The painful truth about teeth

Many work­ing peo­ple still can’t af­ford den­tal care — a vis­i­ble re­minder of the di­vide be­tween rich and poor

The Washington Post Sunday - - FRONT PAGE - BY MARY JOR­DAN AND KEVIN SUL­LI­VAN

sal­is­bury, md. — Two hours be­fore sun­rise, Dee Matello joined the line out­side the Wi­comico Civic Cen­ter, where hun­dreds of peo­ple in hood­ies, heavy coats and wool blan­kets braced against a bit­ter wind.

In­side, re­clin­ing den­tal chairs were ar­rayed in neat rows across the arena’s vast floor. Days later, the venue would host Dis­ney on Ice. On this Fri­day morn­ing, den­tists ar­riv­ing from five states were get­ting ready to fix the teeth of the first 1,000 peo­ple in line.

Matello was No. 503. The small-busi­ness owner who sup­ports Pres­i­dent Trump had a cracked mo­lar, no den­tal in­surance and a nag­ging sore­ness that had forced her to chew on the right side of her mouth for years.

“It’s al­ways both­er­ing me,” she said. And although her toothache wasn’t why she voted for Trump, it was a con­stant re­minder of one rea­son she did: the feel­ing that she had been aban­doned, left strug­gling to meet ba­sic needs in a coun­try full of fan­tas­ti­cally rich peo­ple.

As the dis­tance be­tween rich and poor grows in the United States, few con­se­quences are so over­looked as the hu­mil­i­at­ing di­vide in den­tal care. High-end cos­metic den­tistry is soar­ing, and bet­ter-off Amer­i­cans spend well over $1 bil­lion each year just to make their teeth a few shades whiter.

Mil­lions of oth­ers rely on char­ity clin­ics and hos­pi­tal emer­gency rooms to treat painful and ne­glected teeth. Un­able to af­ford ex­pen­sive root canals and crowns, many sim­ply have them pulled. Nearly 1 in 5 Amer­i­cans older than 65 do not have a sin­gle real tooth left.

Over two days at the civic cen­ter, vol­un­teer den­tists would pull 795 teeth. A re­mark­able num­ber of pa­tients held steady jobs — a fork­lift op­er­a­tor, a li­brar­ian, a postal worker — but said they had no den­tal in­surance and not enough cash to pay for a den­tist.

Matello had both prob­lems, adding to her frus­tra­tion about be­ing cut off from a world that many wealth­ier Amer­i­cans take for granted.

“The coun­try is way too di­vided be­tween well-off peo­ple and peo­ple strug­gling for ev­ery­thing — even to see the den­tist,” she said. “And the worst part is, I don’t see a bridge to cross over to be one of those rich peo­ple.”

Matello voted for Barack Obama in 2008, think­ing he of­fered the best op­tion for work­ing peo­ple, but she sat out the 2012 elec­tion. Last year, she ral­lied be­hind Trump af­ter lis­ten­ing to him talk about “the for­got­ten men and women of our coun­try, peo­ple who work hard but don’t have a voice.”

“I’m run­ning to be their voice,” Trump said re­peat­edly.

What Matello heard was a prom­ise “to re­store pride to the work­ing poor.”

A big part of that prom­ise was Trump’s as­sur­ance that he would build a “beau­ti­ful” health-care sys­tem to serve ev­ery Amer­i­can, a sys­tem that would cost less and do more. But nearly four months into Trump’s pres­i­dency, Matello sees Trump back­ing a Republican health-care plan that ap­pears to leave low-in­come peo­ple and the el­derly worse off.

“I am hear­ing about a num­ber of peo­ple who will lose their cov­er­age un­der the new plan,” Matello said. “Is Trump the wolf in grandma’s clothes? My hus­band and I are now say­ing to each other, ‘Did we re­ally vote for him?’ ”

Matello said she has no op­tion but to keep hop­ing Trump will de­vise “a plan so we can all feel the ben­e­fits of a bet­ter econ­omy.” But since he took of­fice, Trump has fo­cused on so many other things — most re­cently, his de­ci­sion to fire the FBI direc­tor — that Matello has be­gun to won­der about his prom­ises to the work­ing class:

“Was he just out to get our votes?”

‘What I am see­ing is ab­so­lutely hor­ri­fy­ing’

Straight, white teeth are as­so­ci­ated with so­cial suc­cess — just about ev­ery­one on TV or with a big job has them. Peo­ple drop $2,000 per tooth on porce­lain ve­neers to hide the small­est im­per­fec­tions. Trump has un­usu­ally per­fect, snow-white teeth, prompt­ing nu­mer­ous cos­metic den­tists to pub­licly note that he seems to have had ex­pen­sive work done.

