Project and content management for Contemporary Authors volumes
WORK TITLE: Teeth
WORK NOTES:
PSEUDONYM(S):
BIRTHDATE:
WEBSITE:
CITY: Washington
STATE: DC
COUNTRY:
NATIONALITY:
http://thenewpress.com/authors/mary-otto * http://healthjournalism.org/blog/author/mary-otto/ * https://www.theatlantic.com/health/archive/2017/03/why-dentistry-is-separated-from-medicine/518979/
RESEARCHER NOTES:
PERSONAL
Female.
ADDRESS
CAREER
Freelance writer and author. Washington Post, journalist.
MEMBER:Association of Health Care Journalists (leader of topics on oral health).
WRITINGS
SIDELIGHTS
Mary Otto has devoted her journalism career to highlighting various social issues across the country. She has been affiliated with the Washington Post as well as the Association of Health Care Journalists, where she leads the formulation of all topics related to oral health.
Her book, Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America, stems from her longstanding research efforts on oral health as a whole. The very basis of the book was influenced by Deamonte Driver, a 12-year-old boy living in Maryland, who died from a severe brain infection. The infection was caused by a rotting tooth which, due to his family not having dental insurance, was unable to be removed. The infection in his tooth gradually rose up toward his brain, and while doctors tried to treat the problem with surgery, he did not survive. Deamonte Driver’s demise becomes the framing device for the book, as Otto delves into the oral health industry within the United States from a historical and social perspective. She makes the case of how the dental industry has become commodified at the expense of the country’s poor. Millions of people cannot afford dental insurance, which is kept separate from health insurance and normal health care. As a result, they cannot get the dental care they need. This leads to normal dental problems being exacerbated into full-blown health crises because, as Otto asserts, dental health and bodily health are closely intertwined. Otto speaks to several poor adults and families on the absence of dental care and how they have coped without it. She also draws a timeline explaining the rise of the dental industry and how it became what we know it to be today.
Booklist contributor Karen Springen called Teeth a “well-reported and important book.” In an issue of Kirkus Reviews, one writer expressed that Teeth is “[a] focused, well-researched depiction of the dental industry’s social and cultural relevance and its dire need for reform.” Mary Chitty, a writer in Library Journal, felt the book is “highly recommended for all readers concerned about public wellness, health-care disparities and outcomes, and the rising costs of treatment.” A Publishers Weekly reviewer commented: “Otto’s sobering report should not go unheeded.” On the New York Times Online, Sarah Jaffe remarked: “Teeth becomes more than an exploration of a two-tiered system — it is a call for sweeping, radical change.” Adam Gaffney, a reviewer for New Republic, called Teeth a “heartrending and incisive book.”
BIOCRIT
PERIODICALS
Booklist, February 15, 2017, Karen Springen, review of Teeth: Beauty, Inequality, and the Struggle for Oral Health in America, p. 12.
Kirkus Reviews, February 1, 2017, review of Teeth.
Library Journal, February 1, 2017, Mary Chitty, review of Teeth, p. 96.
Publishers Weekly, January 9, 2017, review of Teeth, p. 58.
ONLINE
Association of Health Care Journalists, http://healthjournalism.org/ (October 12, 2017), author profile.
Atlantic, https://www.theatlantic.com/ (March 9, 2017), Julie Beck, “Why Dentistry Is Separate From Medicine,” author interview.
New Press Website, http://thenewpress.com/ (October 12, 2017), author profile.
New Republic, https://newrepublic.com/ (May 25, 2017), Adam Gaffney, “The Devastating Effects of Dental Inequality in America,” review of Teeth.
New York Times Online, https://www.nytimes.com/ (March 23, 2017), Sarah Jaffe, “The Tooth Divide: Beauty, Class and the Story of Dentistry,” review of Teeth.*
Why Dentistry Is Separate From Medicine
The divide sometimes has devastating consequences.
Juan Carlos Ulate / Reuters
JULIE BECK MAR 9, 2017 HEALTH
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Doctors are doctors, and dentists are dentists, and never the twain shall meet. Whether you have health insurance is one thing, whether you have dental insurance is another. Your doctor doesn’t ask you if you’re flossing, and your dentist doesn’t ask you if you’re exercising. In America, we treat the mouth separately from the rest of the body, a bizarre situation that Mary Otto explores in her new book, Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America.
Specializing in one part of the body isn’t what’s weird—it would be one thing if dentists were like dermatologists or cardiologists. The weird thing is that oral care is divorced from medicine’s education system, physician networks, medical records, and payment systems, so that a dentist is not just a special kind of doctor, but another profession entirely.
But the body didn’t sign on for this arrangement, and teeth don’t know that they’re supposed to keep their problems confined to the mouth. This separation leads to real consequences: Dental insurance is often even harder to get than health insurance (which is not known for being a cakewalk), and dental problems left untreated worsen, and sometimes kill. Anchoring Otto’s book is the story of Deamonte Driver, a 12-year-old boy from Maryland who died from an untreated tooth infection that spread to his brain. His family did not have dental benefits, and he ended up being rushed to the hospital for emergency brain surgery, which wasn’t enough to save him.
