Why Teeth Matter: Book Explores History of Dentistry, Fear of Dentists, and More

Health writer
(Left) Nancy Crampton; (right) The New Press

In 2007, Mary Otto was working on the Maryland beat for the Washington Post when a tip about a 12-year-old boy, Deamonte Driver, came across her desk. Deamonte was in the hospital, where she went to meet him and his mother; but after six weeks in two different hospitals, he died.

She reported on the story – making calls, digging deeper – and found that, had he had routine access to dental care, he would likely still be alive.

What killed him?

A tooth.

And an American oral health care system that failed not only Deamonte, but also his family and countless others who didn’t and don’t have adequate access to dental care.

Mary began to dig even deeper. The story she discovered was one of the history of dentistry, about how its origin story in the United States separated it from the overall health care system, and how that separation has proven an issue in access to care ever since. Tooth decay (and subsequent pain) is one of the most prevalent chronic diseases in America.

The story of one child’s death from a dental infection that spread to his brain became the story of her professional career, and a decade after Deamonte’s passing, she wrote a book exploring it in-depth: “Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America." The book has received rave reviews and awards, including being named a NPR Best Book of 2017.

Teeth might not seem sexy – but Mary’s extensive research and easy-to-read writing help turn this topic into a page-turner. HealthCentral interviewed her about her book, her reporting, and what she found out about dental health along the way.

HealthCentral (HC): What was the most interesting thing you learned about oral health while writing this book?

Mary Otto: It really struck me that right in Maryland, right where I was doing my reporting not that far from where Deamonte died even, the separate world of American dentistry was born. That was in 1840 in Baltimore, where the world’s first dental college was created. Its creation was kind of the creation of the American dental system because the two founders of the school, Chapin Harris and Horace Hayden, were self-trained dentists. In those days, dentistry was considered more of a trade than a health care profession. They thought dentistry was worthy of scientific standing and formal training, so they went to the physicians at the prestigious College of Medicine at the University of Maryland and asked to add this course of dental instruction to the medical classes. And they were told that the subject of dentistry was of little consequence.

They did go on their own way and start their own dental college, which has become the University of Maryland’s dental school. That event is remembered as the “historic rebuff,” and it continues to shape the relationship between dentists and physicians.

Dentists drill and fill teeth, and physicians look at the body from the tonsils south, and there’s a gap between these two systems, and it’s not just an academic gap – it affects the way people think about their own oral health and the way they find care, and maybe sometimes the way they fail to find care because they can’t navigate between the health care system and the dental care system.

HC: You write about the disparities in access to dental care in the U.S., including how people without adequate dental coverage or money to pay for care or access to providers experience intense tooth pain, often leading to the loss of their teeth – and sometimes, from infections and other causes, to death. What are lawmakers doing to reverse this lack of funding and care in oral health?

Mary Otto: More than 70 million people rely on Medicaid for health coverage, but adults aren’t entitled to dental benefits under Medicaid. Dental care is left up to the states, so that means it’s an optional part of the Medicaid program, and so dental benefits are among the first thing to end up on states’ chopping blocks in those difficult fiscal years. So those benefits come and go, and that leaves millions of poor Americans without regular dental benefits.

Then there’s Medicare. About 55 million disabled and elderly Americans have Medicare and it’s never included routine dental benefits, so millions of those Americans are dentally uninsured and on top of it, many of them are living on fixed incomes so they put off dental visits. These factors contribute to all this suffering and all this pain.

And when the pain gets too bad, more than a million Americans a year go to the emergency room (ER) with these non-traumatic dental problems like tooth aches, and the visits cost more than a billion dollars a year.

The only silver lining to this is these ER costs are attracting attention of lawmakers in some states and making them pay more attention to the importance of preventive care because it’s so much cheaper than having somebody in an ER where their dental needs aren’t even addressed.

HC: So how do we elevate dentistry to the integrated place it deserves in our health care system?

