The fear, pain and uncertainty that come with going to the dentist can unnerve even the healthiest among us.
Imagine what it can be like for those with autism, dementia, physical limitations, developmental disabilities or cancer.
These are the patients in the working world of Drs. Elizabeth Kapral and Maureen Sullivan, two of a dozen dentists who help staff three dental clinics at Erie County Medical Center.
“You have to have a passion for this work, and also be a leader. You have to be able to make decisions, and articulate them with physicians,” said Sullivan, chief of the Department of Dentistry’s Division of Oral Oncology and Maxillofacial Prosthetics. She has specialized for a quarter-century in providing complex dental care for patients with head, neck and other cancers, first at Roswell Park Comprehensive Cancer Center and, since 2014, in her current post.
Sullivan is a mentor to Kapral, 33, who grew up outside Syracuse and splits her time on the ECMC campus in dental clinics at The Center for Cancer Care, the main hospital building next door, and the nearby Terrace View long-term care facility.
Some of their work is so intricate – or conducted on patients unable to sit through a checkup, cleaning and dental procedure – that it must be performed in an operating room. The job also is a path far less traveled by dental students who can see more patients and make more money in a private dentistry practice.
This helps explain why the federal Health and Human Services Health Resources and Services Administration has given ECMC a five-year grant worth more than $760,000 to provide Kapral extra training so that she can continue to fine-tune ways treat her patients – and teach dental students and residents the skills they will one day use to do the same.
Sullivan and her husband, Dr. John Nasca, also a dentist, live in Amherst and have three grown children.
Kapral and her husband, Brandon, an electrical engineer, live in Williamsville with their young son and daughter.
Both are graduates of the University at Buffalo School of Dental Medicine and took extra training at Roswell before going to work as attending dentists in specialized hospital settings. They generally see three or four patients a day in the operating room or 10 in general clinic, far less than in private practice.
Q. Why did each of you choose to work in dental specialties at Roswell and ECMC?
Sullivan: I was exposed to oral cancer as a kid. My grandmother, Betty Sullivan, had it. I was 16 at the time. She had a pretty large head and neck surgery but lived many years after that and really did fine. I knew I wanted to go into dentistry but I always had it in the back of my mind that if there was an opportunity to work in oncology, I would try to do it. My father, Joe Sullivan, had a lot of dental problems and he said, "You know, you really should be a dentist," and I said "OK, I'll be a dentist." I'm still doing dentistry on him. He just turned 80.
Kapral: I always liked science when I was a kid. I like doing things with my hands and with dentistry you get to have immediate gratification with your patients. They come in with a problem and in many situations we can solve that problem right there. You can do the most good in these complex situations. Many of these people have very severe needs, they're very sick, and we can do a lot of good for them. I don't have a family connection to those with these kinds of needs. When I was getting my master's degree at Roswell, I got to know the patient population and was drawn to that. It drew me here, as well.
Q. How big is the ECMC dental patient base? What needs do they have?
Sullivan: There were about 11,000 general dentistry patient visits in 2017 and 6,000 oncology patient visits.
Kapral: For this grant, I see patients in all three clinics. In the general dentistry clinic, I see adult patients with intellectual and developmental disabilities. In the oncology clinic, I see patients with cancer, with HIV and a lot of renal transplant patients. In Terrace View, I see a lot of geriatric patients, patients who have dementia or who've had traumatic brain injuries. Most children with dental complexities go to the John R. Oishei Children's Hospital.
Q. Dr. Sullivan, how has dental care for special needs patients changed during your career?
Sullivan: There are more modern techniques available and probably more of us in this facility are equipped to treat them but the situations are the same. It's difficult for many patients to get here and it's difficult a lot of times to see them in an ambulatory (clinical) setting. A lot of times, they need to go to the operating room. So in many cases, not much has changed.
Q. How do both of you see it changing during the next generation?
Sullivan: I'm hopeful that through grant situations like this, we're able to train more dentists that are equipped to do this and there won't be such a long waiting list to see someone like Liz or me. Right now, there's a backlog of patients.
Q. How long are the waiting lists?
Kapral: If the patient needs to be seen in the general clinic, we're out probably six or eight weeks. If they need to be seen in the operating room, it's several months.
Sullivan: Hopefully, if we have more people equipped to do it, there won't be so much of a wait.
Kapral: People are realizing that this is a problem and we need to find a way to fix it. This is definitely one of the ways to do that.
Q. How can someone make an appointment?
Kapral: Call the main clinic at 898-3189. They'll do a brief screening on the phone and get patients to the right clinic.
Q. Can you talk about the similarities these clinics have with all dental offices and the challenges unique to them?
Sullivan: When I was in Liz's positon, I did a little bit of everything: started a private practice, did a little teaching, worked in hospitals and worked in community health centers. My most rewarding day of the week was when I could do the most for somebody who couldn't do for themselves.
Kapral: Every dentist is similar in their goals. You want to improve dental health. We all do generally the same treatments: filling, cleanings, crowns, bridges. Our work here is a little more complicated due to the history of our patients, patients who've had cancer and other conditions.
