Book by Mary Otto. The New Press: New York, 2017. https://thenewpress.com/books/teeth
This book represents a seminal work on the social and economic implications of oral health in the U.S. Mary Otto is a former journalist for The Washington Post who first reported on and amplified the story of Deamonte Driver. In 2007, Driver, a twelve-year-old living in Maryland, unnecessarily lost his life due to a cavity that turned into an abscess and eventually went into his brain leading to multiple surgeries. A simple tooth extraction, that could have cost around $80 to perform and likely would have taken away the pain, wound up costing more than $250,000 and the life of a child all because his mother couldn’t find a dentist who would accept their Medicaid insurance. Otto outlines systemic barriers to accessing care and how oral health policy changed after Driver’s death with a focus on Maryland, but also throughout the U.S.
The book also explores “dentistry’s evolution in isolation from the rest of the nation’s health care system,” and how this impacts the delivery of oral health care. This includes an overview of the history of dentistry, examining efforts to bring these two fields back together, and recognizing the importance of oral health for overall health. She also discusses alternative ways of delivering care, such as elevating the right for dental hygienists to deliver preventative care in settings outside of the dental office, like schools and nursing homes, and the emergence of dental therapists.
Otto shares stories she collected from across the U.S. from different actors in the oral health care system including patients, health care providers, policy makers, public health leaders, and dental school faculty. Several chapters can stand on their own as essays, but at the same time Deamonte Driver’s story and its impact are woven throughout the book. The following are key quotes organized under different themes, which could be used to spark discussion.
Health Professional Shortage Areas/HPSA & Dental Auxiliaries
“People may need care, but if they have no public or private insurance or money to pay for care, if they do not understand the importance of oral health, if they defer even routine preventive dental services or do not value them, they do not drive demand for care. It is a problem an additional supply of providers will not solve, dental leaders contend” (p. 125).
“But many of the first dental hygienists spent much of their time in the field. They worked among schoolchildren. They brought dental services to encamped soldiers. Over the years, at moments when urgency of the unmet need for dental care has been highlighted in some dramatic way, during the Progressive Era, at the end of World War II, throughout the deliberations and establishment of the enormous federal health program of the 1960s, there have been calls for the expanded use of trained dental auxiliaries to deliver economical care to people whom the system has not reached—to elders in nursing homes, poor children, and adults. It happened again, in recent years, with the publication of the surgeon general’s Oral Health in America report and with the passage of the Patient Protection and Affordable Care Act during the Obama administration. It is happening now” (p. 134).
“Some dental hygienists continue to challenge their isolation and push for change. Their fight can mean confronting the powerful professionals they work for and depend upon for their livelihood. The advances they have made have been, in some cases, very hard-won” (p. 135).
“The leaders of organized dentistry acknowledged the shortage of dentists when they resisted federal efforts to expand care during the postwar years. Yet they just as adamantly opposed plans to train additional dental workers to meet those needs” (p. 145).
“ADA leaders themselves have acknowledged the lack of care in many places, the costs of emergency room visits, the plight of elders who cannot get to the dentist. They insist that the problems can be solved. They ask for additional federal and state spending on dental services. . . They contend that the shortcomings of the current system can be traced back to the failure of the nation to place a priority upon oral health” (p. 169).
“In recent years, Alaska Native and American Indian communities have gained increasing power to shape and pay for their own health initiatives, based upon their own perception of need, to take back their own health, their own teeth” (p. 176).
“While affluent county residents who commuted to government and private sector jobs enjoyed insurance coverage and a choice of medical and dental providers, poor and working poor families grew increasingly isolated and faced dwindling access to care” (p. 207).
“Dentists should be doing more than drilling teeth. . . They needed to work with nature, to stop seeing like surgeons and to start seeing like healers. To cross boundaries, to speak new languages. They needed to work together, and work with hygienists, with pediatricians, with nurses, with dieticians, with parents, with the children themselves. But first they needed to get to the children at greatest risk, the children who did not even come into dental offices, the poorest, the most vulnerable” (p. 229).
Pain
“The loss of a tooth to disease may prefigure other losses in life quality. . . An extraction is emblematic of defeat. The extracted tooth will not grow back. But when routine care is long deferred, when more complex procedures are out of reach or not an option, the extractions serve the urgent need of relieving infection and relieving pain” (p. 31).
“Toothaches are destroyers of sleep. They make eating painful, working and parenting overwhelming. It is the poor who are most likely to pray to heaven for relief. They turn to drugs, both legal and illegal, and folk remedies. In desperation, some even pull out their own teeth” (pp. 37-8).
“The teeth are made of stern stuff. They can withstand floods, fires, even centuries in the grave. But the teeth are no match for the slow-motion catastrophe that is a life of poverty: its burdens distractions, disease, privations, low expectations, transience, the addictive antidotes that offer temporary relief at usurious rates” (p. 46).
“Deamonte Driver did not complain about his teeth, his mother said. Maybe he felt that it was futile to complain. Maybe he just took the pain for granted” (p. 203).
“The teeth are tools we have been given to survive. We use them for eating, for speaking, even for defending ourselves. Their mineral beauty is a kind of gift. There is the uncanny way they are part of us. The unsettling way they leave us…During our lives, their enamel is demineralized and remineralized in regular cycles. They are washed and cleaned by saliva. When we brush, we disrupt plaque that lives on them. Fluoride can help strengthen them. What we eat and drink can make them more vulnerable to decay. So can neglect. So can the lack of professional care. Infection takes hold. Beyond a certain point the teeth cannot be repaired” (p. 254).
Policy
“Across the United States, in public and private programs, dental care was provided separately from other kinds of health care. It was paid for separately. People had a harder time finding it. Dentists and physicians were educated separately. They seldom communicated. Patient records were kept separately. Medicaid children were very likely to get routine immunizations, but they were far less likely to get routine dental care. In intimate personal ways and in vast public ways, dental care continued to be left out” (p. 224).
“Others died of dental infections before Deamonte Driver, and others have died since. But it was Deamonte Driver, who died just a few miles from the U.S. Capitol, who was spoken about on Capitol Hill. His story became part of the battle over the reauthorization of SCHIP and the guarantee of dental benefits for seven million children from working poor families. And it was the boy’s image, captured in a school portrait, his head cocked questioningly, his white shirt buttoned to the collar, his searching eyes, that gazed down on the lawmakers from screens in the hearing rooms of Congress” (p. 225).
Race/Racism and Oral Health Care
“The complexities of poverty, with its social, emotional, and economic burdens, put millions of Americans, including a disproportionate number of minorities, at additional risk of decay” (p. 184).
“Years had passed since the signing of the Civil Rights Act. The walls between the black and white waiting rooms no longer appeared in the designs. Still, racial disparities in care, and in oral health, persisted…” (p. 193).
Shame
“Shame is common among the millions of Americans who lack dental care” (p. vi)
“In the way that they disfigure the face, bad teeth depersonalize the sufferer. They confer the stigma of economic and even moral failure. People are held personally accountable for the state of their teeth in ways they are not held accountable for many other health conditions” (p. vii)