Decaying Teeth, Decaying System

Rachael Lee Rubin

The Story of Beauty, Inequality, and the Struggle for Oral Health in America
By Mary Otto
New York: The New Press, 2017, paperback edition 2019, 304 pages,
$20 paperback.

WHEN I FIRST learned about Mary Otto’s book, I was both immediately drawn in and internally shaken. I am from Baltimore — where, as it turns out, much of the book is set — and I’ve objected for years to the way poor people, especially Appalachians (many of whom ended up in Baltimore), are frequently mocked for their teeth: in Halloween costumes, in movies, in cartoons.

I was particularly offended recently by a book someone gave me that satirized wealthy right-wing politicians as monsters — because one was represented as a “hillbilly” with bad teeth. Indeed, pretty much every Halloween I end up seeing someone wearing a costume with rotting and missing teeth, and pretty much every Halloween, I want to approach and say, “Oh, it’s so hilarious that people don’t have equal access to dental care!”

In fact, my Baltimore construction-worker brother struggled — and failed — to obtain dental care, which he needed for multiple reasons that are taken up by Mary Otto, a Washington Post journalist who is the oral health topic leader for the Association of Health Care Journalists, and for years has steadily linked health care and class.

Otto’s book is admirably successful at confronting and presenting the class-based health care inequality that is manifested through teeth. Her authorial strategies are multiple and deft; she combines particular examples in a sometimes-tragic, pull-no-punches way with careful historical research and contextualization. (Her effective use of oral history and class-based analysis make it not at all surprising that the book received a grant from a Studs Terkel fund.)

In addition to oral history and broader historical contextualization, Otto addresses dental care from an economic perspective, a philosophical perspective, a business perspective, a geographic perspective, and more. She addresses dental care as a health issue, but also as something that functions as a standard of beauty — in short, convincingly demonstrating that teeth are overly commodified, and that this commodification has far-reaching influence.

In the book’s Preface, Otto notes that bad teeth “confer the stigma of economic and even moral failure. People are held personally accountable for the state of their teeth in ways that they are not held accountable for many other health conditions.” (vi-vii)

This is startlingly true despite the fact that dental insurance is separate from health insurance (Maryland, Otto notes, is one of a small group of states with no adult dental benefits under Medicare) and therefore for many people taking care of teeth is challenging. It is startlingly true despite the fact — as Otto points out multiple times, with convincing historical evidence — that many dental organizations and individual dentists resist preventative care and only perform treatment after dental problems emerge.

It is quite compelling that Otto’s focus on the significance of “the integration of medical and dental records” (86) is still rare and striking. This is a second way I found Otto’s book compelling on a personal level: she discusses how medical and dental treatment are still separated, which I confronted due to the fact that cancer treatment can have a damaging effect on teeth — as do other serious medical conditions, as Otto points out.

Health, Beauty, Overtreatment

The book approaches dentistry from two significant angles. First and foremost is health: in her usual combination of gripping personal stories and useful historical analysis, for instance, she writes about a disabled miner who lost his insurance when he had to leave the mine and how he suffered as a result.

She also explores the significance of dental care (and, it must be noted, economic class) to social standards of beauty — and again, adroitly connects these standards to class though personal stories, quoting for instance a waitress who worries that she will lose her job if she has “bad teeth.” (34)

Meanwhile, Otto points to an editorial by a prominent Utah dentist that calls out certain cosmetic “oral overtreatment” as “nothing less than overt dishonesty.” (25-26)

A particularly good example of Otto’s use of a case study to make institutional claims is when she takes up the fact that — as she quotes dentist and instructor Martin Goldstein saying at a gathering of dentists — “weddings are a terrific way to incentivize people to get their smiles done.” (12)

Otto also explores how an extreme instance of what she considers a shady “selling” of dentistry is the number of people with body dysmorphic disorder who are exploited by cosmetic dentists. In addition to exploring industrial habits and policies, she tracks the story of a beauty pageant contestant who worried deeply about her (healthy) teeth.

The book is usefully divided into three sections. The first is called “Bad Teeth,” where the author lays out how “bad teeth” are defined and how they influence health and beauty culture. In the second section, “The Dental Art,” she approaches teeth through health care and consumerism.

The final section is called “A Sentinel Event,” and here she bundles a great deal of analysis on the tragic story of an under-served 12-year-old boy, Deamonte Driver, who died when an infection in his teeth — which his family could not get treated — spread to his brain and killed him.

This section presents one of the most effective aspects of the book. Otto is able to hang a great deal of social commentary on individual experiences — particularly, but not only, class-based commentary. For instance, she points out that nearly half of young children (3-5 years) in Special Start have untreated tooth decay.

As Deamonte Driver’s story indicates, one of Otto’s most effective approaches overall is her use of particular stories to draw in readers and convey the cruelty of our country’s approach. (In addition, Deamonte’s story spread widely and was used as a carrier of commentary in many places, including on the Congressional floor.)

But then she gracefully pivots, using those stories as a lens on systemic injustice. In other words, she is able to turn sympathy and pain into a national story without turning her work into a series of numbers that are in their own way disturbing, but not quite the gut punch of children dying — or being orphaned after their parents die.

