Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America, by Mary Otto, 2017, The New Press
Mary Otto sets out to paint a picture of the reality of poor dental health and lack of dental care that the working class and especially those living in poverty endure in the United States. She is well versed in the subject, as the oral topic leader for the Association of Health Care Journalists.
Her book, she says, “provides a look into the insular world of dental care in America. It examines the enduring tension between the need of Americans for dental services and the lack of services available to millions of us under the current system.”
Federal data show that tooth decay remains the most prevalent chronic disease of American children and adults. At the end of 2014, about one-third of Americans lacked dental benefits of any kind. The figure included millions of the elderly covered by Medicare, which has never offered dental benefits, and 68 million Americans under the age of 65.
The federal government estimates about 49 million Americans live in an area where there is a shortage of dentists. In addition, more than 114 million people lack either private or public dental benefits. The result is that many people delay getting needed dental care, at a heavy cost, in terms of both health and money. Twelve percent of adults who had unpaid medical bills reported that dental expenses made up the largest share of bills they struggled to pay. In addition, many patients may not be able to afford the antibiotics the dentist prescribes for tooth infections, instead only filling prescriptions for less expensive painkillers.
Under Medicaid, the federal-state health program for the poor, states can decide whether to offer dental benefits to adults. Children covered by Medicaid receive dental benefits by federal law. But when states want to cut funding, they make reimbursements to dentists so low that they won’t treat children with Medicaid coverage. Fewer than half of dentists participate in the Medicaid program and more than half the 35 million children who have coverage go without care, with results that can be catastrophic. (See The tragic and needless death of Deamonte Driver, a victim of dental disease)
Otto describes the effects of tooth decay on people’s lives. People may miss school or work or perform poorly because of pain and illness. It’s harder for them to find jobs, particularly in industries like service and retail where they interact with the public. “Bad teeth depersonalize the sufferer,” Otto notes. “They confer the stigma of economic and even moral failure.”
The origins of the dental profession
An important part of Otto’s work is to trace the historical development of dentistry and how it was separated from medical care as a whole, leading to the present system where there is almost no overlap between the two professions. Of the two, moreover, dentistry is characterized by an extremely narrow and anti-social viewpoint, essentially the outlook of the petty-bourgeois small businessman, even more so than the medical profession.
Originally, dentistry was considered a trade, with the first college opening in 1840. Students learned how to drill, fill and pull teeth and build dentures. Dental schools did not teach the causes of oral disease, rather focusing on the perfection of the skills required to address the symptoms, mainly by removing diseased teeth.
In the early 1900s, dentist Alfred Fones heard a lecture on a regime for patients to prevent dental disease in the first place. It involved removing plaque, laden with bacteria, and patients returning for regular treatments. Patients were also taught how to brush their teeth and how to follow a healthy diet. Using these methods, Fones found that his patients’ teeth and gums got better and the health of the whole mouth improved. Since the work was time-consuming, he taught his cousin and assistant how to use these techniques. She was among the first dental hygienists.
Dental organizations reacted ferociously to guard their control over dentistry and the threat posed by dental hygienists, who dental leaders feared could take away business from the skilled, educated and experienced dentist. Organized dentistry consistently acted to protect its professional autonomy.
In the decades following the Russian Revolution, professional dental leaders, like their medical counterparts, expressed concerns about the “spread of communism,” which they identified as any threat to their status as independent profit-making businessmen.
The campaign against “socialized medicine”
In a paper delivered in 1919 to the Pennsylvania State Dental Society, Thomas Barrett linked the dental hygienist model to socialized medicine. School health clinics began to close. A fearmongering campaign against dental hygienists continued for decades. In the 1940s, hundreds of Massachusetts dentists attended a state hearing to demand repeal of a bill permitting hygienists to fill children’s teeth in school clinics, since it opened “a wedge for socialized medicine.” Dental organizations fought every project to expand the use of hygienists and broaden access to dental care, making it cheaper and more available.
There were sporadic and ultimately fruitless efforts to broaden the social scope of dentistry, initially associated with the rise of the industrial labor movement. Otto makes clear her sympathy with those who tried to overcome the parochialism of the dental profession, and outlines some of the political issues that arose.
While acknowledging that millions of Americans cannot afford and lack dental care, dental leaders have fought federal programs to address the need. They strongly defended the private practice system. When individual dentists took initiatives and set up new ways to expand services to those who couldn’t afford them, dental leaders pushed hard to quash them.
In 1951, Max Schoen was the first dentist to be called before the House Un-American Activities Committee for working with the Civil Rights Congress, founded in Detroit, Michigan in 1946. In one campaign, they built public support for the Martinsville Seven, a group of young black men executed in Virginia in 1951 after being convicted of raping a white woman. The group also opposed the deportation of Harry Bridges as a communist. Born in Australia, Bridges was president of the International Longshoremen’s and Warehousemen’s Union.
After his questioning by HUAC, Schoen returned to practicing dentistry, “actively espousing health care for all regardless of the ability to pay.” A couple of years after the hearings, the Longshoremen’s union leaders approached Schoen about using money in its trust fund to finance dental care for every child up to 15 years old.
