The unique (and surprisingly spiritual) relationship between a dentist, a patient and one’s sense of self
Teeth are our biographers. They record the difficult paths we have walked in life and place the evidence on display. In discolored, broken or missing teeth anyone can read our history of difficult circumstances or bad decisions: childhood neglect, lifelong poverty, depression, addiction. And so healing the teeth can be a first step in restoring hope and giving us a chance to tell a new story with our lives.
For a long time, Nicole Rouse’s teeth told a story she hated. “I had really bad TMJ; I had no control over my jaw,” she says, referring to temporomandibular joint disorder, which causes jaw pain. “[It] was making me bite my tongue till it bled.” Her jaw problems were a symptom of the many stressful aspects of Ms. Rouse’s life. She had come to Toronto from British Columbia to be with a boyfriend, but the relationship fell apart and she ended up on the streets; she had mental health issues, which included addiction; she became involved in a series of abusive relationships; she had a criminal record; her children would not speak to her. Her teeth were rotting from a combination of neglect, drunken accidents, violent abuse and chemotherapy to treat a bout with cancer. One tooth started hurting so badly that she just yanked it out herself.
Ms. Rouse faced a huge array of obstacles to obtaining dental care. Perhaps the most universal one was the most basic: money. Dental care is not treated like other forms of medical care. Even in Canada, which has a single payer health care system, dental care is not included; and coverage can be spotty. In the United States, Medicaid does not require dental coverage for adults, though all states cover children. Even states with robust plans, like New York, cover only select services for adults. Medicare also does not cover most dental care. As of 2016, the number of Americans without dental insurance was four times the number of those without health insurance, and insurance often covers only a small portion of the cost of care. Some people seek more affordable arrangements, like getting care at a dental school, where treatment typically costs about half the price of private care but can still amount to thousands of dollars. In 2018, the financial website Earnin teamed up with the Harris Poll and found that a majority of Americans said they had delayed some form of health care in the past year because of cost; the most commonly postponed form of care was dental work.
About five years ago Ms. Rouse was able to get the care she needed from Dr. Paul Zung, senior dentist at Toronto’s Centre for Addiction and Mental Health. She had landed in medical detox and was having severe dental pain from abscesses as well as the problems with her jaw. According to Dr. Zung, she needed about $15,000 Canadian of reconstructive dental work, which was funded primarily through donations to the center. In their first visit he gave her partial dentures. Although Ms. Rouse trusted Dr. Zung enough to keep coming back to him as he slowly addressed her complex dental issues, she wasn’t really back on her feet, she says. “I was in my addiction the whole time, living on the streets. Basically half the time I wouldn’t show up for my appointments. If I would show up I was coming in exhausted. My teeth were horrible, I was depressed, very abusive men were beating me; I had no self-esteem.”
Dr. Zung would listen to her without judgment. “It was hard to share my struggles,” she recalls, but Dr. Zung “was more than a dentist. He took the time to ask me how I was doing and talk to me.... He had the kindest heart, to watch me as I was deteriorating.” At those early appointments she was so worn-out that she would sometimes fall asleep in the dental chair and even slept through getting tooth implants.
At those early appointments she was so worn-out that she would sometimes fall asleep in the dental chair.
Dr. Parita Patel, dental director at Baltimore’s Health Care for the Homeless, says: “A lot of our clients have a history of trauma, a history of substance abuse. Restoring something as simple as their teeth and their smile brings them back to a time when they were healthier. There’s a part of the denture-making process where they try on their teeth, and it’s a very emotional one even as a provider, because they take a look in the mirror. You will see adults so happy and saying, ‘It’s been decades since I’ve seen that face.’”
She also echoes many of the dentists I spoke with on the dangers of postponing treatment. Delay a filling long enough, she says, and that may result in a need to pull a tooth entirely. The cost of bridges, dentures or implants to fill gaps left by missing teeth soars far beyond what the initial filling would have cost—but that is a highly theoretical concern for someone choosing between paying for groceries and paying the electric bill.
