Doctors are doctors, and dentists are dentists, and never the twain shall meet. Whether you have health insurance is one thing, whether you have dental insurance is another. Your doctor doesn’t ask you if you’re flossing, and your dentist doesn’t ask you if you’re exercising. In America, we treat the mouth separately from the rest of the body, a bizarre situation that Mary Otto explores in her new book, Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America.
Specializing in one part of the body isn’t what’s weird—it would be one thing if dentists were like dermatologists or cardiologists. The weird thing is that oral care is divorced from medicine’s education system, physician networks, medical records, and payment systems, so that a dentist is not just a special kind of doctor, but another profession entirely.
But the body didn’t sign on for this arrangement, and teeth don’t know that they’re supposed to keep their problems confined to the mouth. This separation leads to real consequences: Dental insurance is often even harder to get than health insurance (which is not known for being a cakewalk), and dental problems left untreated worsen, and sometimes kill. Anchoring Otto’s book is the story of Deamonte Driver, a 12-year-old boy from Maryland who died from an untreated tooth infection that spread to his brain. His family did not have dental benefits, and he ended up being rushed to the hospital for emergency brain surgery, which wasn’t enough to save him.
I spoke with Otto about how the dentistry/medicine divide came to be, why it’s stuck around, and what its consequences have been. A lightly edited and condensed transcript of our conversation is below.
Julie Beck: Let’s go back to the origin of how dentistry and medicine became separate in the first place. It’s something we take for granted now, right? But it’s actually really weird. Was there ever a time when dental care was integrated with medical care?
Mary Otto: It stayed generally separate. Taking care of the teeth became kind of a trade. In the barber-surgeon days, dentist skills were among one of the many personal services that barber surgeons provided, like leeching and cupping and tooth extractions. They approached it as a mechanical challenge, to repair and extract teeth. Barber surgery was practiced in the very early part of our country's history. And Paul Revere was a denturist—he was a jeweler and he made dentures too.
But the dental profession really became a profession in 1840 in Baltimore. That was when the first dental college in the world was opened, I found out, and that was thanks to the efforts of a couple of dentists who were kind of self-trained. Their names were Chapin Harris and Horace Hayden. They approached the physicians at the college of medicine at the University of Maryland in Baltimore with the idea of adding dental instruction to the medical course there, because they really believed that dentistry was more than a mechanical challenge, that it deserved status as a profession, and a course of study, and licensing, and peer-reviewed scientific consideration. But the physicians, the story goes, rejected their proposal and said the subject of dentistry was of little consequence.
That event is remembered as the “historic rebuff.” It's still talked about sometimes, not a lot, but it’s seen as a symbolic event and it’s continued to define the relationships between medical and dental education and medical and dental healthcare systems in funny ways. Dentists still drill and fill teeth and physicians still look at the body from the tonsils south. Medical and dental education is still provided separately almost everywhere in this country and our two systems have grown up to provide care separately, too.
Beck: It seems like since the historic rebuff, dentists have really wanted to stay separate. Why is that, do you think?
Otto: People have raised questions about the system over the years, and they’ve called for reforms periodically. Nearly a century ago, in the 1920s, this biological chemist named William Gies was a kind of prophet. He visited every dental school in the country and in Canada for the Carnegie Foundation, for this big report, and he called for dentistry to be considered an essential part of the healthcare system. He said: “Dentistry can no longer be accepted as mere tooth technology.” He wanted oral health and overall health to be integrated into the same system, but organized dentistry fought to keep dental schools separate. [Dentists] emerged as defenders of the professional autonomy and professional independence of the private practice system that we have here. David Satcher, the [former] surgeon general, he kind of said the same thing when he issued this “Oral Health in America” report in 2000. He said we must recognize that oral health and general health are inseparable. And that too, was a kind of challenge. And it seems like things are changing, but very slowly.
Beck: So you think the reason they wanted to stay separate was really just a matter of professional independence?
Otto: Yeah. It’s a marketplace issue. It’s a formidable thing, professional autonomy.
Beck: It’s interesting to hear this separation traced back to one moment because it has shaped so many things—insurance, access to care, all these things. Can you give an overview of what the effects have been of carving dentistry out of medicine?
Otto: One of the most dramatic examples is that more than a million people a year go to emergency rooms with dental problems. Not like they’ve had a car accident, but like a toothache or some kind of problem you could treat in a dental office. It costs the system more than a billion dollars a year for these visits. And the patients very seldom get the kind of dental care they need for their underlying dental problems because dentists don’t work in emergency rooms very often. The patient gets maybe a prescription for an antibiotic and a pain medicine and is told to go visit his or her dentist. But a lot of these patients don’t have dentists. So there’s this dramatic reminder here that your oral health is part of your overall health, that drives you to the emergency room but you get to this gap where there’s no care.
There’s also the fact that our medical records and our dental records are kept separately. Dentistry has treatment codes, but it doesn’t really have a commonly accepted diagnostic code language which makes it hard to integrate medical and dental records and harder to do research on the commonalities between oral health and overall health.
One dental researcher said at a meeting I was at, “Back in the days of the bubonic plague, medicine captured why people die. We don’t capture why teeth die.” There’s this gap in the way we understand oral diseases and the way we approach tooth decay. We still approach it like it’s a surgical problem that needs to be fixed, rather than a disease that needs to be prevented and treated. And we see tooth decay through a moral lens, almost. We judge people who have oral disease as moral failures, rather than people who are suffering from a disease.
Beck: Insurance is all separated out as well, and a lot of times it’s optional. How, politically, did dental care come to be seen as optional?
