by Shirley Gutkowski, RDH, BSDH
I sat on the stool in the oral surgery suite at the Marquette Dental School. I was trying not to be offended by the dental assistant wondering what the heck I was doing there. They don't let people observe during surgery. It's against the rules, and the assistant told me that Renate will never remember if I was there or not.
There are no rules. Renate has been my friend since junior high, and she is losing her battle against cancer — not with recurrent tumors but an insidious malady called radiation caries. Today she's losing her maxillary teeth, as well as numbers 18 and 29.
The doctors saved her life and diminished the quality of her life to a point where she was considering suicide. Her dental pain was so great that without the upcoming date to have these teeth extracted she couldn't go on. The constant pain from her teeth percolated through two 650mg tablets of Darvocet and 10mg of Vicodin every four hours. The extractions were to be sweet relief to her never-ending pain.
Eating was unmanageable. Bits of tooth, undermined by decay, broke free constantly, interfering with chewing. Speaking more than a sentence was difficult without an ever-constant source of liquid.
Renate appeared calm on this day, and so did I. I didn't start out as a dental assistant. I've always worked in a setting where the doctor did dentistry down the hall, and I did dental hygiene in my little corner of the building. As a hygienist providing preventive care, I don't get to see it all. Sometimes I see bits and parts of procedures; I've even been asked to assist in an emergency extraction of a tooth on occasion. But this level of oral surgery was new to me.
As we waited for the doctors, she started to tell me about the conversation that she had during her oncology appointment the day before. Her doctor was showing a resident oncologist the ropes. He explained a little about Renate's history to the new doctor, how her primary lymphoma tumor was on the spine. How she survived surgical removal of the tumor and walks, even though the odds were very much against her ever getting out of a wheel chair. He explained how the chemotherapy made the tumors shrink and the metastasis show up on the base of her tongue a short time after the proclamation of remission. He told the new doctor of her stem cell transplant, and her three-month isolation in the hospital while she lost and regained rudimentary immune functions. The oncologist explained that they thought her dose of radiation was low enough not to warrant shielding to protect her salivary glands.
Renate interrupted his litany of her accomplishments and set the aspiring oncologist straight. "There is no dose of radiation that's low enough," she stated. "All head and neck radiation patients should have shielding of the salivary glands."
She told me how she explained to this brand new oncologist the discomfort of her tongue sticking to other tissues in her mouth without the benefits of life-giving saliva. She told him how she couldn't swallow or talk once the saliva stopped.
She told him of the agony she was in, her teeth chipping and caries so rampant that there was no keeping up with it. Renate told them of the sharp edges she had to try and eat around just to maintain mucosal integrity, which is imperative for survivors of stem cell transplant patients. Her immunological responses are still all-but-gone.
She showed him her decaying teeth, the caries already progressing around restorations placed months ago by dental student Andrew Kissell. The pain she described caused her to concentrate on ways to kill herself — a menacing thought that was all-encompassing, all-distracting, all-consuming. She constantly had to distract herself.
She dared the oncologist to take one last look at the teeth scheduled for extraction the next day. Then she ordered him never to give radiation therapy to another patient's head or neck without a proper oral evaluation. And she took a breath.
I cheered her on! I was happy that she didn't mind being a teaching case. One of her goals now is to make sure that this never happens to anyone else. The miracle of life-giving cancer treatments, for her, robbed her of a quality of life that made hers almost not worth living. The appointment today, the one to extract 15 teeth, was her light at the end of a wretched tunnel.
It's difficult to pin down the cause of radiation caries. It could be one of two issues — the lack of saliva, or radiation dosage to the teeth. I'm still trying to work that out. Are teeth damaged by radiation? Does radiation make them more susceptible to decay, or is it all in the lack of saliva?
As Renate relayed this event to me, I couldn't help but try to figure out which dentist I knew or had ever worked with over the years who would have done anything for her if her oncology protocol included an oral exam by a dentist. Mostly, I hear dentists talk about fluoride trays for people who have head-and-neck radiation treatments. If that's the only recommendation, then I'm afraid that it's wholly inadequate. Even last week, the dentist overseeing the students in the clinic admonished her to brush better! Brushing better wasn't going to make one lick of difference.
Shortly after her radiation therapy, as soon as I found out what they did to save her life, I contacted my dental friends at Sci.med.dentistry and asked them what I could recommend to her to help her maintain her teeth. The only information I got was brush, use fluoride trays, and Biotene products. I couldn't believe that was all I had to offer. Where is the evolution of dental products for people suffering with this intense level of xerostomia? The devastating option scheduled for today came about from a combination of lack of saliva and replacement lubricants not containing the necessary components to rebuild teeth.
