“How do you manage to extract teeth with this forceps? Its beaks do not close and they are blunt. There is no grip. It slips.” That was my son who seemed to be experiencing some difficulty with the extraction he was attempting. He was using one of my extraction forceps, a veteran instrument with more than five thousand teeth under its belt and still going strong (as I thought). He put it down, removed his gloves, rubbed his finger, and looked at me accusingly for providing him with substandard equipment. “The forceps slipped and fractured the crown. Why can’t you throw this out and buy a new one? ” He is just out of the college after getting his post graduate degree in dentistry and has joined me in my clinic.
“Throw the forceps out? What do you mean? I have extracted not less than five thousand teeth with it and it is good for another five thousand.”
“That is precisely what I mean. It has been used so much that it has gone blunt and the gap between the beaks is as wide as India gate. You just can’t get a firm grip with that.”
“The defect is not with the forceps but with your technique. If you cannot extract the tooth, tell me and I will show you how to do it. Don’t blame the forceps.”
“Given a proper forceps I can very well extract any tooth. We have not been taught to extract teeth using pre historic tools like this.”
“If you can’t do it, just leave it there. I will finish this filling and takeover that case.”
This is a sample conversation that can sometimes be heard in my clinic these days after my son entered my practice. Most of the time we manage to work as a team but once in a way such exchanges erupt.
“You call this an operating light? A candle would be brighter.”
“Why does the compressor make such a big noise. I am surprised our neighbours have not complained of noise pollution”
“Are you still using ZOE paste for impression? The only other tube of ZOE (zinc oxide eugenol) that I saw was in the museum” - are few more examples of his observations which irritate me and which start a strong debate.
My clinic is set up to suit my requirements based on the type of work I do and based on my abilities, both professional and financial. Things have been added and deleted to and from my original equipment. I do not find anything lacking. My son, just out of college, with pictures of latest techniques and equipments fresh in his mind is not finding it easy to adapt to my haphazard (as it seems to him) set up. And his lack of experience adds to his troubles.
I washed up after the filling and went over to the other chair where the hapless patient waited with his mouth open and teeth numb, praying silently and waiting for his tooth to be out. Fortunately our exchanges are in Kannada and our Konkani speaking patients are blissfully unaware of our short comings.
I checked for numbness. My son’s numbing injection was working. The forceps had slipped, breaking the tooth a bit and causing some minor injuries to the gums (and probably to my son’s fingers too) but that did not matter. With the confidence gained by having removed more than fifty thousand teeth, I applied the forceps to the tooth and gave a firm tilt. The tooth did not move. I applied additional force. Nothing . I tried to move the tooth in the opposite direction. No use. I applied even greater force, the forceps slipped and the tooth broke at the neck with a loud noise. The patient jumped and the root remained firmly where it was. Ideally, it should have been the other way round.
My son lifted his head, opened an eye, removed an earphone from one of his ears and looked at me enquiringly. (Having left the case to me he was sitting at the table, eyes closed, his MP3 player on and the earphones plugged to his ears - annoying )
I nodded my head.
“You had already fractured the crown and may be the root is also curved.”
“What are you going to do now?”
“I will do an open method.”
(An ‘open method’ incidentally is what we do when there is not enough tooth to get a grip with the forceps. The root of the tooth will be inside the jaw bone under the gums out of reach of forceps. In such a case we cut a bit of the jaw bone around the neck of the tooth so that we can expose more of the root and get a hold to pull it out again. It is done by chipping off the bone at the intended place with a chisel or drilling it out with a bur - a small ‘drill bit’ like thing)
“You have bone cutting burs?”
“I do have them but I don’t use them. I use a chisel for my open methods”
“Using a chisel? As I hear, they were very popular when dinosaurs were around. Haven’t heard of anyone using them these days.”
“I do. Even though the procedure looks somewhat barbaric, using a chisel is simpler, faster and less damaging to the bone.” (The dentist positions the chisel on the part of the bone that needs to be chipped off and the assistant hits it with a mallet - if you have seen construction workers cutting steel bars using chisel and hammer, you know what I mean)
“I feel a bur is better. But do it your way.” He plugged his earphones back into his ears and closed his eyes.
“Switch off that MP3 player, come here and observe what I do. I am sure this is not taught in your college. It may be useful some day.”
He reluctantly detached the MP3 player from his head and came over.
I positioned the chisel. I asked my helper to hit it. She hit and the chisel slipped. I told her to hit it straight on the head - of the chisel I mean - and not from an angle. She got some hits right but nothing happened. The trouble with this chisel and mallet is that both the operator and the helper should be experienced in using it. The hit from the mallet should produce optimum force. Enough to cut the bone but not to cause extra damage. This helper was new and not much experienced with the procedure. I asked her to hit harder and she hit with all her force. The chisel cut through the bone, chipped off the root and fortunately stopped before fracturing the mandible (Lower jaw).
“I hope that the mandible is not fractured. Don’t waste your time and torture the patient more. Use the bur.” - My son.
“She is not able to understand what I mean. I hope you as a dentist do. Don’t stand there making comments. Take that mallet from her.”
“Don’t make me a partner in the crime. Use the bur” he repeated.
I was about invoke my authority and ask him to shut up and take the mallet but then I noticed that the patient was getting wary of my surgery. The bur may generate heat and damage the bone but it is definitely more comfortable to the patient. I took the bur and within minutes had drilled out required amount of bone and loosened the root. I could take it out without even using the forceps but just with the use of an elevator, a screwdriver shaped thing with which we prise the tooth out. The job was over.
My son was smiling. He did not say “See? I told you” but his smile did.
“You need not be so smug” I said “there would have been no need for an open method if you had used the forceps properly right in the beginning and avoided fracturing the crown. Now suture the wound and finish.”
Suturing usually is the job of underlings. But it is also true that I have difficulty doing it and my son does it better.
Making sure that he remained in the clinic, I washed and went into the house to call our material supplier, out of my son’s hearing, for a new forceps and a supply of bone cutting burs.
When my son joined dentistry, everyone who heard about it said “Good. You will be able to guide him. He will surely gain from your vast experience.” !!!!!!!!!.
PS: Apologies. In my previous post I had assured my friends that drawing a picture was a onetime folly and that it will not be repeated. Sorry to have gone back on my words. I did not have any pictures of ‘open method’ and felt that it would be difficult to comprehend without an illustration. The intention at least was good. I don’t know about the result.