When a tooth turns rotten, it's impossible to think about anything else. And a rotten tooth is very much on my mind right now. A week ago, while munching a heel of Italian bread, my fourth and final mandibular molar (those bottom grinders in the back) produced a tiny twinge. I tried to convince myself the tooth was fine. Just because its three brothers had, under similar circumstances, cracked to their roots and gotten infected didn't mean this one would.
Alas, the molar's crankiness soon progressed to rage. Now, one week of putrefaction later, my jawbone has become a symphony of suffering.
Half out of my mind, I trek to see David Iurlano, D.M.D., a Pittsburgh-area dentist whom I view in a spiritual light. On three prior occasions he spelunked his way deep into my jaw, extracting demon molars and extricating me from hell on earth.
"Another one, Jim?" he asks. I nod, eyes watering.
Most patients who lose teeth can blame tooth decay or gum disease. In my case, a predisposition to cracks appears to be the culprit. I am an identical twin, and both my brother, John, and I have lived our 55 years almost entirely free of cavities and gingivitis. Despite this, over the past decade we have both lost — in identical order — the same three molars. (Our wisdom teeth got pulled in college.) It became a race to see which of us would lose his last bottom grinder first. Unfortunately, I've just won.
Over the next hour, Iurlano arm-wrestles the fiend with an assortment of tools, his forearm muscles and veins bulging from effort. At last, the villain surrenders to its fate.
"The socket area is going to be pretty sore for a couple of days," Iurlano says. "But after that, you should start feeling a lot better."
His prediction proves correct — at least physically. As pain recedes, disquiet courses in. With each previous loss, I had managed to chew by shifting to an ever-dwindling number of bottom grinding surfaces. But the difference between having one mandibular molar and having zero is profound. Nuts, raw vegetables, hard pretzels: Will I ever eat them again? I envision myself hamster-chomping pabulum and veggies boiled to mush.
Suddenly I feel very old. What's more, after the swelling abates, I look old. With no back teeth in my lower jaw to brace my jowls, I resemble Edvard Munch's famous screamer.
Thanks to fluoridation of public water and dental-care improvements, Americans under 50 have excellent odds of keeping their teeth. But the picture is not so rosy for most boomers and their elders. Today an astonishing one-fourth of U.S. adults over 65 are completely toothless, according to the Centers for Disease Control and Prevention. And the National Institute of Dental and Craniofacial Research reports that 58 percent of Americans 50 and over have fewer than 21 teeth (out of the usual 32).
Lost teeth can lead to poor nutrition as people avoid vegetables, nuts, and other healthy foods in favor of softer processed fare. And the traditional treatment — dentures — is problematic: They tend to shift, rubbing tissues ragged. Even well-made dentures can withstand only one-sixth the chewing force that healthy teeth tolerate. With less stimulation, jawbones erode. My friend Sally, a retired teacher from Cleveland, told me her father lost so much bone by his 70s he could no longer get a decent fit for his dentures. "He always had a clicking sound as he talked," she recalls.
Sally long feared she would share this fate. In 1993 she lost all but six of her teeth to periodontal disease. Dentures helped her live normally, but the disadvantages bothered her. Her upper palate was covered, which reduced her ability to taste food. Her dentures also tended to slip, particularly when she raised her voice — a liability for a fourth-grade teacher.
Eventually Sally heard of an alternative: titanium dental implants. When inserted into the jaw, these metal posts bond with healthy bone, creating artificial roots for false teeth. Sally underwent a multistage process that resulted in 12 titanium implants, each capped with a porcelain tooth. "It was a long ordeal," she says, " but I am really glad I had it done. I have the straight teeth I always wanted, I can eat healthy foods again, and I don't have to worry about losing my teeth during a swim — and having to dive to the bottom to retrieve them!"
Based on several such endorsements, I make an appointment at the University of Pittsburgh's Multi disciplinary Implant Center.
