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Home: The Toast

homer-simpson-does-not-flossEvery Tuesday I work as a dental hygienist at a practice it took me six years to find.

I’m shocked it wasn’t longer.

I’m extraordinarily selective what dental practices I’ll work in. I’ve treated patients in HMO practices that allowed me twenty minutes of treatment time – that included any radiographs taken, the scaling or cleaning, talking with the patient about proper dental home care, and the examination from the dentist. I always ran behind schedule – one dentist constantly ran 45 minutes behind schedule.

I was let go for speaking up about why HMO dentists can run 45 minutes behind schedule but dental hygienists are not allowed to.

“That’s just life in a dental practice, Eva.”

I’ve worked in “corporate dentistry”: a practice that employed a huge pile of dentists, dental specialists, assistants, and hygienists. The practice was open seven days a week from 8am to 8pm. I had a whopping forty minutes of treatment time with my patients. One afternoon, the dentist/CEO of the business had a “pep talk meeting” with every member of the staff explaining the reason he did not want to treat Medicaid patients:

“They don’t bring in enough production. We don’t want those losers in our practice.”

The “losers” that this dentist spoke of were financially struggling patients on the lower end of the socioeconomic spectrum and had challenges simply feeding their families, let alone paying for exorbitant dental treatment.

I quit a few days later. I never stepped foot into a “corporate dental” setting again.

The industry, as well as dental science, has come a long way. (Thank the gods. Protective gloves were mandated in 1981 – only 33 years ago. Scary.) It’s not easy trying to find the right dental practice that isn’t constantly stressful, truly cares for patients, not full of negative attitudes by staff hurled at each other or towards patients (you read that correctly), or so unethical they make me want to perpetually hork on myself for thinking of working for them ever again.

Why did I keep looking for the right home? Oh, yes, my lovely patients. Practicing clinical dental hygiene is a mentally tough and physically demanding field, but one I’m proud to be a part of.

The practice I now work in a couple of days a week is wonderful. I’ll die peacefully here; the staff will have to pry my corpse, with my dumb-looking, content grin, off of the comfortable operatory chair I adore. Until that day comes, they’re stuck with the strange, geeky woman that wants to bring in microscopes for each hygiene operatory so dental patients can look at the jacked-up oral flora that’s causing their gingivitis.

Come. Let me show you the bacteria that are causing your gums to bleed. Look! Sshh — there’s some now… squeeeee!

Our team consists of me, two other hygienists, our office manager, two dental assistants, and a dentist. We’re a cohesive unit and work very well together — provided there are no voids in our twelve-hour schedule – especially my schedule. I need to be busy all of the time and there’s no time to be bored.

I feel confident my nearly nine years as a dental hygienist has earned me the title of highly skilled. I like both that feeling AND giving myself titles, so I always need more teeth to clean.

One male patient I treated a long time ago in a practice I was temping at apparently had a THING for dentistry so intense that he licked my gloved fingers as I was palpating his intra-oral lymph nodes. That is not an embellishment or overreaction. This man’s tongue was wrapping around my gloved fingers as plain as day.

Some people like the feel of nitrile against their tongues and yes… that did screw with my head. Shudder.

The worst part of that experience was when I explained to the treating dentist what this patient had done, the dentist replied, “Yeah. He’s done that before. He’s weird but he pays out-of-pocket. I’m not dismissing him from the practice.”

That’s another dentist office I did not work for again.

For the most part, I like treating as many patients as possible. I prefer to be as busy as possible. The more mouths I plunge into head-first, the more I learn about patients’ reasons for not flossing, why some canker sores are more recurrent than others, and what possessed little Janey to remove her braces with pliers, a screwdriver, and her fingers (true story.)

I have the best Super-Sonic-Patient-Filled-Twelve-Hour-Tuesday schedule today. They range from simple, adult prophylaxes or cleanings to scaling and root planing therapies to removing subgingival (below the gums) calculus and endotoxins from the teeth roots of my HIV patients to exposing radiographs on emergency patients that present with a fistula (a soft bubble of exudate, indicating active infection at the root apex or failed/previous root canal treatment) to reevaluating a patient that presents with a recurrent, ulcerated lesion on the ventrolateral border of the tongue that is symptomatic, wakes the patient up during the night from the painful lesion, and will not heal.

The last example is…not good. That type of finding may indicate oral squamous cell carcinoma. I hope I never, ever see that in a mouth more than once in my hygiene lifetime. That worries me greatly but it’s uncommon I see malignant lesions of that sort – which is a great thing.

As a Registered Dental Hygienist, I cannot perform any kind of operative/restorative work, or crowns and fillings, in the state I’m licensed and practice in. That’s the job of dentists.

My dental powers are ensuring the foundation of mouths — the teeth, gums, and supporting alveolar bone — is kept healthy by disrupting and controlling the colonized plaque biofilms that cause gum disease and cavities.

