The Entryway to the Divine

Dr. Clive Friedman Reflects on 40 years in Pediatric Dentistry and Working with Individuals with Disabilities (5-minute read)

For most dentists, opting for a career in the profession likely came down to a handful of familiar considerations: the prospect of a rewarding occupation, a passion for health care and helping others, or perhaps simply a buzz for the technical or artistic side of the work. But for Dr. Clive Friedman, a pediatric dentist from London, Ontario, the decision to become a dentist was primarily about something else; it was a way for him to get out of 1970s South Africa.

Born and raised in Johannesburg during the Apartheid era, Dr. Friedman became aware from an early age that staying in South Africa long term was not a sustainable option for him. Under a regime where overt racism and police brutality were part and parcel of daily life, dentistry promised to be a way out - a ticket to “anywhere but here.” “My final year of dental school cemented it for me,” he says. “We used to demonstrate on the grounds of the university and because it was private property, theoretically the police were not allowed to come onto the campus. But every now and then they would come anyway, with their dogs and their batons. As a final year dental student, I think I wired about 50 jaws. That was the last straw for me in terms of making up my mind. I was done with South Africa.”

PEDIATRICS AND WORKING WITH PEOPLE WITH DISABILITIES

Dr. Friedman left his homeland the very day after his graduation from the University of Witwatersrand in 1976 and he never looked back. Initially, he emigrated to Israel where he worked in private practice for six months before deciding on a specialty in pediatrics. After a one-year stint in London, England working in the NHS, he accepted a place at the University of New Orleans (UNO) for graduate training, a school he chose for its broad educational perspective and the opportunity to spend a whole year working in a hospital that only treated individuals with disabilities. “The theory is that, as a pediatric dentist, if you can learn to work on a child with disability you can work on any child," he says. "It gives you the background training in terms of behaviour and the ability to function well as a pediatric dentist.”

It wasn’t long before the work started to make a big impression on Dr. Friedman. So much so, that he can still recall the key learning moment during graduate training that would come to inform his practice for so many years to come: “A child in a wheelchair with cerebral palsy came in and the professor spoke to this individual as if he was intellectually disabled as well as physically disabled. He spoke down to him. But I remember looking down and seeing that the patient was reading a book – The Gulag Archipelago by Aleksander Solzhenitsyn – and I remember thinking that this individual probably had an I.Q. double that of both myself and the prof put together. It was a pivotal moment when I realized that you must never make assumptions.”

Dr. Friedman at an FOP Family Gathering

Dr. Friedman was hooked. A fire had been lit and he found his calling. After graduating from UNO he accepted a full-time position at Western University, a posting that presented an invaluable opportunity to work alongside Dr. Gerald Wright, who was the world leader in pediatric behaviour at the time. Soon after, Dr. Friedman was invited onto the board of the American Academy of Dentistry for the Handicapped (now called Special Care Dentistry) where he was introduced to many leading professionals in the special needs field, including Dr. David Tesini whom he assisted in developing the D-Termined program for treating individuals with autism spectrum disorder, and Dr. Steven Perlman, global director of the Special Olympics. From there, Dr. Friedman progressed to the board of the International Association for Disability and Oral Health (IADH), becoming president in 2004, and has since built an extensive global network of teachers and leaders in the area of special needs care. “I’ve met some phenomenal individuals along the way, many of whom I still have close contact with today. All were very good mentors from whom I learnt most of what I know. It’s been an incredible journey.”

ENTRYWAY TO THE DIVINE

Dr. Friedman’s philosophy on caring for individuals with disabilities has evolved considerably over the years, something he attributes to his own personal growth as much as anything else. He describes his approach to care as something of a spiritual practice that is rooted in a desire to be authentic and not separate his spiritual self from his work self. This authenticity is something he firmly believes can be felt by the individuals he is treating. “I realized that I needed to develop my work as a spiritual practice,” he says. “So many of us make a distinction between work and spirituality. I didn’t want to go to work and have it separate from my spiritual needs. Working with children and individuals with disabilities gives you entry into an authenticity that working with an adult population can’t give you. Individuals with disabilities seldom wear a mask. What you see is what you get. I call it the entryway to the divine.”

He refers to the physical process itself as “presencing” – a kind of meditative process that involves becoming fully present to the point that the disability in the individual falls away, allowing Dr. Friedman to deliver the best care possible. It’s a kind of letting go, a distinctly human approach that he considers a gift, something that pushes him to the edge of his comfort zone and constantly challenges him to learn and adapt. “I need to be present for the person where they are,” he says. “I cannot listen at the level where I am worried about what the individual says and how it affects me. I have to be listening at a level where I am fully there for them.”

