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Aida Basnight stood on a wintry street corner in down- town Washington, D.C. She was dressed in a bright, hand-knit hat and scarf and a heavy coat. She was working to sell a newspaper produced by the city’s homeless. There was solemn beauty in her dark eyes, in her high cheekbones, in her smooth skin, but she was careful to smile with her mouth closed. Her missing teeth bore testimony to her life’s hardships. Her molars had been the first to go. She lost them to infection in her thirties when she was working as a secretary in Chicago. She woke up in terrible pain with a swollen face, and the molars were extracted. Amid other difficulties, other teeth went bad. When she was in her mid-fifties she lost a steady job working with computers. Then she fell behind on her rent and lost her home. She slept in a park for a while. “It’s really scary being out there in the street and being homeless,” she said. She eventually found help through a women’s supportive hous- ing program. But Basnight, who always prided herself on her



work ethic and skills, had been unable to find a lasting job, in spite of dozens of applications. “Nobody’s gonna hire you with that bunch of gaps in your teeth,” her elderly mother warned her. Basnight feared her mother was right. “I always feel self-conscious about them in the interviews. I can’t smile because I’ve got no teeth.” She said she kept hoping for something better. But in the mean- time she stood in the cold with her newspapers, facing the well- dressed commuters. They hurried past her, toward the rush-hour trains. Shame is common among the millions of Americans who lack dental care. More than one out of three low-income adults avoids smiling, according to a Harris poll conducted on behalf of the American Dental Association in 2015. 1 America’s social welfare programs continually emphasize the importance of self-advancement, but, lacking dental care, the poor and working poor find it especially difficult to improve their lives. In the competition for service jobs, working at restaurants or retail counters or reception desks, they are often passed over. “Unless they look good, you don’t want to hire them,” observed dentist Judith Allen, who spends her days working with poor and unin- sured patients in a city health department clinic in Cincinnati, Ohio. When patients get to Allen they are often in pain. Their lips and even eyes may be swollen by oral infections. Their teeth are diseased and ruined. Many have gone for so long without dental care, extraction is the only option. “We remove what we can’t save. And then we go in and we restore what we have left.” Without her help their teeth will continue to mark them as broken people. And across the country, millions go without help. There is a shortage of places like the Cincinnati clinic where Allen works. Stigma is an ancient word: a brand or mark of subjection or dis- grace. In the way that they disfigure the face, bad teeth deperson- alize 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 that they are not held accountable for many other health conditions. There has been a scarcity of sociological research on this sub- ject, but a team of British researchers looked at the phenomenon. “Although tooth decay and gum disease involve diseased tissue, those experiencing these physical states are not generally regarded as being ill,” observed the author of their study. “In part, this may be because oral health problems are seen as a failure of individual responsibility rather than misfortune.” In the study, participants, who lost their teeth through disease and trauma, discussed their feelings. “It’s almost as if I feel as if I’ve failed because I’ve got dentures,” said one woman. “I don’t think people feel the same way about knee replacements, do they?” responded the researcher. “No, that’s right,” the woman said. 2 For reasons including poverty, isolation, and the lack of private insurance and providers available to treat the poor, roughly one- third of the people living in America face significant barriers to obtaining dental care. Medicaid, the federal-state health program that now covers more than 72 million poor Americans, treats adult dental benefits as optional. It is up to states to decide whether to offer them. In hard times, coverage of even the most basic dental procedures often ends up on state chopping blocks. The young and the old also suffer. More than 35 million poor children are entitled by federal law to dental benefits under Med- icaid, but more than half go without care. Fewer than half the nation’s roughly one hundred fifty thousand working dentists participate in the program. Only a tiny fraction work in federally funded safety net clinics. Approximately 49 million Americans live in communities that are federally designated as dental professional shortage areas. Medicare, the federal health care program that cur- rently provides benefits to more than 55 million aged and disabled people, has never included coverage for routine dental care. In the seventeenth century, French philosopher René Des- cartes introduced a theory that changed the world. He uncoupled the indivisible spiritual human mind from the divisible working



machinery of the human anatomy, thus liberating scientific inquiry from religious dogma. He also, it could be said, removed the head from the body. In the wake of Descartes, increasingly specialized healers began laying claim to parts of the body for study and treatment. For cen- turies, along with shaving and tonsuring, leeching and cupping, barber surgeons had counted tooth extractions among the deep- ly personal services they performed. But the teeth were worthy of science too, Pierre Fauchard, the eminent eighteenth-century surgeon-dentist, insisted. He advanced the idea that dentistry was a unique and important branch of surgery. Cartesian dualism served its purpose, opening new possibili- ties for physiological exploration. Yet at the same time, medical research became more reductive and mechanistic, less personal and less holistic. Some have suggested that the formative influence of Descartes stubbornly persists in the ways the modern health care system fails to integrate care. 3 Perhaps, too, it lingers in the gulf between the head and the body, the understanding of oral health and overall health. It has been said that this gulf must be bridged to bring a more complete kind of health to America. “Just as we now understand that nature and nurture are inextricably linked, and mind and body are both expressions of our human biology, so, too, we must recognize that oral health and general health are insepa- rable,” declared the then U.S. surgeon general David Satcher in his landmark report, Oral Health in America, published in 2000. 4 In the ways they connect us to the world, in the ways they allow us to survive and to express ourselves, the teeth and other tissues of the mouth and face “represent the very essence of our humanity,” noted Satcher. Systemic health and disease are mirrored in the components of our saliva. Our first permanent molars bear the time stamp of our births. Pain, loss of function, serious illness, and even death result from untreated oral conditions and offer harrowing reminders that the mouth is part of the body and that oral health is essential to overall health. Yet the separate, carefully guarded, largely private



system that provides dental care in America can be enormously difficult to reach for those without mobility or money or adequate dental benefits. In his report, Satcher warned of a “silent epidemic” of oral disease. This book began in 2007, at the heart of that epidemic, at the bedside of a Maryland schoolboy who was dying of complica- tions from an untreated dental infection. The story of the death of twelve-year-old Deamonte Driver, which appeared in the Washing- ton Post, helped inspire reforms in Maryland and in Medicaid dental systems nationwide. But America’s silent epidemic of oral disease persists. This book provides a look into the insular world of dental care in America. It examines the enduring tension between the need of all Americans for dental services and the lack of services available to millions of us under the current system. Beginning with the world’s first dental college that opened in Baltimore in 1840, not far from where Deamonte died, this book explores dentistry’s evolution in isolation from the rest of the nation’s health care system. Its narrative seeks to explain why obtaining dental services may require a journey that some patients never manage to make. My reporting took me from Florida to Alaska, and in my travels, patients, providers, policy makers, researchers, and public health leaders spoke of their own experiences, their own journeys. Their stories were by turns agonizing, challenging, confounding, and hopeful. They described the raw physical suffering of disease and exquisite moments of understanding. They explained the intri- cacies of enormous government programs, the hidden worlds of microbiology, the vagaries of diagnostic coding. Some proudly defended the current system of providing dental care in America. Some described a vision for a transformed oral health care system— one that incentivizes disease prevention over drilling, that uses new kinds of teams to reach the millions currently not receiving oral health care, a system where dentists spend less time extracting and



more time healing and where patients break the cycle of disease and pain and loss. Some spoke of bridging the gap between oral health and overall health. Some spoke of ending the silent epidemic.