From Holocaust survivors, to stroke victims, to the garden-variety centenarian next door, Alisa Kauffman’s patients have one thing in common: an inability to travel to a dentist’s office. So she brings her practice into their living rooms, bedrooms, and kitchens.
BY TREY POPP | Photography by Don Hamerman
SIDEBAR: The Protégé
Alisa Kauffman’s fourth patient of the day was lying in bed when she arrived to address the pain in his upper right molars. It was half past noon. “He’s sleeping,” his middle-aged daughter had said upon opening the door of her father’s Manhattan co-op apartment. “That’s been more and more common lately.”
She padded down a short hallway to rouse him, leaving us in a darkened living room that felt as though it had been submerged in a long-lasting silence. The puffy cushions of a deep upholstered couch bore no body indentations. Canvases depicting vividly painted singers and musicians were muted by a fine layer of dust in the crepuscular light. An electric piano keyboard was propped in one corner, its dials dark.
Kauffman D’85, whose trim frame practically buzzes with spare energy during momentary spells of enforced stillness, gripped the handle of the hefty roller backpack she schleps around Manhattan to make her rounds. Inside it, her drill nestled among Tupperware containers crammed with denture molds, filling material, latex gloves, canned compressed air, and all manner of periodontal probes, scrapers, chisels, and the like, sealed in sterile bags. Slung over one shoulder was a white satchel stuffed with water bottles, toothbrushes, a headlamp, and sundry other supplies. She wore blue-gray scrubs bearing her name, and a pair of blue suede loafers emblazoned with the University of Pennsylvania’s crest. Her copper-colored hair was pulled back into a shoulder-length ponytail.
In the bedroom, where sunlight poured through the slats of a small fan perched on the window sill, Kauffman’s patient briefly lifted himself to a sitting position on the edge of his mattress. Emerging from his naptime haze, James Johnson (which is not his real name) shifted into the easy charm with which some sociable older men disguise the progression of their dementia. He greeted Kauffman warmly, and bade me to sit in a rocking chair in the corner. It was easy to see how Johnson had come by his affability. His bedroom was filled with newspaper clippings and mementos from a career as a bandleader.
After confirming the source of his oral pain, he made one request of the dentist who had come to resolve it.
“Just one easy thing,” the 86-year-old said with a grin: “Will you take your mask off?”
With the poise of someone accustomed to such requests, Kauffman explained that she wore the surgical mask primarily for his protection—and then cut to the chase. “Do you want to see my face?” she asked, slipping the mask down momentarily.
“Oh, you’re beautiful,” Johnson replied, with a sigh of pleasure.
Up went the mask, and Kauffman placed several instruments on a pale-blue sterile surgical paper towel atop Johnson’s navy blue comforter.
“You’re my favorite kind of patient—you know why?” she said brightly. “You wore red! If anything flies out, I won’t stain your shirt.”
“What are you talking about?” Johnson replied gruffly.
“I’m joking with you!” Kauffman laughed.
The next 20 minutes unfolded with an uncanny mixture of complete predictability and utter weirdness. As Kauffman drew a quantity of septocaine into a needle syringe, Johnson clenched his body. “Oh God,” he groaned.
His daughter walked over to a bedside CD player. “Do you want some music?” she asked.
“Depends on what you want to play,” her father said.
“We’ll play one of your things, so let’s see…” She plucked a CD from a pile as Kauffman stuck Johnson with the needle, eliciting a quick, sharp cry.
“He’s very reactive, even when things are not painful,” his daughter told Kauffman. “Just so you know. Like with nail-cutting, and stuff like that.”
The little stereo now swelled with the iconic clarinet glissando of George Gershwin’s “Rhapsody in Blue,” and Kauffman set about her work. Hunching over Johnson, with one knee digging into the mattress, she asked his cheerful home health aide to lie on the other side and restrain Johnson’s hands. She pricked him once more with the needle, and he yelped again.
“Get out of here!” he exclaimed, in a half-jocular growl. “What is that?”
“It’s called making you numb!” Kauffman replied in her lilting, silvery tone. “I can’t take the tooth out without making you numb.”
“Take the soup out?” Johnson exclaimed.