“If I see some­one with per­fect teeth, I think, ‘Oh, man, they’re out of my league,’ ” Matello said. “Us poor peo­ple ‘sta­tus’ each other. We’re like, ‘Ah, dude, you don’t have any teeth!’ Or if you see some­one with lit­tle jagged yel­low stubs, you think, ‘Oh, man, you have lived here your whole life, haven’t you?’ ”

“Here” is Mary­land’s Eastern Shore, the poor­est part of one of the coun­try’s rich­est states. It’s a re­gion fa­mous for chicken farms: Per­due’s na­tional head­quar­ters is here in Sal­is­bury, a town of 30,000. Matello lives 20 miles north, in Lau­rel, Del., near fields that sprout corn, wa­ter­mel­ons and soy­beans.

In these ru­ral ar­eas, even the wa­ter can work against peo­ple. Many homes, in­clud­ing Matello’s, rely on well wa­ter. Un­like wa­ter from pub­lic sys­tems, well wa­ter is not flu­o­ri­dated. Na­tion­wide, 25 per­cent of Amer­i­cans are not con­nected to a flu­o­ri­dated wa­ter sys­tem and, there­fore, are miss­ing out on what the Cen­ters for Dis­ease Con­trol and Pre­ven­tion called one of the 10 great health ad­vances of the 20th cen­tury.

“It’s all well wa­ter, no flu­o­ride,” said Pa­tri­cia Hig­gins, one of the den­tists vol­un­teer­ing at the Sal­is­bury clinic. “In these places, we see peo­ple with a dif­fer­ent level of den­tal prob­lems.”

Ge­orge Acs, direc­tor of the den­tal depart­ment at Ch­e­sa­peake Health Care, a clinic near Sal­is­bury, said peo­ple with oral pain and in­fec­tions are in­un­dat­ing hos­pi­tals. Last year, more than 2 mil­lion U.S. emer­gency room vis­its were at­trib­uted to ne­glected teeth.

“What I am see­ing is ab­so­lutely hor­ri­fy­ing,” said Acs, who re­cently tes­ti­fied about the prob­lem be­fore the Mary­land state leg­is­la­ture.

Although those hos­pi­tal vis­its cost an es­ti­mated $1.6 bil­lion a year, the ER is gen­er­ally not equipped to fix den­tal prob­lems, Acs told law­mak­ers. So ER doc­tors just med­i­cate peo­ple with “a per­pet­ual cy­cle of an­tibi­otics

1 in 5 Amer­i­cans older than 65 do not have a sin­gle real tooth left. $1.6 bil­lion The costs of those emer­gency room vis­its. 25 per­cent of Amer­i­cans don’t have ac­cess to flu­o­ri­dated wa­ter.

and opi­oids.”

That cy­cle is feed­ing a na­tion­wide epi­demic of opi­oid ad­dic­tion. Mean­while, Hig­gins said, Amer­i­cans’ in­creas­ing re­liance on all kinds of drugs is fur­ther ruin­ing their teeth. Many drugs cause dry mouth, which leads to more cav­i­ties. When she started her prac­tice 35 years ago, she said, peo­ple took far fewer pre­scrip­tion drugs. Now pa­tients hand her com­puter print­outs with long lists of them.

Matello’s prob­lem wasn’t com­pli­cated: a mo­lar shat­tered years ago. The 46-year-old mother of three had not seen a den­tist in nine years. When parts of her tooth broke off, she knew fix­ing it could cost hun­dreds of dol­lars, and other bills were al­ways more ur­gent.

Then she heard on TV that the non­profit Mis­sion of Mercy was com­ing to the Eastern Shore to host one of the free den­tal clin­ics that had drawn overnight crowds in Ne­braska, North Carolina and other parts of the coun­try. So she de­cided to take Fri­day off.

Matello and her hus­band own a small vend­ing-ma­chine busi­ness called DeeLi­cious, spend­ing their days re­stock­ing 69 machines in­stalled in fac­to­ries, schools and of­fice build­ings. They of­fer gra­nola bars and other health­ful snacks, but Snick­ers sell best.

Life was eas­ier be­fore the re­ces­sion hit in 2007. Her hus­band man­aged a fur­ni­ture ware­house, mak­ing more than $70,000 a year, and she sold fish­ing boats, adding to their in­come. But then peo­ple stopped buy­ing bigticket so­fas and boats, and they both lost their jobs.

