The difficulties of psychiatric dental care

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Serkis Massihi has been through a difficult time – and his teeth show it.

Massihi, 38, struggles with post-traumatic stress disorder and became addicted to prescription painkillers after undergoing shoulder surgery more than a year ago. He began using methadone as part of his addiction treatment, but the drug left his mouth dry. It also made him crave sugar. He binged on pop and candies "like a little child."

Within nine months, his self-described "beautiful mouth" was plagued by infection and decay. He had receding gums and cavities on nearly every tooth.

Yet Massihi had trouble finding a dentist willing to treat him.

"They turn you down because they don't have respect for you, they're not getting the money they want and they certainly don't care if a toothache's gonna kill me," he says.

At the dental clinic at Toronto's Centre for Addiction and Mental Health (CAMH), Massihi is now gradually getting his teeth repaired.

CAMH senior dentist Paul Zung has been treating psychiatric patients at the mental-health facility for 30 years. Previously located in the basement of a neighbouring building, his new, expanded dental clinic officially opens on Wednesday on the second floor of the Bell Gateway Building at CAMH's Queen Street complex.

The new clinic, with its four dental chairs, is double in size. Zung says the former location was so cramped that he and his dental students were seeing patients "in my office, in the lunch room, probably breaking a half a dozen rules."

But even with the expansion, the demand for psychiatric dental care is far greater than the dental clinic can accommodate.

Zung says his clinic sees only a small fraction of CAMH patients, those who are most severely affected by dental problems and are well enough to be able to brush and take care of their teeth.

"We don't try to see everybody," he says. "It's a niche role."

Among the broader population in Toronto, Zung says, he has worked on patients at the city's non-profit Evangel Hall Mission and the Yonge Street Mission, where he was hard-pressed to handle the volume of individuals with mental illness seeking dental care.

"There'd be, you know, 15 people lined up, and I knew I'd could only get through the first three of them. And then there'd be a different three the next week," he says, which made it difficult to see patients through an entire treatment plan.

Performing dental procedures on psychiatric patients presents its own set of challenges. Zung says his patients' teeth serve as an archeological record of their ups and downs. Issues like addiction, psychotic episodes and homelessness leave a lasting impact, he says, noting that individuals with psychiatric illness tend to require five to 10 times more dental work than their same-aged peers who do not have mental illness.

Some of his patients are afraid of using anesthetics, and refuse them. Doing intensive procedures without painkillers "borders on the inhumane," Zung says. "But they sit there cool as a cucumber and have deep fillings done, things I would not humanly be able to bear."

Others have anxiety and have had prior negative experiences at dental offices. Some have false fixed beliefs, such as the idea that their teeth will grow back. No-shows are common, and so is having patients suddenly leave in the middle of an appointment.

Maintaining patients' trust is paramount, Zung says, so he tells them that they can stop him whenever they need. "I keep that promise, and it's that promise that gives them a sense of control and their pain tolerance goes way up," he says.

That can lead to tricky situations, however. Zung recalls that he had one patient who had a tendency to bolt before his work was done. She rushed out of his dental clinic immediately after he had drilled a hole for a tooth implant. Worried that the implantation site would be ruined, since bone doesn't grow back easily, he tried to get her to return as soon as possible. When she finally came back three months later, Zung placed implants as quickly as he could, fearing that she might leave and have the bone destroyed.

"My heart was just racing afterwards," he says.

One-third of Zung's patients receive coverage from the Ontario Disability Support Program (ODSP). The other two-thirds receive financial support from Ontario Works and the clinic charges them a fixed fee for each appointment, based on a sliding scale relative to their income.

Zung says private dentists can't be blamed for turning down these patients. Because the ODSP doesn't fully cover the costs, dentists would be volunteering their time to do complex work, and that's assuming the patients actually turn up for their appointments. (Zung is paid a salary by CAMH.)

Yet, Zung finds that his skills and abilities are stretched far more than they would be in private practice, and the work, he says, is satisfying.

"I worked in private practice as well, and I thought, 'I'm cleaning a lot of clean teeth here,' but in a psych hospital, I'm cleaning teeth that are actually dirty. I'm fixing things that are actually broken," he says.

James Bennett, 51, of Toronto credits Zung for helping him regain his self-confidence.

Bennett, a chef who was dealing with mental-health issues and alcohol addiction, had a front tooth knocked out in a fight while living on the streets. He had significant damage to his teeth and suffered from tooth pain. He says that getting his teeth fixed was part of taking better care of himself.

"I wanted to get back to work, and it was really important to me, in terms of self-esteem, and to get my smile back again," Bennett says, who now works in catering. "It was a huge deal to me. It made a huge impact on my life."