Otto: There were discussions all through the 20th century, periodically, about this subject. Organized dentistry, like organized medicine, fought nationalized health care on a lot of fronts and testified against the practicality of extending benefits to everyone in the country. And all the healthcare programs that we’ve come up with as a nation have on some level or another left oral health out, or given it sort of an auxiliary status as a fringe benefit. Private insurance has also treated it that way.
Beck: It’s interesting, on one hand, dental care is treated as “optional,” but on the other hand, as you note in the book, there’s this social pressure to have perfect teeth, especially in America, especially among the rich. And so there’s a lot of money to be made in cosmetic dentistry. Do you think that social pressure to have perfect teeth is kind of exacerbating the inequality?
Otto: I think on some level it must. We do put so much emphasis on perfect smiles and there is a lot of money to be made in that field. One dentist I talked to as I was working on this project said “Nobody wants to do the low-end stuff anymore.” Of course there is a lot more money to be made with some of these really high-end procedures. But on the other hand there’s this vast need for just basic basic care. A third of the country faces barriers in getting just the most routine preventive and restorative procedures that can keep people healthy.
Beck: I wonder if the value put on that perfect Hollywood smile is in part because so many people don’t have access to dental care, so perfect teeth are a very clear way of signaling your wealth. More clear than if everyone had access to good care and had decent teeth.
Otto: It could be. It’s very interesting. This whole “perfect American smile” did have its origins in Depression-era Hollywood. Filmed movies were still pretty new at that point. There was this young dentist named Charles Pincus who had this dental office that opened on Hollywood and Vine and he went to the movies too. And he saw these movie actors who didn’t have perfect teeth up on the silver screen, like James Dean, who actually grew up on a farm and had dentures, and Judy Garland, and Shirley Temple. He started working with the studios. He created these little snap-on veneers for Shirley Temple so we never saw her lose her baby teeth. Over all the years she had a perfect little set of pearly whites.
But you’re right, there’s this kind of feast and famine aspect to this that’s striking. They call the [top] front six teeth “The Social Six,” and the perfect set of veneers for these front six teeth are not just a status symbol here in this country—they’re sought around the world as a marker of success.
Beck: I guess partially because of this market for cosmetic dentistry, dentists tend to cluster in rich areas, and there are often shortages in rural areas or poorer areas. But at the same time, you write about a lot of instances where dentists were really resistant to allowing anyone else to provide that preventive care, like training hygienists to do cleanings in schools. Why is that so controversial?
Otto: There’s been a long history of that and it really came home to me with some of the stories I heard, like the story of Tammi Byrd, this dental hygienist in South Carolina. There’s about a quarter million children living in the rural areas of the state who weren’t getting care, and she and some other dental hygienists fought to get the law changed so they could go out and see children without being first examined by a dentist. The dental association just fought back, they got an emergency regulation passed to stop her from doing her work and finally the Federal Trade Commission came in and took her case and won it for her, in the interest of getting economical preventive care to all these children who lacked it.
But, yeah, there’s this marketplace issue. Private organized dentistry protects the marketplace for care and the power of private practitioners to provide it but that leaves a lot of people out. Stories like the battle of this dental hygienist in South Carolina, or the battle that’s going on over these midlevel providers called dental therapists in a number of states, really illustrate how fiercely that terrain is protected.
Organized dentistry continues to say the current supply of dentists can meet the need, that if the system paid more for the care, more providers would locate in these poorer areas. That we Americans need to value our care more and go out and find care more aggressively. They see the fault as being with society at large.
Beck: This opposition to hygienists stepping up and filling that role, does that have anything to do with the fact that hygienists are mostly women? You quoted some old-timey dentists who were like, “Ah yes, the best assistant for a dentist is a woman because she won’t be ambitious and take over our patients." And it kind of sounds like that attitude is still around in some ways.
Otto: You could say that there might be a sense of that still. There’s certainly a deep sense among the powers of organized dentistry that only dentists are qualified to do the lion’s share of dentistry.
Beck: Are there other plans proposed to fill the gap in dental care, if not letting the hygienists or the dental therapists do it? Is there another plan that would be more pleasing to dentists?
Otto: They have their own alternative model. It's kind of a health navigator who connects people with existing dentists, a community-health-worker type of model. [The navigator] helps divert people from ERs into existing dental offices, helps people make dental appointments, educates them about maintaining oral health, and taking care of their children. But it’s guiding people to existing dentists, rather than expanding the dental workforce.
Beck: And if they don’t have insurance then it’s not going to help very much?
Otto: It’s not as helpful. Unless there’s a philanthropy or some kind of group that’s raising money to pay for the care.
Beck: The separation between dental and medical care is pretty entrenched at this point. Do you think it can be overcome, that it should be overcome, that the two could be integrated a little more? What might that look like, do you think it would help?
Otto: Something that was talked about in the medical world during the work going into the Patient Protection and Affordable Care Act was the “Triple Aim”: bending the cost curve toward prevention, expanding care more broadly and more cheaply, and [creating] a better quality of care. It’s something that needs to be discussed in the oral health world too, and I think it’s being discussed more.
Beck: Do you think it would be like a parallel reform in dentistry or would it be more integrating them back together somewhat?
Otto: It seems like it’s going to have to involve both. There’s been work being done in this area, there’ve been efforts to put dental hygienists into these federally qualified health centers that are part of our public-health safety net, which serve poor rural communities. It seems like it’s capturing an increasing amount of attention from state lawmakers, governors, and public health officials who are interested in bringing costs down for all kinds of health care and seeing that these things show promise. They're saying we’re spending too much on emergency rooms, we're spending too much on hospitalization for these preventable problems, so there are cost incentives to get more preventive and timely routine restorative care to people.
Beck: Trying to undo some of the damage of the historic rebuff.
Otto: Yeah, isn’t it funny?