How do I disrupt plaque biofilms? With the most badass, dental hygiene equipment I’m getting by UPS today, that’s how.

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Formation of plaque biofilms – don’t get me wrong. They’re jerks but this process is totally interesting.

Today I received some brand-new, shiny, dental hygiene instruments. They are sleek and gorgeous. Their smooth metal and aluminum surfaces seem to sparkle when the sun hits them just right. The power behind their modern technology makes me blush. They could call me “toots” and I wouldn’t mind.

The feeling I get when I see new hygiene instruments is like…I don’t know how to describe it. It’s like receiving very expensive, razor sharp, pointy, water-squirty toys that I get to have fun with while having to act intensely professionally (i.e. without giggling like a dumbass.)

On the surface, my patients see nothing other than the highly-skilled clinician: not overly talkative, quite pleasant, gentle, and guiding them calmly and with care during the length of their hour-long appointment.

Inside my head, however, I’m saying, “Hey-hey! How YOU doin’, Mr. Scaler? You’re looking mighty sharp today, you are. I love you cuz you are my new toy… whee!”

There’s nothing normal about this, I’m aware, but to hold brand-new tools of my trade that will disturb microbial colonies of adverse oral bacteria is a rare delight; most dentists don’t want to pay for new dental hygiene instruments. They’re expensive, so today is a unique day.

My patient notices my sloppy grin as I ease my new ultrasonic scaler into his mouth.

He’s not completely calm. He clasps his hands together and prays before I began treatment. I won’t stop him. If that’s what makes himself feel safe and comfortable he may do that before the start of all of our treatment sessions. It’s crucial he’s as relaxed as he can be.

“Are you OK?” I ask.

I’ve only seen this patient once – years ago. I don’t know this patient well. It’s been a long time since his last prophylaxis so I quickly come to terms with the idea that he’s built up mountains of tartar. The poor man looks very nervous – like he’s going to have a full-on freakout from the new, scary-looking technology coming towards him.

I hope he’s OK. His teeth are going to feel so awesome when I’m finished. He’s in good hands. I hope he feels he can trust me at the end of the treatment. He needs to come back for subsequent re-evaluation visits so I can see if his gum tissue is healing properly.

That’s everything – trust. I don’t know why he’s been away from the practice for so long, but for some reason, his home care went completely downhill. There’s a heavy, generalized amount of plaque and tartar on his teeth. I wonder what happened to his home care compliance. Financial troubles? Depression? There are no changes in his medical history whatsoever. I don’t know.

“Oh, yeah. I’m fine. Is that thing in your hand new?” he asks with a cute, half-smile on his face.

He’s referring to my ultrasonic scaler. New toy, dude!
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H20 and vibration are released from the tip to remove calculus and disrupt plaque

It’s the biggest dental toy in my playpen but it’s also vital for plaque biofilm disruption and breaking off the tartar away from enamel and the root surfaces of teeth. It delivers water and high-frequency, ultrasonic tip vibration that creates cavitation, or agitation bubbles, in the water released by the device. When the bubbles break down, energy is released. When that energy hits a surface – the surface of the bacterial cells that cause gum disease — kablamo.

My dental toy just obliterated this fellow’s plaque bacteria in seconds.

This baby is also capable of removing tenacious, supra/subgingival (above/below gumline) calculus that has been stuck to enamel and roots of teeth for decades. I’ve denied it for years but truth be told – I’m a dental nerd when I watch ledges of ten-year-old tartar break away from teeth from the use of this device. It’s so cool… and so efficient!

After I use my ultrasonic scaler, I continue the calculus-removal process but with conventional hygiene instrument scalers that smooth out the enamel and roots of the patient’s teeth.

It’s imperative these scalers of various sizes, shapes, and density are incredibly sharp. The sharper the dental scaler, the less pressure I’ll have to place against the patient’s teeth; they’ll do most of the work for me without making the patient feel like I’m going to press their teeth down their throat.

His gingival tissue is bleeding a lot. I had a feeling it would. He’s going to be sore after this treatment. I hope he starts flossing again. I won’t ask him why he’s been away for so long but I can’t help wondering why he’s been away for so long. I’m just so pleased he’s here now and his gums can begin the healing process. I need him to floss morning, noon and night until his gum tissue starts shrinking and healing around the necks of his teeth.

I don’t know if he’s the kind of man that would get twitchy or embarrassed talking about any kind of ‘tissue shrinkage’. Some men should be made aware that shrinkage, in this case, is a good thing, but some men are easily offended and don’t take any kind of shrinkage anything to be a positive trait.

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Calculus or tartar on root surfaces. Now you see why we tell you to floss? It’s because we love you.

As soon as the calculus is released from the tooth, I ask the patient what he feels.

“I feel… oh, wow… I feel spaces between my teeth. That feels strange… but good.”

This is the first time in a long while that he has felt his natural teeth not encased by dental calculus.