So they started buy­ing vend­ing machines and earn about $47,000 a year. Matello said she doesn’t know if the coun­try’s rich-poor di­vide is worse now, but it sure feels more “in your face.”

“I am just fed up with it,” she said. “I don’t do Face­book. It’s ‘I went on this trip’ or ‘I got this new thing.’ You know, I re­ally don’t need to see how great you are do­ing. It puts me in a state of de­pres­sion.”

She said peo­ple judge suc­cess based on what peo­ple wear or where they live, and she even catches her­self do­ing it. Wash­ing­ton, for ex­am­ple, is just 150 miles west, but to Matello it feels a planet away, to­tally out of reach.

“It’s a beau­ti­ful city to drive through. But I could never live there. I wouldn’t fit in,” she said. “I don’t have the toys, the ed­u­ca­tion, the money to live there. We have noth­ing in com­mon. That di­vide is why you see lower in­come peo­ple ris­ing up, be­ing mad at af­flu­ent peo­ple.”

And teeth, she said, “are the tell­tale, vis­i­ble sign of wealth.”

Fewest den­tists where need is great­est

The Wash­ing­ton re­gion has one of the great­est con­cen­tra­tions of den­tists in the world, with many of­fer­ing high-end ser­vices in of­fices that re­sem­ble lux­ury spas. More than 50 mil­lion Amer­i­cans, by con­trast, live in ar­eas of­fi­cially des­ig­nated by the fed­eral gov­ern­ment as Den­tal Health Pro­fes­sional Short­age Ar­eas. A great many of them are work­ing poor.

“It’s com­pletely skewed. You have the fewest den­tists where the need is great­est,” Acs said. He re­cently sent a pa­tient here with im­pacted wis­dom teeth 120 miles to find a den­tal spe­cial­ist who ac­cepts Med­i­caid.

Louis Sul­li­van, a physi­cian who was sec­re­tary of health and hu­man ser­vices un­der Pres­i­dent Ge­orge H.W. Bush, said “broad sys­temic prob­lems” block ac­cess to den­tists.

First, new den­tists of­ten start out with sig­nif­i­cant debt, and they grav­i­tate to­ward wealthy ar­eas where they have a bet­ter shot at mak­ing money. The typ­i­cal grad­u­ate from a fouryear, post-col­le­giate den­tal school owes $260,000 — more than the av­er­age med­i­cal stu­dent.

Then they set up solo prac­tices, shoul­der­ing pricey over­head — equip­ment, of­fice space, a re­cep­tion­ist — that ac­counts for much of a pa­tient’s bill. While younger den­tists are more likely to join groups that share costs, the cen­tury-old model of the solo prac­tice has re­sisted change.

Then there’s the mat­ter of pay­ment. Teeth gen­er­ally are treated sep­a­rately from the rest of the body, a tra­di­tion that dates to den­tistry’s ori­gins as a spe­cialty of bar­bers, who per­formed oral surgery and pulled teeth. To­day, many pub­lic health of­fi­cials view that divi­sion as a mis­take. Poor oral health can lead to heart dis­ease and other se­ri­ous med­i­cal prob­lems, and tooth loss can lead to de­pres­sion and dif­fi­culty eat­ing and speak­ing.

The sep­a­ra­tion ex­tends to in­surance. Even Medi­care, the fed­eral health pro­gram that cov­ers 55 mil­lion se­niors and dis­abled peo­ple, does not cover den­tal prob­lems. For that, peo­ple must buy den­tal in­surance, which typ­i­cally lim­its an­nual ben­e­fits to about $1,500 per per­son — an amount that has barely budged in decades, even as costs have risen.

The price of em­ployer-pro­vided plans varies greatly, and can cost a fam­ily $500 a year or more, in­dus­try ex­perts said. For those whose jobs don’t of­fer den­tal ben­e­fits, it can be even more ex­pen­sive. So tens of mil­lions go with­out: More than a third of Amer­i­can adults have no den­tal cov­er­age, ac­cord­ing to the ADA’s Health Pol­icy In­sti­tute.

Chil­dren’s cov­er­age has been im­prov­ing. All states are re­quired to pro­vide den­tal ben­e­fits to chil­dren on Med­i­caid and the Chil­dren’s Health In­surance Pro­gram. Obama’s Af­ford­able Care Act cur­rently re­quires med­i­cal plans to of­fer den­tal care to those younger than 19. But that re­quire­ment — and the den­tal ben­e­fits of 5 mil­lion adults newly cov­ered un­der the ACA — are jeop­ar­dized by the Trump-backed health over­haul now be­ing de­bated in Congress.

