
America’s dental-health divide - endswapper
http://www.washingtonpost.com/sf/national/2017/05/13/the-painful-truth-about-teeth/?hpid=hp_hp-top-table-main_rigged-teeth-1109am%3Ahomepage%2Fstory
======
pnathan
I'm sure part of the deeper issue is that preventative care is not really
popular in the US among many, along with far too many sweets. Unfortunately,
even if that changed overnight, tomorrow we'd still have the exact same
problem.

Systemically, we have to consider the costs of dentistry and why they are
high; we have to consider the hand of the insurance company and their price
regulation; the costs of materials; the costs of running a small office &
regulatory compliance of same; the costs of dental school; and more. This is
largely an exercise in system thinking and determining which lever is most
effeciacious in improving public health outcomes. Insurance regulation is a
narrow way to affect costs without disrupting the choices dentists and
patients have made in their life regarding location, choice of careers, etc.

Grew up poor, but we had floridated mouthwash to help cope with well water,
and my parents made _sure_ we hit the dentist 2x a year for cleaning &
sealants. I wonder if the cost curves for dental care are different now, 20
years later. I'm very grateful to them for taking me to the dentist as
diligently as they did.

These days I have dental insurance, but still do the 2x/year clean.

~~~
mancerayder
There's this seemingly unspoken assumption that fluoridated drinking water has
dental properties worthy of whatever other risks it could have. I don't know
either way, in fact I'm very curious for a trustworthy source, not of water
but of evidence.

Anecdotally, I always drank bottled water growing up in the US. I also never
had a cavity. Is it genetic? Both of my parents have terrifying teeth issues.
Is it diet? Partly - thanks to my mom, I was never obsessed about sweets.

Anecdotes aside, why does fluoride belong in drinking water?

~~~
mindviews
I see a couple of other responses here, but let me address why fluoride
belongs in _drinking water_

Fluoride belongs in drinking water in much the same way iodine belongs in salt
---it's an extremely cheap, low-risk, and effective way to improve public
health. Read some of the references for more details
[https://en.wikipedia.org/wiki/Water_fluoridation#Effectivene...](https://en.wikipedia.org/wiki/Water_fluoridation#Effectiveness)
but the short version is that fluoride is safe and effective and because it's
so widespread in use, even if you only drink bottled water you're probably
getting secondary exposure from other food/drink sources. And if you brush
your teeth regularly with a fluoride toothpaste, then you've got that delivery
mechanism covering you as well. In the end, the public health benefits are
there because fluoridation is pervasive and hard to avoid. By similar
argument, you probably also don't have an iodine deficiency because of all the
iodized salt in use.

This is interesting because people relying on anecdotal evidence is pretty
much the same failure mode for why so many people don't recognize the
importance of vaccination. Because it's so pervasive in the US (and other
places) it's easy to find stories of "I wasn't vaccinated and I didn't get
sick" or similar "I didn't X and Y didn't happen" but it's not just the
primary exposure, but all the secondary exposure and effects that also play an
important role in public health efforts.

~~~
mancerayder
_fluoride is safe and effective and because it 's so widespread in use, even
if you only drink bottled water you're probably getting secondary exposure
from other food/drink sources. And if you brush your teeth regularly with a
fluoride toothpaste, then you've got that delivery mechanism covering you as
well. In the end, the public health benefits are there because fluoridation is
pervasive and hard to avoid. By similar argument, you probably also don't have
an iodine deficiency because of all the iodized salt in use._

So, I don't think you're factually wrong in most of what you said. But I have
to say, you're saying that it's pervasive in other sources besides tap water
(since you raise other food/drink sources), but still in your first sentence
asserting that it belongs in drinking water.

So I ask you, if these other sources of beneficial fluoride exist (like our
toothpaste, or even food/drinks), why would it need to be added to the
drinking water?

And why, of all things, would they choose fluoride to add to the drinking
water, and not the myriad other minerals/vitamins we're deficient of. I know
that's proposterous to imagine - but fluoride somehow made it.

~~~
extra88
The secondary food/drink sources contain fluoridation because they're prepared
using tap water. If you don't drink tap water, you'll still get some exposure
but if you take the fluoride out of the tap water, you won't. If literally
everybody brushed their teeth with fluoride toothpaste, I don't know if adding
it to the water would still be worthwhile; it might be good for very small
children before they have enough teeth to start brushing.

