Living with Scleroderma

Reflections on the Messy Complexity of Chronicity

dental implants

Chopper Talk

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It is most delightful to have my molar back. As in my back right lower jaw, which has been missing that tooth since last April, when a painful, resorbing root sent me to my periodontist for an extraction. No fun, that. Nor has it been a treat to eat with a large gap in my teeth in the grinding department. I’ve had to be extra careful for months to thoroughly chew my food, mostly on the left side, to be sure I can actually swallow safely.

Ah, the joys of scleroderma dental problems. And esophageal dysmotility.

But my new post and crown, inserted on Monday, fits perfectly. It’s an odd feeling. What is that thing in my mouth? Oh, it’s a molar! No longer can my tongue wander into the gap for a little exercise. No longer must I consider whether to mush food with my lower gum on the right or chew on the left. No longer does my right cheek sink in ever-so-slightly over my missing tooth.

Fitting the crown and inserting it proved to be the usual challenge in my tight mouth. A month ago, I had to help the dentist and his assistant insert the molds for my upper and lower jaw, because it was easier for me to figure out the right angle than for them to try without stretching my lips to intolerable tension. Yesterday, it took more lip contortions and some deep breathing on my part as my dentist screwed in the post for the crown—not easy for either of us. But it’s done, and it feels amazing.

Turns out, my dentist told me, he had just needed an extraction himself of one of his front teeth. He has a partial, temporary bridge, so you can’t tell, while he traverses the long process of implants and replacement. I found this encouraging, not only because he uses the same periodontist that he’s sent me to (definitely a good referral), but also because one of the next teeth I may lose due to scleroderma resorption is also a near-front tooth. We’ve been monitoring it for years.

Hopefully, it will continue to take its time. But it’s reassuring to know that, whenever the inevitable comes, I won’t have to look like Alfred E. Newman for months until the procedure is complete. Meanwhile, I will enjoy having a full set of choppers. Carpe diem—or should I say, carpe dente? Maybe not. I don’t want anyone seizing any more of my teeth for as long as I possibly can.

Evelyn Herwitz blogs weekly about living fully with chronic disease, the inside of baseballs, turtles and frogs, J.S. Bach, the meaning of life and whatever else she happens to be thinking about at livingwithscleroderma.com. Please view Privacy Policy here.

Image: Stefan Steinbauer

Implanted

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Three-and-a-half months have passed since my latest resorbed molar was extracted, and Monday was the big day for the next step: drilling a hole in my healed jaw and screwing in the implant. When I had my checkup with my periodontist two weeks ago and he proclaimed me ready, his receptionist joked, “Want to come back this afternoon?” Most certainly, not.

I did my best not to dwell on the pending procedure. On Sunday, we got to the beach once again, this time on Boston’s North Shore, for a beautiful afternoon of perfect sunshine, light sea breeze, and warm enough water for me to wade up to my waist several times. Just the right distraction.

I busied myself with writing Monday morning, but as the hour grew near to go, I briefly imagined just staying home and not being my normal Do Bee self. The Do Bee won out. On the 45-minute drive to my periodontist, at least the WGBH radio hosts were talking about something amusing: what listeners watch on TV to ease the stress of the daily news cycle. (Marie Kondo was a favorite.)

Then came waiting for the procedure to start. When I’m anticipating dental work, I really have to force myself to stay in the moment and not get overwhelmed. Sitting in the reclining dental chair, covered by paper drapes, I studied the art on the wall (an interesting abstract painting, not your typical bland office art), the plastic wrapping around the overhead exam light’s handles (why does it need extra covering when they’re wearing gloves, anyway?), and contemplated how much plastic waste that medical providers generate in the interest of sterility. (Literally, tons. According the Journal of the American Medical Association, health care facilities are the second largest generators of waste in the U.S., producing 4 billion tons annually. That’s a lot of disposables, including a lot of plastic.)

Fortunately, my periodontist and I enjoy similar music during these procedures, which are strenuous for both of us. As he injected local anesthetic into my gums, I focused on Vivaldi. This was especially helpful as he prepared my jaw for the implant, which involved a lot of scraping and pressure and pulling my tight mouth into very uncomfortable distortions. The selection was Vivaldi’s Violin Concerto in A Minor, which I played years ago in high school, and I could still remember some of the bowing.

Then came the drilling. This drowned out all the music, causing my entire skull to vibrate. The hardest part was getting the drill and suction and other tools into my mouth. But he managed, thank goodness, and the worst was over in about twenty (long) minutes. Screwing in the implant took some manipulation, but at least I could rest my mouth in-between the different steps. As he’d predicted, we were finished in under an hour. Definitely easier than the extraction, which took twice as long. He was pleased with the result, and I finally relaxed.

After a 45-minute drive, plus waiting at the pharmacy for antibiotics (always a necessary precaution for me), it was a relief to get home. Another three months of healing and trying not to chew on the right side of my jaw, and then it will be time for my dentist to put in the crown. Much as I dread this procedure, I’m glad I took care of it sooner than later. Being a Do Bee—on my own behalf— paid off. (And for those of you who remember Romper Room, here’s the official Do Bee song.)