I spoke with Otto about how the dentistry/medicine divide came to be, why it’s stuck around, and what its consequences have been. A lightly edited and condensed transcript of our conversation is below.
Julie Beck: Let’s go back to the origin of how dentistry and medicine became separate in the first place. It’s something we take for granted now, right? But it’s actually really weird. Was there ever a time when dental care was integrated with medical care?
Mary Otto: It stayed generally separate. Taking care of the teeth became kind of a trade. In the barber-surgeon days, dentist skills were among one of the many personal services that barber surgeons provided, like leeching and cupping and tooth extractions. They approached it as a mechanical challenge, to repair and extract teeth. Barber surgery was practiced in the very early part of our country's history. And Paul Revere was a denturist—he was a jeweler and he made dentures too.
But the dental profession really became a profession in 1840 in Baltimore. That was when the first dental college in the world was opened, I found out, and that was thanks to the efforts of a couple of dentists who were kind of self-trained. Their names were Chapin Harris and Horace Hayden. They approached the physicians at the college of medicine at the University of Maryland in Baltimore with the idea of adding dental instruction to the medical course there, because they really believed that dentistry was more than a mechanical challenge, that it deserved status as a profession, and a course of study, and licensing, and peer-reviewed scientific consideration. But the physicians, the story goes, rejected their proposal and said the subject of dentistry was of little consequence.
That event is remembered as the “historic rebuff.” It's still talked about sometimes, not a lot, but it’s seen as a symbolic event and it’s continued to define the relationships between medical and dental education and medical and dental healthcare systems in funny ways. Dentists still drill and fill teeth and physicians still look at the body from the tonsils south. Medical and dental education is still provided separately almost everywhere in this country and our two systems have grown up to provide care separately, too.
Beck: It seems like since the historic rebuff, dentists have really wanted to stay separate. Why is that, do you think?
RELATED STORY
Why Don't We Treat Teeth Like the Rest of Our Bodies?
Otto: People have raised questions about the system over the years, and they’ve called for reforms periodically. Nearly a century ago, in the 1920s, this biological chemist named William Gies was a kind of prophet. He visited every dental school in the country and in Canada for the Carnegie Foundation, for this big report, and he called for dentistry to be considered an essential part of the healthcare system. He said: “Dentistry can no longer be accepted as mere tooth technology.” He wanted oral health and overall health to be integrated into the same system, but organized dentistry fought to keep dental schools separate. [Dentists] emerged as defenders of the professional autonomy and professional independence of the private practice system that we have here. David Satcher, the [former] surgeon general, he kind of said the same thing when he issued this “Oral Health in America” report in 2000. He said we must recognize that oral health and general health are inseparable. And that too, was a kind of challenge. And it seems like things are changing, but very slowly.
Beck: So you think the reason they wanted to stay separate was really just a matter of professional independence?
Otto: Yeah. It’s a marketplace issue. It’s a formidable thing, professional autonomy.
Beck: It’s interesting to hear this separation traced back to one moment because it has shaped so many things—insurance, access to care, all these things. Can you give an overview of what the effects have been of carving dentistry out of medicine?
Otto: One of the most dramatic examples is that more than a million people a year go to emergency rooms with dental problems. Not like they’ve had a car accident, but like a toothache or some kind of problem you could treat in a dental office. It costs the system more than a billion dollars a year for these visits. And the patients very seldom get the kind of dental care they need for their underlying dental problems because dentists don’t work in emergency rooms very often. The patient gets maybe a prescription for an antibiotic and a pain medicine and is told to go visit his or her dentist. But a lot of these patients don’t have dentists. So there’s this dramatic reminder here that your oral health is part of your overall health, that drives you to the emergency room but you get to this gap where there’s no care.
There’s also the fact that our medical records and our dental records are kept separately. Dentistry has treatment codes, but it doesn’t really have a commonly accepted diagnostic code language which makes it hard to integrate medical and dental records and harder to do research on the commonalities between oral health and overall health.
One dental researcher said at a meeting I was at, “Back in the days of the bubonic plague, medicine captured why people die. We don’t capture why teeth die.” There’s this gap in the way we understand oral diseases and the way we approach tooth decay. We still approach it like it’s a surgical problem that needs to be fixed, rather than a disease that needs to be prevented and treated. And we see tooth decay through a moral lens, almost. We judge people who have oral disease as moral failures, rather than people who are suffering from a disease.
Beck: Insurance is all separated out as well, and a lot of times it’s optional. How, politically, did dental care come to be seen as optional?
Otto: There were discussions all through the 20th century, periodically, about this subject. Organized dentistry, like organized medicine, fought nationalized health care on a lot of fronts and testified against the practicality of extending benefits to everyone in the country. And all the healthcare programs that we’ve come up with as a nation have on some level or another left oral health out, or given it sort of an auxiliary status as a fringe benefit. Private insurance has also treated it that way.
