Teeth

He tells me the dentist pulled his tooth because of the transistor in it. He shows me, pulling back the side of his mouth with one crooked finger: There.

He's 20 years old and this is his first admission. It is not clear whether he has schizophrenia or if the street drugs he's been taking have caused his symptoms. He's been in hospital for a week now, presumably off everything illegal, and it's not looking good.

I check his mouth as he requests, and sure enough there is a space between two molars. Would any dentist really pull a tooth because a patient said he was receiving messages through it? Perhaps it was pulled because it was rotten, and this is the explanation he's come up with after the fact. The other teeth aren't in the best shape, either.

It's not unusual for patients with schizophrenia to lose their teeth. It's hard to remember to brush every day when you're having problems organizing and motivating yourself because of your illness. Dental coverage is also a problem for many people with schizophrenia, and it seems that in such cases dentists often pull teeth rather than embarking on more expensive procedures. On one unit where I worked, patients who knew the system would request to see the dentist before they were discharged. Back the patient would come an hour later with one less tooth. It was like watching leaves fall, the gum gradually becoming bare as a tree branch in winter.

The emergency room physician says, “I'm not a dentist.”

This is only partly true. In my four weeks as a psychiatry intern I have seen him hand out antibiotics for infected teeth, spray dry sockets and inject lidocaine into the gum of a man begging us to just pull his tooth. Please.

But this time he is talking to the mother of a six-year-old boy. Her son is complaining that his tooth hurts, and she wants us to sedate him, take him to the operating room, do something. “He won't go to the dentist,” says his mother. Her eyes plead with us. “He screams when I try to take him. He's impossible to control.”

The supervising physician isn't budging on this one, and I can tell he thinks this is a waste of time. After all, we aren't dentists. Down the hall there's a man with chest pain. A child with a broken arm waits in another room. The doctor's voice betrays his impatience.

The mother is not much older than I am, but she looks impossibly weary. What is she going to do after they leave? To my partly trained eye, the boy looks as though he might have attention deficit disorder. I watch him as he climbs up on a stool and jumps onto a stretcher, which lurches dangerously. I think of the tooth, hidden away inside his tight little lips. He is stronger than all of us. Even pain isn't enough to get him to surrender, hold still, and let us look.

Mr. Smith is dying of lung cancer and has lapsed into a strange delirium. His wife catches me outside the door and tells me he's worse, very confused. The family is always catching the doctors outside the door, not wanting to speak in front of Mr. Smith.

He is lying on the bed with his eyes closed. His three grown sons are at his side. He doesn't look appreciably different, except for the slight flatness and lack of focus that are signs of delirium. “How are you today?” I ask.

Mr. Smith smiles a distant smile. “Fine, doctor. Better, I think.”

One of the sons gives me a look. “Dad,” says another, “tell her about the teeth.”

“What about the teeth, Mr. Smith?”

“Oh.” Mr. Smith opens his mouth to show me. “There is another set of teeth lying over my own. Do you see them? No, of course you don't. They're made out of glass, that's why. I'm not able to eat anything for fear they will splinter and cut my mouth.” He runs a shaking finger over his teeth. “I can feel them, though.”

The eldest son clears his throat. “Dad ...”

“They are there, I tell you,” he snaps. Even through the delirium, he exerts his will. Abashed, his son falls silent.

I will have to have another look at Mr. Smith's chart to see if there is anything else I can suggest. What would it feel like, I wonder, to have my teeth encased in glass? Would it cause my speech to slur? Would every word carry a danger of breakage? Would I still have the courage to bite and snap at my grown sons, or would I fall silent, resigned to my fate, defeated, toothless?

Lara Hazelton Psychiatrist Toronto, Ont.