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Sunday Times Book Review, Mar. 26 2017
The Tooth Divide: Beauty, Class and the Story of Dentistry
By SARAH JAFFEM
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.
Sarah Jaffe is the author of “Necessary Trouble: Americans in Revolt.”
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