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'Just a few questions Ahmed', we explained 'and then we'd like to look in your mouth'. A nurse acted as interpreter. 'When did you last go to the dentist?' The question was translated from Hebrew into Arabic and an animated discussion followed. 'Two years ago? Five years ago?' I suggested. The cleaner put aside his mop and came to join in. Six minutes on the clock and back came the reply, 'Last week!'.

Ahmed (patients' names have been changed to protect confidentiality) is a patient recovering from a hip fracture in Geriatric Rehabilitation at Herzog Hospital in Jerusalem. He was one of the patients I interviewed and examined together with the hospital dentist, as part of an oral health needs' assessment which I was asked to carry out as a dentist with training in dental public health.

Ask anyone in Jerusalem about the Sarah Herzog Memorial Hospital and those who have heard of it will tell you that it is a psychogeriatric hospital on the edge of town — the last stop before the cemetery. It was founded by a group of philanthropic women more than a 100 years ago as a 2-room asylum. Gradually it grew into a psychiatric hospital, moving out of the old city walls and then again to a picturesque spot in the Jerusalem hills where it now stands as an unassuming, low roofed building, stretching down the side of a hill. Twenty years ago, in response to demographic changes, the first department of geriatrics was opened and the number of patients has been growing ever since. In Western countries, these demographic changes coupled with a decline in dental caries mean that people are living for longer and keeping their teeth; factors which are likely to have considerable impact on future dental practice.

In Acute Geriatric Care, we meet Ilya who immigrated to Israel together with his wife in 1991. He is 73 years old and comes from Moscow where, as a diabetic patient, he did not have access to disposable syringes. His left leg has been amputated, he is blind and partially deaf. He is hospitalised for his chronic obstructive pulmonary disease and anaemia. Their Hebrew is minimal, so Leon, the hospital dentist who speaks five languages, translates the questions into Russian. For some reason we start by directing the questions to his wife Lena. On examination he has bleeding gums, caries in four teeth and two retained roots. 'And would you be interested in dental treatment?' 'Da!' (Yes) came the ardent reply. Last question, we turn back to his wife, 'How about you —would you be interested in dental treatment for yourself?' She shook her head with an apologetic smile.

'She's a very sick lady', volunteered a voice in English from the other side of the room where Rose is settling down for the day with The Jerusalem Post. She tells us about her husband, Ben, who has been lying in a coma since his last myocardial infarction almost a year ago. On the wall by his bed is a photo of their godson who is named after him. Actually, we have met before when she came to find out what to do about his sore mouth. Like many patients at the hospital, Ben is fed by nasogastric tube. With nil by mouth and prophylactic antibiotics they are prone to candidal infections.

While the hospital is open to all Israeli citizens and these are typical patients, they are not representative of the elderly in Israel. With an extensive welfare system and strong community networks including a plethora of voluntary agencies, the rate of institutionalisation is actually quite low. Ahmed and Ilya are examples of many poor Israelis who now have health insurance as a result of the 1995 National Health Insurance Law which guarantees them free coverage.

Of some 700000 immigrants who have arrived here since the breakup of the former Soviet Union, almost 14% are greater than 65 years of age; they too are covered. Although it is a very comprehensive healthcare package, dental treatment is not included. As a voluntary hospital it is fortunate that there are dental facilities at all. The clinic was made possible by a donation some 25 years ago and those who have dental treatment have to pay.

Gradually we work our way through the departments. It is a slow process impeded by some of the very barriers that limit access to dental care; a range of cognitive and communication difficulties. These patients are particularly vulnerable and need careful handling. For example, a seemingly innocent question as to whether or not Lena would be interested in dental treatment triggered tears. We learned from Rose that she has disseminated cancer.

Each of the ten departments has its own profile of patients. There is a department for people with depression who have been resistant to treatment at other centres. Here we had the lowest rate of compliance — why should a person who is depressed want to take part in anything, let alone a dental survey? In Psychogeriatrics, 80% of the patients are women; one unit is made up of people with dementia and in the other there are people with psychiatric disorders who have simply become old. The hospital also has the only Department of Neurogeriatrics in the country.