Beck: It’s interesting, on one hand, dental care is treated as “optional,” but on the other hand, as you note in the book, there’s this social pressure to have perfect teeth, especially in America, especially among the rich. And so there’s a lot of money to be made in cosmetic dentistry. Do you think that social pressure to have perfect teeth is kind of exacerbating the inequality?
Otto: I think on some level it must. We do put so much emphasis on perfect smiles and there is a lot of money to be made in that field. One dentist I talked to as I was working on this project said “Nobody wants to do the low-end stuff anymore.” Of course there is a lot more money to be made with some of these really high-end procedures. But on the other hand there’s this vast need for just basic basic care. A third of the country faces barriers in getting just the most routine preventive and restorative procedures that can keep people healthy.
“There’s this kind of feast and famine aspect to dental care that’s striking.”
Beck: I wonder if the value put on that perfect Hollywood smile is in part because so many people don’t have access to dental care, so perfect teeth are a very clear way of signaling your wealth. More clear than if everyone had access to good care and had decent teeth.
Otto: It could be. It’s very interesting. This whole “perfect American smile” did have its origins in Depression-era Hollywood. Filmed movies were still pretty new at that point. There was this young dentist named Charles Pincus who had this dental office that opened on Hollywood and Vine and he went to the movies too. And he saw these movie actors who didn’t have perfect teeth up on the silver screen, like James Dean, who actually grew up on a farm and had dentures, and Judy Garland, and Shirley Temple. He started working with the studios. He created these little snap-on veneers for Shirley Temple so we never saw her lose her baby teeth. Over all the years she had a perfect little set of pearly whites.
But you’re right, there’s this kind of feast and famine aspect to this that’s striking. They call the [top] front six teeth “The Social Six,” and the perfect set of veneers for these front six teeth are not just a status symbol here in this country—they’re sought around the world as a marker of success.
Beck: I guess partially because of this market for cosmetic dentistry, dentists tend to cluster in rich areas, and there are often shortages in rural areas or poorer areas. But at the same time, you write about a lot of instances where dentists were really resistant to allowing anyone else to provide that preventive care, like training hygienists to do cleanings in schools. Why is that so controversial?
Otto: There’s been a long history of that and it really came home to me with some of the stories I heard, like the story of Tammi Byrd, this dental hygienist in South Carolina. There’s about a quarter million children living in the rural areas of the state who weren’t getting care, and she and some other dental hygienists fought to get the law changed so they could go out and see children without being first examined by a dentist. The dental association just fought back, they got an emergency regulation passed to stop her from doing her work and finally the Federal Trade Commission came in and took her case and won it for her, in the interest of getting economical preventive care to all these children who lacked it.
But, yeah, there’s this marketplace issue. Private organized dentistry protects the marketplace for care and the power of private practitioners to provide it but that leaves a lot of people out. Stories like the battle of this dental hygienist in South Carolina, or the battle that’s going on over these midlevel providers called dental therapists in a number of states, really illustrate how fiercely that terrain is protected.
Organized dentistry continues to say the current supply of dentists can meet the need, that if the system paid more for the care, more providers would locate in these poorer areas. That we Americans need to value our care more and go out and find care more aggressively. They see the fault as being with society at large.
Beck: This opposition to hygienists stepping up and filling that role, does that have anything to do with the fact that hygienists are mostly women? You quoted some old-timey dentists who were like, “Ah yes, the best assistant for a dentist is a woman because she won’t be ambitious and take over our patients." And it kind of sounds like that attitude is still around in some ways.
Otto: You could say that there might be a sense of that still. There’s certainly a deep sense among the powers of organized dentistry that only dentists are qualified to do the lion’s share of dentistry.
Beck: Are there other plans proposed to fill the gap in dental care, if not letting the hygienists or the dental therapists do it? Is there another plan that would be more pleasing to dentists?
Otto: They have their own alternative model. It's kind of a health navigator who connects people with existing dentists, a community-health-worker type of model. [The navigator] helps divert people from ERs into existing dental offices, helps people make dental appointments, educates them about maintaining oral health, and taking care of their children. But it’s guiding people to existing dentists, rather than expanding the dental workforce.
Beck: And if they don’t have insurance then it’s not going to help very much?
Otto: It’s not as helpful. Unless there’s a philanthropy or some kind of group that’s raising money to pay for the care.
Beck: The separation between dental and medical care is pretty entrenched at this point. Do you think it can be overcome, that it should be overcome, that the two could be integrated a little more? What might that look like, do you think it would help?
Otto: Something that was talked about in the medical world during the work going into the Patient Protection and Affordable Care Act was the “Triple Aim”: bending the cost curve toward prevention, expanding care more broadly and more cheaply, and [creating] a better quality of care. It’s something that needs to be discussed in the oral health world too, and I think it’s being discussed more.