His eyes widen. The patient has a look like, “Wait… is this normal?” I let him just feel what teeth are supposed to feel like.

“Are you alright?” I ask.

“Yeah… it’s just weird. I feel like I’ve lost five pounds from my mouth.”

We both laugh. In a sense, he’s correct. His calculus is thick, tenacious, and dense — possibly indicating it’s been there for a very long time. How long is unclear but the dark brown color of his calculus suggests more than five years.

To be honest, and I can say this definitively, the adverse oral bacteria that cause these communicable diseases are a bunch of opportunistic jerks. Oh, yes. Plaque is transmittable, contagious. But what’s worse, these (gram-positive/primarily aerobic) microorganisms, such as Streptococcus mutans and Porphyromonas gingivalis (gram-negative/primarily anaerobic), can be controlled and kept to a minimum, by us, every day, with electric toothbrush and floss use.

More work. I know. Tough love, my lovely patients. It’s good for you.

I’m not going to candy-coat this (bad pun, sorry); these bugs are prolific, little crappers that force us to work daily to diminish their colonization numbers so they don’t eat away at the bone that supports our teeth.

Loss of alveolar bone support means teeth mobility. Increased teeth mobility results in loss of teeth.


As I approach my ninth year of practicing clinical dental hygiene, I convince myself I have seen some of the worst cases of refractory periodontal/gum disease, rampant childhood caries, or some of the least aesthetically-pleasing and dangerous, restoratively-made dental work this side of the galaxy.

All of those concerns disintegrate, as if they never existed, when I see a new patient today, a seventy-five-year-old man that has not visited a dental practice in almost two decades and presents with the following:

Type IV Advanced Periodontitis with more than 30% Class III tooth mobility and bone loss; life-long smoker and alcohol drinker; diagnosed with Type II diabetes less than six months ago, undiagnosed hypertension with blood pressure reading at time of appointment of 188/99, his breathing is laboring even when he’s been resting in my operatory chair for twenty minutes while his legs and ankles exhibit swollen and edema-like signs, possibly indicating undiagnosed Chronic Obstructive Pulmonary Disease.

Apart from all of his oral and physical manifestations he wrote down on his medical history form that may be killing him…he’s lonely.

He talks to me about the recent death of his wife of thirty years who he misses smoking cigarettes with, how his adult kids don’t visit him anymore, and that he only watches FOX News, all day, by himself, until he goes to bed.

He tells me the only reason he came to the practice is his next door neighbor telling him his “breath smells bad.”

I find I interrupt his casual talk frequently, though in as friendly a manner as possible, as I attempt to take full-mouth radiographs of his teeth and alveolar bone.

Some of the worst dental-neglect cases I’ve seen were my first year out of school at an HMO practice. There was so much calculus on a particular patient’s mouth’s upper right quadrant that I had no idea how to approach breaking down the tartar mass that covered up nearly all three of the molars in question.

(This visual is important: try to imagine three of your teeth completely encased in calcified, dark brown and black, cauliflower.)

Back to present day: the worn, lonely, but friendly patient in front of me that idolizes Bill O’Reilly has dental calculus that encases almost every tooth in his mouth, sans his top two front teeth.

This is now the worst case I’ve ever seen.

I hold a mirror up to his mouth to show him the calculus that has been building and building up over the years. Upon inspection, he states, “Ohhh…that’s not supposed to be there?”

My patient doesn’t even realize there is anything wrong. All he does is smile and laugh.

I have so many concerns about this new patient I honestly don’t know which to address first. He recently had his left knee replaced with a prosthetic so he’ll need to be premedicated with an antibiotic prior to any scaling/root planing therapy he must have. I need to contact his general physician to find out when his last physical took place, double-check if he has any medication allergies, when or will this patient be prescribed medication for his hypertension, blood tests to determine if there is liver damage due to chronic alcohol intake, how did the patient travel to the office: if he opts for sedation, who will pick him up and take him home?

And my concerns go on…

The dentist says we can’t start any treatment on him today due to my list of concerns and the doctor’s agreement. We’ll have to wait.

In the meantime, my new patient and I talk. We talk about how long he’s been a smoker, if he has any hobbies, his grandkids he rarely sees, and his favorite television shows.

As serious as this patient’s oral condition is, I couldn’t help but feel happy with him. It was strange.

Even with his teeth completely covered in plaque and tartar, along with the rest of his body decaying away, I feel he is simply pleased and tickled pink that someone, anyone, is validating his presence; giving him attention — feeling a connection with someone.

I don’t think he gives a damn about his teeth. I think he just wanted someone to talk to.

My hope is to continue treating this man for the rest of his days. I don’t know how long that will be but that thought makes me happy. I want to help him.

I’ll also need time to convince him flossing is good and Bill O’Reilly is a demon.

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Eva does freelance writing and is a fan of science, baking, and animation.

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