As already stated, fluoride is cheap and safe in the water. Other substances
aren't cheap, have risk of overdosing (possibly only for people with
sensitivities), or are readily supplied through diet. Some substances may also
not be transportable through a water system because they too readily bind with
others or don't remain in suspension long enough to reach your faucet.

------
habosa
The article is pretty poorly written and lacks focus, but the problem is real.
Dental health is just health, it shouldn't be this separate part of our
system. It's also one of the few parts of your health a stranger can judge
from the outside. I can't see if you have arterial plaque but I can tell if
you don't clean your teeth.

I have two dentists in my family and when this topic comes up they focus on
the Medicaid issues presented in the article. Medicaid reimbursement rates
haven't budged in years and​ for whatever there's a much higher no-show rate
among Medicaid patients. The end result is there's no incentive at all for
dentists or orthodontists to help these people who need it most.

~~~
blablabla123
> I can't see if you have arterial plaque but I can tell if you don't clean
> your teeth.

Maybe if you are a dentist. Having not the best teeth myself, people sometimes
think I don't clean my teeth.

I think tooth health is actually similar to other parts of human health. If
you maintain a healthy lifestyle from childhood on, do all recommended
inspections, then everything is likely to be good. However most people don't
know better or just don't do better.

Politicians would do good in truly reforming a health system. I'm only aware
of one example where efficiency got a 10x improvement, which is the Chinese
one in the 50s. It's cool to complain about [insert politician] about cutting
health cost but add the end of the day it's not how to solve the problem. Too
sad Trump is intellectually too limited to make real cost savings.

~~~
blablabla123
Not sure why that's downvoted but I see that health care is a highly complex
topic. On the one hand everybody knows (at least I hope so) that all the care
systems are going to be more and more expensive every year. On the other hand
people still want to maintain highly unhealthy lifestyles because those are
more fun. But I think nobody is ready for a paradigm shift yet, that would
allow for cheaper health, higher coverage and better health.

------
firasd
After I read in 2011 that funk musician Bootsy Collins' nephew died because he
couldn't afford antibiotics for a tooth infection the fact really stuck with
me. It really puts in perspective statements like “Nobody dies because they
don’t have access to health care”, said by a politician just last week.

~~~
pkaye
Walmart has Amoxicillin, a commonly prescribed antibiotic for tooth infection
for $4 for a month supply. [https://www.walmart.com/cp/4-dollar-
presscriptions/1078664](https://www.walmart.com/cp/4-dollar-
presscriptions/1078664) They have quite a few common generics all for the same
low price. The generic medications are often times cheap but the catch is you
need a doctor's prescription and that is where it costs.

~~~
konschubert
I'm not from the United States, so I have to ask: is amoxicillin available
without prescription?

~~~
kakarot
Online, you can purchase fish or cow antibiotics with purportedly the same
stuff, but these are not medical grade and I have heard stories (not sure if
it is big pharma propaganda or not) of dangerous impurities.

It is probably best for species survival that we keep antibiotics behind a
wall. But only if that wall comes down when people need it, not only when they
pay the toll.

------
eddieone
I resell a lot of dental equipment. The tools are incredibly cheap now and the
composites are becoming increasingly more advanced and easy to use. It's all
coming from China where things have become deregulated. Also, aligners are now
made using machine learning, so those are more affordable than ever.
Basically, the tech is there but the regulation in US is lagging as always.

~~~
petra
As someone from inside the field(and other replies are welcomed of course),
let's say you had total regulatory freedom and could control everything - how
would you write the rules, how would the businesses look like, what tech will
be used, and maybe if it's possible to guess, how cheap can the common
treatments(filling/root/crown) get ?

------
bluedino
You need two things for nice, straight teeth: Either good genetics, or parents
with good dental insurance.

Any kid who's parents had money in school had braces. I remember hearing
parents complain/brag about spending $3,000, $5,000, and even $7,000 on their
braces. The other kids? You better hope they came in straight.

Mine came in fairly straight, but like others in my family one of the adult
canine teeth never came through. It's still in my upper jaw. The baby tooth is
still just barely there, and it's shifted my top row of teeth around a little
bit.

The other thing with teeth is you have to take care of them. You have to brush
twice a day, you shouldn't eat things that get stuck in there, and avoid
crunchy things that can break them.

