Who's smiling now? Disparities in American dental health.

• Author: Dolgin, Janet L.
• Position: Introduction through I. Dental Status and Poverty C. Dental Coverage in the United States 5. The Patient Protection and the Affordable Care Act, p. 1395-1421

Introduction I. Dental Status and Poverty A. Lacking Dental Coverage and Dental Care B. The Worst Consequences of Poor Dental Health C. Dental Coverage in the United States 1. Health Coverage Compared with Dental Coverage: Why Is Dentistry Not Part of Medicine? 2. Opposition to Expanding Dental Coverage for Poor People 3. Medicaid and SCHIP 4. Private Insurance for Dental Care 5. The Patient Protection and the Affordable Care Act 6. Comprehensive Dental Reform Act of 2012 II. Teeth Even the "Tooth Fairy" Might Envy III. Ethnicity and Geography (Urban v. Rural): Disparities in Dental Care and Dental Health A. Urban Teeth and Rural Teeth 1. Differences in Access to Dental Health Care and Dental Health Status 2. Differences in the Significance of Teeth as a Sign of Class Status in Urban and Rural Areas B. Differences in Dental Care and Dental Health Among Various Ethnic Groups C. Class and Dental Condition in the United States and in Britain IV. Socioeconomic Status and Dental Status A. Teeth Throughout Time and Space B. "American Teeth" and Consumer Culture Conclusion "I am very angry that my son had to lose his life just because we didn't have insurance .... My son had to die--12 years old--because of a tooth." (1)

"Dental practitioners credit wealthy baby boomers, reality television makeover shows and new dental technology for the surge in demand." (2)

INTRODUCTION

Teeth tell stories. Disparities in dental condition--as well as social perceptions of those disparities--reveal a great deal about class structure in the United States. Missing teeth suggest poverty. (3) Straight, even, white teeth mark middle and upper class status." Such differences offer visible signs of socioeconomic status in a nation long confused about how to identify class status and how to understand the nation's opaque class hierarchy.

Moreover, the legal system in the United States has never focused vigorously on ensuring access to dental care for low-income people. (5) Even after implementation of most provisions of the Patient Protection and Affordable Care (ACA) (6) in 2014, many adults will not have coverage for basic dental care.

In short, a person's dental condition is a powerful sign of socioeconomic status at both ends of the nation's class hierarchy. People without dental coverage and financial resources are often reduced to pulling out diseased teeth, even without the aid of a dental professional. (7) And at the same time, for those who do have financial resources, teeth have become consumer goods--more effective markers of class status, even, than clothing, jewelry, and hairstyle. (8) Yet, people do not speak (except perhaps with humor or chagrin) about "wearing their teeth." Rather, teeth are a very visible part of a person's embodied self. It is much harder to change teeth than to change jewelry or hair. All of this is significant in a society within which, to quote Sarah Nettleton, "The body has come to form one of the main sites through which people develop their social identities." (9)

This Article approaches American dental health as a reflection and re-enforcer of class status in the United States. Within that frame, it explores two poles of oral health. Those without adequate dental coverage or other resources to pay for dental care are at risk of losing teeth and suffering from gum disease and other serious health problems correlated with poor dental health. (10) At the same time, many wealthy people purchase cosmetic dentistry in a manner similar to the purchase of face-lifts and bariatric surgery procedures." An adult's teeth are presumptively a permanent part of his or her body (at least for most people and in most parts of the United States) and may, therefore, suggest aspects of a person's underlying identity far more powerfully than other symbols of class status.

Part I explores the medical, legal, and social implications of dental status in the United States. It describes the potentially life threatening consequences of dental disease, considers access to dental care in the United States, and notes how limitations in the ACA suggest that the ACA's implementation for many people will not make it significantly easier to gain access to health care. Part II considers "good teeth" as a sign of prosperity and examines the consequent focus of many groups within the United States and elsewhere on cosmetic dentistry. Part III reports on disparate dental status and differences in the symbolic importance of dental condition in urban and rural settings and across ethnic groups in the United States. Finally, Part IV presents an overarching frame within which to understand the potential significance of teeth as both a sign of poverty and of socioeconomic success.

1. DENTAL STATUS AND POVERTY

In 2007, a New York Times story about anti-immigrant responses toward an amnesty bill under consideration in the United States Senate featured comments from a Wisconsin man, a retired police officer. (12) The man, whose photograph accompanied the story, had lost a tooth on the left side of his mouth--the side shown in the photograph. After the story appeared, the Times received an avalanche of emails criticizing the paper for picturing a man with a missing tooth. (13) According to Clark Hoyt, the Times's public editor, many of the emailers complained about what they saw as the paper's presumption that all those who opposed the Senate bill on immigration, as did the man pictured in the photo, had missing teeth. (14) E-mailers referred to the photographed man as a "'toothless freak' and worse," reported Hoyt, (15) who concluded by criticizing those individuals who "assumed" that because the man pictured "was missing a tooth, he was missing a brain." (16) Equally, he criticized those who assumed that the New York Times's editors "shared their prejudices." (17) The prejudice exists, however, and for those without either dental coverage or resources adequate to pay for dentistry, losing teeth and the prejudice that follows can be painful.

Most importantly, lack of dental care and its consequences can result in serious illness and even death. Many low-income people in the United States have no dental coverage and very little access to dental care. (18) Although Medicaid covers pediatric dentistry, (19) many children in low-income families may not be able to find a dentist who will treat them. (20)

1. Lacking Dental Coverage and Dental Care

   In the United States, scores of millions of people lack coverage for dental care and do not have the resources to pay privately for that care. (21) In 2012, 130 million people in the United States had no dental coverage. (22) Medicare provides very little coverage for dentistry, and depending on the state, Medicaid includes no benefits or only minimal benefits for non-pediatric patients. (23) For many people with some dental coverage, the cost-sharing requirements of most dental plans make it hard, if not impossible, to obtain comprehensive dental care even though they have some coverage. (24) The ACA, passed in 2010, (25) will leave about thirty million people in the United States without health coverage and many...