But as effectively as Otto uses individual stories, one of the most admirable aspects of the book is its persuasive systemic commentary. A powerful example is how, in a chapter called “The System,” Otto directly confronts the many ways that dental organizations have pushed back against efforts to change our dental system and make it accessible, preventative, and not only cosmetic.

For instance, when Franklin Delano Roosevelt (and others) called for national health insurance, a dental journal referred to it as a “monster of exploitation of the dental profession.” (143-144) Similarly, the American Dental Association stood up against a study showing a worthwhile service provided by dental therapists in other countries, writing that “throwing more ‘treaters’ into the mix amounts to digging a hole in an ocean of disease.” (169)

The ADA has long used a range of strategies to push back against accessible care, including what Otto refers to as “a rich war chest” for making campaign contributions and hiring lobbyists and legislative experts in Washington, DC. (170) Otto also notes that the ADA has resisted training so that there would be enough dentists to treat everyone — despite the fact that they had also pushed against national insurance by saying that there were not enough dentists.

Race, Class and Neglect

While Otto focuses usefully on how many reasons dentists and dental organizations give for not accepting Medicaid, she also pays attention to people who have tried to help bring access to dental care.

She writes about an occasion in Lee County, Virginia, when temporary tents were set up to give dental service to people without other access. Before dawn, Otto notes, more than 400 people were already there waiting, many of them experiencing a great deal of pain due to untreated dental conditions. (33)

Similarly, she writes about a mobile dental clinic at an elementary school (and movingly describes the reactions of some children who had never been to a dentist before). Otto is careful to note that lack of access to dental care is not just about ability to pay for the care. For instance, many people can’t get time off work, and don’t always have adequate transportation or phones.

Of course, race and class in the United States have always been mutually shaping  — but Otto effectively takes up the racialized nature of dental care in the United States, writing, “In America, access to health care has always been divided along racial lines.” (181)

She takes this up in two ways: segregation being maintained longer than many readers might think, and the ways in which American racial history has left a physical mess. Certain diseases, for instance, are far more widespread in “minority children.” Some African Americans, she quotes an African American doctor as saying, who were kids during legal segregation, have seriously “paid the price for not getting oral health care as a child.” (184)

Meanwhile, from the other end, Black dentists had to form their own professional organization in 1913. Otto’s chapter on race takes up both patients and dentists. While she explores reasons for insufficient dental care, she remains a little bit optimistic about the future, at least in some states. But she notes that “dental care has remained far scarcer for poor children,” and that adult dental care visits have “have been in a state of decline.” (124)

With her usual adept and strategic application of an individual story, she writes about a blacklisted dentist — who worked hard to bring good dental care to poor Californians, which included many African Americans — who was called before the House Committee on UnAmerican Activities. (Happily, he pushed back hard.)

Although she does not state the concrete specifics of his political alignment, this man’s story does indicate that capitalism is against health care for all, for he is seen as a traitor for wanting to expand access to dental care.

Another significant approach of the book is the author’s confronting of the relationship of drug abuse to dental health. Once again, she is not blaming of addicts — instead, she movingly confronts a social problem that has been getting more attention in the last few years because use of certain dangerous drugs has shifted to wealthier users.

She also flips this assumption to note that not only do certain drugs have a bad effect on teeth, but that suffering from dental pain frequently leads to poor Americans turning to both “legal and illegal drugs, folk remedies, and in some cases, pulling out their own teeth.” (38)

In addition to drug abuse, lack of access to dental care causes children with poor oral health to be nearly three times as likely to miss school, as a result of dental pain.

It is easy to think of the effects of missing school as building up and becoming more and more dangerous  — a kind of avalanche — and while the author is not direct about this, it reveals that lack of access to dental care is not only due to class position, but also works to keep poor people trapped in their class position.

Finally, Otto’s historicizing is ambitious and successful. She introduces significant figures and their discoveries and assertions before the Civil War, and notes that cultural depictions of teeth go way back as well. For instance, she quotes a short story about a young woman selling her good teeth in 1833 to “ease her father’s dying days” and points out that graverobbers frequently stole teeth from buried bodies. (99, 102)

The one shortcoming of the book, in my opinion, is that Otto writes as though lack of access to dental care is largely ignored or unknown (although one-third of Americans have insufficient access), when the fact is that it is also frequently mocked — culturally as well as personally.

In fact, how teeth are mocked is quite telling as well. In my office, for instance, I have two offensive versions of costume teeth from the same company: what started as “hillbilly” teeth is now packaged as “junkie” teeth.

Perhaps the most summary and telling line in this incredibly engaging book is “The rate of dental suffering is a grim kind of economic indicator.” (37) I personally think it is, indeed, an economic indicator — one that is read by many and rarely evokes enough sympathy among well-off Americans.

Overall, this is a deeply ambitious, engrossing and significant book — successful in terms of both content and rhetorical strategies. Otto’s writing is, at times, impressively efficient. Indeed, there are multiple phrases that, when I read them, made me think, “That would have made a good title!” But perhaps the most summary line in the book is a reference to insufficient access to dental care as “America’s silent epi­demic.” (ix)

March-April 2020, ATC 205