Beck: Do you think it would be like a parallel reform in dentistry or would it be more integrating them back together somewhat?
Otto: It seems like it’s going to have to involve both. There’s been work being done in this area, there’ve been efforts to put dental hygienists into these federally qualified health centers that are part of our public-health safety net, which serve poor rural communities. It seems like it’s capturing an increasing amount of attention from state lawmakers, governors, and public health officials who are interested in bringing costs down for all kinds of health care and seeing that these things show promise. They're saying we’re spending too much on emergency rooms, we're spending too much on hospitalization for these preventable problems, so there are cost incentives to get more preventive and timely routine restorative care to people.
Beck: Trying to undo some of the damage of the historic rebuff.
Otto: Yeah, isn’t it funny?
Mary Otto, a Washington, D.C.-based freelancer, is AHCJ's topic leader on oral health and the author of "Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America." She can be reached at mary@healthjournalism.org.
Mary Otto
Mary Otto is the oral health topic leader for the Association of Health Care Journalists. She began writing about oral health at the Washington Post, where she worked for eight years covering social issues including health care and poverty, and she is the author of Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America (The New Press). She lives in Washington, D.C.
Teeth: Beauty, Inequality, and the Struggle for
Oral Health in America
Karen Springen
Booklist.
113.12 (Feb. 15, 2017): p12.
COPYRIGHT 2017 American Library Association
http://www.ala.org/ala/aboutala/offices/publishing/booklist_publications/booklist/booklist.cfm
Full Text:
* Teeth: Beauty, Inequality, and the Struggle for Oral Health in America. By Mary Otto. Mar. 2017. 304p. New Press,
$26.95 (9781620971444). 617.600973.
Eyes may be the window to the soul, but teeth may well trump them when it comes to their importance to overall
health. Former journalist Otto covered an impoverished 12-year-old boy who died in 2007 when bacteria from a rotted
tooth spread to his brain. (A routine $80 extraction might have saved his life.) This inspired her to investigate Americas
neglected dental system. She found that more than one in three low-income adults avoid smiling to conceal the fact that
they're missing teeth. Yet Medicare doesn't cover routine dental care, and Medicaid treats dental benefits for the 72
million poor Americans it covers as optional. In 2000, then U.S. surgeon general David Satcher issued a report on
"Oral Health in America" that stated it was inseparable from general health. Yet wealthy Falls Church, Virginia, boasts
one dentist for every 350 people, whereas poorer Dickenson County boasts only one for every 15,486 people.
Preventable tooth decay is the most common chronic disease of childhood in the U.S. and the cause of life-altering
medical problems. Otto's well-reported and important book will arouse concern over the fact that dental health, which
is so essential to our well-being, gets such short shrift and, hopefully, help instigate reform.--Karen Springen
Source Citation (MLA 8
th Edition)
Springen, Karen. "Teeth: Beauty, Inequality, and the Struggle for Oral Health in America." Booklist, 15 Feb. 2017, p.
12. General OneFile, go.galegroup.com/ps/i.do?
p=ITOF&sw=w&u=schlager&v=2.1&id=GALE%7CA485442450&it=r&asid=d1600df1727486cbf183b36a88bbc5ee.
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Otto, Mary: TEETH
Kirkus Reviews.
(Feb. 1, 2017):
COPYRIGHT 2017 Kirkus Media LLC
http://www.kirkusreviews.com/
Full Text:
Otto, Mary TEETH New Press (Adult Nonfiction) $26.95 3, 14 ISBN: 978-1-62097-144-4
An astute examination of the complex, insular business of oral health care.Former Washington Post journalist Otto
recognizes poor oral hygiene and maintenance as a major public health problem, and she adroitly probes the
ramifications of this persistent "silent epidemic of oral disease." While those in disadvantaged communities cite
affordability, accessibility, and shame as factors in their lack of dental care, the opposite can be said for more privileged
socio-economic groups, in which vanity and self-consciousness inspire an obsession with teeth bleaching, porcelain
veneers, and spatial alignment. "Bad teeth depersonalize the sufferer," writes the author. "They confer the stigma of
economic and even moral failure." Aside from economic variances, Otto charts the history of American dentistry,
including the astronomical educational debt of dental school students and, consequently, why more progressive dental
offices are often established within wealthier enclaves. The author meticulously examines the inexplicable
fragmentation of oral health from established American health care systems, the increase in emergency room dental
visits by uninsured patients, and how unregulated costs, a shortage of free clinics, and plans like Medicaid further
isolate poorer populations from obtaining dental care. She also addresses the widely debated medical claim directly
connecting oral health to overall health. Otto presents several case studies reflecting the state of the industry, including
a young Miss USA pageant contestant's pursuit of the "Hollywood smile" and the shocking deaths of two young men
from untreated dental abscesses. Though the situation is certainly a grim national concern, Otto presents hope via
radical initiatives to stave off the flow of dental demand. Still, she implores, prevention and upkeep are paramount, as
"people are held personally accountable for the state of their teeth in ways that they are not held accountable for many
other health conditions." A focused, well-researched depiction of the dental industry's social and cultural relevance and
its dire need for reform.