There are a number of ways in which Dr. Friedman achieves this state of presencing, but most commonly he achieves it through breathwork. “I might sit down with them and not say a word. Just put my hand on their shoulder and get myself aligned with their breathing. If they are anxious, they will be breathing fast. If I want them to calm down, I start to slow my own breath and they will mirror me. That’s presencing.”

He also highlights the importance of maintaining a curiosity mindset and learning to let go of judgment so that he can see the individual for who they really are. “I say to my staff that it’s okay to be judgemental. We all have judgements. It’s who we are as human beings. But what we need to do is acknowledge it. Recognize it and then let it go. Then I can see the person for who they really are and get an understanding of what is happening for them.”

THE FUTURE OF SPECIAL NEEDS CARE

More than 40 years into a career in pediatrics and special needs care, Dr. Friedman laments that in many ways dental care for those with disabilities has not advanced all that much since he started. At least not when it comes to certain fundamentals, such as access to care. When I ask him how he would like to see special needs care evolve, the first item on his wish list is for it to be recognized as specialty in its own right. He envisions a time when the special needs dentist will receive both the remuneration and prestige that acknowledges the extra training and expertise they have acquired. Until then, he fears that it will continue to be challenging to attract younger dentists to the field. “What we do is very complex, but it is not a single item. It’s not just surgery or endodontics or prosthodontics. It’s treating the whole person and I think that’s where people have great difficulty in recognizing it as a distinct specialty.”

Dr. Friedman believes that such recognition would have a knock-on effect on formal dental education, where improvements in training would build awareness and credibility for special needs care over the long term. This is something that has already happened in countries such as Ireland, England, Argentina, Brazil, Malaysia, and Australia where research and credibility is attracting more young dentists to the field. And yet despite the recent development of comprehensive undergraduate and postgrad curricula by the IADH education committee, upon which Dr. Friedman sits, uptake by dental schools has so far been limited to countries outside of North America. “If we don’t have a specialty, how do we get the general practitioner to engage?” asks Dr. Friedman. “Why do we have so many pediatric dentists still treating adults in their 50s and 60s? When a GP graduates and has no idea how to place an implant or to do orthodontics, they go and take further training. Why can’t they take further training to learn how to work with a patient with disability?”

Funding remains a constant challenge. And although Dr. Friedman admits that the funding levels for preventative care are actually quite good, he cites gaps in the system: “If you are 65 years old and you get dementia, how do you access care if you don’t have the means? Who is the dentist who will go and work with you? Where is the training in our institutions for that? It’s not there. Why is it not there?”

His frustration is evident and yet Dr. Friedman remains calm and philosophical to the end. “One step at a time,” he says. “That’s why I continue to be involved in organized dentistry. Trying to shift the education.” To this end he has played a key role in the recent development of new special needs dental care resources with the CDA, including valuable tips for parents, caregivers, and the dental team on oral health care for persons with autism spectrum disorder, Alzheimer’s, and dementia. In the pediatric field he is also heavily involved in the development of a pacified app which allows the user to take a picture of a baby and determine the size and shape of soother the baby should be using, as well as a gnathic app which can determine the relationship of the mandible to the cranial base and suggest interventions that may impact growth and development.

It all seems such a long way from growing up in Johannesburg but looking back Dr. Friedman can see a clear path back to those days when he was wiring jaws at the University of Witwatersrand: “Growing up in South Africa you were sensitized to racism and discrimination,” he says. “Sensitized to seeing people in different ways. I think that gave me the sensitivity to look at individuals with disabilities from that perspective.”

It’s encouraging to think that something so positive has come from something so dark. That the poisons of inequality and injustice have forged such a force for good in the world of dental health care. You get the strong sense that Dr. Friedman’s work here is far from done. His passion for progress and learning in his chosen field burns as brightly as ever: “I have always tried to find things within the field of pediatrics that push me out of my comfort zone,” he says. “Because that’s where learning begins - at the edge of our comfort zones.”

Gabriel Fulcher is Digital Content Editor for CDA Oasis. He is an Ottawa-based writer who specializes in medical, scientific, and health-related content. He holds a BSc in Health-related Sciences and an MFA in Creative Writing from University College Dublin, Ireland.