Even though I had dental insurance from work, I skipped out on going to the
dentist after I wasn't living with my parents anymore. And like other hackers,
I lived on sugary, acidic, and caffeinated drinks. Years later I succumbed to
toothaches, finally went to see the dentist, and spent a couple thousand
dollars (with insurance) getting fillings, crowns, root canals, and an
extraction or two - all on the rear teeth that nobody can really see.

Back to the top row of front teeth, I saw a orthodontist about having those
fixed. When you're an adult, insurance doesn't cover braces. So I was looking
at between $10,000 and $12,000 to get it fixed, which would all come out of
pocket.

Now, I don't think everyone has the right to perfect teeth, and you can't
control everything about how they come in. But most people avoid the dentist
until it's too late, they're in pain, need to get in right away, and the fix
is expensive procedures like root canals and crowns. If you go every months (a
regular visit doesn't cost much, even out of pocket) you can fix a lot of
issues while they're cheap and easy to fix.

~~~
eikenberry
> You need two things for nice, straight teeth: Either good genetics, or
> parents with good dental insurance.

Dental insurance doesn't help much with braces. Every dental plan I've seen
maxes yearly dental coverage at $1500 or less. And at least one of those is
known for having one of the best benefits packages. So while it helps, most of
the cost will be out of pocket. So really either way you need $$$.

~~~
bluedino
My crappy Delta Dental plan covers 50% of Ortho up to age 19

~~~
LyndsySimon
I've never seen a dental plan without a yearly maximum benefit.

------
jbuzbee
Every time I hear about bad dental care, I think about these articles that
were floating around ten years or so ago:

[http://www.nytimes.com/2006/05/07/world/europe/07teeth.html](http://www.nytimes.com/2006/05/07/world/europe/07teeth.html)

Ouch!

------
andybak
I'm British and yes - I have what you over the pond like to call "British
teeth". I do wonder if it's fairly healthy from a social mobility standpoint
that we haven't taken quite so passionately to US views on the value of
cosmetic dental procedures.

It's one less way to spot at a glance whether someone has a large disposable
income.

------
alistproducer2
I used to have cavities every time I went to the dentist. Then I got a timer
from the dollar store and use it to time 2 minutes. Use floss at night and the
timer twice a day. No cavities in 3 years.

------
systemtest
In the Netherlands, dental is outside of the national health care plan. And we
are still doing fine. I pay all my dental bills out of pocket because its
cheaper than insurance(#). So it is possible to have great national dental-
health without having a national health care plan.

(#) We have plans that compensate up to 75% of €500 per year, but it will cost
you €250. Doesn't really make sense.

~~~
konschubert
I'm down voting because you are saying: "This policy is good because it is
good for me."

You are saying "we are doing fine", but you provide no evidence and no
explanation for it.

Social policies should be evaluated by their impact on everybody in the
society, not just on you.

------
louithethrid
One thing nobody taught me was that stressors and psychological problems can
ruin your teeth. I spend years without nightguard- and bear the marks of that.

If your dentitst mentions gnawing marks on your teeth- get a nightguard as
soon as possible. Also get rid of the stressfull situation.

------
ciconia
> But since he took office, Trump has focused on so many other things... that
> Matello has begun to wonder about his promises to the working class: “Was he
> just out to get our votes?”

This is truly sad. So many people put their faith in that con artist.

------
droithomme
The article seems to blame Trump for dental problems. This is strange since
none of the described problems have anything to do with Trump. Adult dental
coverage is not a required part of ACA plans so changes to ACA can't make it
worse as the article implies.

~~~
anigbrowl
You're skipping over the art where Trump promised voters like this an
affordable and comprehensive solution to their healthcare needs. That's a
matter of fact, and refuting it with legal technicalities is exactly the sort
of thing that make his voters feel they've been had.

~~~
mjevans
They were (had / taken advantage of). Does anyone at all remember even an
outline of a real plan for /HOW/ that campaign promise would be realized? All
I remember is marketing puffery, pure factless, baseless, hot air.

Come to think of it, I can't even remember what Hillary was running on. Bernie
was someone I could believe in and wanted to vote for.

~~~
pnathan
Hillary would have expanded and improved Obamacare, basically.

Relevant to this article, a goal was to add a public option; along with adding
optional Medicare coverage down to age 55 and significantly enhancing the
ideas of "community health centers", which are currently pretty effective.

Of course, the goals of a product often conflict with implementation realities
in the process of getting it done, so not all the features would have landed,
I think. Er, I mean political candidate & campaign promises, not product &
features. What _was_ I thinking?

That you don't remember Hillary's policy is an artifact of her marketing
combined with the media's coverage, which was not on her policies.