Source Citation (MLA 8
th Edition)
"Otto, Mary: TEETH." Kirkus Reviews, 1 Feb. 2017. General OneFile, go.galegroup.com/ps/i.do?
p=ITOF&sw=w&u=schlager&v=2.1&id=GALE%7CA479234433&it=r&asid=bd75811758113f9362b53f17ed340bcf.
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Otto, Mary. Teeth: Beauty, Inequality, and the
Struggle for Oral Health in America
Mary Chitty
Library Journal.
142.2 (Feb. 1, 2017): p96.
COPYRIGHT 2017 Library Journals, LLC. A wholly owned subsidiary of Media Source, Inc. No redistribution
permitted.
http://www.libraryjournal.com/
Full Text:
* Otto, Mary. Teeth: Beauty, Inequality, and the Struggle for Oral Health in America. New Pr. Mar. 2017.304p. notes,
index. ISBN 9781620971444. $26.95. HEALTH
Former Washington Post reporter Otto, oral health topic leader for the Association of Health Care Journalists, writes
compellingly about the integral role of oral health in overall wellness and how seldom dental care is available to lowincome
families, Medicaid patients, and nursing home residents. Surgeon General David Satcher's 2000 report, "Oral
Health in America," warned of a "silent epidemic." While the biological understanding of oral health continues to
evolve, access to dental care remains uneven, subject to the vagaries of state funding and "dental deserts." Tooth decay,
largely preventable, remains the most prevalent chronic disease in America. Residents who live in rural areas are
particularly subject to dental health disparities. Lack of access to routine dental care led to the 2007 death of 12-yearold
Deamonte Driver, of Baltimore, who suffered from a brain infection caused by an infected tooth, which could have
been prevented by an $80 extraction. His death led to Congressional hearings. This eye-opening look at the abyss
between medicine and dentistry, between the mouth and the rest of the body, is not just about dentistry. It is about
public health and health-care economics. VERDICT Timely and highly recommended for all readers concerned about
public wellness, health-care disparities and outcomes, and the rising costs of treatment.--Mary Chifty, Cambridge
Healthtech, Needham, MA
Source Citation (MLA 8
th Edition)
Chitty, Mary. "Otto, Mary. Teeth: Beauty, Inequality, and the Struggle for Oral Health in America." Library Journal, 1
Feb. 2017, p. 96. General OneFile, go.galegroup.com/ps/i.do?
p=ITOF&sw=w&u=schlager&v=2.1&id=GALE%7CA479301308&it=r&asid=76586974c3d8ca0f79b7af5a6289fd1e.
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Teeth: Beauty, Inequality, and the Struggle for
Oral Health in America
Publishers Weekly.
264.2 (Jan. 9, 2017): p58.
COPYRIGHT 2017 PWxyz, LLC
http://www.publishersweekly.com/
Full Text:
Teeth: Beauty, Inequality, and the Struggle for Oral Health in America
Mary Otto. New Press, $26.95 (304p)
ISBN 978-1-62097-144-4
This full-length debut from Otto, a health journalist who writes for the Washington Post, takes a hard-hitting look at the
current state of oral health in a beauty-obsessed America. She highlights access disparities, poorly addressed by our
national support networks, that can have lifelong devastating, or even fatal, effects. Otto's complex history of dentistry
depicts dental care as a field on the fringes of modern medicine. She begins in 1840 with the founding of the Baltimore
College of Dental Surgery, elevating dentistry from a trade to a profession, and traces its evolution perpetually in
isolation from the rest of America's health care system. More moving are the book's portraits of the effects of neglected
dental health care in poor communities: chronic pain is a given, the stigma of missing teeth hinders job prospects,
untreated infections lead to emergency room visits, and traveling clinics are left to pull teeth too rotted to repair. Otto
highlights the case of 12-year-old Deamonte Driver's death from complications of an untreated abscessed tooth, which
eventually led to the 2009 expansion of the Children's Health Insurance Program. With many adults still uninsured,
children's dental care far from universal, and the future of government-supported health care unclear, Otto's sobering
report should not go unheeded. (Mar.)
Source Citation (MLA 8
th Edition)
"Teeth: Beauty, Inequality, and the Struggle for Oral Health in America." Publishers Weekly, 9 Jan. 2017, p. 58+.
General OneFile, go.galegroup.com/ps/i.do?
p=ITOF&sw=w&u=schlager&v=2.1&id=GALE%7CA477339344&it=r&asid=ef2e8c5b90ae24d40377594846333d03.
Accessed 30 Sept. 2017.
Gale Document Number: GALE|A477339344
The Tooth Divide: Beauty,
Class and the Story of
Dentistry
By SARAH JAFFE MARCH 23, 2017
TEETH
The Story of Beauty, Inequality, and the Struggle for Oral Health in
America
By Mary Otto
291 pp. The New Press. $26.95.
