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

• Author: Dolgin, Janet L.
• Position: I. Dental Status and Poverty C. Dental Coverage in the United States 6. Comprehensive Dental Reform Act of 2012 through Conclusion, with footnotes, p. 1421-1446

6. Comprehensive Dental Reform Act of 2012

The Comprehensive Dental Reform Act, (199) introduced in the 112th Congress by Senator Sanders (I-Vt.) in the Senate and Representative Elijah Cummings (D-Md.) in the House, proposes doing what the ACA does not do: ensuring comprehensive dental coverage to a wide group of people, including the elderly and those with low incomes. (200) Title I of the bill details the need for dental coverage: 47 million people have difficulty accessing dental care; 17 million low-income children do not get coverage for dental care; and the Medicaid program is not required to provide dental coverage for adults. (201) The bill described those most likely not to get adequate dental care to include "individuals with low incomes, racial and ethnic minorities, pregnant women, older adults, individuals with special needs, and individuals living in rural communities." (202)

The bill, if passed, would provide dental care for Medicare recipients as well as for adults receiving care through Medicaid, (203) and for those covered by the Veterans Administration. (204) In addition, the bill would create mobile units providing dental care in places where access to dental providers is thin, and it would help fund the training of dental care professionals, including "dental therapists." (206) It would also provide funding to educate emergency room physicians in emergency dental care. (206) The bill provides for funding by imposing a tax of 0.025% on securities transactions. (207) The bill would significantly minimize disparities in dental health in the United States. The bill provides a good model for what needs to be done. However, it has virtually no chance of becoming law--at least not at this time--as it died in committee. (208)

2. TEETH EVEN THE "TOOTH FAIRY" MIGHT ENVY

   For people with financial resources, dental care in the United States provides not only for patients' health needs, but also, often, for their aesthetic yearnings. The latter is significant in promoting a culture where people may assess each other's teeth to determine socioeconomic status. Such assessments cross class boundaries. (209) A person's dental condition can signal poverty and low socioeconomic status. For those without teeth or with visibly mangled teeth, social and economic opportunities can be significantly limited. (210) At the other end of the nation's socioeconomic hierarchy, however, teeth can signal wealth. (211) For middle- and upper-class Americans, contemporary dentistry has diverged from its counterpart of a half century ago. (212) The fluoridation of water and routine dental care for middle- and upper-class children have significantly limited the types of problems that once brought many Americans to dentists. But dentistry--once considered a has-been profession--has flourished as Americans with means have become hooked by cosmetic dentistry. (213)

   "Americans," reported June Thomas, have become "obsessed with teeth" (214)--a reference not to dental health, but rather to the presumptive importance of dental aesthetics. "A beaming smile," Thomas adds, "is the ultimate testament to American prosperity and self-confidence." (215) The dental profession itself has supported the presumption that one's teeth reflect one's values. This is evident, for instance, in the profession's support for the proposition that dental health is a product of individual responsibility and choice. (216) The condition of a person's teeth allows others to place that person on the nation's socioeconomic hierarchy (217) and to assess his or her moral grit. (218) In short, teeth have become a barometer of class status.

   Unsurprisingly, as middle- and upper-class Americans have focused more and more on the aesthetics of teeth, they have become less satisfied with the appearance of their teeth. At the start of the 1990s, 57% of people in the United States were "very satisfied" with the way their teeth looked. (219) By the end of the decade, only 46% of the population was similarly satisfied with the appearance of their teeth. (220) The business of reshaping and whitening teeth--cosmetic dentistry--has flourished.