I've never worked in private practice as a dentist. I've only ever worked here, so it's hard to compare.
Q. When you talk with them in generalities, what is that like?
Kapral: I might say something like, "I was in the operating room on this day," and they'll say, "Wow, what's that like?" Their pressures are different from mine. They have staff they need to keep employed and certain goals to meet financially. I'm a little bit more focused on patient care. I love it. I think I have the best job. Because of our patient histories, it changes the way that we do things.
My patients who have intellectual and developmental disabilities sometimes can't sit in a dental chair. They may be in wheelchairs. Patients with severe autism won't let me near them to look in their mouths. A lot of times, we need sedation of some kind. Sometimes, we need general anesthesia in the operating room, to put a lot of our patients to sleep, and do all the work while they're asleep.
Q. What about patients going through cancer treatment, or who've had cancer or HIV?
Kapral: It varies depending on the cancer treatment. If they had radiation to their head and neck, or had chemotherapy, their mouths are often very dry. They can get radiation-induced cavities, which are a little harder to treat. If they need extractions, they can have problems with their jawbone not healing well.
Even patients who've had breast cancer or lung cancer, depending on the chemotherapy drugs they've been given, it can change the way their mouth functions.
There's lots of things with HIV. Patients are more likely to develop lesions in their mouth that sometimes can turn into cancer, so they're at higher risk. Pappilomas and benign growths also can pop up and cause discomfort.
Geriatric patients with dementia are very similar to our patients with intellectual and developmental disabilities. They have a hard time communicating what their problems are, so our goals are a little bit different with that patient population. If it's something that's bothering them, we need to address it, but if they have small cavities or something similar, sometimes the risk of trying to treat certain things is greater than the reward of having it done.
Q. Where does prevention come in here? That would seem to be more complex, as well.
Kapral: It is, and it's probably the most important thing that we do. If we can prevent patients from developing cavities or losing teeth, that's our goal. But to have a patient with severe autism who won't let you near them, trying to find a way to have them brush their teeth is challenging. It's the same for a patient with dementia. We work with a lot of group home staff to find ways to make it easier. Sometimes we start with a washcloth or a little sponge on a stick to clean teeth. We work with family members on this, too. We try to do it one-on-one when a patient comes in for their six-month exam and cleaning. We teach them the best ways to approach home hygiene. Sometimes they can't be as effective as we want them to be but we know they're up against a lot of challenges. We put a lot of our patients on prescription-strength toothpastes, which have higher levels of fluoride, which can help prevent cavities.
Q. Talk about the grant. How will the money be spent?
Kapral: Some of the monies are for salary reimbursement to spend my time on training activities. Those come in a lot of forms including travel to various meetings for training on oral medicines, with the Special Care Dentistry Association, the American Dental Education Association meetings and trainings.
Dr. Sullivan is my mentor. We work together every day and she's spent a lot of time helping me advance my career in this field.
The University at Buffalo has a leadership program through the American College of Physicians that I'll be taking next year. Near the end of the grant, we'll also be providing training for outside dentists to attend. We're also starting a course for UB dental students.
Q. How do the daily financial and work aspects differ in this clinical work?
Sullivan: If you're someone like Liz, you will know how to handle these patients, schedule the day – ayou can't double book your patients. That's a game changer for somebody in private practice. You can't shut down your office for half a day, then figure out you can't take care of a person and have to send them to a hospital.
Q. Are the financial rewards great?
Sullivan: Not as great as private practice. That's the big lure. It'll definitely be more lucrative – but for some people, it won't be enough. We've been blessed for being exposed to people like Liz, who are smart, enthusiastic and want to go outside the conventional lines. It's a special person who wants to do this type of work.
Q. What are some of the qualities dentists need to be successful in this line of work?
Sullivan: When you have an opportunity to interview somebody, you can tell pretty quickly if they have great communication skills, if they're an ethical, honest human being that would do the right thing for any patient, that would treat a patient like they would want their family treated. You would want them to treat your family. Those are the characteristics.
Q. How helpful is a grant like this?
Sullivan: Very helpful. This is an opportunity for ECMC to say, "We can now afford to extend all these additional educational opportunities to Liz that otherwise makes little sense." It would be far more lucrative for ECMC to have Liz in clinic all day, every day. This is a great opportunity to have all of her salary covered for five years and handle her other expensive educational opportunities.
It's great for ECMC. The long-term goal for us is to always be able to replicate ourselves. As clinicians, as educators, as stewards in our community, we have to find the next generation of people who want to do the work that we do. All of us – not only Liz, but all of the people she trains and our faculty – are in the same boat.
Q. There's no requirement that you stay in Western New York after the grant ends but is that something you'd like to do?
Sullivan: We won't let her go.
Kapral: I think we’re really unique and I would love to stay here. I love what I do. Not only do I love the patient population here, the team we have here, the attending dentists, the incredible leadership, but all the mentors that I have in this department are many steps ahead of me and I have a path to follow to get where I want to be. I would not be able to replicate that somewhere else.