a fixed bridge that included her other upper front teeth as these were covered by crowns that were many decades old and no longer looked good.  Classic approaches to this would have been to extract the broken canine, now just a root in the gum, and replace it either with an implant and a crown, or alternatively, with a bridge that, with connected crowns, tied together at least one tooth on either side of the canine in order to use those teeth to lend support for the missing one.  Both of these options would require extracting the broken off canine root and the final restoration would have to wait for the extraction site to heal and require extra visits—not so easy as Florida is not just around the corner and FL, being diabetic, could have had a long and complicated recovery from the surgery.

 A third option can sometimes be used, especially if there is already a plan to place crowns on multiple teeth near the missing one: a so called, “cantilever bridge”.  This kind of bridge uses support not from teeth on both sides of the missing one, but from many teeth only on one side.  Its main advantage is that it does not require the shaving down and crowning of an otherwise perfectly healthy tooth that would not otherwise need a restoration.  Its main disadvantage is that biting pressure on the unsupported end can cause the bridge to flex—in the same way that a diving board bends down when you jump on the very end. In this case, though the flexing is very slight—barely noticeable—it can cause the glue to loosen on the bridge, possibly leading to decay, or else it can cause the porcelain that is baked onto the gold support structure to form unsightly crack lines. 

 But in this case an elegant solution presented itself: save the root, put a hard flat filling on top of the stump and have the undersurface of the cantilevered canine ‘sit’ on the stump to resist any flexing of the unsupported end.  Although the broken off tooth could not support all of the normal chewing forces, it could very well handle straight, vertical compression and with a cantilever bridge this is the exact force that needs support.  It is like putting a steel I-beam from the bottom of a swimming pool to just a fraction of an inch from the underside of the end of its diving board.  If you walked out to the edge and jumped, the board would not flex downward.  In addition, there is an added bonus to saving this root and having it compress slightly with each chewing motion. There are ligaments that anchor this root into the gum and these ligaments are connected to sensory nerves that transmit the ‘feel’ of chewing.  It is a quality of life thing—the experiencing of ‘crunchiness’ of cookies, the ‘chewiness’ of dried apricots or the ‘flakiness’ of pastry.  These things are diminished with the loss of natural teeth to the point that chewing with full dentures or full implants can be like being tone-deaf or color-blind to the textures of food. This is a point rarely taken into account by dentists when evaluating the options for treatment.

 Keeping this part of the bridge clean is a snap with dental floss as it passes between the stump and the underside of the bridge.  This fix wouldn’t work in the case of someone prone to tooth decay as it would be tough to repair the stump once the bridge is in place.  In FL’s case though, her diet is great and her oral home care is great—just the thing to give me a bit more creative freedom in designing her new smile! 

 Thank you for your continued presence in my practice and for continuing to send me your family, friends, and colleagues. 

 Be Well.

Winter 2015 (2)

Winter 2015

 Imagine that you are at a bank, standing at the teller’s window, and wishing to get her attention you take your fingernail and tap it a few times on the glass partition.  You wouldn’t use the ball of your finger because it would only produce a dull thud, but using your nail creates a distinct ‘tap’.  At the same time if you pay attention to the sensation that this tapping produces on your finger you’ll notice a sharper sense of feeling than if you had just thudded the glass with the ball of your finger.  The tiny ligaments that knit the fingernail to the finger have nerves that sense compression and stretch.  This makes the fingernail a handy diagnostic tool that is often underused in dentistry.

 A tooth is knitted to the gum the way a fingernail is knitted to a finger.  But in the mouth the knitting can come undone and when it does it is often called ‘gum disease’.  Most adults know if their dentist has told them they have ‘pockets’—narrow gaps between the tooth and gum where the graveness is gauged by how many millimeters of knitting are gone.  It is so common for pockets to be caused by bad germs that it is easy to miss any other cause; so common that patients are often treated for years by their dentist or specialist with all assuming that there are germs to kill, teeth to be kept cleaner, and often a need for gum surgery.  These treatments are well and good as long as the problem starts with bad germs.  But when pockets arise for other reasons none of these treatments will fix the problem.  It is like the old saying: “If you’re a hammer every problem can look like a nail.”

 M.S. came to my practice more than a decade ago with a history of being a patient of a periodontist.  She went four times a year to have her pockets cleaned out.  During my examination I found that her mouth was immaculately clean and she had a high quality diet and was physically fit—all factors that make it hard for bad germs to multiply in the gums.  In fact she only had a single tooth that had any gum pocket at all: on her upper right last molar. And though the pocket was seriously deep (6mm) it was only present on one side of her tooth.  She came for a second opinion as her periodontist wanted to place a slow release antibiotic into this pocket to help it to ‘heal.’

 In my experience the presence of a single gum pocket points away from overgrowth of bad germs, pointing instead towards something peculiar going on with that particular tooth: food wedging, a lack of bone support, or some kind of bite problem that stretches and tears at the knitting that anchors the tooth to the gum.  Bite problems are often missed because they are barely mentioned in dental school; it is only if a dentist has gotten post graduate training in the subject that he or she can understand how these issues can lead to gum pockets and what must be done to fix the underlying problem.