“The tooth out!” Kauffman laughed. “You’re in a lot of pain back there. You’re just a big chicken, so you don’t want to admit it!”
He chuckled and visibly loosened his limbs. Waiting for the numbness to set in, Kauffman bantered for a minute with her patient, who gradually lost track of the conversation amid the first big crescendo of the Gershwin composition. Then, with no-nonsense efficiency, she reached into Johnson’s mouth with a pair of dental pliers and yanked out a crown spanning three molars.
Johnson let out a smaller cry. “God damn,” he sputtered. “That’s vicious!”
“You didn’t even have time to scream,” Kauffman playfully retorted.
The crown’s existence was news to Johnson’s daughter, who presently began taking notes. The removal of the crown had exposed three bloody root tips, and Kauffman said they all had to come out. One after another, she tugged them out with the heavy-duty pliers. The physicality of dentistry, the raw force it takes to pull teeth out of someone’s jaw, is striking to behold. Watching it happen to someone else can be even more jarring than undergoing it yourself, because the dentist’s bodily exertion is so fully revealed in the clenched muscles of her arms and neck and shoulders and back. Johnson’s daughter, queasy at the sight of broken root tips landing on Kauffman’s disposable blue towel while blood pooled in her father’s mouth, disappeared into the living room to lie down.
Then, with a quick bottled-water rinse and a wad of gauze tucked into the wound, it was all done. Kauffman gave the health aide some instructions about what Johnson could and shouldn’t eat and drink over the next few hours. To Johnson she said, “Sit there and try to look pretty while I clean up!” He laughed. She packed up her tools and medical waste. Before she could leave the bedside, Johnson grasped her hand and froze for a moment, as though he wasn’t quite sure what to do. Then he slowly raised it to his lips and gave it a chivalrous kiss.
On the way back down the hall, Kauffman paused to make sure Johnson’s daughter had understood everything. Later, the daughter would tell Kauffman that when she returned to her father’s room, he had already forgotten what had just transpired. For now, she fixed her with a grateful smile and marveled, “You’re like a dentist ninja.”
Kauffman has devoted her career to “the old old,” as demographers call the fastest-growing segment of America’s senior-citizen population. She estimates that the average age of her patients is 90. She cares for them in a setting that’s even more unusual for dentists than for doctors: their homes.
The first time we met, in Kauffman’s office in the Robert Schattner Center, where she’s the clinical director of the Penn Dental Faculty Practices, she told me about a 105-year-old woman she had treated not long before. This patient had a “very famous grandson,” Kauffman said, confessing that she’d hoped he would be home during her visit. He wasn’t, alas, but the consolation prize was better still. The patient beckoned Kauffman to her side with a conspiratorial air, and said she wanted to tell her something. Kauffman politely made to listen. “I can still do a split,” the woman proclaimed. As she told me the story, Kauffman was still giddy with the memory of it. “She was 105 years old, and she got down on the floor and did a split!”
Kauffman also showed me a video that she shares (with permission) with her students at the Dental School, where she’s a clinical assistant professor in the community oral health division. It was a recording of a conversation she’d had with a patient suffering from advanced dementia. She was an elderly woman with untamed white hair, blotchy skin, and a scratchy, nasal voice that made me think immediately of Miracle Max, the wizened old potion-mixer portrayed by Billy Crystal in The Princess Bride.
“The most horrible dementia,” Kauffman said, setting up the clip I was about to see. “They either get really nice or really mean. Her son never got married, which she just couldn’t handle, and she lost her lower partial, so I had to make her a new lower partial.” I didn’t quite follow the connection between her son’s bachelorhood and her denture problem, but before I could interject, the story gained an additional layer of complexity. “It was that snowstorm a few years ago, where nobody could get out of their house for days. And I got there, and she wouldn’t let me put the partial in her mouth unless I lied to her,” Kauffman said.
I must have looked puzzled.
“Oh, I have to do a lot of lying,” she explained. Some patients can’t bear to spend a dime on themselves, no matter if they’re as rich as Croesus, so their children beg Kauffman to tell them Medicare will pay (which it doesn’t, unless a dental problem evolves into a medical emergency). If a patient refuses to let Kauffman touch him, she might pretend to be his daughter’s friend, coming all the way from her office to do a personal favor. And of course like every dentist who’s ever drilled a cavity, she tells people they’re only going to feel a tiny little pinch.
