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Magazine / HEALTH

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)

photo of Margot Sanger-Katz
May 3, 2012

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.

The basic incentives push providers toward affluent communities. Insurance pays for only a fraction of major work, and more than one-third of Americans have no coverage at all, so dentistry is often a cash business. Accordingly, practitioners need patients with money. “Dentists establish practices where people can pay for dental care, and they do not practice where people cannot afford to pay for care,” says David Nash, a professor of dentistry at the University of Kentucky.

“I felt like I was standing here on the line of the fire with a squirt gun.”—Dr. Nikki Stone

The 2010 Affordable Care Act, which aims to make the medical system work better, barely deals with dentistry. It deems dental coverage an essential part of any health plan for children, but regulators have yet to spell out what insurers must cover to meet that definition. The law expands existing loan-repayment funds for dentists who relocate to underserved areas, but it offers no expansion of dental coverage for adults and doesn’t try to integrate dental health into the larger health care system.

It also does nothing to fill a growing gap: The improving health of Americans’ mouths helped close seven of 61 dental schools in the 1980s and ’90s and pushed many others to scale back. Eventually, that meant 2,000 fewer dentists every year, a 33 percent drop in supply, just as an older generation of dentists started retiring. More dentists leave their practices every year than graduate from dental school; at the same time, more adults are retaining their teeth into old age, requiring ongoing care to combat decay, periodontal disease, and other problems. “If you had no teeth, you had a set of dentures, and that took care of you,” says Richard Valachovic, the executive director of the American Dental Education Association. Not anymore. All those extra teeth make the dearth of dentists more troublesome.

Unlike in medicine, where mid-level professionals such as nurse practitioners and physicians assistants are proliferating to fill shortages in primary care, dentists have fought aggressively to prevent new types of workers from entering their turf and competing for patients. Advocates and state legislators are moving to establish a new type of provider, the dental therapist, who could provide preventive care and fill children’s cavities without receiving a full debt-inducing dental education. Alaska and Minnesota have started certifying such therapists, and other states are considering it. The American Dental Association, however, argues that accrediting such providers will create a two-tiered care system. It’s also unclear if these cheaper providers would be any more altruistic or rural-minded than dentists, considering that they would practice in the same private-payment system.

In response to the unanswered demand for care, seven dental programs have opened since 2001; about 4,800 new dentists now join the ranks each year, up from 4,000 at the schools’ nadir. But few of them are gravitating toward the areas that need them most. Molly Housley, a third-year dental student at Kentucky, grew up in Hazard and likes the idea of returning. But she thinks she’s more likely to practice in a larger, more affluent community, where she can build a stable practice and maintain ties with an academic center. “I think most people want to set up near a big city,” says Housley, 24. “I wish there were more incentives to go into rural areas.” Some people joke that dental schools should admit only students who have hunting or fishing licenses, to boost the number of rural providers, Valachovic says. But as long as the financial math doesn’t work, rural recruitment will be a tough sell.


Charitable providers, like the mobile clinic that Stone oversees, have tried to plug some of the holes, but they can’t fix a systemic access problem. Most rural and inner-city communities have no special roving office to serve Medicaid beneficiaries and the uninsured. About half of all children covered by Medicaid have not seen a dentist in the past year. Even in places where children can get school-based care, such as Hazard, Ky., adults without cash have few options. And those who can pay must fight geography: 47 million Americans live in federally designated “dental shortage areas,” where there simply aren’t enough dentists practicing to care for local populations. “The people who are not getting dental care now are the most vulnerable people in this country,” says Sen. Bernie Sanders, I-Vt., chairman of the Senate Subcommittee on Primary Health and Aging, which recently held a hearing on dental access.

Across the country, people with toothaches and abscesses are turning to hospital emergency rooms for lack of a better alternative. But doctors aren’t trained to pull teeth or fill cavities, so they can do little more than prescribe painkillers and antibiotics and refer patients to a dentist. In February, the Pew Center on the States reported a 16 percent increase in preventable dental emergency-room visits from 2006 to 2009. At Johns Hopkins Hospital in Baltimore, the emergency department has seen a 14 percent jump in just the last year. “Most of the patients that we see with this complaint don’t just have one tooth that looks like maybe it has a cavity; they will have a mouth full of decay,” said Dr. Rita Cydulka, the vice chairman of emergency medicine at the MetroHealth Medical Center in Cleveland and a spokeswoman for the American College of Emergency Physicians. “It’s frustrating that they have an acute or chronic problem that we know we can’t solve.”