Evelyn Herwitz blogs weekly about living fully with chronic disease, the inside of baseballs, turtles and frogs, J.S. Bach, the meaning of life and whatever else she happens to be thinking about at livingwithscleroderma.com. Please view Privacy Policy here.

Image: Jenna Lee

Another Extraction

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So, I was hoping that my resorbing molar would hang in there at least until the summer. Not to be. After a brief hiatus a few weeks ago, the tooth began acting up, with no signs of abating. Last Monday, I realized I needed to take action, because the coming weeks are busy with Passover and travel plans, not to mention my birthday later this week, which I was not about to ruin with a toothache.

Fortunately, my periodontist was able to fit me in last Wednesday. I tried not to think about it too much in advance, and there wasn’t much time to angst, anyway. A good thing, because it is such an unpleasant experience. My periodontist is very skilled and has incredible patience, both essential to extracting a big molar from the back of my jaw when I can’t fully open my mouth due to skin that remains somewhat tight. But it’s a struggle—for both of us.

The main problem, other than simply getting all the tools in my mouth and the constant tugging at my less-than-flexible lips, was that the ligament surrounding my molar had been destroyed, thanks to scleroderma. This is the membrane that enables the tooth to wiggle when loose and be easily pulled out. Instead, as had been the case the last time I had this procedure done, the roots of my very big molar had fused to my jawbone. So he had to drill them out. Not fun. I tried to calm myself by listening to the soothing classical music in the background and focusing on my breath, which definitely helped.

Because he had to drill so deeply, it took a lot of novocaine to numb my nerves. He finally used a combination of novocaine and epinephrine, which has the advantage of intensifying the local anesthetic, but the very big downside of causing my heart to race and giving me the shakes for a while after the shot. I absolutely hate the stuff, but had not realized I hadn’t told them in advance. So that detail will go into my chart for next time.

The whole process of extricating the molar, taking an X-ray to see if he’d gotten the whole root, drilling some more, then inserting the bone graft and stitching me up again, took about two (very long) hours. Knowing it would be hours more before the novocaine wore off (my body processes anesthesia very slowly), I drove 45 minutes back to my home pharmacy, picked up medication (and was pleased that my new Medicare Part D pharmacy card works), got home, finished up loose ends of work, and then lay down with an icepack on my jaw. (Icepacks are tricky, because they can set off my Raynaud’s, but better to put up with that than have a really swollen face.)

Five days later, my jaw continues to heal. Swelling is receding. One of the stitches already fell out on its own, as expected. It’s not comfortable, but significantly improved from the nerve pain that was only going to get worse if I waited any longer. I charged the expense to one of our travel credit cards, so at least we’ll get some points from the ordeal.

I’m glad it’s over, and that it will be mid-summer, at least, before the next step of drilling and inserting the implant that forms the base for the crown. I’m also glad that the gap in my teeth is not visible, so I don’t have to look like Alfred E. Newman for the next nine months. I’m very grateful that we have the resources to deal with this, and I really, really hope that it will be years more before I have to go through it again.

And, so, another tooth bites the dust.

Evelyn Herwitz blogs weekly about living fully with chronic disease, the inside of baseballs, turtles and frogs, J.S. Bach, the meaning of life and whatever else she happens to be thinking about at livingwithscleroderma.com. Please view Privacy Policy here.

Image: Daniel Frank

Chew on This

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Last week was one of those weeks when I burned up a lot of time going to, being at, and going home from medical appointments. Most were routine and anticipated, but one was not: a visit to my periodontist.

One of the rarer complications of scleroderma is resorption of tooth roots. As my periodontist has explained it to me, my body thinks some of my teeth are invaders and begins to attack the roots like PacMan (albeit much slower). I’ve lost four teeth to this phenomenon over the years. Two were lower rear molars that were simply extracted, and two others involved extractions and implants. My dentist has identified two other teeth that are endangered and has been monitoring them for years.

A couple of weeks ago, one of those teeth announced it was not happy, provoking unpredictable waves of sensitivity in my jaw that felt like a dull ache. I have no idea what caused it to spark. I was not pleased.

When I saw my dentist to get his opinion, he was quite candid. At some point in the not-too-distant future, I would need to go through the expensive process of another extraction, implant and crown. So I made a follow-up appointment with my periodontist to see what steps I needed to set in motion.

By the time I saw him last Wednesday, the tooth was calming down. He took a look and confirmed that my molar was, indeed, on the way out. But he also said that it was really up to me to determine when to take action. If the pain were tolerable or even reduced to background noise, I could leave it be until it inevitably got worse. I could also just have it extracted and skip the implant, but that didn’t make a lot of sense, given the fact that I don’t want to have any more issues chewing and swallowing than I already have (more complications from scleroderma and Sjogren’s Syndrome).

