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A healthy smile hard to come by

By Monique Johnson

Janet is passed out and doesn’t know what’s about to happen.

Her dentist, Dr. Raymond Lee, bends down and gently rests her head on the headrest of her wheelchair. Janet (whose name was changed to protect her privacy), has cerebral palsy and can’t speak.

She’s on Valium to help relax. And Lee hopes Janet won’t wake up and be startled by his presence. Just in case she does, his dental assistant and Janet’s support worker stand by.

Lee opens her mouth and begins the examination.

“This is not good. This is gingivitis,” Lee says as he points to her inflamed gum line. “This disease is very uncomfortable.”

Janet moans. Her eyes slowly open and widen in panic. She suddenly jerks her head away from Lee’s grip. Janet’s moan now sounds like a cry.

“It’s okay sweetheart, you’ll be okay,” says Janet’s support worker (who also can’t be named).

Dr. Raymond Lee busy at work
Photo by Monique Johnson
Dr. Raymond Lee treats a special-needs patient.

Janet’s aggressive behaviour forces Lee to stop the examination; the Valium didn’t work well enough. But Lee says because of the severity of her gingivitis, she’ll have to return and be given general anesthesia to get her teeth cleaned. There’s no other way to do it because of her anxiety and behaviour, he says.

But Janet’s lucky she got an immediate appointment.

The waiting list is so long at London Health Sciences Centre’s dentistry deparment, that special-needs patients wait 12 to 14 months to see Lee – sometimes for a routine check-up. Dentists recommend a check-up every three to four months for such patients.

The long-waiting is partly caused by referrals. Lee says some dentists in the area often refer adult patients like Janet, who are deemed “too difficult to work with,” to him.

He and his support staff treat about 600 adult special needs patients. And the average dentist in Ontario treats five to 10, says Dr. Ira Kirshen, president of the Ontario Dental Association.

Most of Lee’s patients are from London while some travel from as far as Thunder Bay, Windsor and Kitchener to see him because they can’t find a dentist in their area who’ll treat them.

These patients have intellectual, developmental, or physical disabilities that range from down-syndrome to cerebral palsy.

“A lot of dentists won’t see them ... it’s difficult work,” Lee says. “It’s that small group of patients who have high needs. A lot of times they’re non-verbal and don’t even speak.”

Many of them are anxious and scared -- and may act out by running away from the dentist, refuse to sit in the dentist chair and open their mouths or sometimes get combative, Lee says.

“There’s a couple of scars there ...,” he says as he points to his forearm. “They scratch ... I’ve gotten pushed.”

But when he deals with difficult patients, his people skills kick into high gear.

For Lee, it’s about talking and negotiating – easing them in – making them feel comfortable, he says. “A lot of it is common sense.”

Even though other dentists are qualified to treat special needs patients, some of them say they’re uncomfortable and don’t know how to manage their behaviour. Instead, they refer the patients to Lee, a pediatric dentist-- or the few other dentists in the community who may handle such cases.

Western dental student helps participants
Photo by Monique Johsnon
Western dental student Nelly Hashem teaches Roger Rommeloo how to properly brush his teeth on Sharing Smiles Day.

This doesn’t just occur in London. It happens throughout the province and Canada, says Ali Sigal, a dental student at the University of Toronto. She’s the founder of Oral Health Total Health, an advocacy group working to educate dental students about treating people with special needs.

OHTH launched its London branch at the University of Western Ontario late last year.
OHTH recently hosted its first Sharing Smiles Day in London at the Best Western Lamplighter Inn.

“I call it the happiest day of the year,” says Sigal.

It was like an indoor carnival – without the giant Ferris wheel. Dental students got a chance to interact with special needs people, in hopes they’ll treat them later in their careers.

“A lot of (students), their hearts are opened ... If you were to ask them today if they’d feel comfortable with someone in a wheelchair coming to them in their clinic when they graduate, they’d say yes. So to me, that’s success,” says Sigal. 

OHTH focuses on educating emerging dentists because dental schools across the country are not doing enough to teach students about treating people with special needs, she says.

Students have to be equipped with knowledge to treat that population because if they’re not -- when they start practising, they may never treat them, she adds. Instead, they’ll refer their patients to dentists like Lee. And “the cycle will keep perpetuating,” Sigal says.

Some local dentists say the University of Western Ontario’s dentistry program is falling short in that area of education. Lee, who is also a faculty member at Western, says he sees this first-hand when students are on placement and exposed to patients like Janet. 

“The students come here and they’re shocked. They don’t know this stuff exists.”  

However, the dentistry program is revamping its curriculum to include more on special needs education, says Dr. Sahza Hatibovic-Kofman, division chair of orthodontics and pediatric dentistry at Western. “With our new curriculum, we’re going to be very aggressive,” she says.

They hope to hire more instructors who are knowledgeable about treating people with special needs, she says.  “We are trying very hard to attract people who are very willing to work with people who are disabled.”

Ali shares smiles with participants
Photo by Monique Johsnon
Sharing Smiles Day was a success for its founder Ali Sigal.

But Dr. Clive Schneider-Friedman believes it should be taken a step further.

A dentistry specialty should be created for those who are genuinely passionate about helping special-needs people, says Schneider-Friedman, a pediatric dentist and instructor at Western.

It takes passion, commitment and empathy to work with that population -- and those qualities can’t be taught; they’re learned as you grow-up, Schneider-Friedman adds. “You should already have that passion before coming to dentistry school.”

Back at the hospital, after a quick break, Lee speed walks through the hospital corridor. He stops at a counter and picks up his next patient’s file. He reads it.

“You see, this is what I’m talking about,” he says, as he looks at the file. It’s another referral of a special needs patient -- from a dentist who could do the work, but chose not to, he says.

This patient needs teeth cleaning, but has to be sedated like Janet.
At the LHSC, sedation takes place in an operating room, but this patient will have to wait more than 12 months from now for that to happen.

Operating room time is tight at the hospital for the dentistry department. “It’s not enough,” Lee says. “There needs to be an improvement in access with respect to facilities.”

According to him, this can happen with more funding to add more operating rooms. But those decisions are made at the provincial level.

The dental association says it has urged the government for years to act on this problem.

“We do get frustrated year after year when government shuns us aside because it’s not a glamorous cause to fund ... it’s not dentists who are the problem,” says the ODA’s Kirshen.

But while more money may help with operating room expansion, which may ease wait times – more money may also heighten some dentists’ interests in treating special needs people, says Dr. Chris Guiltinan, a London dentist.

“There are lot of patients not being seen as much as they should be because of remuneration,” he says.

Most of this population are on the Ontario disability support program. And dentists in London say they lose money when treating them – around 50 per cent less, in comparison to treating an average patient. 

“It’s definitely charity work ... how many (special needs) patients can a dentist afford to see without causing a deficit for the day?” says Kirshen.

The provincial government is working to remedy this problem, says Charlotte Wilkinson, a spokesperson with the Ministry of Community and Social Services. “We’ve increased the fees for services each year by two per cent since 2006 in light of those concerns,” she says.

But for Lee, remuneration isn’t as important compared to the gratification he feels when helping those in need.

“There’s a bunch of us who do it for financial reward ... but for me it’s a balance. I have enough. It’s about giving back,” he says. “If everyone just did their share for these difficult patients, we would all be in a better place.”

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