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Nothing to Smile About

The number of teeth in this country grows, even as the number of dentists shrinks. Guess who gets squeezed out.


A dentist works on a patient at the Remote Area Medical Health Clinic at the fairgrounds in Wise, Va.(AP Photo/Steve Helber)

CORRECTION: An earlier version of this article gave the wrong name for the American Dental Association.

HAZARD, Ky.—MacKenzie Doolittle, 9, isn’t afraid of the dentist. As she climbs into Dr. Nikki Stone’s exam chair, she chats amiably and explains that she knows all about plaque, cavities, and the importance of brushing her teeth. She started brushing every morning and afternoon after hearing in school that, if she didn’t, she could have “all false teeth” by the age of 28.


“I decided that I didn’t want that,” she says.

Thanks to an enterprising local public-health provider, Doolittle is the rare rural child with access to free dental services that come to her. Every year, a mobile van—donated by the Ronald McDonald House and affiliated with a nearby community health center—visits Doolittle’s elementary school so the dentist can clean teeth, apply sealants, and dispense fluoride treatments.

But when the second-grader opens her mouth, it’s clear she’ll need more than that. Despite her newfound vigilance, she has nine cavities, and Stone can’t fix them. The traveling clinic offers free care, but its mandate is limited to prevention: Kids who need cavities drilled or teeth pulled have to go elsewhere. And in Hazard, like many other rural areas, that’s not easy.


The United States faces a shortage of dentists that is particularly acute in poor, rural regions. Huge pockets of the country have few (or no) providers. The federal government counts 4,503 mostly rural regions where more than 3,000 people share one dentist, making it tough for many residents to find someone to fix their teeth.

For more than 100 years, dentistry has run on a separate—and more laissez-faire—track than the rest of medicine. Dentists have their own schools and treat patients in their own offices; fewer laws and regulations govern the field. Insurance plans typically demand high co-pays and limit their payouts for invasive procedures. About half of all dental expenses are paid out of pocket, compared with less than 10 percent of costs in the overall medical system.


In some ways, the free market has worked: People do not drive up insurance rates by seeking frivolous procedures. Patients tend to shop around for care, and prices vary according to local economies. The rate of dental inflation, although higher than the rate for the economy overall, is lower than the rate in medicine, which is typically several points above the growth rate of the gross domestic product. (You don’t hear policymakers complain about the burden of “runaway” dental costs.) And because of other advances, American mouths are much healthier than ever before. Increased medical literacy, fluoridation of public reservoirs, and public-education campaigns about tooth-brushing have helped more Americans hold onto their teeth. In 1958, 55 percent of those over 65 had lost all their teeth; today, the number is just 25 percent.


But overall progress has not ensured broad access to dentistry. “It’s very much a free market, with a greater spread between the haves and have-nots,” said Burton Edelstein, a professor of dentistry at Columbia University and the founder of the Children’s Dental Health Project. Dental insurance is much less widespread than medical insurance; 130 million Americans lacked dental coverage in 2009, but only 50 million lacked medical coverage. And with most payouts capped at $1,000 to $2,000 per year, insurance can’t cover much beyond basic services. (So even if Doolittle had insurance, which she doesn’t, it might not pay for the care she needs.) Medicare does not pay for dental care at all—during its creation, dentists feared price-fixing and lobbied against inclusion—so 70 percent of seniors lack any dental coverage, according to an Institute of Medicine report. Medicaid, the government program that insures poor children (and a few adults), also fails to provide meaningful dental access for many of its beneficiaries: The program pays dentists so poorly for treatment that only about 20 percent of them see Medicaid patients.

The result is a crisis. Dental disease is the largest unmet health need in the U.S. among both children and adults, according to the Pew Children’s Dental Campaign. The worst-off are the poor, the young, the old, and those in rural America. Dental disease is among the most common reasons that children miss school. It’s the most common medical reason that soldiers can’t deploy. It is a leading cause of emergency-room visits in several states. For proponents of a freer health care market, who want patients to be motivated by financial incentives to shop around and avoid “unnecessary” care, the dental system offers a glimpse of how such a system might work.


The business of medicine has changed substantially in recent years, driven mainly by consolidation: Large companies typically own several hospitals, and doctors increasingly close their solo practices to join large groups. But the business of dentistry has remained unchanged for generations. According to the American Dental Association, more than 80 percent of dentists still practice alone or with one partner, making them small-business owners. They have to keep the lights on and generate enough revenue from local patients to support operation in good times and bad. Unlike titanic medical conglomerates, dentists don’t have an economy of scale or the ability to spread financial risk.

This article appears in the May 5, 2012 edition of National Journal Magazine.

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