By Callie Shanafelt
California Health Report
The Mickey Mouse Club blares on the TV in the waiting room of La Clinica de La Raza’s dental clinic at Oakland’s Children’s Hospital. As a mother and grandmother speak Spanish and English to the three children in their care, their eldest sits by the door, jerking her arms up and down, talking to herself occasionally.
That child is called in to see Dr. Ed Rothman with her mother at her side. He calms her fears by explaining what he’s doing as he examines her recently cleaned teeth for cavities. Two years ago, he had to put her under general anesthetic in a hospital operating room to fill in her cavities.
Children’s Hospital opened the dental clinic nearly thirty years ago to address the oral health of hospital patients who had special behavioral or medical needs, such as hemophilia, cancer or heart problems.
Rothman spent his residency working with special needs children at the Kennedy Institute at Johns Hopkins School of Medicine and the University of Maryland, and he likes serving special needs kids. “It’s more thinking than just filling and drilling and cleaning and looking at x-rays,” Rothman said. He’s been at the clinic for almost two decades.
Children’s Hospital planned to close the dental clinic due to budget cuts in 2003. Dr. Rothman worried that his patients wouldn’t have anywhere to go.
“The patients we see here are not only special needs, they are poor,” Rothman said.
More than 80 percent of their nearly 6,000 patients are on Medi-Cal, which very few pediatric dentists serving special needs patients will accept.
“Special needs patients take extra time to be treated,” said Rothman “So you are taking extra time and getting paid less.”
When the hospital was threatening to shutter the clinic’s doors, Rothman scrambled to find a way to keep them open. He met with the dental director at a community-based clinic, La Clinica De La Raza who agreed to take over operations.
That alliance has allowed them to expand to include patients from the community at large, not just hospital patients. Now about half of their clients are Spanish speaking and about half of their patients have special needs.
Some, like the little girl Rothman was examining for cavities, are Spanish speaking and have special needs. It turned out that she had developed more cavities and Rothman had to refer her out for general anesthesia.
Rothman has to make sure he knows about any medication the child may be taking to ensure they won’t interfere with his dental procedures. He must be especially careful not to cause a bleeding incident for his hemophiliac patients.
“Sometimes kids with developmental delays or autism have to be restrained,” said Rothman.
For that, he uses a papoose restraining board that wraps patients in a kind of cocoon. “Autistic patients like the feeling of being wrapped and secure,” said Rothman.
“It’s not something we take lightly,” said Rothman of restraining his patients. “If we can’t do a good job, we’ll get permission from parents to use the board.”
Such creative methods keep caregivers like Fabiola Gonzales bringing patients to Dr. Rothman. Gonzales is the guardian of her grandniece, Amanda Price. When Amanda was three, doctors at Children’s Hospital determined that she would never be able to talk or walk.
They also referred her to Dr. Rothman for her dental needs. Since she hates having work done in her mouth, the only way to clean her teeth is to secure her in the papoose board.
“It’s less physical for us and less physical for her – we don’t have to have 12 people holding her down,” said Rothman.
Now 26 years old, she still comes to Dr. Rothman. Gonzales has tried to find other places using the papoose board, but no one at the dental offices she has called have even heard of it. Instead they propose putting Amanda under full sedation.
“Absolutely I wouldn’t have that,” said Gonzalez. “I don’t want her put under every six months just to have her teeth cleaned.”
Dr. Rothman did have to sedate Amanda in 2009 in a hospital operating room to do a deep cleaning and deal with three cavities. It is a procedure he tries to avoid, but it is also a major advantage of having the clinic in a hospital.
Due to a lack of access to the operating room, however, the waiting list for a general anesthetic procedure is 10 months long.
“It took forever forever forever to get her an appointment,” Gonzales said.
Rothman refers out about 10 percent of his patients to other dental clinics that can fit them in quicker for procedures requiring general anesthesia or oral conscious sedation.
“I keep only special needs patients that are really embedded in the hospital,” said Rothman.
One key to his success working with patients with special needs like Amanda is establishing a rapport and ongoing relationship with patients and parents.
“After a while you know what to expect from them,” Rothman said. “I write notes in their chart – ‘this worked or that didn’t’ to know what to do.”
Rothman gets frustrated when parents don’t stay on top of their children’s oral health, though he understands the challenges.
“It’s hard to maintain oral hygiene on kids and it’s even harder to maintain oral hygiene on special needs kids,” said Rothman. “Parents put that on the back burner because there are other things—getting them cleaned, getting them up, getting them to school—oral issues become secondary.”
But for special needs kids it is critical that they visit a dentist at least twice a year, brush at home and eat well, Rothman says.
Fabiola Gonzales said Amanda hates to have her teeth brushed. “It takes two of us to take care of her.” Gonzales, 83, lives with her 75-year-old sister, who helps care for Amanda. Much of her time is spent advocating for Amanda in the medical system.
Dr. Rothman, she said, is “an angel” for all he’s done to maintain Amanda’s oral health.
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