“Good” Teeth: American Dental Care and Classism

I used to hide my own teeth. It started in fourth grade during spring photos. When my big adult teeth were just coming in, I gave a toothy smile as I leaned on a white picnic table fragment in front of a backdrop of someone else’s nice country porch. My classmates snickered. My teeth were too big to come in straight; they fought against each other and pressed in at odd angles. One of my bottom teeth has been making a steady retreat into my throat since grade school, and while my two top front teeth are well positioned (centered anyway), the teeth flanking them turn in. When I’m photographed from the side with my guard down, it’s apparent how much my teeth flare out away from my face, but over time I’ve learned how to hold my bottom lip up and out so that some people won’t know.

Photo of the author as a child.

I want, and have wanted so badly, to look like I had worn braces, something my family could never afford for my siblings or myself. It felt for a while like everyone at middle school and high school had braces in the past or present. So many people’s parents had straight, white, Hollywood teeth. I started buying generic drugstore whitestrips, but even those aren’t cheap and they didn’t really help me pass for middle class either. My teeth gave me away. Of the myriad of physical insecurities I developed in grade school, it was my uneasiness about my teeth that most reeks of class anxiety. And while nearly every actor and musician on television or Instagram flaunts straight white teeth, most families in the United States can neither afford braces nor regular visits to the dentist at all. It seems that “good teeth” are defined by a cosmetic appearance that is expensive to maintain or create, but “bad teeth,” which can be defined in more medical terms and are often symptoms of poverty, may come at a higher social cost.

Dental care in the United States is not optimal. According to the National Association of Dental Plans, only about 77% of the population of the United States has dental coverage, with over 51% of that population receiving coverage from public programs. This sounds much better than it is: 78.1 million Americans have NO dental plan. That means no regular checkups, no root canals, no wisdom teeth removal, no preventative care, and of course no orthodontry or cosmetic dentistry. Preventative care and maintenance can prevent heart disease; they can prevent the wholesale loss of teeth, years of pain, and social stigma. One in five low-income adults surveyed by the American Dental Association reported their teeth being in poor condition. And 56% of low income individuals stated that “life in general is less satisfying” due to the condition of their teeth, whether because of pain, social anxiety, inability to interview for a job, or low self-confidence.1 Despite this, the rate of poor adults visiting the dentist has dropped in the last decade.

Lessons in the care of the teeth used in American Red Cross Child Welfare Exhibition. (Library of Congress)

In a 2010 article on the origins of “bad teeth” as a symptom and concept, two University of Connecticut professors concluded that fear of the dentist, rather than hesitation over cost or lack of insurance, was the primary reason for low-income individuals to avoid the dentist and, therefore, end up with the fabled “bad teeth.”2 This conclusion, which I respectfully disagree with, does not surprise me because the same article also claimed that bad teeth rarely impact the lives of an individual and  constitute only a “hidden” problem.3 The authors of this study noted that their work was most representative of their area in Connecticut. However, similar misunderstandings that “fear” of the dentist is the major hurdle in accessing basic dental care are littered throughout both academic literature and popular media.

When the fashion and lifestyle site Refinery29 covered the Jones sisters’ episode of Netflix’s Queer Eye, they made a similar claim. In one of the most emotional moments of the season (which is saying a lot), the Fab Five took Mary Jones to get her teeth fixed. I cried. This woman reminded me of members of my family who devised ways of holding their lips as they talk to keep their teeth hidden. This was someone normal; this was a working-class woman getting dental care that she needed. Dr. Holli Caswell, the dentist who performed the restoration, is quoted in Refinery29 as listing “fear” of the dentist and being overwhelmed as reasons Mary had been unable to undergo this life-changing procedure for the previous several decades of her life. She promised that dental care doesn’t have to be scary. Another Refinery29 article about veneers (sponsored by cosmetic dentist extraordinaire Michael Apa) also shouted from the headline that going to the dentist doesn’t have to hurt!