After a while, when looking at the patients' hospital notes we cannot help predicting what their mouths will look like. Where someone comes from, for example, can greatly influence the state of their mouth. This is especially noticeable in Israel from the telltale stainless steel crowns of those who come from Eastern Europe to the immaculate teeth of recent immigrants from rural areas in Ethiopia. But there are always surprises because while extra-oral predictors of oral health may hold true for groups of people, individuals are another matter. For example, after a morning of checking full dentures in the Department of Advanced Medical Care, we found Zvi, a 93-year-old man with 22 teeth in his mouth. 'Of course I've got a toothbrush', he bellowed sitting himself up in his wheelchair. Actually he is one of the few.

They say there is no text without context. Move back in time and place and many of these people who are now so dependent were once society's providers, including Zvi who worked in a Jerusalem dairy for more than 40 years. Consider their illness in the context of their lives. Ilya is a former lawyer who cannot speak the language and Ben, who suffered with Parkinson's disease for years, used to be an artist. As dentists we should put oral health in context too. Ilya has enough difficulty coping from day-to-day without the added burden of toothache. It is not enough to describe his dental need in terms of the number of decayed, missing and filled teeth. What is the impact on his everyday life? Is he in pain? Can he chew properly? Does his mouth feel sore? Such socio-dental indicators tell us much more about his real need for treatment. Normative need1 defined by the professional, in this case the dentist, can differ greatly from the perceived need defined by the client, in this case the patient.2 It is particularly relevant to consider perceived needs when resources are limited, including the patient's reserves of energy to undergo treatment.

There are patients in their nineties at the hospital and patients in their twenties. Some like Ahmed may only be hospitalised for a few weeks whereas most of the psychiatric patients have been here for years. Like Dan who has manic depression, who can regularly be seen shuffling along the corridor holding a bottle of Coca Cola — a far cry from the fresh young image in which the manufacturers would have us believe. And there is Rivka who has schizophrenia, breast cancer and a broken denture — proudly sporting a pair of pink plastic earrings which are a gift from the occupational therapist.

By making a mouth feel comfortable, dentistry can contribute to an overall sense of wellbeing and help a person feel that little bit more worthy.

Prevention has a particularly important part to play in Dan and Rivka's dental care as a side effect of the medication which they are prescribed is to dry up their saliva, so denying the oral environment of its protective effects. Special care dentistry has much to offer such patients. Part of it is to repair that denture or restore that tooth so that a patient can chew. But it is also to make that denture wearable for someone with dementia making them look like more of a person to those who come in contact with them. And it is to restore that smile for a psychiatric patient with low self esteem. By making a mouth feel comfortable, dentistry can contribute to an overall sense of well-being and help a person feel that little bit more worthy. It sends a message that we care; we even care about your teeth.

In Advanced Nursing Care, a number of patients, who are post-CVA, are prescribed phenytoin as they are prone to convulsions. So is Saul who suffers from grand mal epilepsy. We notice him straight away as he is lying with his mouth wide open. As we approach we both fall silent at what we see. His mouth is covered in plaque and his upper premolars are almost completely buried by gingival hyperplasia. His body is arched back with his eyes looking heavenward; his hands main accoucheur almost as if he is begging. He reminds me of a poem about sleeping children with their arms above their head, who are overlooked by enchanted admirers. 'Why are they surrendering', wrote the poet,'when they have captured us?'3

'Brush his teeth?' challenged a nurse. 'Why should we?' It would be easy to be indignant and to assume that their priorities should be the same as ours, but dental plaque is not on the agenda. Their work is demanding enough and not all of them were born 'Florence Nightingale'. The bulk of nursing staff are auxiliaries, largely made up of newcomers to Israel for whom the job represents a steady if modest income for the time being, until they move on. There is even the odd ex-ballerina who now spends her day dealing with double incontinence.

I am not suggesting that the oral health of such a medically-compromised patient should be top priority, but somehow not to brush Saul's teeth or repair Rivka's denture is to truly render them sans teeth sans everything. The issue here is not teeth, it is humanity. These patients should have their teeth brushed for the same reason that they have their hair brushed, to give them the dignity of being treated like human beings.