Delay leads to systemic problems. Periodontitis (serious gum infection) may increase the risk of cardiovascular disease, including stroke. Untreated cavities can cause tooth infection; the infection in turn can spread to the face and even, in rare cases, the brain. A 2017 report from the Centers for Disease Control and Prevention found that almost one-quarter of children living below the poverty line had untreated cavities. Cavities are the most common chronic disease among children and adolescents between 6 and 19, according to the C.D.C.
Dentistry may be treated differently because tooth decay is seen as an easily preventable problem. Who does not know you should brush and floss? Poverty, mental illness and addiction—common reasons for delaying dental care until damage is visible—are themselves often treated as moral failings. The shame felt by people with visible tooth problems is an emotional and spiritual problem. It is a political problem, too, as few voters or legislators see dental care as a right.
The shame felt by people with visible tooth problems is an emotional and spiritual problem.
Armstead Hetherington speaks with a soft drawl that melds Baltimore, his home since 1987, with his native Pittsburgh. He is a client and advocate with Health Care for the Homeless. “I was homeless since I was 19,” he says. He got into drugs and alcohol, and his teeth paid the price, chipping and breaking. “I was brushing my teeth, but all the abusing that I was doing to my mouth was just ferocious,” he says. “I was embarrassed—I wouldn’t laugh. You know, that smile, just half a smile.”
Things reached the point that his teeth began to fall out while he was eating. “Sometimes when I talked I had to step back from somebody because I didn’t want [crumbling teeth] coming out of my mouth at them,” he says. The dentures he received at Health Care for the Homeless “changed my life all around,” Mr. Hetherington says. He now finds himself laughing without reservation, and the 55-year-old boasts that “a lot of females” like his new smile.
He first came to Health Care for the Homeless for dental care; now he volunteers there. He also advocates for Maryland to expand dental coverage for adults and has testified at the state capital.
Unfortunately, even where Medicaid has expanded, many dentists do not take Medicaid patients because Medicaid reimburses so little of the cost of care. Dentists with heavy student loan debts—according to the American Student Dental Association, average dental school debt for the class of 2017 was $287,331—or other financial pressures simply cannot afford to see Medicaid patients. So even patients who are covered, including children, may not be able to see a dentist because of cost. Possible solutions have been floated, including a year of public service in dental school, or allowing nondentists (such as hygienists) to perform more procedures. All of these suggestions have complexities and drawbacks; so for now, dentistry is expensive to provide and shockingly expensive to receive.
Craving Respect and Kindness
If you cannot afford a dentist, there are options—sort of. You can go to the emergency room, which generally results in some combination of antibiotics, opioid pain relief, huge bills and the same dental problem you walked in with. Few emergency departments can fully treat an acute dental issue, and not all will have a dentist on call. You can join tens of thousands of Americans heading south of the border each year, to places like Los Algodones, Mexico’s “Molar City,” where street barkers advertise cut-rate crowns and root canals. Dental work in Mexico can cost less than half what an American practitioner would charge. If you do not have half, you can take your chances with folk-wisdom remedies to stem the pain.
If you cannot afford a dentist, there are options—sort of.
If you are very lucky, there will be a free clinic near you, like the Franciscan Daughters of Mary Center for Hope and Healing Dental Clinic in Covington, Ky. The dental clinic is affiliated with a pregnancy care center and a medical clinic. The dental clinic has caught untreated diabetes and saved the lives of at least two patients who could not get necessary heart surgery until their teeth were fixed because of the increased risk of infection. The clinic sends patients home with brushes, toothpaste and floss for their household; they can offer patients medical care, including psychiatric care, plus food, diapers and books. It is a place, says the executive director, Sheila Carroll, where patients’ needs for dignity and respect are honored as much as their material needs.