~~~
droithomme
I would like to see a reference to Hillary promising to add dental coverage to
Obamacare. Thanks in advance.

I would also like to see a reference to Trump making the same promise as
anigbrowl has claimed. Thanks in advance.

It's interesting that several people in the thread are suggesting that adult
dental coverage was going to be part of the ACA insurance overhaul proposals
by both Hillary and Trump. I can find no reference to either candidate making
such a proposal. Those claiming they did make these promises should provide
references showing so.

~~~
pnathan
> I would like to see a reference to Hillary promising to add dental coverage
> to Obamacare. Thanks in advance.

Can't give that, sorry. I wanted to specifically provide the high-level claims
Hillary was making, as GP couldn't recall her promises. My source is the
campaign promise book, _Stronger Together_. Dental is not mentioned in the
area I surveyed.

A more policy oriented remark by HRC is found here:

> We need to address the lack of access to primary health care, dental care,
> and mental health care by catalyzing partnerships between public health
> departments, health care systems, and community-based organizations. As we
> do, we must promote integrated mental health care, and enforce insurance
> coverage parity requirements to ensure that mental health care is not
> siloed.

[http://www.nejm.org/doi/full/10.1056/NEJMsb1612292](http://www.nejm.org/doi/full/10.1056/NEJMsb1612292)

Clearly dental was not a headline coverage promise, unfortunately. I'm not
sure it would have mattered....

With respect to Trump's promise:

> DAVID MUIR: Let me ask you, Mr. President, about another promise involving
> Obamacare to repeal it. And you told The Washington Post that your plan to
> replace Obamacare will include insurance for everybody. That sounds an awful
> lot like universal coverage.

> PRESIDENT TRUMP: It's going to be -- what my plan is is that I wanna take
> care of everybody. I'm not gonna leave the lower 20 percent that can't
> afford insurance. Just so you understand people talk about Obamacare. And I
> told the Republicans this, the best thing we could do is nothing for two
> years, let it explode. And then we'll go in and we'll do a new plan and --
> and the Democrats will vote for it. Believe me.

Source: [http://abcnews.go.com/Politics/transcript-abc-news-anchor-
da...](http://abcnews.go.com/Politics/transcript-abc-news-anchor-david-muir-
interviews-president/story?id=45047602)

~~~
droithomme
Thank you, I appreciate that reference. To summarize my reading, Ms. Clinton's
statement to the NEJM does in fact show what has been claimed, that dental
coverage was to be considered as part of ACA improvements Ms. Clinton wanted
to work on. She even discusses dental specifically in a letter discussing how
to "Improve the ACA". On the other hand, Mr. Trump's statements likewise don't
seem to specifically support addressing problems with dental coverage and
accessibility. Therefore it is reasonable to take the position that the
election of Trump did in fact reduce the chances of improving dental care in
the US, is it was part of Ms. Clinton's plan, but not Mr. Trump's.

~~~
pnathan
I believe Trump made some pretty grandiose promises. Now, he may have
_intended_ in good faith to follow through, but he harnessed his star to the
Republican party, which has systematically opposed Obamacare since it was
announced. Therefore, unless Trump decides to be genuinely maverick and jump
to the Democratic policies, it will be unfortunately unlikely that his
promises would be followed through. I'm kind of curious to see if Trump does
that - many of the desperate voters profiled in the original article voted for
him on that kind of basis.

------
massysett
Turns out this is another article about Trump. Now it seems so much press has
to twist any possible story and make it about Trump or in this case "Trump's
America." It seems WaPo is trying to make up for missing the possibility that
Trump would actually win. But this article just underscores how they missed it
in the first place: the issue of people not having dental care is not a
standalone issue worthy of journalistic attention. Instead, the third
paragraph has to say that someone voted for Trump, with a later paragraph
saying someone voted for Obama. To WaPo these issues don't exist outside of
the lens of presidential politics I guess.

Unfortunately it seems WaPo has merely gone from ignoring some parts of
America to simply taking a few safaris there to report on the exotics who
voted for Trump and have rotten teeth. WaPo will tire of its safari soon
enough and return to its usual class blinders, like reporting about "how hard
it is to get into a good college" and then quoting the anxieties of a bunch of
upper middle class kids from the Virginia and Maryland suburbs, and somehow it
won't be worth mentioning that their parents voted for Clinton.

