Probing the roots of neglect
Dental hygiene among the ultra-Orthodox is often disastrous, a consequence of lack of both money and awareness. The new reform in dental care may help the situation, but some are dubious
As the 12-year-old girl steps out of the treatment room at the Chabad dental clinic in Jerusalem's Mea She'arim neighborhood, she asks: "How long will it take?" The answer she receives from the female dentist, concerning how long the thin metal wires encircling her teeth will have to stay on is apparently satisfactory; the girl gives a little smile.
Tuesdays is orthodontics day, for girls only, at this clinic for disadvantaged residents, in the heart of the ultra-Orthodox neighborhood. Girls aged 10 or 11 flock there: How their teeth look is a very important aesthetic issue for them. Indeed, within just a few years they will begin getting offers for potential husbands.
Considering the high cost of the treatment and the large number of children in these religious families, orthodontics cannot be taken for granted. Today - as Chabad dental clinic director Rachel Donat relates, and as emerges from conversations with mothers - the accepted practice for ultra-Orthodox preteens who want to have their teeth straightened is to save up money from babysitting jobs.
At the clinic, where dental care is subsidized, they charge about NIS 6,000 for the whole process, which may sound astronomical to a girl who slowly accumulates her shekels, but is lower by several thousand shekels than orthodontic care offered by health maintenance organizations and certainly by private clinics.
In some cases, says Donat, there is a medical justification for orthodontic treatment as a result of teeth being neglected from an early age. Thus, for example, the extraction of baby teeth because of decay is very common at the subsidized clinics run by nonprofit organizations, of which there are a number in Jerusalem. Instead of preserving teeth, parents - to the child's detriment - often prefer to extract and save money.
The Chabad clinic serves "families that barely make it to the end of the month, in which the fathers study at a kollel" (a yeshiva for married men ), according to Donat, a resident of the Betar Ilit community outside Jerusalem.
"This is a population that opts for minimal dental care. Whatever hurts is taken care of; they come to the clinic only when a child isn't sleeping at night and there is an emergency. It's shocking to see a 5-year-old child with only one whole tooth in his mouth. It isn't that they don't care, but parents say to me: 'I'd like to [give my child dental treatment], but don't have the money.'"
Donat adds that many families cannot afford even the lower prices at the clinic, which charges about NIS 100 for a child's filling. "The cheapest is to extract baby teeth. To rehabilitate a tooth, or put a crown on it - that's hundreds of shekels. In very many cases we extract, because there is no alternative."
Supposedly, all this will change in the wake of the reform spearheaded by Deputy Health Minister Yaakov Litzman, involving free dental care for children under the age of 8. While the reform, which went into effect earlier this month, does not include orthodontics, it does include such services as tooth reconstruction, fillings, extractions, root-canal work, temporary crowns, anesthesia with nitrous oxide, and x-rays, with a deductible of up to NIS 40 per visit.
Although Litzman's scheme is intended for the entire public, members of the ultra-Orthodox sector are among those that need it most. Donat believes the reform "will solve a great deal of problems," but adds that it is inadequate, as "there are children up to the age of 12 or 13 who also need treatment."
A dentist who works at a Meuhedet HMO clinic in an ultra-Orthodox neighborhood doubts the reform as planned will help much. According to him, his clinic's management recently instructed dentists to limit the number of procedures per visit and thereby save on certain treatments: "A child comes in and might need three fillings on each side. But according to the instructions, and because up to NIS 40 is charged per visit, I can do only two."
Asked about the policy, a spokesperson for Meuhedet says these instructions come from the Health Ministry, not the HMO itself.
Another dentist who works at Meuhedet and at a subsidized clinic says the HMO is worried about being inundated with patients, with the advent of the reform scheme. According to her, ever since the HMOs started offering free dental treatment as part of their complementary insurance plans (Maccabi up to the age of 6; Clalit until the age of 18, or 6 under a cheaper plan; and Meuhedet until the age of 12 ) about a year and a half ago, there has been an influx of ultra-Orthodox seeking treatment for their children. She says the HMOs have not prepared themselves for the reform yet, but in any event nowadays, "by law, you have to treat everyone. If you're treating one child for an hour, though, how are you going to take care of the others?" She fears the HMOs will not be able to keep up and people will have to wait a very long time for appointments, which will consequently affect the level of treatment. She also fears dentists' salaries will decrease, good dentists will leave HMOs and the quality of service will decline even more.
From conversations with ultra-Orthodox parents it emerges that most are not yet aware that they are entitled to free treatment. In general, they are skeptical. Nor has Litzman become the "hero du jour" in the Haredi press, though the reform has been depicted as positive there.
"It's a pity the reform has come along only now, when I have only one child under the age of 8," says Rivka, a mother of nine in Jerusalem (who preferred, like others, that her real name not be published ). "Today I am paying thousands of shekels for my son because I didn't give him dental care when he was little. I have taken out a loan. The dentist told me this was the result of neglect. I once thought I didn't need to worry, that it was only baby teeth and why invest? When you have nine or 10 children, you say: 'Never mind.' Do you know how much laughing gas costs? Or a filling? Where can I find the money to pay for this?"
A matter of poverty
Various perceptions have taken root among the poorer ultra-Orthodox populations: for example, that small cavities and baby teeth need not be treated. Plus - as a woman from the Toldot Aharon Hasidic sect related - among women there is usually great attention to oral hygiene, but among men brushing their teeth is not considered essential. Some parents interviewed noted that at the heders and Talmud Torah schools, sweets are handed out as rewards and there is no awareness of the damage they cause.
According to Dr. Yaron Avda, who in the past worked at the Chabad clinic and is currently employed at another clinic in Jerusalem, people belonging to the religious community will only pay for dental treatment if they are in pain. "When I see other teeth that are neglected while I work," he says, "they usually insist that I not deal with them. I try to persuade them they should get treatment but it doesn't always work."
Another issue involves dealing with many children, notes Avda: "Our view is that until the age of 8, children can't brush their teeth alone. The model we aspire to is for the big ones to help the little ones. In this [ultra-Orthodox] population, it is common for an older child to accompany a small child to the appointment; therefore, we are trying, for instance, to make the big sister responsible since the mother cannot see to all of them ... Extraction is often a lot less painful for children, but cases come in with teeth entirely destroyed and only the roots left in the gums."
Today, Avda says, he is seeing a change. "A child comes in with his mouth completely destroyed, we perform very complex treatment and six months later fewer procedures are necessary - in families that care, we really see an improvement. This is a population that wasn't exposed to a dentist before the supplementary insurance plans, and today parents are coming in for preventive treatments as well."
According to Prof. Harold Sgan-Cohen, head of the community dentistry department of the dental school at Hadassah University Hospital, Ein Karem, the upsetting situation in the ultra-Orthodox sector has nothing to do with religion, but rather with poverty.
"Research has shown," says Sgan-Cohen, "that poor people tend to be sicker and there is a lot of illness that isn't treated because people have no money, and this is the case with dentistry." He notes that poor families are also usually less strict about brushing teeth and often consume a lot of sweet foods. "The cheapest way to quiet a child," he says, "is with chocolate spread or raspberry juice made from syrup."