This patient was a tougher cookie, and couldn’t be persuaded that she needed her dentures to continue eating solid food. “So I told her that I was marrying her son,” Kauffman recalled, “and she needed to put that partial in before she could go to the synagogue.”
The video depicted their conversation afterward, as Kauffman attempted to make sure the new prosthetic was not causing pain.
Kauffman: How do your teeth fit?
Patient: I don’t want you.
K: How do your teeth fit?
P: I don’t want you.
K: But are your teeth fitting well now?
K: Are your teeth fitting well now?
P [relenting]: Very good.
K: So you love me?
P: Why should I?
K: I fixed your teeth.
P: Big deal.
K [laughing]: Well, you’re not easy, you know!
P: I can go to the synagogue with them.
K: See, if you didn’t have your teeth,
you couldn’t go to the synagogue!
P: Alright, go. Go, go, go.
K: Go where?
P: Go wherever you want.
K: Where do you want me to go?
P: Wherever you want to go.
K: I want to be with you!
P: I don’t want you, I don’t need you.
K: You do! Yes! Yes! We love each other!
P: Okay, go to the synagogue.
K: Okay, I’m glad that you have your
P [pauses, then suddenly softens her tone]: Me too.
“When you hit 100, there’s no filter,” Kauffman says. That’s the joy and the challenge of her practice, which is restricted to patients who are physically or mentally incapable of traveling to a dental office.
“I love working on patients who have all of their wits when they’re older,” she says. “I was in a guy’s house who showed me pictures that he took in the concentration camp. He had pictures! I don’t know how he had a camera, but he had little pictures, and he told me how he survived … I had a woman who was one of the survivors on the Titanic! I mean, you really have fun with old people. And the fact that you’re not in a rush and that you’re there for them—they don’t have to get to the office, they don’t have to wait in the waiting room … they have whoever they want to be there— it’s just, the best job in the world.”
But frequently a difficult one.
“There are skills that you can only develop over time working with this population,” she continues. “You have to be so patient, you have to be so kind, and you have to have the time. If you have a patient with dementia coming into your office, there’s no way—with all the patients in the waiting room—that once that dementia patient starts to scream, you can bring them in, sit with them, calm them down—while they’re still screaming and the rest of the patients in your waiting room are listening.
“There are dementia patients with huge amounts of decay in their mouth, and they can’t even keep their mouth open for more than 10 seconds, and they’re biting, kicking, spitting, hitting—they just can’t help it.”
Jessica Meier D’12 trained under Kauffman at LIFE, a West Philadelphia public health center that serves independently living seniors which was run at the time by the School of Nursing. (It was acquired by Trinity Health PACE in 2016.) The experience gave her a lasting appreciation of the challenges of geriatric dentistry, particularly for patients with complex medical histories.
“A lot of these patients are unable to do something like brush their teeth on their own. A lot of them suffer from syndromes where they cannot even open their mouths, or they don’t understand what you’re saying. Or the ones who are suffering from dementia, they forget what you’re doing, so they get terrified. All those psychological factors exacerbate the difficulties.”
When I accompanied Kauffman on a series of home visits in Manhattan, I watched her care for an elderly woman who’d lost the power of speech and the control of her body to advanced Lewy Body Dementia, whose cognitive and physical impairments resemble Parkinson’s Disease. We encountered her in an Upper West Side studio apartment, where she lay quietly in a hospital bed. Her daughter and a home health aide were present. An old upright piano abutted one wall, and ragtime piano music played on a small stereo.
“The last things to go are prayer, poetry, and music,” Kauffman remarked later, in a sober moment in the hallway of the apartment building. She had confided that caring for this patient, who was “the same age as my mom,” took a heavy psychological toll.
