The Silent Epidemic in Oral Health

In a Tell Me More podcast, author Mary Otto and Tufts dental students talk about the many patients who can’t get dental care—and the people trying to help
A woman getting her teeth examined. In a Tell More More podcast, author Mary Otto and Tufts dental students talk about the many patients can’t get dental care—and the people trying to help
“Oral health has become part of our health-care conversation now,” said Mary Otto. Photo: Ingimage
February 27, 2020

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TRANSCRIPT

JULIE FLAHERTY:  In 2007, Alyce Driver was a mom in Maryland scraping together a living working at a grocery store and caring for the elderly. One of her struggles was trying to find a dentist for her kids—one who would take Medicaid—but despite countless phone calls and even the help of a pro bono lawyer, the family ended up with no care. Then one day, her 12-year-old son, Deamonte, got a toothache.

MARY OTTO: So Deamonte comes home feeling sick, and his grandmother takes him to a little community hospital where he was diagnosed with an infected tooth and a sinus infection, and he was given medicine and they were sent home. And he got much worse.

FLAHERTY: That’s Mary Otto, who was a reporter for the Washington Post at the time.

OTTO: By the time I had met him, he had been in the hospital for a couple of weeks. His mom was really worried about him. It seemed like he was making progress toward getting well but ultimately, after about six weeks of care at Children’s and at a smaller rehab hospital, he died. This infection had spread to his brain and it ultimately claimed his life.

FLAHERTY: Otto’s reporting on Deamonte’s story shocked people across the country. They couldn’t believe that something like a toothache could kill a child.

“It can be really hard to find a place to get care if you’re living in a lower income, or minority community, because there are a shortage of providers,” said Mary Otto. Photo: Nancy CramptonOTTO: It was just one of those tragic stories that awakened me to the serious nature of the shortage of oral health services for not only children in Maryland it turned out, but Washington, Virginia. And as I continued to follow this story, I learned throughout the nation.

FLAHERTY: Otto heard the same stories over and over—people in pain who couldn’t find a dentist who would take Medicaid. People who couldn’t afford treatment that would save their teeth. Even loved ones who died because they couldn’t get care. It was a health crisis that no one was talking about.  

This is Tell Me More, the Tufts University podcast where we catch up with our favorite guest speakers on campus. I’m Julie Flaherty. Today, we hear from journalist Mary Otto about her book Teeth: The Story of Beauty, Inequality and the Struggle for Oral Health in America.

FLAHERTY:  For your book, you traveled all over the country talking to people about their teeth. And one story that really stood out to me, you talked with one young woman, Tabitha Hay, and she was at a mobile health clinic in Virginia. And she had driven thirteen hours all the way from Florida to get help for an infected molar. Can you tell me why she would do that?

OTTO: She had this tormenting pain and her tooth had been told that it would cost $500 to get it extracted in Florida, where she was living and working. So she and her boyfriend and her boyfriend’s mom piled in the car and made this night-long drive to this free clinic where they hope she could get some care. And they got there too late to be seen the first day so they slept in their car and she was in this awful pain. And she did get seen, got the tooth extracted, some other care provided.

She’s one of millions of Americans who are working poor, she’s self-employed, she didn’t have on-the-job health benefits that many of us are lucky enough to have. And dental benefits are even harder to find than your medical benefits in that situation, so she was dentally uninsured just like tens of millions of other Americans and had really had no place to turn for this procedure and no money to pay for it.

FLAHERTY: Mary Otto often speaks at Tufts School of Dental Medicine, where her book is read by each new class.

NEGIN TAGHIZADEH: Hello, my name is Negin Taghizadeh. I’m a first-year dental student at Tufts University. I’m from West Palm Beach, Florida.

FLAHERTY: Taghizadeh said the book drove home everything she had seen as a volunteer at a free dental clinic in Tampa, Florida.

TAGHIZADEH: It was a little room behind a church, and it was only open two times a week. People who knew of this place and wanted treatment, would have to come up hours early and line up because we only could take so many number of patients. And given their circumstances, that for a lot of them, this meant that they had to pull their kids out of school, come alongside with them, and stand in line for hours because they didn’t have an opportunity or a babysitter or anything like that to watch over their kids.

I heard a lot of stories of patients telling us how they tried to pull their own teeth just because they simply did not have access to anybody that could provide such a treatment. And if they were to go to the hospital, to the emergency room, which many of them had before, they would get antibiotics, maybe painkillers, but the issue wasn’t solved. The issue was still there. They still had that infected tooth. So they would either try to do it themselves or travel to a location where they could have it done for free.

One day we extracted a tooth for somebody who came to this free dental clinic, and the dentist had to prescribe antibiotics to them because they had such a bad infection. And the patient literally said, “I appreciate you pulling my tooth and giving me a prescription, but unless this prescription is free, I just don’t have any money. I don’t have more than $5 in my pocket. I can’t do it.” They could literally die from a tooth infection that can be simply be fixed.

FLAHERTY: If you don’t have insurance, a teeth cleaning could set you back more than $100, an extraction can cost $500, a root canal can be more than a thousand. Lots of people can’t afford that and have few options—Otto says sometimes just home remedies and prayer. Many end up in the emergency room, costing the health care system hundreds of millions of dollars each year.

OTTO: So the patients typically get a prescription for an antibiotic, maybe a painkiller, and they’re told to go see their dentist. But many of these patients don’t have what you consider a dental home or routine dental provider. That’s one of the reasons they are in pain and have this problem that’s brought them to the emergency room. So these visits cost hundreds of millions of dollars a year and the patients don’t get the care they need.