 I suspected that this one tooth had a particular kind of bite problem that was perpetuating her gum pocket.  Sometimes teeth shift or wear into each other in a way that causes them to hit unevenly.  In this case I suspected that her lower molar was hitting this tooth not in its center but more towards its outer edge, producing a tipping force leading to what I call,  “a slow motion extraction’.  I put my fingernail on the outer side of the tooth and had her tap her teeth together several times.  Sure enough my fingernail detected the same kind of feeling as when you tap on a pane of glass with your nail: a sharp ‘tap, tap, tap’ when her teeth came together.  This confirmed my suspicion and after repeatedly reshaping the biting surface of this molar and rechecking with my fingernail, I was able to allow her teeth to come together without the tooth being jostled in its socket.  As the trauma had been going on for a very long time I knew it would take a long time for her gum pocket to heal. But she made steady improvements in this area and after just under two years this gum pocket was completely healed and her ‘gum disease’ was cured.

 Thank you for your continued presence in my practice and for continuing to send me your family, friends, and colleagues.

 Be Well

Winter 2016

Winter 2016

   From time to time we all need a little help.  Several years ago I managed to tear the rotator cuff in my shoulder; not so badly that it needed surgery but enough that I had limited strength in that arm for the year that it took it to heal.  I didn’t realize how this injury would limit me until one day at the supermarket I found it difficult to lift shopping bags from the counter into my cart.  The bagger, a strong fellow, asked if he could help me get the bags into my car. I was first taken back by this as I considered that kind of help appropriate for the elderly or the frail and I was not feeling to be either. But it dawned on me that I really could use a little help and I gladly accepted his offer.

 

   From time to time teeth can need a little help too.  And it falls to me to determine just how much is appropriate and what form that help ought to take.  R.L.K, a long time patient who lives in Las Vegas, came in to have an upper molar, second tooth from the back, crowned.  At that appointment I noticed that her upper wisdom tooth, just behind the one I was going to be working on, was a little loose.  This surprised me as R.L.K. is a master when it comes to a healthy lifestyle, a good diet, and great brushing and flossing habits. I suspected that her bite had worn into this tooth a bit too deeply causing it to loosen as she chewed.  I adjusted the bite to take chewing pressure off and was then faced with what to do to stabilize it, as it was unlikely to firm up all on its own.  The usual options both seemed too extreme: fusing the loose tooth to the one in front of it by making a two crown ‘splint’ or extracting the tooth. The fusing is appropriate when the loose tooth would never heal without this procedure—but in this case the situation wasn’t that bad; in addition it would have doubled the cost of her care and made it very difficult to ever floss this area again and R.L.K. loves to be able to floss her teeth! And extraction would have been like ‘killing a fly with a cannon’.

  

   I thought deeply about if there might be a way to design the new crown I was already working on to offer this other tooth just a little bit of help—and I came up with something readers of my newsletter series will recognize that I refer to as, “an elegant solution.”

 

   In this case the looseness was limited to the tooth moving from its ‘home position’ to flexing outward towards the cheek.  It was not loose in any other direction, so the help needed was just something to assist the tooth when biting forces would cause it to deflect in that direction.  By slightly altering the shape of the flossing contact of the new crown so that it slightly wrapped around the outside of the wisdom tooth, I could use the strength of this second molar to help hold this wisdom tooth in place.  It would be like standing next to a person who was being blown by a strong wind and putting a firm hand on the back of their shoulder—just a little bit of help.  The fix worked perfectly and R.L.K. was immediately able to master flossing this newly shaped tooth.

 

   Help takes on a lot of forms.  I wrote about this in my second book, The Charm Carver.  As a bonus, I have reprinted an excerpt from the chapter entitled, “Help”, here for your reading pleasure. 

 

   Thank you for your continued presence in my practice and for continuing to send me your family, friends, and colleagues. 

  Be Well

          

 HELP

 (from The Charm Carver ©2005.   D. Shuch, Integrative Arts Press)

     “Ah Madeline!  When I was small I saw a girl cry at a kiss from an ugly boy.  His kiss was like a shackle being added to her chain.  Later on I broke my arm and a kiss stopped me from crying.  A kiss can be a thousand things and some of them are helpful.  And I have learned a few of these, but never could I master every kind of kiss. 

   “And years ago our king was killed by an evil potion.  Yet I have been at deathbeds, and seen the moribund revived, with finely crafted potions made from sacred flowers.  Potions can be many things and some of them are helpful.  And I have learned a few of these but never could I master every kind of potion.

   “And when I was a quarryman, mining blocks of stone, my foreman enslaved us with hard, heartless tasks.  Yet some of these lifted the ignorance from me. A task can be a thousand things and some of them are helpful.  And I have learned a few of these but never could I master every kind of task. 

   “And I have looked for answers and some cost me dearly when they weren’t true.  Yet others, like the sun above illuminate my days.  Answers can be many things and some of them are helpful.  And I have learned a few, but never could I master every kind of answer. 

   “And questions still fill me.  And I have held questions that torment my soul and I have held others that light the unknown.  They can be so many things and some of them are helpful.  And I have learned a few of these but never could I master every kind of question. 

   “And I have seen blessings that bind souls to idols, while others align them with the Devine.  Blessings can be many things and some of them are helpful.  And I have learned a few of these, but never could I master every kind of blessing.

   “But charms for me are different.  Carved with bad intentions they are like millstones, weighing one down even to Hell.  Yet carved with good intentions and clarity and light, they illuminate the link that binds a soul to Heaven.  A charm is but a wish, confined, but to be of any help, the wish must be weighed, the stone must be known, the carving precise; the polishing, perfect.  And I have only shown you precious few of these.”