Politicians, journalists and researchers have a long-running problem when it
comes to talking about class. The definitions we use are myriad and not always
overlapping. Is the boundary of the middle class a college degree, a certain level of
income? Perhaps a certain type of job: a teacher or a doctor versus a coal miner or
factory worker? We might be missing a still more useful — and more personal —
indicator, however.
This is the premise, though not so bluntly stated, of Mary Otto’s new book,
“Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in
America.” The dividing line between the classes might be starkest between those who
spend thousands of dollars on a gleaming smile and those who suffer and even die
from preventable tooth decay.
If the idea of death from tooth decay is shocking, it might be because we so
rarely talk about the condition of our teeth as a serious health issue. Instead, we
9/30/2017 The Tooth Divide: Beauty, Class and the Story of Dentistry - The New York Times
https://www.nytimes.com/2017/03/23/books/review/teeth-oral-health-mary-otto.html?mcubz=0 2/4
think of our teeth as the ultimate personal responsibility. We fear the dentist because
we fear judgment as well as pain; we are used to the implication that if we have a
tooth problem, if our teeth are decaying or crooked or yellow, it is because we have
failed, and failed at something so intimate that it means we ourselves are failures.
Otto’s book begins and ends with the story of Deamonte Driver, a 12-year-old
Maryland boy who died of an infection caused by one decaying tooth, and the system
that failed him. In pointing out the flaws in that system, Otto takes us back through
the history of dentistry and shows us how the dental profession evolved, separately
from the rest of health care, into a mostly private industry that revolves almost
entirely around one’s ability to pay. In other words, all of the problems with health
care in America exist in the dental system, but exponentially more so.
On the high end of the $110billion-a-year dental industry, there are veneers for
$1,000 each, “gum contouring” and more than $1 billion per year spent on tooth
whitening products. A dentist tells Otto that members of his profession “once
exclusively focused upon fillings and extractions, are nowadays considered providers
of beauty.” And thanks to decades of deregulation, allowing medical advertising and
then medical credit cards, they are doing well at it — according to a 2010 study,
dentists make more per hour than doctors.
But on the other end of the spectrum, which stretches from a free clinic in
Appalachia to the Indian Health Service in remote Alaska to a mobile clinic in Prince
George’s County, Md., dental providers struggle to see all of those who cannot access
regular care. One-third of white children go without dental care, Otto notes; that
number is closer to one-half for black and Latino children. Forty-nine million people
live in “dental professional shortage areas,” and even for those who do have benefits
under public programs like Medicaid, which ostensibly covered Deamonte Driver
and his siblings, it can be difficult to find a provider. The dentist treating Driver’s
brother DaShawn, Otto writes, “discontinued treatments because DaShawn
squirmed too much in the dental chair.” Medicare doesn’t cover routine dental
services. Remote Area Medical Volunteer Corps, the charity that operated the
temporary clinic in Appalachia, was begun to reach suffering people in developing
countries, but wound up seeing Americans. “We have a very serious social problem
that we are trying to solve with private means,” a researcher tells Otto.
9/30/2017 The Tooth Divide: Beauty, Class and the Story of Dentistry - The New York Times
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Yet in a country where the party in power fights tooth and nail against
expanding regular health care benefits, what chance do we have of publicly funded
dental care? After Deamonte Driver’s death, elected officials battled to add dental
benefits to the State Children’s Health Insurance Program (Schip), only to see the
law vetoed by George W. Bush. Barack Obama signed the Schip expansion in
February 2009; newly confirmed Secretary of Health and Human Services Tom Price
voted against it.
Donald Trump, who has promised to repeal the Affordable Care Act and who
nominated Price, makes a cameo in “Teeth,” looming over the Miss U.S.A. pageant as
the owner of the Miss Universe Organization, a subtle reminder of which side of the
American divide — on teeth as on everything — Trump stands.
The focus on pageant competitors underlines another divide in the dental
profession, one between men and women. Though more women are dentists these
days, the job of hygienist grew from men’s expectations of women’s appropriate
work, and it has always, Otto notes, made dentists nervous when hygienists move to
be more independent. Plans to put dental hygienists in public schools, for instance,
have been squashed by dentists’ associations. Yet Otto rarely brings up the role of
sexism, leaving the reader to ask the unanswered questions — if the dental industry
revolves around beauty, who is consuming most of these beautifying treatments?
Those in the service professions, it’s reasonable to assume, most of whom are
women.
In addition to the fear of competition from hygienists, Otto details dentistry’s
fear of socialized medicine and how that fear kept the profession largely privatized —
it is likely not an accident that the invention of still rare dental insurance came from
a man named Max Schoen, who “earned the distinction of being the first dentist to
be called before the House Committee on Un-American Activities.” Working with the
legendary labor leader “Red” Harry Bridges, Schoen helped the International
Longshoremen’s and Warehousemen’s Union set up not just a dental plan but a
racially integrated prepaid dental practice to provide the care. It could have laid the
groundwork for a radically different dental care system from the one we have now.