FLAHERTY: Taghizadeh saw how severe the problems could get when she worked as a surgical assistant at a hospital.

TAGHIZADEH:  Each night, I would say, multiple times, they would get called in to come to drain an abscess, to pull a tooth. And sometimes it would be so severe that the patient’s had such a bad swelling where they almost couldn’t breathe, so their breathing was compromised. It’s very interesting and sad that dental pain, dental abscess, such infections can literally take somebody’s life in a matter of just a couple of hours if they don’t get the appropriate treatment.

FLAHERTY: So why isn’t there a safety net to help low-income people get dental care? Well, here’s the thing—Medicaid only covers kids for dental care. It’s up to the states whether they cover dental for adults. And even when someone does have dental benefits through Medicaid, it can be hard to find a dentist who will see you.

OTTO: There is a shortage. It’s way less than half of dentists are Medicaid providers overall.

Affluent metropolitan areas, sometimes dentists are competing with each other for patients, right? And yet, in poorer communities, there are often shortages of providers. And the providers who are there may be so busy they’re not accepting new patients. It can be really hard to find a place to get care if you’re living in a lower income, or minority community, because there are a shortage of providers.

Dentists complain that there’s paperwork and that the program in many states doesn’t reimburse as well as private insurance. They complain that patients might not show up for their appointments. They make different arguments that it’s just too much trouble to serve Medicaid patients.

FLAHERTY: Now before you blame dentists, consider that dental students have an average of a quarter million dollars in debt when they graduate. Taking Medicaid patients doesn’t help with that debt. It’s something a lot of dentists struggle with.

ALEXANDRA DINU: I’m Alexandra Dinu. I’m from New Jersey and this is my first year at Tufts University School of Dental Medicine.

FLAHERTY: Before dental school, Dinu worked in the office of a dentist who accepted Medicaid patients. She saw the problem from both sides.

DINU: Most of the patients, not most of them, but a lot of them didn’t show up, and I would have to call, and call, and call. And then, it turned out they couldn’t afford the bus, or they couldn’t afford their phone bill, so we couldn’t even reach out to them to remind them about their appointment. A lot of the patients would have to take vacation just to get to their dental appointment and I thought if I took a vacation day, I probably wouldn’t spend it at the dentist’s either.

But it was interesting in Mary Otto’s book a lot of dentists called these patients problem patients, but when you actually hear their stories, it’s not a problem for us, it’s like these are barriers that it’s hard to overcome and it’s very unrealistic for some of these people to overcome.

FLAHERTY: So why is dental care not part of medical care? It goes back to the middle ages, when barber-surgeons, not physicians, were typically the ones who pulled teeth. Dentistry and medicine just sort of grew up separately.

But the real schism between dentistry and medicine can be traced back to the 1800s and a couple of dentists named Horace Hayden and Chapin Harris. They had the idea that dentistry should be taught in medical school, so they brought their idea to their local medical college.

OTTO: And as the story goes, the physicians told them, “The subject of dentistry is of little consequence,” and sent them on their way.

So these two dentists started their own college of dentistry right down the street. And there’s been this gap ever since in the way physicians and dentists are trained, they’re trained separately.

We pay for our dental care separately from our medical care. Our dental records are typically separate from our medical records, our research. It’s hard for researchers to work together. The codes are different. Diagnostic codes. Because we haven’t integrated our understanding of oral health and overall health in our system. Our heads are attached to our bodies but our system just doesn’t reflect this basic reality.

FLAHERTY: Despite all this, Otto is optimistic.

OTTO: Oral health has become part of our health-care conversation now. Community health centers are integrating dental records into their patient’s medical records. A number of them have added dental services under the same roof with medical and mental health-care services.

Providers are doing warm handoffs, helping a patient into the door of the dental hygienist or the dentist there at the community health center. I think slowly, and this is just me, it seems like dental students of today are going to inherit a system that’s probably different than it has been for many years. So there may be more opportunities for them to find ways to reach more of those publicly insured patients.

FLAHERTY: Dinu is already envisioning how she can fit Medicaid patients into her practice when she gets out of school.

DINU: So I really thought about having these hours on a Saturday, or opening up really early on weekdays for people to actually make it to their dentist appointments without having to sacrifice their vacation days, or their sick days, or things like that.

I thought about having transportation maybe to appointments, which I hear is something that they’re actually doing around here in Massachusetts, so maybe like a big kind of bus, very similar to buses that nursing homes take their patients to casinos and things like that. I think it could probably be put do better use for dental appointments.

What I want to do in maybe a private practice, but I think a group practice would work better, because we can pass that sacrifice around to all of the dentists. Maybe I’ll come in on Saturdays, my colleague will come in really early on Mondays to accommodate for the patients that work really early at 6 a.m. or something.

FLAHERTY: As for Taghizadeh, she thinks all dentists should devote a couple hours a week to uninsured or Medicaid patients.

TAGHIZADEH: Just so we help the community, just so that we can avoid what happened to Deamonte Driver, from happening again. It shouldn’t all be about making profit. I think given the platform that we have, given the skills that we have, we can really help save a life, and we should take that opportunity and gladly do it.

FLAHERTY: Thanks for listening to Tell Me More. This podcast is produced by Anna Miller and Julie Flaherty. Web production and editing support by Taylor McNeil and Sara Norberg. Our music is by DeWolf Music and Blue Dot Sessions. We would love to hear what you think of our second season. Please subscribe and rate and review us wherever you get your podcasts. Or shoot us an email at tellmemore@tufts.edu. That’s T-U-F-T-S dot E-D-U. Thanks for joining us.