A Little Perio and a Little Anatomy

Fear and ignorance led me to stall for three months between my dentist’s suggestion that I see a periodontist and my doing so. When in the sixties I told my thesis director, an obsessive Austrian with military posture, that I wouldn’t be in the lab the next afternoon because I had to see a periodontist, he barked, “Don’t!” I jumped. Why not? “Once the gum dentists get a hold on you, they never let go!” I took that for a warning, not humor, and declined the attentions that first gum dentist offered, but in the army a few years later, I let a full bird colonel do terrible things to me for reasons, which, in retrospect, did not convince, and after that I steered clear.

Nevertheless, here I was again with deep pockets and deep pockets. It turned out that the man she referred me to had treated an old friend of mine, who spoke well of him. The periodontist in person was clear, kind, straightforward, young enough to remember his training and old enough for humility about what treatment could achieve. We set a date for him to scale my roots.

He greeted me, acknowledged that my experience of the injection could be negative, characterized the swab and the needle stick to follow as ’little,’ but never said ‘just.’ Once numbness had set in, he went to town on my upper teeth while I, soothed by Donizetti through ear buds, ignored him. I rinsed. Now for the lowers, he said. Is your tongue numb? It was not, nor were my lower teeth. When the block doesn’t work you go high and wide, he said, and injected more anesthetic.

More minutes, but no less feeling. My gum dentist frowned. Let me give it a try, he proposed, but his first ultrasonic dig left me ready to betray the movement and confess anything. Yet one more injection scarcely dulled what I felt when I tapped my tooth and left the sensation of my tongue and the skin over my jaw intact.

Something like this had happened before. Other dentists who had had trouble numbing my left lower teeth opined that I had an anatomical variation that made the block hard to do, but in the end they always succeeded. This periodontist and I stared at each other: it was a node, a moment of decision. I will try to be good, I mouthed carefully, if you will try not to compromise what you have to do.

What followed rated solid sixes and sevens with a scattering of eights and a nine or two for crown jewels. When it was over, my shirt was soaked, my mind addled, yet that second part of the procedure seemed quicker than the upper half. In the afternoon I felt wrecked and couldn’t concentrate so I put in some miles on an exercise bike at the gym. I needed cocktail hour and a night’s sleep to regain my composure.

The next day, with half my mouth still unscaled, I wondered how rare my odd wiring might be. A 2007 article in the Journal of Dental Education quotes an anesthesia handbook to the effect that the standard inferior alveolar block I had is “one of the first clinical skills students learn in dental school,” but it has a fifteen to twenty percent failure rate when properly administered. Another article blames improper technique for more failures than anatomic variation. Other less familiar ways to block the nerve named Gow-Gates and Akinosi may have higher rates of success without more complications, but seem to be used less because “alternatives to the conventional inferior alveolar nerve block remain, for the most part, absent from formal predoctoral dental training in the United States.” The Intertragic notch

The Gow-Gates technique, described here, may, indeed, have been the way my periodontist did my last, partially successful injection. Note that Doctor Spiller calls the external target for the tip of the needle the “intertragal notch” (the notch between the tragus and the antitragus), while the illustration he provides labels that structure “intertragic.” Today, looking back, I consider my experience in the chair to have been troublesome rather than tragic. In a few weeks I shall return to that chair with my ignorance reduced; I’ll estimate my fear as the day gets closer.

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