For those who do not live near a year-round clinic, free pop-up clinics called Mission of Mercy are sponsored by the American Dental Association and state dental associations, sometimes partnering with Catholic Charities and other nonprofits. Other free clinics range from small mobile units to massive operations held in airplane hangars or fairgrounds. The largest provider of pop-up dental clinics is Remote Area Medical, which conducts more free dental clinics than any other outfit in the country. If you have the time and transportation, you can camp out for a couple of days in a 2,000-person line to get free dental work done at R.A.M. pop-up clinics in the heart of Appalachia or in Los Angeles.
I had a chance to read through a sheaf of patient feedback notes from the Covington clinic. These comments—like the comments of people interviewed while waiting for care through R.A.M.—made it clear that people who need free dentistry also crave respect and kindness. How else can you explain patients who responded to a visit to the dentist with, “I love the old-school love that is here” or “the Jesus in this place”—or “I love you all”?
The longer someone has been away from the dentist, the more intimidating it can be. Fear of pain, fear of cost, fear of judgment can all keep people away—and meanwhile their dental health deteriorates. According to the Cleveland Clinic, between 9 percent and 15 percent of Americans avoid the dentist out of “anxiety or fear.” The dentists I spoke with, who serve especially vulnerable populations, described their efforts to make traumatized people feel comfortable “opening up”—quite literally—to white-coated strangers.
Dentists use a range of techniques to build trust.
These dentists use a range of techniques to build trust. One used a hand-signal system; he would stop working the moment the patient moved a hand. As patients learned that he would reliably stop, their trust grew, and they let him complete the work.
John Osborne, the volunteer dental director of R.A.M., notes that while the chaotic setting of the huge free clinic might not seem conducive to trust, there are ways to honor patients’ humanity. “We have volunteers that will come and sit with them and hold their hand; we let their family hold their hand when we’re treating them,” he says. “In a dental office that’s not necessarily something that’s allowed, but we have a picture on our website of a man who’s sitting holding his wife’s hand. He’s got a mouthful of gauze where he’d had his teeth extracted, and she’s having dental work done. Sometimes it’s easier being in an environment like that, where it’s not so structured.” Even the overnight waiting can provide “a sense of camaraderie” and commiseration—you’re not in this alone.
Celia Ashton, a former dentist and sister of the Baltimore Carmelite community, recalls, “When I was a dentist, I tried to always be Christ’s healing presence for that person without saying ‘I’m a Catholic woman’ directly,” she says. She practiced sedation dentistry, so many of her patients came to her because they were anxious or afraid of the dentist. She would ask about the roots of the anxiety and build a treatment plan only after she had heard the patient’s story. “Yes, my scope is the mouth,” she says, summarizing her approach, “but you have to recognize that that mouth is attached to a person.”
In her former life she would work with patients whose psychiatric conditions or addictions made treatment difficult for them. She learned to earn trust with patients to the point that they could reveal secret vulnerabilities, like the eating disorder that had caused their tooth corrosion. She began to sense the spiritual longings that are as important in healing as the medicines and instruments. Now, she says, when people come to the monastery for prayer, “A lot of the same skills translate into this life. People are seeking healing in some way.”
‘What I Remember Is the Care’
Dr. Paul Zung, who treats Nicole Rouse’s teeth, has worked at the Center for Addiction and Mental Health in Toronto since 1986. For the patients he sees, “the routine daily care is gone. They know they’ve let themselves go, but they were too concerned with survival to care about brushing or bathing or shaving. Some people have stepped back from suicide. A lot of people have been out on the street, moved from boarding home to boarding home.”
Dr. Zung is a compact, thoughtful man, with deep laugh lines at his eyes, who has spent much of his life meditating on the meaning of teeth. Teeth represent beauty and vitality, he says, aggression and strength. Tooth decay or tooth loss is “a precursor of death”; a missing tooth is a visible sign of helplessness. He notes that in Chinese culture, as in several others, dreaming of lost teeth signifies “loss, separation, death of parents.”