“It’s really hard to work with dementia patients,” she’d told me. “You know that their lives have changed so much—and not just their lives, but their families’ lives. It’s hard, on a day-to-day basis, to be around a demented loved one. For me, I do a great service, I make everybody feel happy and good, and I make sure that when I leave, everybody’s good. So if someone’s bleeding, I might be late for the next one, but I don’t leave until everybody knows what they have to do, and it’s all written down. Everybody is on board with what I just did, and what we’re going to do next time. But I leave. They stay. And it’s just so hard for me to understand how to deal with that. Because I’m really just doing it as, you know, a dentist. I’m just there to do my job and to leave. Their job never ends.”
All this patient needed was a routine cleaning. Kauffmann donned a headlamp, glasses, a mask, and gloves. “Well hello! How are you!?” she sang out, as the daughter turned a crank to lower the bed. “That filling is still fine—I’m so happy,” Kauffman said after her examination, swiveling to face the daughter. “Are you using the gel?”
No, the daughter confessed.
“Why?! Put it on after brushing,” Kauffman urged. Later, she gave the younger women a xylitol spray to try instead—pumping a sneak-attack spritz into their mouths before they had time to react, hoping to sell them on its pleasant flavor and ease of use.
“She has a very high palate, so if she doesn’t drink a lot, you’ll get a little yeast in there,” Kauffman now told them. “There’s a little in there now.” She demonstrated how to swipe it out without triggering a gag reflex. A minute or two later, when the patient did gag, Kauffman quickly withdrew and, in a simple gesture that was eloquent with tenderness, massaged her shoulder for an extended moment before resuming.
Next came the tooth polisher—“Here comes the fun part!” Kauffman exclaimed.
All along, the daughter endearingly narrated the visit for her mother, occasionally stroking her face while calling her by pet names: Peanut and Monkey. “Now the dentist is going to floss,” she said now. “You used to do that…”
“That’s why your teeth are so good!” Kauffman interjected, then turned to the younger adults in the room. “I’m going to give you some advice,” she said. “Only floss the teeth you want to keep.”
The patient twice snapped her teeth at Kauffman’s nimble fingers, which emerged unscathed, and just like that, the visit was complete. Kaufman left a bill for a routine cleaning on a small table. The patient’s daughter gave her mom a comforting squeeze and asked her, with no way to know whether her words would be understood, “What do you want, Peanut? Ice cream? We have homemade mint ice cream…”
Kauffman’s journey into geriatric house-call dentistry— a term whose top Google result is a link to her Manhattan practice’s website—was equal parts fate and happenstance.
“When I graduated from Penn, I won all the accolades for making the best dentures—which was kind of like a booby prize” she laughs. “Everyone was doing cosmetic dentistry and full-mouth reconstruction, and there I was, doing dentures. But I loved doing it.” She liked hanging out with the lab techs who helped craft them—even if it meant enduring airborne carcinogens “back in the days when they were smoking in the lab”—and the work appealed to her artistic side. When she isn’t working or teaching, Kauffman makes jewelry and paints.
“Dentures are one of the creative outlets you have in providing for the dentistry needs of older people,” she says. “Now it’s a dying art,” she adds, noting that most people prefer implants, “but it’s a necessary art. There’s always going to be people who either can’t get implants—they don’t qualify because they’re on Coumadin and can’t have surgery—or they’re just too old to say that they’d go through with it.”
“[And] what is left in their life to enjoy?” Kauffman asks. “TV and eating. Chewing their food, enjoying their food. Not eating baby food and mush. So I think for that population of people, you need to be able to eat, you need to continue to have a good quality of life.”
The patient encounters I witnessed bore that out. There was a chatty and occasionally profane 88-year-old woman, who complained—with more than a touch of drama—about “screaming” pain inflicted by new dentures that her home health aide privately confided she had not worn at all, but reminisced about dining on beef Bordelaise. Kauffman tuned her pitch to her patient’s personality: “Getting old is not for sissies!” she exclaimed. “You’ve got to be tough!” Kauffman likes to tell her spunkiest centenarian patients that she’s going to make them “look 90 again.” (“She’s a honey,” the patient told me. “I’m kind of on the old side—but you get someone in that’s sparkly and bubbly, that you can kid around with.”) Another patient was turning the pages of Fine Cooking magazine when we arrived, and had issues of Saveur and the like stacked on his kitchen island.