Instead, the decline of union jobs in America has led to a corresponding decline in
9/30/2017 The Tooth Divide: Beauty, Class and the Story of Dentistry - The New York Times
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dental benefits. Like hygienists, Schoen wanted to focus on prevention and earned
the ire of conservative dentists.
Those conservative dentists used their social clout as medical providers to
consolidate their own power over their industry, to control hygienists and rebels like
Schoen, yet ultimately they wanted their practices to be treated more like optional
services bought on the free market than social goods.
Otto does not say such things outright. A veteran journalist, she never strays
into polemic even when her material screams for it. She has a knack, though, for an
illustrative anecdote that underscores her point about inequality, for example that in
the 1800s, poor people would sell their teeth to the rich, whose own had rotted away
from the consumption of sweets that the poor could not afford. Other times, she
raises a fascinating fact — such as the idea that the extraction of wisdom teeth may
be unnecessary, but continues to be performed on patients who can pay — only to
move on, leaving the reader wanting more.
The problem of oral health in America is, Otto argues, part of the larger debate
about health that is likely to grow larger and nastier in the upcoming months. At the
moment, our broader health care system at least tenuously operates on the belief
that no one should be denied health care because of ability to pay. But dental care is
still associated in our minds with cosmetic practices, with beauty and privilege. It is
simultaneously frivolous, a luxury for those who can waste money, and a personal
responsibility that one is harshly judged for neglecting. In this context, “Teeth”
becomes more than an exploration of a two-tiered system — it is a call for sweeping,
radical change.
Sarah Jaffe is the author of “Necessary Trouble: Americans in Revolt.”
A version of this review appears in print on March 26, 2017, on Page BR21 of the Sunday Book Review
with the headline: Molar Mobility.
The Devastating Effects of Dental Inequality in America
The state of our teeth reveals—and reinforces—economic disadvantage in society.
BY ADAM GAFFNEY
May 25, 2017
That our teeth are in our heads seems natural, though the location is something of a liability. The trouble starts with tooth decay, which permits the usually harmless bacteria in our mouths to enter the spongy, supportive core of the tooth (the “pulp”). Something untoward can then unfold. The germs proliferate, white blood cells amass, pus accumulates, and a dental abscess is born. Hence the liability: It’s not good to have all this happening so close to one’s brain.
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An untreated dental abscess can invade the tissues of the head and chest. It can infect and clot the veins of the neck, and spread between the skull’s many sinuses. If it reaches the brain, it can result in a brain abscess or meningitis. This is now a rare event, but it wasn’t always. In the seventeenth century, “ ‘teeth’ were continually listed as the fifth or sixth leading cause of death,” a 1999 article in the Journal of the History of Dentistry asserts. Two hundred years ago, the author notes, tooth pain was a killer.
TEETH: THE STORY OF BEAUTY, INEQUALITY, AND THE STRUGGLE FOR ORAL HEALTH IN AMERICA by Mary OttoThe New Press, 304pp., $26.95
But here’s an unfortunate rule in medical history, at least in the United States: The untreatable conditions of the past become the untreated tragedies of the present. Mary Otto’s heartrending and incisive book, Teeth, builds on her Washington Post story on Deamonte Driver, a black twelve-year-old from Maryland who “died of a toothache” in 2007. His life could have been saved, she wrote, if his family had insurance, or if they had not been stripped of Medicaid for a time when they were homeless, or if Maryland’s underfunded Medicaid program had provided adequate access to dentists. “By the time Deamonte’s own aching tooth got any attention,” Otto reported, “the bacteria from the abscess had spread to his brain.” Surgeries and no doubt much suffering followed, but it was too late.
Deamonte Driver’s death was the direct result of a system of commoditized dental care. Some 114 million people lack any sort of dental coverage in the United States, and about half of children on Medicaid did not receive a single dental service in 2012. We could implement a system of universal coverage that would make treatment available on the basis of health needs, not means. But we have not. As Otto traces the history of modern dentistry, from eighteenth-century surgical experiments to the founding of the first American school of dentistry in 1840, she explains how the United States instead developed a “carefully guarded, largely private system,” one that is “enormously difficult to reach for those without mobility or money.” The state of our teeth, she argues, reveals—and reinforces—deep inequalities in society.
The story of our privatized dental system runs parallel to the more familiar story of America’s health care system. Over the past century or so, right-wing political forces have again and again impeded efforts to create some sort of national health insurance system. In the early postwar era, when many countries in Europe were creating or expanding systems of national health care, a health insurance plan proposed by President Truman was famously sunk by a vitriolic campaign of red-baiting, spearheaded by the American Medical Association—a historical episode Monte M. Poen relates in his book Harry S. Truman Versus the Medical Lobby. “Would socialized medicine lead to socialization of other phases of American life?” an AMA pamphlet asked in the late 1940s. “Lenin thought so,” it groundlessly answered.
