Why We Leave Out Teeth: America’s Broken Oral Health System

Apr 26, 2017
Originally published on May 10, 2017 4:14 pm

In the current debates over health care, one topic rarely gets mentioned: dental health benefits. That’s because dental health has historically been separated from the rest of medicine. But today, that separation leaves many Americans with no way to prevent or treat debilitating dental health problems.

Author Mary Otto tells the story of the rampant disparities in dental health in the United States and how those play into other disparities of race, class and income in her new book, Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America.


As Otto points out, many low-income adults can’t afford or access care. The Affordable Care Act mandated dental coverage for children—but not for adults—as an essential benefit required in all plans. And Medicaid programs are required to cover children's dental care but not adults. 

This leaves some adults with unsightly and unhealthy tooth troubles unable to improve their lives. According to research, 29 percent of low-income adults said  the condition of their teeth affected their ability to interview for a job.

Otto discussed the strange history of oral health care with Side Effects Public Media’s reporter Bram Sable-Smith.

This interview has been lightly edited and condensed for clarity.

Bram Sable-Smith: Your book centers on the story of a young man named Deamonte Driver. Who was he?

Mary Otto: Deamonte was a 12-year-old Maryland Medicaid child. He was a school boy and he died of complications from untreated tooth decay. He got an abscessed tooth and ended up in the hospital. Doctors told his mother that the bacteria from the infection has spread to his brain. And after six weeks of hospitalization and two brain surgeries he died.

BSS: How preventable was it?

MO: Well his care in the hospital cost about a quarter of a million dollars and basic, simple preventive care might have kept him from even having tooth decay in the first place. He was a Medicaid beneficiary in Maryland and like most Medicaid children he didn't get routine dental care. It turned out that his case was emblematic of a huge problem in the country.

BSS: And how did it come to be that in this country we treat our mouths as separate from our bodies when it comes to medical care?

MO: Well I found out the story of the separation of the dental profession started in Maryland not too far from where Deamonte lived and died. In 1840 the first dental college in the world was established in Baltimore. And it was a separate school from the medical school and it became the sort of creation story of the day dental was a separate profession. A whole separate system grew up around the profession of dentistry. That separation is a very hard thing for people to navigate. I mean roughly a third of Americans face significant barriers getting routine dental care.

BSS: So we're in the midst of a giant health care conversation in our country right now, where does oral health care fit into that conversation?

MO: It's really hard to pick up on the signals, I listen really closely. If history is any indication it's getting left out of the conversation from the founding of the first dental school. The Medicare program has never included routine dental care, Medicaid entitles children to care but leaves the care of adults up to the states so millions of poor adults have terrible problems with their teeth.

A third of low income adults are reluctant to smile, which holds them back from moving up in the workplace or social advancement. They suffer in terrible pain, some of them pull their own teeth. They stand in long lines for free care.

You don't hear mention of dental care in these epic battles that are going on over our healthcare system. And it remains to be seen what will happen.

BSS: Why is it so hard to pin down the conversation on oral health care? Why is it potentially absent?

MO: It's a really great question. There's no other part of our body where you think of amputation as being a good solution to a problem, but people say, "you can pull a tooth, you can extract a tooth."

You know, Descartes separated the head from the body, like our minds are separate from the mechanical operation of the rest of our bodies and our organs. And on some level that was a big advance for science, we could study the body and learn how it worked. But there's something about the fact that we can specialize in the understanding of parts of our bodies that does lead us away from taking care of the whole patient and seeing a person.

Side Effects Public Media is a reporting collaborative focused on public health.

Copyright 2017 Side Effects Public Media. To see more, visit Side Effects Public Media.