October 09, 2023

The Mouth of Privilege

Karen sternheimer 72523By Karen Sternheimer

Like many people, I’m not typically excited to go to the dentist, but I appreciate having the ability to do so, especially after reading Mary Otto’s book Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America.

The book provides in-depth reporting on the tragic death of Deamonte Driver, a twelve-year-old boy who died after an infection in his tooth spread to his brain. Otto documents how despite the attempts of his mother to get he and his siblings dental care, their lack of private dental insurance and status as Medicaid recipients, created an inability to receive regular dental care.

I have written before about the privilege of being able to receive dental care. Not only do I have dental insurance and the ability to pay for the additional costs not covered by it, I live in an area with plenty of dentists. Otto points out that access to dentists vary wildly based on where one lives. In 2015, there was one dentist for every 350 residents of affluent Falls Church, Virginia, compared with just one for every 15,486 residents in the next county (p. 53).

When I have had dental emergencies (such as a chipped tooth, or when a crown fell out),  was able to get an appointment at my dentist’s office immediately. The office is just a short drive away, and I have a car and the time to get the problems fixed quickly. But this is not the case for many in the U.S., as dental treatment is the least affordable kind of health care.

According to the Centers for Disease Control and Prevention (CDC):

For children aged 2 to 5 years, 17% of children from low-income households have untreated cavities in their primary teeth, 3 times the percentage of children from higher-income households. By ages 12 to 19, 23% of children from low-income families have untreated cavities in their permanent teeth, twice that of children from higher-income households.

A large part of the problem is structural; dental insurance is separate from overall health insurance, even though the mouth is part of the body and can be a predictor and cause of other health problems.  The CDC explains that, “Medicaid programs are not required to provide dental benefits to adult enrollees, so dental coverage varies widely from state to state. Currently, 15 states provide no coverage or only emergency coverage.”

Even when children receive dental benefits through Medicaid (health insurance for low-income Americans), they still might not be able to access care. Deamonte Driver’s mother had been struggling to get care for him and his brother, who also needed dental care urgently. Within Teeth, Otto quotes an attorney for the family: “It took the combined efforts of one mother, one lawyer, one help-line supervisor, and three health care case management professionals to get help for one Medicaid child,” and unfortunately help came too late (p. 246).

Unfortunately, this is not an isolated case. Otto reports on an audit study from 2011, where matched pairs attempted to get a dental appointment for a child with a dental emergency. The study included 170 paired calls, one requesting an appointment for a child with private dental insurance and another with Medicaid. Only 36.5 percent of Medicaid children were given appointments versus 95.4 percent with private insurance (p. 132). She notes that “In 2013, only 35 percent of private practice dentists reported treating any patients on public assistance, down from 44 percent in 1990” (p. 131).

Children aren’t the only ones impacted by a lack of dental care. The CDC reports that the lack of access to dental care leads to “over 34 million school hours…lost” as well as “over $45 billion [in lost] productivity…because of untreated oral disease.” Descriptions of throbbing pain keeping people awake at night and unable to concentrate pepper Otto’s book.

We tend to see oral health as a personal rather than structural issue. Brushing and flossing and limiting sugar-laden foods are important, but Otto points out that 1 in 3 Americans has trouble getting regular dental care (p. 10).

For most of my life I have been fortunate enough to have regular dental care, and I don’t remember ever having a toothache. But as a graduate student, I went to my university’s dental clinic and can understand why people might not go back. First, I had to wait a long time in a crowded waiting room to be seen. The dental student who treated me not only took a long time to do my cleaning, but it was painful and caused more bleeding than a cleaning ever did before or since (so much so that I was concerned that my white sweater underneath the bib would be stained).

Students often leave dental school with massive debt—an average of almost $250,000 in 2014, according to Otto (p. 53). This provides a real disincentive to practice in an area that might not be profitable, and it rewards performing surgical procedures for those who can pay for it over preventative care for low-income patients (p. 261).

The mouth and teeth are not separate from the body, and Otto’s book details the history of how and why the dental profession became isolated from medicine. We learn a lot about how organizations work to secure their own status, prestige, and income and how this reflects and reinforces inequality. The CDC notes that “Nearly 18% of all working-age adults, and 29% of those with lower incomes, report that the appearance of their mouth and teeth affects their ability to interview for a job,” continuing the cycle of poverty and oral health problems.


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