   David Plotz, a journalist who writes for Slate, asked scores of people at the end of the twentieth century what bothered them about dentistry. (221) Almost none complained "about cosmetic dentistry.... They like their whiter, straighter teeth." (222) Rather, many "griped about the medically advisable treatments that their dentists prescribed." (223) Plotz quotes a St. Louis dentist, Dr. William Hartel: "'Dentists are aware of providing what patients want.' ... 'I had a woman come in with a terrible toothache. She needed a root canal, but she did not want it. But she did want her teeth bleached, and she paid cash for it.'" (224)

   Similarly, historian Alyssa Picard attributes the stunning growth of cosmetic dentistry to both the value of "good" teeth as a mark of status and to the push of the dental establishment, which feared that the successes of twentieth century dentistry (e.g., fluoride) would result in falling incomes for dentists. (225) Cosmetic procedures include whitening, bonding, bridges, implants, contouring, and reshaping, among others. (226)

   [T]he most powerful and intentional force militating in the direction of the new norms of dental appearance was the activism of American dentists themselves. In the late twentieth and early twenty-first centuries, dentists fearing real and imagined threats to their incomes and professional autonomy sought to inculcate Americans with an aspirational vision of dental health and appearance that depended on extensive individual investment of time and money into dental treatment, and they were largely successful in doing so. (227) This success illustrates a more widespread pattern by which industry creates a need in order to sell a product or service. (228) And as Picard reports, in the second half of the twentieth century, dentists encouraged their current and potential patients to consider forms of care that were cosmetic in character. (229) They could not have successfully motivated people to spend thousands of dollars to alter the color, placement, or shape of their teeth were the project not also of service to a deeper set of goals. For Americans, expensive dental care, resulting in teeth indicative of their owner's wealth, became an envied mark of class status in a nation deeply concerned with class status and yet at the same time, uncertain about how to assess it. (230)

   The process through which dentistry for middle- and upper-class Americans has increasingly included cosmetic care has participated in a larger process through which, at once, cosmetic care has become medicalized and dental care has become de-medicalized. Anthropologist Alexander Edmunds noted a similar process affecting the provision of various forms of plastic surgery in Brazil:

   [B]iomedicine can act as a form of politics by other means.... [F]rom its unique position on the borders of proper medicine, plastica [cosmetic surgery] not only medicalizes the body but also in a sense "de-medicalizes" itself. Of course, cosmetic surgery is a medical specialty.... But as plastica becomes infused with the frustrated desires of patients, the competitive logic of markets... and the medical and consumer fetishisms of popular culture, the question arises as to whether it is "medicine" in any recognizable form.... (231) In Brazil, cosmetic surgery is offered in public hospitals. (232) In contrast, in the United States, the cost of good teeth--the sort of teeth that mark high class status--can be stunning. Some dentists suggest that remolding teeth offers an alternative to face-lifts and Botox. (233) Remolding teeth can cost between $5,000 and $80,000 and is generally not covered by insurance. (234) Even procedures requiring no structural work, such as teeth whitening, can come with hefty price tags. (235) Dentists charge $500 to $1,000 or more in metropolitan areas for whitening done in the office. (236) Even "at-home" whitening products can cost several hundred dollars. (237) And for cases of serious discoloration, dentists may recommend porcelain veneers, which cost up to $2,000 per tooth. (238) A variety of factors keep the price of cosmetic dental care high.

   Among other things, dentists have been able to resist non-dentists' providing such care. North Carolina State Board of Dental Examiners v. FTC (239) involved responses to North Carolina's dental board's antagonism to permitting non-dentists to offer teeth-whitening treatments. (240) More specifically, a FTC administrative law judge found the state's dental board engaged in anticompetitive acts by attempting to prohibit teeth-whitening services in centers operated

   by non-dentists, (241) which would cost less than the services provided by dentists. (242)

   In sum, impressive advances in preventive dental health care in the last decades of the twentieth century significantly reduced the number of dental patients with routine problems such as cavities to be filled. As June Thomas put it, "Dental health has improved enormously in the post-fluoride era, but Americans' satisfaction with the way their teeth look has declined." (243) That dissatisfaction provides both business for dentists and an increasingly great disparity between the teeth of the middle--or upper-classes and those without the means to pay for cosmetic dentistry.

3. ETHNICITY (244) AND GEOGRAPHY (URBAN V. RURAL):

   DISPARITIES IN DENTAL CARE AND DENTAL HEALTH This Part examines differences between urban and rural environments in the United States as well as the role of race and ethnicity in determining dental condition and in shaping the significance of dental condition in identifying class status. By way of comparison, this Part also examines British, as compared with American, understandings of the significance of dental aesthetics. Differences in geography (within the United States and globally) and in...