The stretched-out "panoramic radiograph" is pinned to the light box. To this layman, it looks like the X-ray of a gorilla's mouth. Steven J. Kukunas, D.M.D., Pitt's director of implant prosthodontics, assures me the mouth in question is owned by a much smaller primate, namely me. He and his colleagues will rely on X-rays and a plaster model of my mouth to assess my suitability for titanium screwing.
The good doctor's first concern is whether I still have enough healthy bone to anchor the implants. A second worry is two specific nerves: Are these buried deeply enough in the jaw so screws won't penetrate them?
Some patients can have implants only after their jawbones are built up via bone grafts — a time-consuming, expensive procedure. Others, including those on intravenous drugs for osteoporosis, shouldn't have implants because of the risk of bone disease.
But the news for me is good. Even though my four lower molars have been missing for 11, 8, 7, and 1 year respectively, my underlying bone has not begun to erode. And the nerve canals are deep enough that the titanium screws can't reach them.
"Gorgeous!" says Kukunas's colleague Mark Ochs, D.M.D., of my X-ray. "You have great bone."
Kukunas tells me the success rate at his clinic exceeds 97 percent for lower-jaw implants, but I must practice scrupulous hygiene, including daily flossing. Those who don't are more prone to failure — as are heavy smokers, alcoholics, and diabetics.He says the process will take about six months. "And then," I ask, "I can eat nuts and hard pretzels again?"
"You can eat whatever you want," says Kukunas.
It sounds like a miracle. But at what cost? Across the nation the price of implants varies widely, and dental insurance rarely covers more than half. Because I've opted for treatment at a dental school, my cost will be about half that charged by a private-practice specialist. I'll pay $850 for the implant, $380 for a metal abutment to cover it, and $550 for each crown — a total of $1,780* for each tooth I get replaced.
I do a rough amortization based on best-case life expectancy. My conclusion: Each tooth will cost 17 to 19 cents per day, a relative pittance. Moreover, not getting the implants could have its own costs, especially if I continue on the ice-cream-and-lard diet that has become my routine.
I sign up for four.
(*Prices have risen since the writer's procedure.)
The placement of implants proves a breeze — much less traumatic than extraction. A supervised resident numbs my jaw with lidocaine, cuts and peels back the gums, then drills four holes into the mandible. She uses what machinists call a tap to slowly cut threads inside my bone, then screws a threaded implant into each hole. Finally she screws in temporary abutments and sews my gums around the base of each. Regarding her handiwork in a mirror afterward, I see what look like four stainless-steel nail heads hovering at the gum line.After a visit to have my stitches removed, I need to wait four months for jawbone to bond with the titanium, a process called osseointegration.
When I come back, my mandible earns another "Gorgeous!" from Ochs. A resident makes a mold of my teeth so a lab can fabricate lower molars.
En route to my final appointment six weeks later, I make a detour to the grocery store for pretzels and mixed nuts. When I arrive at the office, resident Faraj Sedeqi, D.D.S., replaces each temporary abutment with a permanent one and installs my bionic teeth. In less than an hour, it's done.
"When can I eat?" I ask eagerly.
"Anytime you want," says Sedeqi.
In the car I rip open the pretzels and nuts and chomp down ferociously. The implants feel fantastic, which is to say, they don't feel anything — exactly what I've always hoped for in a tooth. The upper molars, on the other hand, prove a little more boisterous. It's not pain, exactly, but it occurs to me that teeth, like people, resent too abrupt a transition from indolence to labor.
Two weeks later my whole mouth has successfully made the switch.
I call up my twin to ask him how his final mandibular molar is hanging. We both know it's only a matter of time before he will face his own rendezvous with dentistry. For now, however, there's a new winner in the molar sweepstakes: John 1, Jim 4.
Pennsylvania freelancer Jim Thornton writes for Men's Health, Field & Stream, and Swimmer, among other magazines.
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