Wide Angle: Episode 26 – Teeth: Windows into Individual as well as Societal Health



please they help us eat enable us to formulate words and communicate they can even be weapons if need be and if we look closely enough they have much to teach us about our society ahead on wide-angle most of us know that the growth rings of trees reveal volumes to a knowledgeable observer including much beyond a tree's age droughts fire pest damage they're all in there to be read like a book turns out our teeth serve much the same function for we humans providing insights into not only our individual health but perhaps our societies as well joining me today to discuss teeth and dental care in the United States is Mary Otto a journalist who began writing about oral health at the Washington Post where she worked for eight years covering social issues including health care and poverty she is also the author of the new book teeth the story of Beauty inequality and the struggle for oral health in America welcome to wide angle Mary it's wonderful to be here thanks so much for inviting me pleasure – pleasure to have you dental care has become something of a mission to you yeah since 2007 and as is frequently the case with missions you're started with a tragic even maddening event it strikes me that that starting point is probably the right starting point for us as well so if you could tell us a little bit about what happened with the amante driver well diamonte driver was a 12 year old school boy he was a Maryland boy and I was working at the Washington Post as a reporter as you said and about ten years ago this very to this day that I was standing by his hospital bed and it turned out he was dying of the complications of run treated tooth decay his mom had actually been seeking a dentist for his brother when diamonte came home from school with a headache and his grandmother took him to a hospital and he got a prescription for a medicine for pain and for infection and they said he had a dental abscess but he went back to school and he just got worse he ended up being rushed to the hospital with meningitis doctors told his mother that the bacteria from his dental infection had spread to his brain and he was in the hospital for about six weeks had two brain surgeries care cost about two hundred and fifty thousand dollars but it didn't save him from this routine preventable gentle infliction so he died and I was just left wondering what happened here you know what is going on here and I found out his story was much larger than that tragedy of his death right and and I suppose that even more tragic news to this is as you found in your research is that many Americans could have an experience similar to that of diamantes yeah the number I think that you cite in the book is over a hundred ten million Americans who do not have dental coverage and I think the that's shorthand for a hundred ten million Americans who don't get dental care because they most likely if they don't have dental coverage can't afford what is what tends to be expensive care yes um yeah but but but truthfully I'm wondering to myself where is where is the safety net what about Medicaid what about Medicare the Affordable Care Act certainly there's something to catch I mean this is a third of the population of the United States what where are those where are those safety nets well if you make really good points here I the amante was actually a Medicaid child and over 30 million children in this country are covered by Medicaid they are entitled to dental coverage ental coverage under that program for the poor Americans it's a state federal program yet fewer than half actually receive routine care and this is a shortage of dentists is especially in poor areas there's a shortage of dentists to participate in Medicaid rural places urban places there's their barriers even though they have the actual benefit you know they don't always get care the situation is even harder for poor adults who are covered by Medicaid they're not entitled to dental benefits under the Medicaid program it's less optional two states whether they're not they provide down benefits for poor adults and since this these benefits are optional they're often cut in times of budgetary difficulty for the states or they tend to disappear right when people need them the most the other problem is Medicare which covers over 50 million retired and disabled Americans has never included routine dental benefit so many of those millions of dentally uninsured people you mentioned are elderly people you know who who look you know when they retired their dental benefits expired and they went on to Medicare and don't have dental deficits anymore so so yeah it's a difficult problem in terms of the safety net you asked about the Affordable Care Act didn't fully address this issue either over history dental benefits have just kind of been left out of a health care conversation as well so it's still a very very serious problem yeah well it's interesting you say that because you you certainly note in teeth that the development of dentistry was was quite distinct from from its founding in around 1840 from the development of the wider medicine yeah and that sort of feeds into why it is that we today look at teeth as something completely separate from the rest of our health and body yeah can you explain that the development of that history a little bit that's a really interesting story and as I went on with my rhetoric I realized it's all unfolded within a short distance of where diamante lived and died it was in Baltimore Maryland and it's kind of the creation story of our separate American dental profession and as you said it happened in 1840 a couple of kind of self trained dentists who were very serious about science and and understanding their work decided that dentistry which up until that point had been cracked is kind of like a tray from from the days of the barber surgeon kind of tsk ills were kind of passed down from one provider to to the next highest considered manual skills uh anyone who called himself a dentist was one you know you pick up the basic skills or teach them to yourself barbers blacksmiths Paul Revere actually did dentures along with making silverware and other things in his jewelry shop so so anyway they wanted to bring more formality and a professional perspective to dentistry so these two dentists Chapin Harrison and Horace Hayden went to the physicians at what was then a very prestigious installers medical school at the University of Maryland and they proposed that they add a course of Dentistry to the medical teaching at the school and as the story goes these the physician said the subject of Dentistry was of no interest to the group so these two founders went off and started their own independent dental college it was the first dental college in the world and this event is known in dental has as a historic rebuff and it's been used to explain and even kind of defend the separate nature of Dentistry in this country you speak of a dividing line between dentistry and the larger practice of medicine