Research increasingly links oral health and overall health. Dental disease is correlated with bad pregnancy outcomes, heart disease, and other serious illnesses. And studies haven’t even measured the way that painful or missing teeth can contribute to unhealthy diets that promote obesity, diabetes, and other chronic diseases. Every few years, the country gets a shocking reminder of how the mouth is connected to the body when a patient dies from a brain infection linked to an abscessed tooth. The story of Deamonte Driver, a Maryland 12-year-old who died after his mother tried—and failed—to get him care for his dental emergency, was national news in 2007. (Now Prince George’s County, where Driver lived, has a mobile clinic like the one in Hazard that tours schools and supplements the private system.)


Stone, the dentist who runs the Hazard-based mobile unit, grew up in the Kentucky mountains and wanted to return once she had paid her student loans. She works for a federally qualified community health center—one of 1,124 clinics funded by Washington to provide medical and dental care to underserved communities. That allows her to treat children who have Medicaid or no insurance without worrying about financial stability. But Stone’s situation is rare in the profession; the average new dentist, after all, graduates with debt exceeding $150,000 and then must take out additional loans to purchase or build a practice. Young dentists, sensibly, gravitate toward jobs that pay the bills.

Stone, 40, knew that children in Eastern Kentucky weren’t getting enough dental care, but she was still staggered by the prevalence of dental disease when she began examining them in 2004. Large numbers of the kids had never seen a dentist. Half had untreated tooth decay, and nearly 20 percent had urgent needs—more than six cavities or an active abscess. She and her staff “cried a lot,” she recalls. Crisscrossing four counties in her van, she painted fluoride on all the teeth and sent notes home with the children who needed immediate attention. In the early years, only 8 percent of those youngsters with urgent problems got the care they needed. The job was like fighting a forest fire on a mountain, she says. “I felt like I was standing here on the line of the fire with a squirt gun.”


A few dentists practice nearby, including one whose office is in the “mall” on Hazard’s deserted Main Street. But Stone doesn’t know anyone local who treats Medicaid children with complex needs. She ultimately recruited a dentist from 50 miles away. Seth Hyden spends one day a week at the Hazard Appalachian Regional Healthcare Medical Center, where he puts his patients under general anesthesia and fills cavities. He gets Stone’s neediest cases, although sometimes the patients don’t show. MacKenzie Doolittle, for instance, doesn’t qualify for Medicaid, which would have covered Hyden’s hospital-based care; that may explain why she didn’t make her scheduled appointment.

Over time, Stone has increasingly focused her attention on children in the Head Start program. Her clinic travels to elementary schools annually, but she visits day-care centers three or more times a year. There, she hopes to arrest decay before it sets in by applying fluoride to children’s teeth as they lie on her lap. “We’re the ones over here on this mountain that’s not on fire, trying to soak it down,” she said. She hopes that prevention will lead to better population health, even if she can’t help every kid who develops dental disease.

On this Monday, she gets a glimpse of what happens when prevention fails. Two brothers step into her van, which is parked outside A.B. Combs Elementary School. Both have black baby teeth rotted nearly to their gums and molars with visible pits. Nick Owens, 9, has 15 cavities and an abscess above a front tooth. When Stone presses on the swollen site of infection, it oozes pus. Nick’s brother Coy, 8, has seven cavities and an adult tooth growing behind his gum line. He’s lost so many baby teeth prematurely that the remaining ones have spread out, leaving no room for the adult replacement that later arrived. Four other adult teeth show telltale chalky white spots, early signs of decay.

“Are you a pop drinker?” Stone’s hygienist, Pam Cornett, asks Coy.

“Yup,” he says. “Dr. Pepper.”

Nick, sitting at the edge of the chair with his arms across his chest, chimes in. “My mom says after school, she’s going to take me to the dentist,” he says. The family will try, anyway: The Owens brothers, after all, live in rural America.

This report is part of an ongoing series supported by a fellowship from the Association of Health Care Journalists.

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