The American Dental Association opposed dental care reform with equal vigor. Otto quotes ADA leaders who went to Washington to testify against the Wagner-Murray-Dingell Bill before the Senate Committee on Education and Labor in 1946: “Because of the limited number of dentists,” they argued, “it is impossible to carry out any program that promises complete dental care to both children and adults.” What these medical professionals lacked in compassion, they at least balanced with frankness: They were effectively admitting that much of the nation should be allowed to have their teeth rot. At the same time, the ADA and other dentists’ groups, then and now, have fervently opposed the expanded use of auxiliary dental professionals—mainly dental hygienists—to shore up the gap in care.
The victims of the profession’s obstruction are exactly who you would expect: the poor and—disproportionately—racial minorities. In her impressively wide-ranging reporting, Otto describes firsthand the effects of dental deprivation on impoverished indigenous communities in Alaska and impoverished white ones in Appalachia. She visits the town of Jonesville in Virginia, a municipality so neglected that a nonprofit known for delivering medical care to remote communities in the developing world decided it needed humanitarian assistance.
Toothlessness spells joblessness, which means lack of access to dental care, which in turn leads to more suffering.
The whole town, it seems, shows up to the new clinic to have teeth yanked out. Otto speaks to a disabled miner who lost his dental insurance when he was no longer able to work. He seems to be on the verge of losing a leg, and only recently managed to pay off $1,500 in dental debt for three tooth extractions. Now he shows up to have a fourth tooth pulled. “I’m a good person,” he tells Otto, “but I sure have been tested.” He is in better shape, however, than one woman Otto meets waiting in line before sunrise outside a clinic in Maryland. She is looking to have no less than eleven teeth pulled. The woman, Otto says, has been slitting her own infected gums to “relieve the excruciating pressure.”
And while economic inequality—whether through poor diet or lack of access to dental services—can result in dental inequality, bad teeth also reinforce economic disadvantage. Work in heavy industry may, for instance, require a strong hand, but the service worker of today increasingly needs a sweet smile. Service workers are expected to perform what sociologist Arlie Russell Hochschild has termed “emotional labor” in their jobs, transmitting happiness to the consumer—a task that demands a degree of oral health. At a time when service jobs are the predominant working-class occupation, missing teeth make it harder to get hired. Toothlessness spells joblessness, which means lack of access to dental care, which in turn leads to more suffering.
Can dentistry be decommodified? Of course it can. To some extent or another, it already has been in other countries. The United Kingdom’s National Health Service—implemented in 1948, just as Truman’s national health insurance plan collapsed—included access to dental care, which was initially free at point of use. When fees for dental care were introduced a few years later, the Labor health minister, Aneurin Bevan, resigned in protest. While America’s private dental industry makes it difficult to institute universal care, the option remains the only salve for our country’s dental inequality.
Some may counter that universal coverage would lower quality. That’s simply not true of NHS dentistry, even despite the cuts and privatization it has suffered in recent decades. A 2015 study published in the British Medical Journal, titled “Austin Powers Bites Back,” found that England enjoyed dental health that was, overall, as good as America’s. Americans actually had more missing teeth than the English, but scored somewhat better on an oral health survey. At the same time, the study noted that “there are consistently wider educational and income-related oral health inequalities in the United States compared with England.” In short, tooth problems in America disproportionately affect the poor.
While socialized dental care may seem a long way off in our political moment, Otto’s book sympathetically explores a range of ideas for improving the current system. She describes efforts to expand the use of auxiliary dental professionals in neglected areas of the country, sending dental hygienists or “dental health aide therapists” to do tooth cleanings and other routine sorts of dental work. She notes how dentists could take a more preventive—and less surgical—approach. And she details attempts to expand access to dental services for those using Medicaid.
Although there is a lot of sense in such suggestions, they would not completely alleviate the current crisis. No doubt non-dentist dental professionals could be more widely employed, but a system in which the well-off see dentists and the poor see dental professionals with lower levels of training would be fundamentally inequitable. And no amount of prevention—not even the reduction of socioeconomic inequality itself—would eliminate the need for dental care, any more than it would eliminate the need for the care of cancer or heart disease. Another world is possible, as the leftist slogan goes, but that world would still need universal dental coverage.
We have, of course, known this for decades. In 1943, Harper’s profiled a left-wing dentist named Maurice William who wound up having a profound impact on the political philosophy of Sun Yat-sen. Raised by Russian immigrants in Brooklyn, William was a fierce socialist from a young age. He had entered law school, but his legal studies increasingly seemed inconsistent with his political ideals. One day, he visited his dentist—who, as it happened, was himself a socialist—to have a tooth pulled, and a serious conversation about William’s future ensued.
“I can’t see any purpose in my going to college, in all my studies,” William pondered aloud. “What can an honest socialist do in this world?”
“Become a dentist, comrade,” his dentist responded. “Under the most perfect system of society there will still be rotten teeth.”