A couple years after Kauffman graduated from dental school and set up a traditional brick-and-mortar practice, the father of one of her best friends had a stroke.
Her friend didn’t know what to do about his dental care and asked Kauffman for advice. “I said, ‘Well, why don’t I just come over and do it?’ And she said, ‘You can do that?’ And I said, ‘I’ll figure it out.’” She obtained his most recent x-rays, assembled a mobile kit, and cleaned his teeth as he lay in bed. It became a regular thing.
Around 2000, Kauffman got an unsolicited offer to buy her practice. She was now the mother of a five-year-old daughter. She sold the practice, and started to look for geriatric patients like her friend’s father. She went around to hospitals, and eventually became affiliated with Lenox Hill and Mt. Sinai, both in Manhattan. She put together a tool kit that now runs from a portable suction apparatus to a state-of-the-art piezoelectric tooth scaler. Apart from procedures like root canals and impacted teeth, which require a degree of emergency medical support that’s not possible in a home setting, she can do “almost any service” offered at a traditional office. By not maintaining one of her own, she lost overhead costs and gained greater control over her schedule—which was attractive as the parent of a young child, and for patients who wanted or needed care outside ordinary business hours. She practices in Manhattan, where she can get around via ride-sharing services and on foot.
Dentists willing to make house calls are rare enough that Kauffman says she gets calls from people as far away as Mississippi asking about her services.
“In major metropolitan areas, there’s probably only one dentist that will do it,” says Meier, who has a traditional private practice in Philadelphia. “Dentistry’s hard enough in and of itself. When you complicate it with people who are difficult to work on, it’s just very difficult. You have to really be in shape, and be able to treat patients who can’t go back all the way. It’s really tough on your neck, on your back, just on everything to be able to try to perform these services for people in complex circumstances.
“And you have to remember too, you’re dealing with your malpractice insurance,” she adds. Dental offices are very controlled environments. People’s homes can harbor surprises ranging from spatial constraints to bedbug infestations. Kauffman told me about one patient, a hoarder, whose apartment was so overwhelmed with accumulated debris that the only way the patient could receive treatment was by sitting on a kitchen stool with her head against the refrigerator. “It takes a lot of will and drive to want to be able to do that,” Meier says.
Yet for Kauffman, it’s a calling with unique rewards. She likes to point out that, whatever ailments may be afflicting them now, her patients are survivors. And over the years, Kauffman has become interested in what accounts for their longevity. So she’s become a collector of elder wisdom.
“I always say, ‘You’re 100 years old, or you’re 92 years old, can I ask you a few personal questions?’” she says. “And they’ll say, ‘Sure!’ Because they’re open books. You can ask them anything!” In addition to all the particular experiences that make every life unique, she has also spent her career probing the relationship between lifestyle and longevity. She likes to ask whether her patients drink, or drank when they were younger, and how much. She asks about exercise, about smoking, about how old people were when their parents died. “I love asking them those questions because they really give you detailed answers.”
After listening to them for the better part of her professional life, Kauffman says she has only found one common characteristic. Clean living isn’t it. “Some people have had a drink every day. Some have never had a drop in their life,” she says. Smoking quite clearly shortens more lives than it prolongs, but plenty of people have survived the habit. (The most physically fit and one of the most quick-witted patients I saw was a 101-year-old woman who told me she had smoked since she was 16.)
“But the one answer that I always get,” Kauffman says, “is that if you don’t let your life aggravate you, that you just live, that having less stress makes you live longer. Live your life one step at a time, and don’t let stress influence you.”
She says it has changed the way she carries herself through her days. “When I’m getting upset about something,” she says, “I really, really stop and think about the importance of it tomorrow. If it has no importance tomorrow, and it’s just something that’s aggravating me—whether it’s people I work with, or that I didn’t call my daughter back quickly enough, or anything that’s not a real problem—you just have to let it go.”
And so she keeps seeing patients, one home visit at a time.
“As long as my back stays strong,” she says, “I’ll be okay.” The 57-year-old allows that she won’t be able to carry on forever—and has already run up against the limit of what she can do on her own, especially facing a growing demand that she expects will mount further. The American population continues to grow older, and the oldest senior citizens increasingly survive significant impairments to their mobility and cognitive health. She has lately been looking to bring on a partner in her own practice [see sidebar, pg. 38], and continues to evangelize the merits of geriatric practice to her students at Penn.
