This review brings up an issue, dental health, that we never see any
articles about so I thought it would be thought provoking.
Miriam
Molar Mobility. By SARAH JAFFE. Sarah Jaffe is the author of 'Necessary
Trouble: Americans in Revolt. 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 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 $110? billion-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. 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 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.. PHOTO:
Dental X-rays from a Louisville, Ky., patient who had gone most of her adult
life without insurance. (PHOTOGRAPH BY WILLIAM DESHAZER FOR THE NEW YORK
TIMES).