So, I decided to wait. Sure enough, a week later, the molar is relatively silent. I know I will undoubtedly have to deal with it over the summer, but at least I don’t need to jump.

This decision is made more complicated by the fact that I have to switch over to Medicare by the end of the month. All of the supplemental dental plans have a 12-month waiting period for the kinds of procedures involved—unless I stick with my current provider, in which case they might wave that waiting period, but I have yet to confirm.

Even with dental insurance, for which you pay a decent chunk of change, there is typically an annual benefit cap of about $1,000 or a little more. As my periodontist observed, I have to be really sure the premiums are worth it, given that what I’d receive is only about an eighth of what the process will cost. The net benefit is small.

While I’m fortunate to have the financial means to have options, the tradeoffs are infuriating. Why is dental insurance so lousy? Especially as you get older, keeping your teeth is as important to your overall health and well being as staying in shape. It’s not a vanity project. It’s about being able to eat comfortably and safely. It’s also about avoiding complications of infections and other serious dental health issues. But so many people cannot afford the care necessary to preserve their teeth that the simple act of smiling is a very visible marker of social class and economic disparities.

All of which is to say that as our nation wrestles with the question of whether and how to provide universal health care, we must make sure the conversation includes dental health care, as well. Our mouths aren’t separate from our bodies. We can’t just swallow the status quo.

Evelyn Herwitz blogs weekly about living fully with chronic disease, the inside of baseballs, turtles and frogs, J.S. Bach, the meaning of life and whatever else she happens to be thinking about at livingwithscleroderma.com. Please view Privacy Policy here.

Image: Umanoide (And no, those aren’t my teeth.)

 

Crowning Glory

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At long last, ten months after I had to have a painful molar extracted, I finally have a full set of teeth. Nasty old 19, which nearly ruined a weekend vacation in New York City last May, has been replaced by an implant.

None of this has been fun. My scleroderma creates many complications for dental work, especially much difficulty opening my jaw wide enough for my dentists and hygienists to manipulate all the probes and pics and suction tubes and needles and pliers needed for the various steps in the process.

Despite the fact that the roots of my molar had resorbed to the point of exposing the nerve—a rare complication of scleroderma—pulling the damn thing out of my jaw was quite the ordeal last spring. My periodontist, whom I trust implicitly, had to drill it into pieces and extract it by segments, because the roots just didn’t want to let go.

After my gums healed up, the next step was a bone graft. Then setting in the foundation for the implant. All of this required long visits, a lot of Novocaine, and much pulling and stretching of my lips and cheeks, which don’t have much give. Plus months for my gums to heal, in-between. 

Finally, in February, I was ready to go back to my dentist and get impressions made for the crown. He, like my periodontist, understands how hard it is for me to keep my mouth open wide and is always as careful as can be, apologizing whenever I wince. But there’s just no getting around it—even when he uses the smallest tray for the impression or whatever, it hurts. I always feel like my lips or cheeks are about to tear.

Last week, my new 19 arrived. I went to the dentist Wednesday afternoon, looking forward to getting it over with, at last, and being able to chew thoroughly once again—without taking twice as long as normal (which is long enough already) to eat a meal. My dentist tested the placement three times, made adjustments and set in the molar. But when the cement dried, it had settled too close to the next tooth, so he had to jigger it a bit so a piece of floss would pass between the two teeth.

When I left, I noticed a crunching sound inside the molar when I bit down, but I told myself it was okay. I enjoyed chewing a piece of gum—on both sides of my mouth—on the drive home. But by evening, it was clear that the crown was loose. I could click it with my tongue. Saliva was pooling under the base. The left side of my tongue was really sore from all the poking and prodding earlier that day.

So on Friday, I made another 80 mile round trip, back to my dentist, to have the crown reset. I was frustrated, but there was no point in getting angry about it. I can’t open wide, and that makes it much harder for my dentists, no matter how good they are, to do what needs to be done.

Fortunately, this time, the procedure was successful. Ninenteen is now firmly in place. My tongue has healed up from the second round of poking and prodding, and my inner cheek has gotten used to feeling a tooth instead of a gap. I’m still relearning how to chew on the left side. I can’t sense food through the crown the way I can with a real tooth, so it’s taking some practice.

We’re still catching up with all of the dental bills, too. Insurance only covered about a fourth of the $7,500 total—better than nothing, certainly, but still. Talk about sticker shock.

But I can chew again. You don’t realize how important each tooth is until you lose one. Missing that molar has increased the risk of gagging on food, which happened far too many times over the past ten months. I’m grateful that I have excellent care, that I’m able to work my schedule around all these appointments, and that we’re managing to pay for it. There will undoubtedly be another tooth that needs replacing at some point in the future, but, with any luck, it won’t be any time soon.

Meanwhile, pass me the biscotti.

Evelyn Herwitz blogs weekly about living fully with chronic disease, the inside of baseballs, turtles and frogs, J.S. Bach, the meaning of life and whatever else she happens to be thinking about at livingwithscleroderma.com.

Photo Credit: Kitchen Wench via Compfight cc