Mornings with Drs. Steve Ellen and Diane Ede-Nichols at Nova Southeastern University’s spacious new dental clinic in North Miami Beach begin as they did in their former Davie cubicle — with rounds.
They listen as five residents report their patient loads for the day in a litany of routine dental procedures, for clients who are anything but:
“Francine, cerebral palsy, for a cleaning.”
“Michael, autism, for an orthodonture consult.”
“Patricia 50, schizophrenic with SIB, for a cleaning.”
SIB stands for self-injurious behavior.
As they rattle off each patients’ medications, which for some number in the teens, Ellen peppers the discussion with humor that has served him as a special care dentist for 38 years. “Our clinic satisfies a need that no one is addressing. We work with a fruit salad of clients — the people no one wants to treat.’’
In 2002, the Florida Developmental Disabilities Council learned that out of an estimated 544,500 Floridians with developmental disabilities, cerebral palsy, spina bifida or Prader-Willi syndrome, 500,000 did not receive state services, including dental care, during the study year.
The problem is twofold: Dentists are reluctant to treat this population for the Medicaid fees they receive. Nor are most trained to handle the patients’ special needs.
In 2003, the Nova Institute for Special Needs Dentistry was founded by the late John Tabak, then head of community dentistry at Nova Southeastern Dental College. Through the institute and the resident dentists it trains, thousands of severely disabled patients have received treatment. In 2012 the clinic saw more than 2,500 patients and trained 33 resident-doctors in special care dentistry.
By 9 a.m., the eight dental chairs are filled. A team of three works with each patient using a technique Ellen calls six-handed dentistry. While one set of hands operates, a second pair stabilizes the patient, and a third pair controls the moisture in the patient’s mouth. It’s not the procedures that make this kind of dentistry challenging, but the management of the developmental, cognitive or physical conditions that prevent these patients from receiving routine care.
“One, two, three, four … .” The staff count, breaking the treatment into manageable steps. At the first sign of struggle, they take a break. One resident holds an iPad for a patient to watch Beyoncé while fellow residents perform a cleaning. Another patient is rewarded for making it through her exam with a can of Coke (sugar-free). A surprising amount of work is accomplished. The patients’ moods are good.
Most of the clients live in group homes where their caregivers have little special training and are usually underpaid. Those who are unable to brush their own teeth often receive inadequate help. The resulting tooth decay causes chronic pain, along with periodontal disease, which has been increasingly linked to type 1 diabetes, Down syndrome, stroke and coronary artery disease.
A woman with autism arrives from Miami’s Sunrise Community, a group home for six. When asked for details of the patient’s oral hygiene routine, the caregiver replies, “I don’t know. I come, do my shift and go home.”
At the other end of the care spectrum is Songya Bailey, who brings patients twice weekly to the Nova clinic from Sandy Park Development in Fort Meyers. Her charges, two developmentally disabled men, take their turns in the dental chair eagerly, looking forward to cheeseburgers for lunch, a treat Bailey provides out of her own pocket.
Bailey says many private dental practices have turned away her residents. Ellen acknowledges that too few providers are willing and trained to treat patients with special needs. According to the American Dental Association (ADA), which does not recognize special care dentistry as an official specialty, pediatric dentists help fill the void, but most do not continue seeing patients into adulthood.
In general, dentists eschew special care treatment because of the low profit margin of a Medicaid clientele that requires more staff time and longer appointments. Only a small proportion of Nova’s general dentistry students opt for a special care residency because, unlike competitive residencies that offer salaries, it is unpaid. “If you have $200,000 in dental school debt, that stipend can be pretty important,” says Ede-Nichols, who replaced Tabak as the school’s community dentistry chair.
On the plus side, the special care residency allows dentists from foreign countries to take national boards after two years, saving a year’s tuition.
Eselle Lemus, a second-year resident from Cuba, was a periodontist in her country. The two-year residency will enable her to practice in the United States, provided she passes national exams.
“We know it’s an immigration lift for some people,” says Ede-Nichols, “but we try to instill an interest in special needs.”
A tall, slender autistic woman arrives at the clinic for a cleaning. Nervously she settles into the dentist chair, her stomach distended from hyperventilating and swallowing air. Flanked by second-year resident Arwa Alwehaib and dental assistant Pia Velasquez, Ellen reassures her. When the suction sound of the water device upsets her, they switch to a hand tool. They coax her to continue with toys. Finally, the patient reaches her limit. The doctors show her a soft blanket-like restraint called a papoose. They ask her permission to use it. Warily, the patient nods yes. Wrapped in the papoose, she relaxes.
“It simplifies things for her. It gives her a secure space,’’ Ellen says. “The papoose should never be used for the dentist’s convenience, only to protect the patient from hurting herself.”
Her cleaning finished, the patient embraces Velasquez for several minutes.
“It’s so difficult, but it’s a blessing for me to help her,’’ says the dental assistant. “My goal is to help people who really, really need it.”