I’m sitting in the dentist chair trying to be the best patient ever. I want the dentist to tell me I’m doing great. I’m aware that the desire for such praise is silly, but am I not in the dentist chair because I’ve been a bad girl and have not taken care of my teeth? Wasn’t the unpleasantness of this dentist treatment preventable?

According to the 2022 research at the esteemed Cleveland Clinic, 36% of people in the US have a fear of dental treatment, with 12% having extreme fear. About 3% of adults in industrialized countries may have dentophobia and avoid going to the dentist at all. Fear of dentists is more common in females than in males, say the researchers. And that’s for all of us who grew up with access to modern dentistry.

But now I’m thinking differently of all those dentist commands. How can boys and girls, or men and women with intellectual and physical disabilities carry them out? For them, just sitting in the chair amid the machinery for long periods is a hardship.

Take a Jerusalem boy named “M.” He didn’t get all his baby teeth until he was five. His upper jaw is small, so he has trouble with his bite. He doesn’t understand how to use a toothbrush, so he’s getting cavities. M. has Down syndrome, and among the many difficulties with which he and so many children and adults with special needs have to cope, dental care is major. Turn your head. Relax your jaw. Bite slowly. Rinse. Don’t swallow. Place your tongue on the roof of your mouth, don’t fidget – are commands nearly impossible for M. to comply with.

One option is for the dentist to put him out, but anesthesia has its own complications and needs to be used sparingly. And how can you know what hurts a sleeping boy? Better is a long process of getting him used to dental care, from holding an electric toothbrush to wearing a simple appliance he can’t swallow. That takes expertise, time and patience.

My awareness of these difficulties has been raised by attending a recent conference called “All Smiles Shine,” which focuses on “oral health for persons with disabilities, and the power of partnership.” The main partners are our Jerusalem Hebrew University-Hadassah Faculty of Dental Medicine and the Philadelphia-based School of Dental Medicine, University of Pennsylvania. The University of Pennsylvania is my alma mater, and I’ve always been proud of the role it has played in nurturing Israeli dentistry. The keynote lecture at this conference is in memory of Dr. D. Walter Cohen, whom I was privileged to meet. Dr. Cohen was one of the UPenn dentists who brought high-level dentistry to Israel.

Sitting in a lecture hall full of dentists from Israel, the US and France, I’m made aware of the enormous obstacles there are for the disabled to obtain dental care. How does a patient in a a wheelchair get into a dentist office let alone transfer to the dental chair? How can a person take good care of a disabled non-compliant child or a child’s teeth when there are so many other daily tasks to care for this dependent? And then there are all those mouth-related problems no one likes to talk about like swallowing and not aspirating, gag reflexes and drooling. Yes, drooling- it’s even hard to type the word.

It isn’t surprising that many dentists (and other medical practitioners) do not accept disabled patients. Dr. Miriam Robbins, who directs the Care Center for Persons with Disabilities at Penn Dental Medicine, spoke of patients who had been rejected by dentist after dentist, suffering for years without being able to get help. And while it’s true that the average dental office may not be equipped to handle these special cases that require anesthesia and surgery, the dentists themselves often feel professionally unprepared to provide safe care.

Known diseases – such as familial dysautonomia, a genetic nervous system disease with a remarkably high carrier frequency in the Ashkenazi population, and so-called unnamed orphan diseases – often come with abnormalities of the teeth and jaws. Congenital problems are of course exacerbated by deficiencies in brushing. That results in disabled children and adults often having missing and crooked teeth. Many have distorted facial features.

It’s hard to integrate into society and feel good about yourself if everyone is startled when they see your face. According to Hadassah orthodontist chairperson Stella Chaushu, who treats M. in her clinic, 67% of intellectually and disabled persons with abnormalities of their teeth and jaws want to improve their appearance – even more than those who are concerned with eating comfortably. They hate the way they look. Likewise, their parents believe their children (and maybe their own) social acceptance will be significantly aided with improved appearances. But who can help?

Listening to the lectures, the gap between the needs and the resources seems overwhelming. The most difficult cases – if they are fortunate enough to be accepted – need years of complex treatment. Such treatment is almost unknown in the developing world, where dentists are scarce. For example, in Ethiopia, outside of the capital there are only around 50 qualified dentists for a population of more than 100 million.

There is some light. First, the speakers at the conference showed amazing pictures of successful cases where nearly impossible to imagine malformations were corrected. Second, this first international conference and other current initiatives are putting oral health on national and global agendas.

Good news for us Israelis is the government decision to provide free dental care for kids and teens, and now for seniors 72 and older, and the opening of specialized clinics for the disabled. Chief Dental Officer from the Health Ministry Dr. Lena Natapov spoke of the ministry’s commitment. Israeli experts like Chaushu have been pioneers, leading in the previously sparse data-driven research on treating patients with disabilities. Dental schools here are now teaching students to treat this special population. Among the attendees at the conference was Dr. Musa Bajali, an associate professor at the Faculty for Dentistry at Al-Quds University, so training dentists to treat the disabled will cross ethnic lines.

Nonetheless, there’s a long way to go. Hadassah’s Prof. Nardi Caspi showed a picture of a futuristic dental chair into which a patient in a wheelchair could transfer without being lifted – a dream for every dentist treating a disabled patient.

In the meantime, on my personal list of blessings not to take for granted, I’m putting the ability to chew my food, to smile, and to be able to kiss my loved ones. And also, just being able to open wide.