‘I can’t chew, you know, because the teeth are very weak’

My Wonkblog column today was on the scandal of American dental care

Robert (pictured right) has been homeless for years. When I asked about his dental problems, he pulled his lips back to show the damage.  A sweet, soft-spoken man, he has unfilled cavities. He needs a crown. He is waiting on a long-overdue root canal. It would cost about $1,000, which he doesn’t have. He doesn’t have the $50 needed for a basic cleaning. So he hasn’t had his teeth cleaned in two years. All that time, he has chewed all his food on the left side: “These teeth are very weak.”

More here.

By the way, the $180 million capital costs associated with a single proton beam radiotherapy machine–a technology with highly speculative therapeutic benefits over cheaper therapies–could finance routine teeth cleanings for 3.6 million low income people.

Author: Harold Pollack

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He has served on three expert committees of the National Academies of Science. His recent research appears in such journals as Addiction, Journal of the American Medical Association, and American Journal of Public Health. He writes regularly on HIV prevention, crime and drug policy, health reform, and disability policy for American Prospect, tnr.com, and other news outlets. His essay, "Lessons from an Emergency Room Nightmare" was selected for the collection The Best American Medical Writing, 2009. He recently participated, with zero critical acclaim, in the University of Chicago's annual Latke-Hamentaschen debate.

13 thoughts on “‘I can’t chew, you know, because the teeth are very weak’”

  1. thanks for this. i attended grad school at a university that had a dental school. part of the training was for students to go up to the mountains and provide free service. they came away with horror stories.

  2. Yes, and you don’t even have to go that far. I know non-homeless people in LA who can’t afford care. Every time they have one of those free clinics, they’re swamped.

    What I don’t get is, why this fantasy that your teeth and your eyes are separate from the rest of you? What the foxtrot??? I don’t care how it happened historically. I just want it fixed.

    Single payer already, too.

    1. From the full story:

      Dr. Van Kanegan explains: On a policy level, oral health care should have been part of the core services covered in health care reform. We talk so much about how the oral cavity is connected to the rest of body, but we don’t want to be part of an integrated health care system… We isolated ourselves in the ’60s when Medicare was being planned.

      Actually I find the history tantalizing. My understanding is that doctors have become increasing Democratic Party members, whereas dentists remain mostly faithful to the Republican Party. The support of the AMA was one reason the ACA actually finally happened this go around. I suspect the entrenchment of Republicanism in Dentistry is why things are so primitive, and why we have so many snaggle-toothed Americans. Let’s call that a working hypothesis.

    2. “What I don’t get is, why this fantasy that your teeth and your eyes are separate from the rest of you?”

      Not just your eyes and your teeth, but also your ears. There has been much progress in hearing aid technology in the past decade, but they are certainly not priced for working people, i.e. those most likely to have suffered hearing loss from there work. And I only found out about my own hearing loss when I happened to have a routine physical exam in Europe; none of the America doctors felt that they should make such an examination, apparently.

    3. Whatever the history of this is, it’s not specific to the United States. Many single-payer countries are comparatively stingy when it comes to dental care, too. You often have to deal with considerable co-insurance or deductibles.

      That said, you can do much better than that still. In the UK, there’s a “per course of treatment” deductible. A band 1 treatment (cleaning and checkups) costs a maximum of £18; a band 2 treatment (fillings, root canals, extractions, no matter how many) costs a maximum of £49, no matter how many teeth are treated. A band 3 treatment (crowns, bridges, dentures) is capped at £214. This deductible is waived for children and youths up to age 18 and for low-income individuals (especially the unemployed). A person in Robert’s condition would have to pay at most £214 to have their teeth fixed, and given how poor he is, Robert specifically likely would have to pay nothing at all if he were a UK resident. And he could have gotten treatment much earlier, meaning that his teeth wouldn’t have been as bad.

      In Germany, under the public health insurance system, all medically necessary treatment (annual checkups and cleaning, root canals, fillings, extraction) is completely covered by health insurance. Crowns, bridges, and dentures come with a co-insurance of about 50%; this is reduced to 30% if you have had annual checkups for at least five consecutive years, 20% if you have had annual checkups for at least ten consecutive years. Co-insurance is completely or partially waived for low-income individuals (in particular, anyone with an income below approximately EUR 1000 is completely exempt). Again, Robert would likely be eligible to have his teeth fixed at no cost at all if he were a German resident, assuming that he would be on public insurance.

      Note that in either country this only covers what is medically necessary; if you want white crowns or implants, that comes out of your pocket; dental insurance exists to ensure that you can afford good oral health, anything that is cosmetic is considered a luxury.

      Neither scheme is ideal; there are many corner cases in either country that can make somebody forgo necessary dental care (e.g., struggling self-employed individuals in Germany with private insurance and a high deductible). But it’s still a hell of a lot better than the American roulette type of health insurance.

  3. Once upon a time, I spent a sabbatical at a State Human Services Department looking at Medicaid expenditures and expansion issues. One of the things we did was to survey uninsured people to see what they needed.

    The survey had one glaringly obvious outcome: the uninsured needed dental care as part of the package. Oral health was in many ways more important to them than a doctor’s care. One survey respondent pointed out that when you for a job interview, employers judge candidates on the basis of appearance. Someone with serious oral problems is viewed as someone who doesn’t take care of themselves. Oral health is visible and affects many aspects of life.

  4. Somebody needs to capture America’s suffering on video, and do it well, then start showing it to groups of American women, many of whom will actually care.

  5. Ford PJ, Yamazaki K, Seymour GJ (2007) Cardiovascular and oral disease interactions: what is the evidence? Prim Dent Care 14(2):59–66 PMID 17462139

    This paper reviews the evidence for the interaction of oral disease (more specifically, periodontal infections) with cardiovascular disease. Cardiovascular disease is a major cause of death worldwide, with atherosclerosis as the underlying aetiology in the vast majority of cases. The importance of the role of infection and inflammation in atherosclerosis is now widely accepted, and there has been increasing awareness that immune responses are central to atherogenesis. Chronic inflammatory periodontal diseases are among the most common chronic infections, and a number of studies have shown an association between periodontal disease and an increased risk of stroke and coronary heart disease. ….

  6. One of the things that’s interesting here is that for people who go to a dentist, the dentist has also become a sort of default bottom-half-of-the-head family practitioner. Exams include soft tissue inside the mouth, glands, the TMJ and associated musculature, upper jaw…

    There are a fair number of conditions that a dentist will see and recognize before a GP does.

    1. eg, http://en.wikipedia.org/wiki/Ranula .
      It bugs me too that dental care is yet another mound of paperwork we have to cope with.

      It bugs me that many folks on the street can not eat healthy vegetables and fruits because their teeth are rotted away.

  7. Yes. I ride public transit and people like me stand out glaringly, despite my extremely casual or downright slovenly attire much of the time. I asked my wife why we can immediately tell who is slumming in a tourist setting and who is actually down and out, and she pointed it out immediately: teeth and haircuts.

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