Mary Otto: I think David Satcher, M.D., Ph.D., the former surgeon general, made an important statement with his landmark Oral Health in America Report back in 2000. I kept re-reading that report as I worked on the book. One of the points he made is this really articulate call for integration of oral health and overall health. He’s talking about whole patient care. He said, “Just as we now understand that nature and nurture are inextricably linked, and that mind and body are both expressions of our human biology, so, too, we must recognize that oral health and general health are inseparable.”

He went on to say that we need a system that reflects that, and I think people are coming to understand that better, but we’ve obviously got a way to go.

HC: What is one important fact people should know about their teeth – but they might not?

Mary Otto: Something I’ll never forget – I had a chance to study oral health at Harvard as a Knight Science Journalism Fellow – is the day I met a paleoanthropologist, Tanya Smith, who was interested in work on ancient teeth. She told me, we have this faithful clock in our mouths. There’s a neonatal line in the enamel of our baby teeth and our first permanent molars that’s kind of like a birth certificate. It records the physiological changes that occurred when we emerged from the womb. It was just such a wondrous thought.

It’s reminded me over and over about the intimate connection we have with our teeth and how our teeth are connected to our lives. And yet on the other hand, how they’re thought about as expandable, they get diseased, they get amputated, they’re thought about as ornamental or superficial somehow. They don’t always get the respect they deserve.

HC: You quote Claudia Rosas, a dental project supervisor in Florida, who said that our teeth are like "pearls" that we should value and protect. What did she mean?

Mary Otto: Yes, she was working in this amazing free clinic in St. Petersburg [the St. Petersburg Free Clinic] and this clinic had been working for years providing free medical care to people. A lot of working poor people in Florida were working in the hospitality industry, cleaning and painting, doing construction work, taking care of elders, and doing all this hard work, and yet most of them didn’t have adequate medical care, and after the Affordable Care Act went into effect, many of them received medical care but still needed dental care.

So this free clinic starting branching out to try to find ways to get dental care for people. The days I visited, they didn’t even have their own dental clinic in the free clinic, they borrowed a county health facility after hours and got volunteer dentists and hygiene students to come and provide this care. It was amazing.

She was talking about how part of the job is to help people from childhood realize how important that their teeth are and being very proactive about taking care of them. In families where there have been generations who haven’t had adequate dental care, there’s a kind of fatalism. That ‘oh, we lose our teeth in my family, my family has always had bad teeth.’ But they may have just lacked adequate routine care over the years.

HC: “The issues of pain, anxiety and fear have always been a major part of dentistry,” you quote researcher Robert Pawlicki as saying. Many people fear going to the dentist. How can people work through that?

Mary Otto: It kind of surprised me to find out that one out of 10 Americans, according to federal statistics, don’t visit the dentist out of fear of dentists and dental care. At the same time, fear also makes the experience of pain worse. And patients who are afraid are more likely to miss dental appointments, which makes dentists very upset because they have an empty chair and lose money.

It’s a hard problem because there are many things that may excite fear in people about a dental visit. They may have had past bad experiences, which I heard about a lot – ‘I had a bad dental visit when I was a child, and I’ve been afraid ever since.’ There are other things too. The sounds and the smells set people off. Sometimes it’s that feeling of opening up this really intimate, vulnerable territory of yourself to someone else for inspection.

And there’s just not a lot of research, at least some researchers say, on dental pain and the dynamics of it. They say it’s not discussed as much as it should be in dental schools, so dental providers don’t know as much as they should about how to recognize fear in patients and address it.

One of the suggestions that came out of the research I read, and I even saw a couple of dentists working with this technique, is that they should try to build confidence in patients over time. Talk with them, meet with them in a setting other than the dental chair about the care they might need and expect.

Another thing I saw in practice was beginning care very early, even with infants, and Mom is right there. It’s just very gentle. Over time, the familiarity of a dental visit then is not something to fear – it’s just something routine.

I think it’s important to find a dental provider you can trust and talk with and discuss your worries and concerns. And find someone who understands and is willing to work with you and talk with you. Even ask a friend who is comfortable with his or her provider about who that is – a recommendation might help a lot.

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