“The Great Rebuff”: Why Dental Care Isn’t Medical Care

Did you ever wonder why your health insurance doesn’t cover dental care, and why your mouth is treated separately from your body? The answer is in a new book “Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America,” by Mary Otto.

“Teeth” tells the terrifying story of America’s oral disease epidemic, detailing the critical connections between our overall health and our dental health.

Otto explains exactly how oral infections can make us very sick and even kill us. She also delves into the personal, social and financial cost of tooth decay, showing the impact that “bad” teeth have on people’s ability to obtain a good education, a decent job, and a social life.

Otto notes that the [top] front six teeth are referred to as “The Social Six,” and getting an exceptional set of veneers for these front six teeth are a pricy status symbol in America – and increasingly around the world.

But very few Americans can afford to finance that “American” smile. Toothaches, writes Otto, are a constant fact of life for millions of people in the U.S., “including disproportionate numbers of the elderly and people of color.” And how do people manage this pain? Otto found that far too many Americans try to pray the pain away, since they can’t afford dental care.

Otto also looks at the history of that legendary American smile and how the U.S. separated dental care from the medical mainstream, despite decades of medical research that show how oral health and overall health are closely related.

Going back to the earliest days of dentistry, a dentist was a tradesman. He (and it was always a “he) was likely to be a “barber-surgeon,” and would have provided many personal services including hair and beard trims, cupping, leeching plus tooth extraction – and occasionally tooth repair. Dentistry wasn’t thought of as a science, it was a basic mechanical skill.

That’s not to say that some of the early dentists didn’t elevate their skill to an art. Paul Revere was silversmith who also made dentures. In an ad that Revere placed in the Boston Gazette in 1770, Revere stated that he could fix teeth “in such a manner that they are not only an ornament but of real use in speaking and eating.”

Dentists tried to be recognized as professionals. The first dental college opened in 1840 in Baltimore, Maryland, with the idea that dentists should study, get licensed and work together as scientists to find new ways to manage oral disease. But physicians officially refused to recognize dentists as peers, in an event that is now called the “historic rebuff.”

The rebuff separated medical and dental education, and created the huge rift between medical and dental care that still exists today.  Sadly, some dentists have embraced the rebuff, defending their professional autonomy. But, as noted in a review of the book by The Atlantic, “… 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.”

Otto notes that more than a million people in America annually end up in hospital emergency rooms with dental problems, costing 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,” Otto told The Atlantic.

The gap that Otto refers to also drives 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,” says Otto.

How can we combat tooth decay, both medically and socially? Research shows that basic preventive and restorative procedures can keep people healthy. Some states are reviewing the idea of allowing
“dental therapists,” people trained in preventive care, to treat patients to reduce the cost of care and expand the dental workforce.

Insurance models also need to be expanded to deal with today’s realities. Those who can’t afford or access dental insurance can consider dental savings plans, a more affordable and less-restrictive alternative to traditional dental insurance.

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