A way to try and motivate carers, whether formal or informal, to help with maintaining oral health, is to focus on their own dental needs. Which is how one sultry summer's day I found myself in an airless hospital workshop distributing questionnaires to staff, on their perceived need for dental care. It suddenly dawned on me, that after months of avoiding public transport because of a wave of suicide bomb attacks during which one member of staff had been killed and another seriously wounded, here I was, one Jewish female in discussion with eight Arab males. To see Arab and Jewish hospital workers discussing the previous night's basketball match over a cigarette and other simple everyday examples of coexistence that never make the headlines, makes the stereotypes disappear.

Such stereotypes can also be a barrier to care. I remember that as a dental student back in England a geriatrician came to speak to us as part of the prosthetics course. It was the last lecture before lunch. 'When dealing with people we have to consider the environment from which they come', he said. Down went the lights and up went a slide of a dingy looking bedsit. An unmade bed, a pile of clothes on the floor, an opened can of baked beans on the counter. Considering the deprived area in which the dental school was situated it seemed a reasonable assumption that there would be prosthetics patients coming from such a background. 'This', he said, 'is a typical student's bedroom!'

One day at the hospital, the regional dental officer, whose role is largely disciplinary, was due to inspect the clinic. Leon was up in arms, 'Never mind the equipment, one look at that window shared with the toilet from Psychogeriatrics and he'll close us down!' he said. 'Perhaps he should first see some of our patients', suggested the hospital director with a twinkle in his eye. So we took him on a grand tour, starting in Rehabilitation on the first level, working our way toward the Departments of Psychiatry down on level five. As we walked along the corridor, he told us of some of the trauma cases and war disabled that he had been responsible for as a former army colonel.

We entered the Department of Advanced Nursing Care. 'Would you like to have a look?' asked Leon offering examination gloves and a probe. Visibly moved, he declined keeping a respectful metre from the bed. He had seen it all — and now Saul.

A year later, the Sarah Herzog Memorial Hospital is delighted with its new dental clinic complete with scenic view of the Jerusalem hills. After his visit, the Regional Dental Officer pulled out all the stops to give support. As for Leon, these days he is all smiles. And summoned by the operative imperative, he is poised to drill happily ever after.

To carry out dental treatment without preventive measures is an approach which those in dental public health compare to bailing out a leaking boat

And yet for me, as a public health dentist, the story is not quite over: this hospital boasts an innovative outreach programme for medical treatment for psychiatric patients in the community, and yet the majority of its in-patients are unable to access the dental facilities on site. This is not just a matter of physical accessibility. Access must be considered in all its dimensions:4 availability, accessibility, accommodation, affordability and acceptability. Consider too that as dentists, we are dealing with the most preventable of diseases. To carry out dental treatment without preventive measures is an approach which those in dental public health compare to bailing out a leaking boat. Indeed, for many of these patients who are at high risk for dental diseases, it can be compared to bailing out a sinking ship.

Of course, we each have our personal view of what is appropriate for a given situation, which is often determined by training and experience. I once heard about an artist who uncovered a bee's nest inside her home. As the bees swarmed throughout, she decided that her first priority was to run for the camera and take a picture!

And so, before I prepare yet another plea for toothbrush holders, denture marking and time off for hospital staff to hear about the link between plaque and humanity, I need to take a few steps back and assess how best to communicate the situation as I see it. As one noted scientific writer has commented,5 it is not always enough to present dry facts for people to fully understand an issue. Sometimes you have to use 'all the tricks of the advocate's trade' to really put your point across so that they can feel it 'in the marrow of their bones'.

Perhaps I simply need to explain that if special care dentistry is about humanity then dental public health is about equality. It is about identifying those people whose oral health is most compromised and taking action to make it better. It is to bring them in from the periphery and put them at the centre; to bring them up from the lowest level and put them at the top. For those who are neither seen nor heard, it is to see them and be heard on their behalf.

So how can I promote this branch of dentistry whose processes are unseen and unfamiliar? How can I open the doors of Herzog Hospital and let others see what I see? How can I capture the context of these people's lives? If only I could simply run for the camera and take a picture.

Instead I reach for a thesaurus. If I could somehow take a snapshot with words, that might just be the first step on the road to making a difference.