“There are so many needs for geriatrics,” she says. “I try to make geriatric dentistry fashionable. That’s the word I use when I’m lecturing my students. Because nobody wants to work on these people—it’s just not fashionable. You’re not doing anything pretty! You’re just making sure their necessary, day-to-day needs are met. So it’s a whole different mindset.”
“I love the helping aspect of my practice,” she says. “I don’t have complaining patients. What I do, people are so grateful for. You go into someone’s home, and they’re in the bed, and the families or the aides are so concerned—like, ‘How are you going to be able to do do this?’ So it’s kind of cool that I can say, ‘Don’t worry about it.’”
“I have the world’s most unusual dental job,” says Steven Lin D’15, who certainly has one of the most unusual commutes. Traveling by bush plane and plying remote roads in temperatures that can fall far below zero, he helps to care for the teeth of some 30,000 indigenous Alaskans in settlements spread over a wilderness as vast as Texas. Since 2015, Lin has worked for the federal Indian Health Service. Packing portable dental equipment into a five- or six-seat Cessna, his team ventures into the Alaskan outback for five days at a time, providing everything from oral surgery to community-based public-health education to communities that are in some cases so far off the grid that overland travel to Fairbanks is impossible for much of the year.
“We feel like we’re not tied down by physical infrastructure,” says Lin, who believes mobile practitioners are the vanguard of dentistry. “By bringing these services to these communities, we are challenging our profession to think bigger about what can or cannot be done. I think that will be a big movement, in both urban and rural areas, going forward. This is one of the pioneering efforts to bring healthcare to communities who are unable to leave their homes.”
He frames mobile dentistry as a disruptive public-health model.
“The traditional dental model emphasizes patients making appointments to come into offices. And what if you can’t come in? Well, sorry, we can’t treat you. So the public-health approach is to come up with a radically disruptive mechanism in order to get people where they need to go.
“The bulk of public health serves low-income, high-risk communities,” Lin adds. “But we recognize that there are [also] people who are able to afford treatment and yet still unable to get it, for various reasons. The public-health approach is targeting these communities.”
Lin credits Alisa Kauffman with awakening him to alternatives to the traditional dental model.
“I feel like the geriatrics course [she taught] is one of the least appreciated courses,” he says. “In dentistry, we treat adults like adults, and kids like kids. But when you look at adults, you realize that elderly adults have to be treated a little differently.” That epiphany changed his thinking about specialization. “I thought, why don’t I take a different approach and see if we can work with this population that hasn’t been given the kinds of clinical and organizational resources to seek their own kinds of care? So Alisa is one of the teachers who inspired me to consider doing things differently—going out to the patients themselves, rather than bringing them in.”
His work for the Indian Health Service has deepened his appreciation for the cultural dimensions of oral health.
“Alaska’s indigenous communities have had a continuous culture for millennia. Three generations ago, they didn’t speak English and had no contact with the outside world. But the modern civil society they grow up in now is very different from what it was like 60 years ago.” And one of the biggest differences is dietary. “Processed foods and other elements of the non-native diet have decreased the ability of their teeth to withstand the day-to-day chewing and grinding forces,” while playing a role in the rise of chronic health conditions like diabetes and heart disease. “In particular, many native communities eat very tough meats raw or hardened jerkies, and one of their biggest sorrows is without healthy teeth, people are unable to appreciate the native diet. So poor oral health is accelerating the decline of native cultures.
“I thought I was promoting healthcare,” Lin reflects, “but I’ve also been helping communities continue to appreciate the traditions they’ve grown up in.”
Come this fall, however, Lin will be trading the Alaskan outback for a quite different terrain: the outer boroughs of New York City. As of January, he was planning to join Kauffman as a partner in her practice.
“Since the practice concept is unique, there are many details to be ironed out,” Lin wrote in an email. “It is our mutual goal to expand the practice from Manhattan to the other boroughs and beyond. We want to not only become a clinician team but also advocates and innovators in geriatric healthcare to other professionals in the future.” —T.P.