When a patient just can’t sit still, what’s a dentist to do?

Using full anesthesia for dentistry in an operating room

At first, everything goes smoothly, as Naomie Joseph-Dandurand enters an operating room at the JGH, slides easily onto a surgical table, and smiles at members of OR team. But moments later, the unpredictable aspects of her autism make themselves felt.

Though never intentionally uncooperative, she flops onto her stomach after being asked to lie on her back. When she does turn over, her hospital gown becomes twisted around her waist. Then she gleefully pulls the plastic mesh cap off her hair and flings it to the floor.

Before her dental exam begins in a JGH operating room, Naomie Joseph-Dandurand (bottom of photo) begins to feel the effects of a general anesthetic. She is calmed and reassured by Dr. Robert Karanofsky (centre), her mother, Chantal Dandurand, and Dr. Matthew Cameron, an anesthesiologist.

This type of behaviour is why Ms. Joseph-Dandurand has been brought to an operating room, early one autumn morning. The physician in charge, Dr. Robert Karanofsky, is a dentist who can only examine his 20-year-old patient by having her placed under general anesthesia, a procedure that must be performed in an operating room.

Once a month, Dr. Karanofsky devotes a full day to patients like Ms. Joseph-Dandurand. Some have physical problems (such as cerebral palsy or uncontrollable tremors), while others have behavioural conditions (autism, extreme anxiety) that make them unable or unwilling to give a dentist access to their mouth for even the briefest examination.

Before the age of 18, they can get help at hospitals like Saint Justine or the Children’s. But this ends when they become adults. In the Montreal area, the JGH is the rare hospital—in fact, one of the very few in Canada—with the professional expertise and the facilities to provide dental treatment under full anesthesia to adult patients with complicating medical conditions.

Once Ms. Joseph-Dandurand is fully sedated, Dr. Karanofsky begins his extensive oral exam, which includes cleaning her teeth, filling cavities and making a series of on-the-spot decisions about additional procedures.

Having only seen Ms. Joseph-Dandurand for a limited consultation a few months earlier, he must be prepared to tackle almost any problem he may discover. Earlier this morning, the patient’s mother, Chantal Dandurand, told him that three weeks earlier, her daughter had had a painful abscess that caused her cheek to swell. This probably means that a tooth will now have to be extracted.

A source of comfort

Later, while taking a breather in a family waiting area, Ms. Dandurand says she counts herself lucky that her daughter makes hardly any fuss when asked to take medication or to submit to injections or bloodwork. But conventional dentistry is something she would never tolerate.

Another source of relief, says Ms. Dandurand, is simply knowing that Dr. Karanofsky and his team are available to help Naomie. “If not for them, I don’t know what we’d do,” she says with a sigh.

“Naomie can’t explain what she’s feeling when she’s in pain. So getting her teeth checked this way is beyond a necessity—it’s essential. She couldn’t face the future properly without it.”

This type of dental service, though largely unfamiliar to the public, has actually been around for years. It was a responsibility that Dr. Mel Schwartz, Chief of Dentistry at the JGH, “inherited” from his predecessor, Dr. Bernard Slimovich, in the early 1980s, and now the baton has been passed to Dr. Karanofsky.

It’s also a significant component in a wide array of dental options that are geared to the needs of certain JGH patients. For instance, depending on their medical condition, a patient might be treated in the dental clinic while seated in a wheelchair or even standing up. An electric hoist is also in place in two of the department’s examination rooms to lift a patient out of their wheelchair and lower them into a conventional dental chair.

Dr. Schwartz notes that demand has been rising for dentistry in the operating room, especially since CIUSSS West-Central Montreal came into existence in 2015. Today, JGH dentists are called upon to treat a much wider range of patients from elsewhere in the CIUSSS, including elderly residents of long-term care facilities, as well as individuals with various physical and mental disabilities from other locations.

While general anesthesia is often unavoidable, Dr. Karanofsky says, it comes with risks, so if possible, he tries to avoid it or minimize its use. One alternative is “doubling up” with another procedure. For example, this past summer, when a severely autistic patient underwent general anesthesia for a colorectal exam, Dr. Karanofsky used the opportunity to check the patient’s teeth after the other medical team had finished.

This type of dentistry has appealed to Dr. Karanofsky ever since his 2013 residency at the JGH, where he arrived soon after graduating from McGill University. Aware of his growing interest in this aspect of dentistry, Dr. Schwartz invited Dr. Karanofsky to join him for the general-anesthesia cases, and then asked him to take charge of these patients about two years ago.

Patience is crucial

Asked about the qualities that enable Dr. Karanofsky to provide this care, Dr. Schwartz replies that even when Dr. Karanofsky was new to the department, “I saw in him a very competent young man, in terms of his professional skills. But beyond that, I found him to be an empathetic and warm-hearted person who is very good at communicating.

“What a dentist of this sort absolutely needs—and what Dr. Karanofsky has—is patience. He has to take extra time with the patients, and in speaking with the relatives or caregivers, he has to clearly explain what his goals and intentions are.

“You need to be able to reassure a relative or caregiver that you have the patient’s best interests at heart. You have to make them understand that you’re going to do all of the necessary work in the limited time that you’ve got, in order to be as sure as you can that the patient will be pain-free.”

From a professional perspective, Dr. Karanofsky says he enjoys his work, because “every day is different. You can’t have a cookie-cutter approach when you see the kinds of people that I do—everyone from run-of-the-mill patients to the sickest of the sick. You have to be prepared to meet every individual’s needs.”

On a more personal level, however, Dr. Karanofsky finds it rewarding to be involved in improving the lives of especially vulnerable patients who have no recourse but to be treated in an operating room. “I don’t necessarily get any feedback from them, because they’re often non-verbal or non‑communicative, or they don’t understand what’s going on.

“But the caregivers and families do tell me how appreciative they are. Some of them have been searching for help for months or even years, and after I’m done, the warmth of their thanks means a great deal to me. It’s very satisfying to know that I’ve been able to step in and make a difference for these patients.”