more generally you speak in the book to a number of other dividing lines as well yeah yeah in dental care both both in its practice as well as in how it's delivered to patients between males and females between wealthy and poor between white communities and communities of color could you could you fill in that picture a little bit about those dividing lines in those various communities yeah you asked about some really important divisions and of course affluent people are far more likely to get care to dance then poorer people from some of the reasons we already talked about there's a big racial divide and it is honey tooth decay just looking at it as a from a population standard it's the most prevalent chronic disease of American children and adults but minority children are far more likely to suffer than white children white about 1/3 of white toddlers and primary school children have to cade teeth that the disease of affect closer to half of black and Hispanic children and minority children are twice as likely to go without treatment for decay as white children and by the time we reach adulthood decay is almost universal most of us have it across races and and colors but treatment disparities remain very great less than a quarter of white Americans have untreated decay with more than a third of Hispanics doing more than 40% of black working age adults have untreated decay and decay only gets worse you know it doesn't get better if you're out of reach of care it ends up you end up having lost teeth tooth aches toothpicks are a huge burden there of life was for many many millions of Americans people rely on home remedies they pull out their own teeth they play I mean there's just so few options for so many people who suffer with this does it use yeah let's take a quick break there if we can Mary and will ask viewers to join us on the other side where we'll explore what steps are being taken today to make access to dental care more rights than privilege welcome back to wide angle Peter Bermudez speaking today with journalists Mary Otto about teeth because it strikes me that the first step in actually trying to address this issue if the clearly clearly identified dental care as a health issue yeah as opposed to a luxury item or something along those lines and that's exactly what then Surgeon General David Satcher did back in 2000 yes when he referred to the state of oral care in the United States as a public health crisis this was this was something of a watershed moment if you will and I'm wondering how the medical profession in general the dental profession certainly in particular responded to that call to action did they take it up and it's that's 17 years ago now it's a really good question at dr. sacher's call to action really redefined dental care as oral health care and oral health care oral health as being in a kind of a state of crisis in this country but the organized dentistry is very good and focused on rep presenting private practitioners who have a complete they have a different world view they're worried about their private practices they consider themselves health care providers but also small business men and women because they open Dell practices they're concerned about their patient bases and taking care of the people who come to them for care and earning you know a decent profit to keep their lights on and pay off their dental school debts so this distance it's a kind of a there's another gap there you know between the world views of public health and private practice fee-for-service dentistry as most dentists in America practices so there's been some there has been a somewhat of a disjoint between what dr. Satcher was asking for and what private practitioners deliver in terms of of care so dental care certainly been something that has been on the radar if you will for quite some time in this country even if even if dentists if dental organizations didn't pick up Surgeon General sacher's call to action back in 2000 yeah a quick question for you just to loop back around to there not being enough dentists back around World War two are there enough dentists do you given your research do you sense that there are sufficient dentists to care with the the population of Americans we have what 340 million Americans do we today have enough dentists even though they may not be distributed in order to see everybody do we theoretically have the numbers it depends on who you ask and it depends on what the workforce actually looks like they're like 150,000 working dentists American Dental Association says the supply is adequate but there is as you pointed out a Mal distribution issue of the US Department of humans health and human SEZ SEZ 49 million Americans live in areas that are classified dental professional shortage areas there are communities that whether they're rural places lack a dentist for a you know entire counties laughs Dennis across much of many parts of this country here urban areas where there aren't enough dentists to meet the needs of the population in some cases it may be a poor population where there aren't enough Medicaid dentists there's also the issue of the way the rest of the workforce the dental workforce is you used I mean most cases you know there are 200,000 dental hygienists in this country but in many it depends on the state in many cases they work within the private practice system some states are expanding their ability to reach to go out to communities to get care to say children a child can't take himself or herself to the dentist but a hygienist can go to the school like in the early days of the dental hygiene profession I think – you're speaking now – as as medical practices have certainly made use of nurses and in the past two decades or so certainly much more making use of the services of nurse practitioners – to expand the amount of care that practices can can can reach a community with dentistry has been resistant to adopt that model for various reasons you cite in the book but now we are seeing in particular locale what are called dental therapists yeah so what is it what is it the dental therapists do and and where are they practicing today they're yeah yeah this is a really good point um dental therapists have been around for decades and and they've been in use in about 50 countries around the world but they've been strongly resisted here in this country they're technically trained dental providers they think they go to school for like half as long as dentists they get paid about half as much as dentists but they do some of the same procedures in dentistry their common routine procedures that people need drilling and filling teeth they some of them do some extractions they work as part of dentist headed teens but in many many parts of the world they go out from dental clinics and offices and do field work you know to get care out to people who might not be able to get into a dental office and the first place they were used here in the United States was in Alaska and the tribal the did the tribes got together they decided to try to try this dental therapist