Annotation — From the September 2019 issue

Bite Marks

What a dental x-ray reveals about poverty

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1. When I was in third grade, a metal cap on one of my teeth cracked and became partially dislodged while I was in gym class. My family didn’t have a telephone, so the school couldn’t reach my mother, and I spent the rest of the day with the cap hanging from my mouth, dripping blood. Although the state-provided health insurance plan we had during my childhood included basic dental coverage, very few dentists accepted it, and because of overwhelming demand it was nearly impossible to get an appointment with those who did. When we were lucky enough to see a dentist, our policy often didn’t cover the full cost of whatever procedure we required. On that particular day, my mother couldn’t find anyone in town willing to take me on such short notice. Eventually, my uncle pulled out the cap himself—along with what was left of the tooth underneath.

2. For many years now, I’ve had to avoid eating apples. I’ve also had to avoid peanuts, celery, bagels, caramel, corn on the cob—anything crunchy or chewy. I stick with things like soup, mashed potatoes, and other items with the consis­tency of baby food. My teeth are damaged, broken, and in many cases missing, the result of spending most of my life with limited or no access to adequate dental care. I grew up very poor, on public assistance from the day I was born to the day I graduated from high school. Poverty—and the dental problems that tend to accompany it—has been passed down through my family for generations. My mother, for instance, had lost all of her teeth by the time she was twenty-one. She has worn the same set of dentures for sev­eral decades. One in three adults has no form of dental coverage at all. The problem is even worse in rural areas, where employers are less likely to provide coverage and dentists are scarce—according to the Pew Charitable Trusts, nearly 57 million people in the United States live in regions suffering from a lack of dentists.

3. Indigent patients who do find a dentist often receive suboptimal care. In 2012, I was uninsured and needed a root canal. I was living in Pennsylvania coal country, where dentists who accept uninsured or government-insured patients are hard to come by. I managed to enroll in a dental discount plan, and, miraculously, found a local dentist who accepted it. Despite hearing horror stories about this dentist from local residents—mostly concerning botched procedures that later had to be redone—I had no choice, so I went through with the root canal. The procedure was agonizing, but so was all the dental work I had previously undergone, and I figured the problem had been dealt with. A few years later, however, another dentist discovered that the root canal was perforated—in other words, something had breached the root canal system and impacted the surrounding tissue—and that pieces of a broken metal tool used in the procedure remained in my gum. The subsequent operation to excavate and remove those embedded pieces of metal was about as grueling as you can imagine.

4. The roots of one’s upper teeth sit just inches from the brain, meaning that infections of the jaw can have serious health consequences elsewhere in the body. In this area of my mouth, I’ve had several serious infections of the teeth and gums, two of which caused so much swelling that I was barely able to open my eyes. Both times, I went to the emergency room and was given antibiotics and anti-inflammatory drugs, which brought down the swelling but didn’t do anything to solve the underlying issues. Then, two years ago, I suffered a stroke. As I recovered, I started wondering whether my dental problems could have been a contributing factor. Numerous studies have shown that oral health problems can significantly increase the risk for diabetes, heart attacks, strokes, and other potentially life-threatening conditions. Nevertheless, four times as many Americans have health insurance as have dental insurance, and insurance companies (as well as medical professionals) continue to regard oral and bodily health as two separate realms.

5. In the most recent American Dental Association surveys, 29 percent of low-income adults reported that their dental issues have affected their ability to perform well during a job interview, and 23 percent said that they have limited their participation in social events out of embarrassment. I lost this tooth in 2015, when a previous, temporary repair finally failed, and the dentist told me I needed a permanent bridge, which would cost roughly $2,500. It took me more than a year to save the money, during which time I lived like a hermit. The large empty gap in the front of my mouth was impossible to miss, so when I did interact with someone face to face, I employed a tactic I’d mastered years earlier: exposing as few of my teeth as possible while speaking. (I could still occasionally catch someone trying to avoid staring.) I remembered how, as a child on school picture day, I watched the photographer coax other kids to smile broadly. When it was my turn, the photographer gave me a sad look and said, “That’s okay. You don’t have to smile.”

6. I still dream of getting dental implants—probably the only way I could ever have a nice smile—while knowing I will likely never be able to afford them. People like me have few options. Grassroots organizations have made admirable efforts in parts of the country that lack sufficient care, arranging “dental fairs” at which volunteer dental professionals provide basic services at no cost. These events can attract hundreds of people, many of whom wait in line for days in the hopes of snagging a coveted spot, but they can service only a tiny fraction of the people who desperately need treatment. Far more promising are proposals such as Medicare for All, as supported by Bernie Sanders and others, which promise to include dental care. But even if universal coverage is achieved, many of the most painful memories of a life without dental care will never leave me. I still recall having an infected tooth removed when I was eight years old. Our insurance didn’t cover anesthesia, so I felt every excruciating yank. I will relive that scene in my mind, along with many others, each time I enter a dentist’s office for the rest of my life.

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is a freelance writer and a communications fellow at Community Change. She’s currently working on a memoir about growing up in poverty.

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