Teeth- is our dental care system rotten?
Updated: Aug 9, 2020
Teeth: Beauty, Inequality, and the Struggle for Oral Health in America
by Mary Otto 2017
Why is dental insurance separate from health insurance?
Why are people showing up in hospital emergency rooms with teeth problems?
Why did a young 12-year-old boy die because of a tooth infection?
These and many other tooth-related questions are dealt with in this eye-opening book about a little-discussed topic- our dental health care system. Mary Otto is a healthcare journalist and one of the nation's experts on dental and oral care, and this book covers what she calls a crisis of poor care for a large number of Americans and their teeth.
Our dental care system is a microcosm of the rest of the for-profit healthcare system, and Ms. Otto places a lot of blame at the feet of the nation's dentists and dental societies. For those that can afford it, dental care in this country is excellent. Because a white, straight and strong smile is seen as vital to many for a positive image, there is a big emphasis on appearances. Tooth whitening and veneers help cover up blemishes and make teeth look unnaturally bright, but they have little to do with general oral health.
At the other extreme are the 100 million plus Americans who have no dental care at all and suffer with serious pain and decay that could be easily treated today. The author visits a Remote Area Medical facility in Appalachia where thousands of untreated adults and children come to a series of tents to have teeth pulled and long-neglected problems addressed. There's a disturbing racial aspect to this as well- people of color are much more likely to have untreated tooth decay and no dental insurance than white people.
Many dentists start out their practices with huge loads of student loan debt, often in the six figures. From the day they open their doors there are enormous pressures to maximize income with expensive treatments like veneers ($2000 per tooth), extractions, and crowns. Some dental practices have been taken over by private equity firms and are only about maximizing profits, while the lone dentist is more common but has bills to pay. (Dentists have one of the highest suicide rates of all health professionals.) They take on charity cases at their own financial peril. Even with Medicaid, which sometimes covers dental care and sometimes doesn't, the reimbursement rates are half of what privately paying customers bring in.
Ms. Otto goes back in history to show how dentistry evolved, and how, in 1840 it split with the medical profession to go down its own path. Early dentists knew little about germs and hygiene, and were mostly about pulling teeth. Gold and other metals were used for fillings back then. For a while dentists were pulling healthy teeth as protection from future problems, but thank goodness research into germs and bacteria stopped that practice.
"We don't know why teeth die," says Ms. Otto in a chilling admission from the dental profession. Our mouths are a delicate soup of 600 different types of bacteria that help us digest food, and if the balance gets off just a bit, tooth decay happens. The best protection against this onslaught on our teeth is regular brushing and flossing, but even that can't stop it completely. One of the biggest helpers in the fight for oral health has been fluoridation, which started in the 1940's because researchers noticed lower cavity rates where waters naturally contained fluorides. Now almost all water is fluoridated, and this type of public health approach is sorely missing in the rest of the dental profession.
Dentists, because they have invested so much in their craft, protect their turf zealously. Otto details how dental groups have opposed most attempts at nationalized healthcare, because the sad secret is that there just aren't enough dentists in America to treat everybody, even if they all could afford it. (We effectively ration dental care by ability to pay for it). Healthy teeth are more of a privilege than a right. Dentists have also fought against allowing hygienists and dental therapists- professionals with less training than dentists- to provide more routine dental care in schools, nursing homes, and in remote locations where there are no dentists. By protecting their high-income practices, they deprive the country
of lower-paid professionals who could fill in the gaps.
The main point in this book is that there is a crisis in dental care for nearly half of the nation. People don't go to see dentists because of fear of the pain, which is very real for those who've had bad experiences, and also because of the expense. Some have no dentists in their area at all. When people do finally go to get help, many of them go to the hospital emergency room, where the best they can hope for is some pain killers and a referral.
Children are especially vulnerable because once their teeth start going bad, they are prone to expect misery the rest of their lives. Medicaid often covers children's dental care, but only a minority of dentists see a significant number of these kids according to the book. There are some promising alternatives, such as group practices, remote clinics, and dental therapists that can drill and extract problem teeth.
Mixing medical care with the profit motive is a tricky situation, as has been found with pharmaceuticals and most medical procedures. Prevention is minimized and costly procedures are emphasized if they help the bottom line. The health of the patient is secondary to the health of the balance sheet.
The book closes with the story of Deamonte Driver, a 12 year old boy who died of a tooth infection that went to his brain. While Deamonte's single mother spent months trying to fix his brother's six rotted teeth, he quietly nursed a growing toothache that eventually took him to the emergency room. Dental sepsis entered his brain, and after $250,000 in treatments he still died- all for want of a single tooth extraction. Deamonte's death woke up a lot of politicians in Maryland where he lived, and brought the dental poverty crisis more to light nationwide.
Otto tells some inspiring stories of people who bucked the system to try to improve the dental health of those who need it most. They are the heroes of this book. The villain is a system that disappoints on so many levels. The world of dentistry is one few of us ever know, and this book made me appreciate my pain-free (though imperfect) mouth every day. Expanding health care is a great goal for the next decade, but for Medicare, Medicaid, and the Affordable Care Act, oral care is often not covered or subsidized, so people neglect it. Our mouths are forever our most important opening to the world, and it's high time we took better care of them.