In the beginning, Renate's dentist gave her a prescription for a fluoride gel. It was cinnamon flavor and it burned so that she couldn't use it. The gums and mints I've learned about that contain components to rebuild teeth or confuse bacteria are flavored too strongly for someone without saliva. It's hard to believe that we could radiate a tumor the size of a golf ball on the back of someone's tongue and not have anything to offer patients dentally.
Dr. Best, the oral surgeon, entered the room and cheerily said good morning. He had seen Renate for an evaluation a few weeks before, and he helped Andrew Kissell treatment plan this difficult case. It was determined that, at 3600 rads, the dose was low enough not to need hyperbaric oxygen (HBO) therapy before or after surgery. Didn't he know Renate was contrary? Her physiology is different from nearly everyone else on the planet? I remain silent, staying out of the way.
HBO therapy is helpful in many situations. For oral surgery of radiated bone, HBO infuses the bone with oxygen, a necessary ingredient for rebuilding and healing. HBO therapy is also helpful in diabetics whose extremities (particularly feet) are not healing due to impaired circulation. It appears oxygen is an important element.
Renate was prepped for IV sedation. The new dental school at Marquette is set up for learning everything possible about care and treatment of the mouth. The surgeon dosed her with Versid and some other medications. Renate relaxed a little more. He leaned her back, gave her some dark glasses and started the local anesthetic injections. She nearly flew out of the chair for the right mandibular block, and then that portion of the appointment was done. He injected a total of seven carpules.
I sat in a corner while the surgeon dosed her with the drugs. The others in the room stood off to the side as there was nothing for them to do yet. An oral surgery resident acted as the assistant. Andrew Kissell, the dental student, also stood off to the side with his hands in his pockets. The assistant was assigned the task of errand girl, getting more medication, the doctor's headlight, and other items.
Then the real fun started. The surgeon took a scalpel and flapped the gingiva, then used an elevator on each tooth. The first to go was tooth number two, but it didn't want to leave. Although her teeth were rapidly decaying, the bony support was excellent, and the doctor started to earn his income through problem-solving, brute strength, and sweat. All of the molars had to be sectioned and removed in bits. The majority of the other teeth broke off. The few that didn't break off had active root anatomy — one a figure S. Another had two apicies that bent apart from each other in 90-degree angles like an American eagle preparing to take a fish from a lake. The doctor ordered Versid three more times.
I had a good view from my corner as, one after another, her teeth were replaced by black socket holes. Like fence post holes, they appeared in place of her pearly white broken down teeth. Dr. Best was working up a sweat as if he was using a post-hole digger into the earth.
Alveoplasty was next. It reminds me of liposuction. At first, the procedure sounds elegant. It sounds like a great idea. Adipose tissue gets vacuumed away while under anesthesia. The patient happily wakes up with new hips, new tummy, and becomes a babe magnet. Watching the surgery done, though, is a scary thing. The plastic surgeon jams the tube in and out of an incision, vacuuming away fatty blobs with all the gusto of a young woman cleaning her apartment after a fight with her boyfriend.
All hygienists have heard of alveoplasty; it doesn't sound scary or brutal. Seeing the procedure done isn't pretty. The doctor uses a rasp (like a file only chunkier) and rubs down the alveolar bone to facilitate proper anatomy. Then he sews up the tissue, forever closing up the sockets where just a few hours ago she had her own teeth. The assistant who was so abrupt with me was now apologetic as she cleaned up the room.
Andrew Kissell, the student, had fabricated a beautiful interim denture. The three of us picked out the teeth at an appointment a few weeks ago. They really were a good choice. Without her real teeth, she looks different. With her new teeth in, she still looks different. I've been looking at that face for more than 20 years; it's aged as gracefully as mine. Without teeth, well, she's different. It'll take some getting used to, that's for sure.
She'll have the interim denture until next fall. Andrew will be Dr. Kissell by the end of the semester, and he's moving to the east coast. Renate's plan is to sell her house and move to Missouri where the weather is better than Milwaukee and job prospects are better for her husband. If her husband gets a job with dental insurance she'll get herself a dentist down there. If not, she'll sign up for a dental student at UMKC School of Dentistry when the semester starts next fall. Renate still needs a full upper denture, a lower partial and continual care to keep up with the rest of the decay that will undoubtedly crop up.
I called her on the following day to get a report. Her face was swollen. No surprise there. The surprise was that her face was so swollen that her eyes were swelled shut. She was supposed to be resting, but she just had to strip the floors and bake a cake for a baby shower she was throwing the next day. All attempts failed at getting her to sit the heck down and order a cake. The floors couldn't wait until after the party. Always contrary.
Shirley Gutkowski, RDH, BSDH, has been a full time practicing dental hygienist in Madison, Wis., since 1986. Ms. Gutkowski is published in print and on Internet sites, and speaks to groups through Cross Links Presentations. She can be contacted at [email protected].