Schoen’s pilot program was a prepaid group practice in the Los Angeles and then San Francisco areas that brought together a racially integrated group of dentists who formed a salaried partnership. Providers included dental specialists, hygienists and assistants. The union paid a fixed fee for each beneficiary, who received whatever dental services were needed. The Journal of the Southern California Dental Association warned, “We in the United States, suffer from a rash of Pale Pinks, Parlor Pinks on up through Crimsons” who “threaten our livelihoods.”
Another dentist, Ralph Lobene, launched Project Rotunda in the 1970s, a clinic in Boston for training hygienists to drill and fill teeth. The goal was to develop an approach that would bring dental care to the whole population of the country. Dental leaders organized to stop the project. Lobene noted: “The outdated philosophy that this health service is a privilege to be enjoyed only by people affluent enough to afford it has long been tacitly accepted by the dental profession.”
Even though patients today regularly have their teeth cleaned by dental hygienists in dentists’ offices, dental organizations make sure their activities are limited. One example occurred in Georgia in 2016. A bill was killed that would have allowed hygienists to clean teeth in nursing homes and school clinics. The dentists association in the state was hostile to it and made sure the bill died.
The separation between dentistry and medicine
William Gies, researching the study of oral disease at Columbia University in New York in the 1920s, believed dentistry should be regarded as a healing science. He advocated for closer ties between dental and medical schools and dentists and medical doctors. In 1926, he published a landmark report that stressed the importance of dentistry as an essential part of higher education in the health professions. Such an education would help health care researchers study how dental disease and other medical conditions related to each other and the most effective ways to prevent dental disease.
In 1945, Gies tried to integrate the faculties of the medical and dental schools and was opposed by the dental faculty. The Journal of the American Dental Association wrote: “The views of the majority of dentists in the country cannot be misunderstood on the question of autonomy. The profession has fought for, secured and maintained its autonomy in education and practice for too many decades to submit now to arbitrary domination and imperialism by any group.”
The separation between dentistry and medicine was maintained and even codified when Congress enacted Medicare, in the form of sweeping amendments to the original Social Security Act of 1935. Medicare underwrote medical care for the elderly, those 65 and older, but dental care was not covered, even though—or more likely because—losing one’s teeth was such a common experience of old age, making dental care costly.
The turn to cosmetic dentistry
In the more recent period, Otto shows how the profit motive has led dentists to concentrate on more costly procedures rather than preventive services such as cleanings. In the early 1980s, fluoridation, dental sealants and other innovations were reducing tooth decay. As a result, dentists turned to cosmetic dentistry, expanding their businesses so they could be part of the beauty industry. They embraced cosmetic dentistry—where the money was. As a result, many people today visit the dentist to have their teeth cleaned, but are pressured to buy products and have procedures to make their teeth “perfect,” their smile brighter.
Dental offices offer everything from bleaching, to veneers, to complex full mouth restorations. Veneers usually cost one thousand dollars per tooth. Smile makeovers that can involve bleaching, orthodontics, crowns, implants or gum contouring cost many thousands. Dentists have become part of the dream factory, telling patients the perfect smile will change their lives. A perfect job … a perfect mate … self-confidence. Cosmetic dentistry is the fasting growing part of dental practices.
Surgical procedures, such as drilling, are more lucrative for dentists than preventive procedures, such as applying sealants that can help prevent and slow tooth decay. A 2011 study revealed that only 40 percent of dentists apply sealants, even though the ADA recommended in 2008 that they be used more generally.
Most wealthy communities have an abundance of dentists. At a 2015 convention, dental marketing guru Roger Levin told the assembled dentists, “All too often, dentists have laxly marketed, missing opportunities to sell procedures.” For example, “Mrs. Jones. You owe it to yourself to find out how dental implants can improve the quality of your life. ... Let us review our four wonderful payment options.” Make sure the patient pays the bill before the procedure is finished, he advised.
Levin warned the crowd about the dangers of seeing Medicaid patients. They miss appointments, hand towels disappear, they take things home. “The only way we play a little gray is sequestering the hours of Medicaid patients. If people come in, they want to be with people like themselves.”
Mary Otto’s book provides important information about the health crisis faced by millions of Americans who cannot get dental care. She admires those who have historically tried to expand care and have faced vicious opposition from the dental establishment and politicians. She recognizes that social inequality and the private practice system of dentistry are social issues. That is, she counters those—both the dental establishment and politicians—who have argued that decayed teeth result because the poor don’t care about their teeth and don’t take care of them.
In contrast to that position, Otto quotes Clemencia Vargas, faculty member at the University of Maryland School of Dentistry: “Dentists cannot turn away anybody for any reason. Unless the patient doesn’t have money. … We have a very serious social problem that we are trying to solve with private means. And that doesn’t match.”
However, while outraged by the crimes of the private practice dental system, Otto does not draw any larger political conclusions about the root cause of these scandalous conditions, the capitalist profit system. Especially today, when even the remnants of social reforms are being destroyed, the only solution to the crisis of dental care and health care as a whole is socialized medicine, through the broader struggle for socialist policies and a workers government.
[11 January 2018]