What lies beneath: Donald Rumsfeld, Defense Departments and Deep Dentistry
So today, I had to have a medical assessment for an insurance policy.
It was at Meridian Healthcare in Blanchardstown - I was very impressed at the care and attention from Dr Claire Cunningham and her nursing and admin colleagues. There was a multi-lead ECG connected to me while I walked on a treadmill that got faster and faster and steeper and steeper until I approached my maximum heart rate, there were also eye exams, height and weight measurements and various blood tests that were taken from me quite painlessly by a very skilled nurse. But the most unusual test for me, the one that stuck with me most was the hearing test.
I was familiar with the other tests - I have given blood for tests and blood donations on several occasions. When I worked in oral and maxillo-facial surgery teams, I must have taken blood samples on scores more occasions. I've worn glasses since I was 17, I don't know how many eye tests I have had, but the hearing test was a novelty.
I had one of these as a child, and as I remember it, some people visited my school and gave me a lollipop stick (with no lolly attached) and I was to tap the desk with it when I heard a beep from their machine. Fast forward a few decades and I'm ushered into a sound proof booth and given some seriously solid looking headphones and cable with a button on the end, and the instructions: " when you hear a sound, press the button".
It starts in one ear, there are some noises and I press the button. The noises get more quiet, and I press the button. They get to a point where they're barely audible and they change pitch, and I press the button when I hear them. It's unnaturally quiet. So much so, it's difficult to concentrate on the task on hand, my mind wanders off too easily. It would probably best be done in a meditative state where I prepare for the silence, but that's not the situation I'm in, I have to keep bringing my concentration back to distinguishing between silence and near-silence. A shout outside, the rub of the earphone lead against the stubble on my face derails the silence so much, I don't know if I've missed something or not. And then there's just silence. It's like swimming in really deep water - there might be nothing beneath me, or there might be a submarine or a whale, but I'll never know (even if they know I'm there).
And then it starts all over again in the other ear.
And when the persistent silence returns, it's almost like an earthquake when the nurse opens the door of the booth and tells me the test is over.
It's a test, of course, but I have no idea how I did. There was a US Defence Secretary (they spell it Defense, of course) called Donald Rumsfeld that famously talked about "known knowns...known unknowns...(and) unknown unknowns..." At the time, I remember people laughed at him, but honestly it's a very wise and simple way of explaining the limitations of the information you have at any time compared to the information that other people have, or what's actually happening. With the hearing test, I know when I hear the sounds at the start. Can't miss 'em. Loud as music. They're the "known knowns". I know I'm meant to hear a sound and I know I hear it. When it gets quieter, I get less sure. I know there might be a sound there, but I'm not sure I hear it every time. Eventually you get to a point where I don't hear anything, but that doesn't mean there's nothing to be heard. There may be sounds so high pitched that only a dog can hear them, there may be sounds that are a lot lower, and I could have heard them when I was that child tapping the stick on the table, but as I get older, those sounds are lost to me forever. I'll never know what noises were there that I didn't hear, and that was the most disconcerting bit. It wasn't so much to do with ageing or mortality, just the idea that there was something going on literally an inch from my head and I wasn't aware of it at all....
But what has this to do with teeth? Well, apart from my enthusiasm to know about what's going on it ties in with why I love orthodontics. It's a dental specialty that thrives on the known knowns. I have patients that know they have a problem with their teeth, I fix that problem, I know that it's fixed and so do they. Everyone gets to see the results of their efforts and it's a wonderful thing when we remove braces at the end of a successful treatment.
Most dentistry, and this includes orthodontics, involves known unknowns: the dentist knows there's a problem, the dentist knows if it's fixed, how well it's fixed or even if it can be fixed, and the patient knows none of this - they have to trust the dentist. If I did a root canal treatment for them, as long as it wasn't painful, they don't know if it would win a prize for a well done root canal*. That trust is a privilege that the entire dental profession places a high value on. In orthodontics, there are all sorts of things that the orthodontist is looking out for that might not be obvious to the patient, but are still important for the patient.
When I fix a problem for an orthodontic patient, they know the problem that they knew about at the start is fixed, but they probably don't know what goes on to make certain teeth fit together on some jaw movements and separate for other jaw movements. It's unknown to them, but it's known to me.
And the unknown unknowns....? That's where the patient isn't aware of the problem and neither is the dentist - or at least they aren't aware of it as early as it could be detected and something simple can be done to sort it out. That probably happens to all of us at some stage, and it should happen less as the dentist becomes more experienced and more knowledgeable about their area of practice. That's why we put a high value on continuing education, and why some dentists specialise in areas to go really deep into them.
*That's sort of why I haven't done a root canal since 1993, and why I've done nothing but orthodontics since 1997.