When I was a dentist, I tried to always be Christ’s healing presence for that person.
And so when he has to tell someone that he can’t save their teeth—that he’ll have to remove them—“I try to be alert to a sort of grieving. I’ve had people say, ‘Yeah, they’ve been hurting me and they’re so ugly-looking, and you’d think I’d want to be rid of them—but I don’t.’ Or they’d simply cry.”
Patients look on the dentist almost like a judge, he suggests. “They walk in with their mouths covered. [They say], ‘Oh, I’ve been avoiding dentists for 10 years because I didn’t want anybody to see this.’ ‘Get ready for a shock.’” Instead, Dr. Zung offers mercy, and says that he too feels “the relief, when I tell them, ‘To be honest, I’ve seen much worse.’ They feel really, really happy when I put into concrete terms what we can do to reconstruct the mouth.”
He sees dentistry as “a cross between gardening and auto mechanics. I have to make the mechanics work—and I have to set an environment which is kind to everything I plant in the mouth.” One patient, he says, lost all his teeth over the course of their work together (“He’s had several sets of dentures, but he’s lost them.”), and yet “still greets me with a big hug and says, ‘What I remember isn’t the teeth. I know you did your best. What I remember is the care.’” He immediately adds that this patient’s words are “like a line out of [Henri] Nouwen.”
Dr. Zung opens himself to his patients’ emotions; he’s close to them literally as well as figuratively. He bears the brunt of their frustration or fear, and he shares in their relief. “Our faces are 13 inches away for hours and hours!” he laughs. “I’ve spent more time in close proximity with some of these patients of mine than with my own wife and family! So closeness comes out of that.”
That closeness is essential because major dental work is not a one-and-done procedure. “The healing part is an intensely engaged walk with another person,” he says. “I can’t give them a pill that makes them all better, because they can destroy everything that I do within months or years. So unless they get that I am deeply invested in them and they need to be brushing, and it means the world to me that they’re keeping this up, I’ll see failure after failure. They have to see that it means something. So later on, if they’re in a psychotic episode or depressed or hate themselves, they’ll remember: Yet I was loved, somebody worked really hard; so if I don’t owe it to myself, I owe it to the people who took care of me to get fixed up and try.”
He sees dentistry as “a cross between gardening and auto mechanics.
The spiritual core of Dr. Zung’s work lies in what he says next: “What puts people at ease is hope.”
During her treatment, Ms. Rouse was in and out of detox. Her dentist was one of the few stable features in her life. Sometimes she had to hold back tears of shame when she met with him, but as treatment progressed, this was accompanied by some relief. “I started looking forward to going to the dentist,” she says. “I started feeling better once the pain in my jaw went away and I stopped biting my tongue. It took a lot of pressure off my face and off my head, so I could focus more.”
For the first time, she was able to concentrate on what she was learning in detox. She became a Christian, and through Christian music and motivational speakers she is gaining the confidence to change her life. “I got out of the abusive relationships. I’m working on getting my health back,” she says. “I have one filling left to do; I’m not in any pain anymore. I’m out shopping and buying clothes—before, I used to wear nothing but worn-out clothes out of the garbage. Now I want to buy makeup and do my hair, and listen to music and preachers every morning. I go to church and I want to help others.”
Ms. Rouse still sees Dr. Zung. He recently agreed to pull an abscessed tooth immediately, knowing that her income and schedule did not allow her to wait. She lives in a sober living building, in a light-filled apartment with decorations from the dollar store, including a placard above the microwave that says, “FAITH HOPE LOVE.” Silhouettes of birds flying between slender, leafy tree branches adorn her white walls.
Nearly 40, Ms. Rouse has become exuberant and chatty. She is speaking with her children again. She pays rent; she prays daily, and meets weekly with a counselor and a spiritual advisor. “I’ve cleaned up the wreckage of my past,” she says. “I went through the courts, and I’ll be through my probation on my birthday this year. And it all started by going to the dentist.”