Preface

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 citys 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 lifes 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 wentbad.
When she was in her mid-fi fties 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. Its really scary being out
there in the street and being homeless, she said.
She eventually found help through a womens supportive hous-
ing program. But Basnight, who always prided herself on her
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work ethic and skills, had been unable to find a lasting job, in
spite of dozens of applications. Nobodys 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 cant smile because Ive 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
Americas 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 dont 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 cant 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
 Preface vii

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. Its almost as if I feel as if
Ive failed because Ive got dentures, said one woman. I dont
think people feel the same way about knee replacements, do they?
responded the researcher. No, thats 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 72million 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 35million poor
children are entitled by federal law to dental benefits under Med-
icaid, but more than half go without care. Fewer than half the
nations roughly one hundred fifty thousand working dentists
participate in the program. Only a tiny fraction work in federally
funded safety net clinics. Approximately 49million 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 55million aged and disabled
people, has never included coverage for routine dental care.
In the seventeenth century, French philosopher Ren Des-
cartes introduced a theory that changed the world. He uncoupled
the indivisible spiritual human mind from the divisible working
v iii Preface

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 2000.4In
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
 Preface ix

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 Americas 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 worlds first dental college that opened
in Baltimore in 1840, not far from where Deamonte died, this
book explores dentistrys evolution in isolation from the rest of
the nations health care system. Its narrative seeks to explain why
obtaining dental services may require a journey that some patients
never manage tomake.
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
x Preface

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.