Adults who are poor enough, and live in cer­tain states, can get cov­er­age through Med­i­caid, the state-fed­eral health pro­gram for low-in­come Amer­i­cans. But only about 38 per­cent of den­tists ac­cept Med­i­caid — about half the rate of physi­cians — in part be­cause of low re­im­burse­ment rates. On av­er­age, Med­i­caid cov­ers about 37 per­cent of the bill, ac­cord­ing to a re­cent ADA anal­y­sis. Den­tists who don’t ac­cept Med­i­caid also com­plain of bu­reau­cratic has­sle and high rates of can­celed ap­point­ments.

In a hand­ful of states, Med­i­caid of­fers no den­tal cov­er­age for adults. Delaware, where Matello lives, is one of them. Which is why, on a damp Fri­day morn­ing, she found her­self lin­ing up with hun­dreds of other peo­ple with aching teeth.

116 den­tists, 1,165 pa­tients

At 9:44 a.m., five hours af­ter ar­riv­ing in Sal­is­bury, Matello fi­nally made it in­side the civic cen­ter and be­gan to warm up.

“What do you need done?” she asked an older vet­eran in a wheel­chair.

“Need nine teeth pulled,” he said. “My wife works at Rite Aid, and we don’t have any in­surance.”

A lit­tle af­ter noon, Matello’s num­ber was called. A vol­un­teer took her tem­per­a­ture; she was run­ning a slight fever but not high enough to stop treat­ment.

Two more hours. Fi­nally, she was waved over to an X-ray ma­chine un­der a bas­ket­ball hoop.

Just as Matello ex­pected to be called for her turn in the den­tist’s chair, a vol­un­teer an­nounced in a loud voice: “Those up to num­ber 500 will be seen to­day. The rest will have to come back to­mor­row.”

“You have to be kid­ding!” yelled a frus­trated woman be­hind Matello. “I have to do this all over again?”

Matello’s eyes filled with tears. She had been waiting 10 hours.

A vol­un­teer gave her a wrist­band that would put her at the head of the line the next day. So she drove home in her 18-year-old Jeep, ate din­ner chew­ing only on the right side yet again, and set her alarm.

By 7 a.m. the next day, she was fi­nally in one of the re­clin­ing chairs, with a den­tist point­ing a bright light into her mouth.

She stared up at the arena’s high in­dus­trial black ceil­ing. The whir of drills across the open room com­peted with Billy Joel’s “New York State of Mind” play­ing over a loud­speaker.

Robert Tes­tani, a vol­un­teer den­tist from Ca­tonsville, Md., ex­am­ined Matello and checked her X-ray be­fore eas­ing a sy­ringe of Novo­cain into her mouth. He pre­pared to pull her bro­ken mo­lar.

“Don’t worry. This is rou­tine,” he said. He paused and looked around. “Ex­cept for the set­ting.”

Over two days, 116 den­tists treated 1,165 pa­tients, pro­vid­ing $1 mil­lion worth of fill­ings and other care, ac­cord­ing to the Mis­sion of Mercy. Matello was grate­ful. She was told her panoramic X-ray and ex­trac­tion would have cost $600 to $800 in a reg­u­lar of­fice.

She looked at some of the oth­ers who had come here, de­spite work­ing for a liv­ing cut­ting down trees, build­ing homes, mind­ing a town li­brary, run­ning small busi­nesses.

“We are not staying home, not sleep­ing and liv­ing off the gov­ern­ment,” she said.

She won­dered why there wasn’t a bet­ter sys­tem for peo­ple like her. She tried not to look at the 51-year-old truck driver ly­ing next to her who had three teeth pulled, his mouth stuffed with bloody gauze.

“I am try­ing to think that this is not de­mean­ing,” she said as she cleared the chair for the next per­son in line. “But it is. It’s like a Third World coun­try.”

PHO­TOS BY LINDA DAVIDSON/THE WASH­ING­TON POST

LINDA DAVIDSON/THE WASH­ING­TON POST

TOP: Vita El­liott and Ed­ward Hall, both 63, wait in line out­side the clinic in Sal­is­bury. BOT­TOM: Den­tist Robert Tes­tani holds Dee Matello’s head as he ex­tracts a mo­lar that broke years ago. Matello de­cided to forgo treat­ment at the time be­cause of con­cerns about cost.

Matello, at her home in Lau­rel, Del., tries to floss a bro­ken mo­lar she needs pulled. She re­ceived treat­ment for the tooth at the clinic the next day.

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