they sent their first few tribal members to New Zealand to be trained actually to get this training and a lawsuit by the American Dental Association and the state Dental Association sought to stop to stop these therapists from going to work but the philosophy was settled and the therapists went to work in the tribes there now about thirty of them maybe thirty three of them and they're serving over 40,000 Alaska native people in you know regional clinics Bush you know like little villages out on the tundra you know they fly and spend a couple of days you know you know small clinic in a village and then go back to their their main hospital or clinic and they work by tell they use telemedicine to communicate with their supervising dentist you know they can take an x-ray with portable equipment and the dentists look at it decide whether they need to bring the patient in for you know extensive care in a in a regional place or whether they can just do the care right there in the village so it's an interesting there are real pioneers in this area since there's their lawsuit resettles the dental therapists have gone to work in Minnesota so there are about 60 of em there again sir serving in underserved areas Vermont and Maine have passed laws allowing dental therapists they haven't actually gotten to programs up and running yet and a certain number of other states are exploring the idea of dental therapists so I just want to pick up on the the notion of of access because that seems to be another critical piece of this puzzle of re-establishing dental care as a necessary piece of our healthcare diamante driver theoretically had had coverage the challenge was getting to a doctor who accepted that coverage and maybe a maybe another bright spot here is that you you report that in August of 2009 some 650 dentists were enrolled in Maryland's Medicaid dental program by August 2015 so six years later almost fourteen hundred dentists were enrolled so I guess two questions may be why the increase that's a that's a two-fold plus increase in dentists and also are we seeing similar shifts across the country really good question yet a lot happened after diamante died not just in Maryland but it cost the country you're right Maryland raised its reimbursement rates and you the new governor martin o'malley appointed a panel a special panel to look at the problems with the state because it had it was one of the worst states in terms of getting care to children in terms of how many dentists were participating in terms of how much care was being delivered so anyway this panel it was a multidisciplinary panel children's advocates insurance people dentists pediatricians all kinds convened came up with a plan to radically reform the state's medicaid system and they not only got the legislature to raise reimbursement rates to attract more dentists to the program the dentists have felt like they really took a hit you know in with this death they felt ashamed and and just humiliated join the program and began taking were children in addition they put the state reformed the systems of kind of contractors that provided dental care it was sort of a patchwork system they put a single administrative service organization into place to kind of deal not only with patients but with Dennis and answerable to the states so there wasn't so much loss you know in communication and accountability so that part was fixed and they also gave dental hygienist something they've been asking for for a while which was the right with special training to go out into schools to get care directly to children who needed it in many places they also entitled physicians and nurses who are much more likely still to see little infants and children you know they get boo a baby checkups and immunizations quite routinely you know as Medicaid children but they don't always get to see a dentist so these medical providers are actually allowed to Bill Medicaid for well baby oral health checkups and fluoride treatments they often refer the children's parents to a dentist after they see them so these are all making they've all ended up making Maryland a kind of example for the rest of the country and the reforms have been adopted by other other states in the country so overall children are getting more care dental Medicaid children are getting worked here since diamonte died certainly it's it's it's no secret that the Trump that the Trump Whitehouse Mary doesn't seem to be a friend to health care in general I'm wondering if at this point in in the Trump presidency if you can glean a sense of what the future of dental coverage particular might be over the next three years in counting well I've been listening really closely for signs of how things will go and a lot of rural health advocates have been to you know history's any indication gentle don't care has been left out of other conversations like well it's been missing from federal programs like Medicare and I'm kind of an unstable basis and Medicaid and the Affordable Care Act didn't totally address it either so now of course the people are really paying attention to what will happen to the larger Medicaid program I mean it's considered an entitlement now for children but what if the entitlement system goes away you know if with a block grant system for the state that could change the way benefits are delivered and how they're considered so it's a moment of a possibility for dental care to be more fully integrated or it could get left out again people are waiting to see oh well we'll we'll wait with you I certainly thank you for taking the time to speak with me today I thank you for writing for writing the book for a decade of research in putting it together and I will say although you probably wouldn't that and congratulate you on the impact that your Washington Post articles on diamonte had because I think in in no small way they helped move this dialogue forward yeah thank you can you thank you at a biological level teeth illuminate the arc of our lives the teething pains of infancy rights Marriott oh and teeth Herald the appearance of the baby teeth the deciduous teeth they're shedding and replacement with the permanent teeth are part of our passage from childhood to adolescence the eruption of the molars the wisdom teeth signals the advent of young adulthood as time goes on our aging is reflected in our teeth they wear and darken the gums receive and we grow long in the tooth time and disease take their toll they take their toll of course given that we live that long and that's where our biology sometimes runs headlong into lives complicated by politics economics geography policy and law are often what mediate those two worlds and though our words on paper are often dim reminders they to illuminate they reveal what we value an old dear and that and those we do not may such words reveal us as people vigilant of the memory and trials of diamante driver and his family on behalf of Mary Otto I'm Peter Bermudez thank you for joining us for this edition of wide angle you

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