I know — and most people without dental coverage know — that going to the dentist does not necessarily hurt. Uninsured and low income individuals certainly have the same reservations about having sharp metal instruments put in their mouths as the rest of the population, but the fear of not being able to afford a procedure recommended while you’re at the dentist office is greater. Even for those of us lucky enough to have some form of coverage, anything more complicated than a cleaning can quickly become unaffordable. Medicaid states that children’s dental care must fulfill the purposes of restoring the teeth, maintaining dental health, or relieving pain and infections. The EPSDT (Early and Periodontic Screening, Diagnostic and Treatment Benefit) says that any service deemed medically necessary must be performed and covered, but individual states determine the medical necessity of treatment. As another barrier, it can often be difficult to locate a dental healthcare provider who accepts Medicaid. With these factors in place, many families may put off dental visits, even those they know are necessary, because of fear that Medicaid will not cover the recommended procedure. The path of least resistance — often the only option — is to avoid dentistry and orthodontics altogether.

The biggest trends in dental care in the U.S. have next to nothing to do with health. Teeth whitening, invisible braces startups, dental veneers and false teeth are all soaring in popularity. These trends have nothing to do with the prevention of bad teeth, only the maintenance of good teeth, and the confidence that comes with them. Veneers alone have seen 4 billion dollars in revenue growth in 2018.  Advances in technology that allow for more realistic dental reconstructions have contributed to the rise in popularity of veneers in the last few decades. However, the rise of influencer culture has introduced the idea of veneers to many consumers who may have never considered the imperfections of their smile previously. Lifestyle bloggers, such as Amber Fillerup Clarke and Jennifer Lauren, TV stars, rappers, and Instagram models have made cosmetic dentistry an incredibly popular (and profitable) form of SponCon.

The price of straight white teeth can be one of the most cost-prohibitive standards of beauty in the United States and it is increasingly presented as a norm in the media. Jordyn Woods is a clothing designer, model, actress, and former best friend of Kylie Jenner. For years, one of her defining characteristics as a model was a significant gap in her front teeth, a feature that she celebrated and defended. Six months ago, Woods closed the gap at one of LA’s many celebrity cosmetic dentists, prompting backlash from many of her fans. Woods is hardly the first celebrity to undergo a dental transformation after life in the public eye. There is no debate that a straighter, whiter smile changes how a person is treated. The fact that so many celebrities do casually get veneers doesn’t shock me at all and perhaps I even envy their ability to undergo these treatments. In 2014, journalist Sarah Smarsh called it “psychological hell” to have “poor teeth in a rich country,” and it’s a hell millions of Americans find themselves in. We may all wish that, like Cardi B, we could “get a bag and fix (our) teeth,” but we’d probably also settle for affordable routine dental care.

Notes

  1. Oral Health and Well-Being in the United States,” Oral Health & Well-Being – Health Policy Institute State Fact Sheets (American Dental Association, 2015). Return to text.
  2. W. Handwerker and Stanton Wolfe, “Where Bad Teeth Come From: Culture and Causal Force,” Human Organization 69, no. 4 (2010): 402, 404. Return to text.
  3. Handwerker and Wolfe, 401. Return to text.

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2 Comments

Christina E. Mitchelli

Bravo! Bravo! Bravo!

I was born without a permanent eye tooth on the left side of my mouth. I had dental care growing up, so from x-rays I knew there would never be a permanent tooth that would come in. For years…for as long as I could…I nursed the baby tooth that held the spot.

Fast forward to my mid-20s in the early 1990s. At that time I was a single mother who just got off of welfare by completing an associates degree and finding a entry-level job at a nonprofit which offered no health insurance. At work one day, I bit down and out came the tooth. The cost at that time for any repair was too much for me to even fathom. For the next 25 years, at times having dental insurance and long periods between without, I learned to hold my mouth so the gap could not be seen. I simply could not afford repair. Finally at 48, with dental insurance and, ironically, with modern technology which significantly lowered prices for partials, I walked out of the dentist’s office being able to smile. My partial is my saving grace.

I would like an implant. That permanent remains cost prohibitive. I am told to fix my teeth correctly requires braces as well as an implant. The estimated cost is over $5,000. As I struggle to save the money, the prices continue to increase. It seems like a losing battle. The worst part for me to accept is my impediment is of no fault of my own. I took care of my teeth as best I could. The missing permanent tooth is the way I was born. Yet, I know how much it impacted the way others…especially potential employers…saw me.

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