Coming Soon: The Big Book of American Smiles

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The New York Times reports:

Previously unreleased figures from the Centers for Disease Control and Prevention show that in 2003 and 2004, the most recent years with data available, 27 percent of children and 29 percent of adults had cavities going untreated. The level of untreated decay was the highest since the late 1980s and significantly higher than that found in a survey from 1999 to 2002.

It's hard to think of a more obvious class signifier than bad teeth, especially as it grows more difficult to distinguish between income levels by other superficialities like dress. You can't buy a knock-off set of incisors at H&M. And given the correlations between physical attractiveness and financial success, a British smile is likely to reinforce crippling structural inequalities poor kids already face. For this they can thank the dental cartel:

Despite the rise in dental problems, state boards of dentists and the American Dental Association, the main lobbying group for dentists, have fought efforts to use dental hygienists and other non-dentists to provide basic care to people who do not have access to dentists.

Meanwhile, the A.D.A. does not support opening new dental schools or otherwise increasing the number of dentists. The association says it sees no nationwide shortage of dentists, though it acknowledges a shortage in rural areas. Dentists note that in the early 1980s, when schools were graduating nearly twice as many dentists relative to the overall size of the population as they are now, some dentists struggled to keep their practices afloat.

So back when the licensing system was liberal enough to force dentists to compete for patients, some of those dentists "struggled."  Sorry kids, we can't have that. 

NEXT: The Great Protectors

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  1. Aha! So the justification for licensing, at least as far as the ADA goes, is to ensure that dentists don’t have too much competition. Hoo-ha!

  2. Hey, gotta keep those dentist salaries propped up. Suck it up, poor rural people.

  3. The justification for AMA was the same.

  4. This is the sort of thing that, with a sufficient amount of attention, could ridicule the ADA into changing its tune.

  5. Centuries ago, the state blocked medical classes, because they didn’t want corpses defiled. Sigh, the more things change …

  6. This is the sort of thing that, with a sufficient amount of attention, could ridicule the ADA into changing its tune.

    Hahahaha Fat chance chancelikely. The push for ending the ADA rent regime, will never equal the ADA’s commitment to keeping it.

  7. The dirty secret is that being a dentist isn’t really that hard. Filling a cavity is about as complex as refinishing a coffee table. Yet, dental school is nearly impossible to get into and a license to print once you get there. We really don’t need people with elite intelligence to be dentists. Further, most basic dental care like cleaning and filling in small cavities can and should be done by trained dental assistants. It is all a scam.

  8. The guy on the one dollar bill had wooden teeth; why should anyone had any better than that anyway?

  9. John,
    Don’t forget the real money in X-rays and cosmetic procedures.

  10. I suspect that the obstacle for most people is the high cost of dental care. In a rational world, more dentists would equal lower prices. I’m not sure that it would make any difference in this world.

  11. This has nothing to do with insurance. At all. No way.

  12. This has nothing to do with insurance. At all. No way.

    Many insurance plans do not include dental. Many, many otherwise insured people pay out of pocket for their dental care. And even with dental coverage, the plans don’t usually pay for much other than routine care. Most will not pay for a (extrememly expensive) root canal.

  13. I have a dental plan, but my dentist still managed to bilk me for $700 this year. I had some extra work done, but don’t try to tell me they’d still have the stones to charge me $100 just to get my teeth cleaned without the licensing racket.

  14. Dentists…who needs ’em? Also blacks and Jews.

  15. Does this explain that fifth dentist who doesn’t recommend sugar-free gum?

  16. For further reading regarding the situation in Alaska’s Rural Villages start here.

    Key quote from the Times’ article:

    Use of therapists would create a two-tier system where some people have access to dentists, while others must settle for less-qualified practitioners, she said.

    Even if you have insurance, does it cover airfare or a two day boat ride to get to the nearest Dentist? That is the reality of living in the villages here and having ANY form of care is better than none, the ADA be damned.

  17. “This has nothing to do with insurance. At all. No way.”

    I long for the dental care enjoyed by well insured British.

  18. Politely unmentioned here is that fewer jobs theses days offer a benefits package that includes dental. Rising tide that lifts all boats anyone?

  19. The guy on the one dollar bill had wooden teeth

    “W” (the first one) did not have wooden teeth.

  20. Use of therapists would create a two-tier system where some people have access to dentists, while others must settle for less-qualified practitioners, she said.

    As opposed to the two tier system where some people have access to dentists and some people get to have woefully bad teeth and awful mouth pain without any kind of treatment! Brilliant!

  21. OK, here is something to smile about.

  22. Eryk Boston | October 11, 2007, 1:36pm | #

    Does this explain that fifth dentist who doesn’t recommend sugar-free gum?

    I nominate Eryk’s post as thread win of the year.

  23. Good H&R piece. I was wondering why dental work is so ludicrously expensive.

  24. It’s not class, it’s bottled water and sodas.

  25. This has nothing to do with insurance. At all. No way.

    Insurance has a lot to do with it, but so does ADA meddling.

    But I have to admit, I’m a bit surprised about Reason‘s take on it. The general consensus from other “libertarians” on this issue is that people who can’t afford dental care brought it on themselves by eating too much candy and not brushing enough.

  26. Darn it, forgot the italics tag.

  27. “people who do not have access to dentists.”

    What – do they have no access to a toothbrush either?

  28. What – do they have no access to a toothbrush either?

    That doesn’t explain people who still get cativites even though they brushed their teeth regularly and stayed away from sweets.

  29. It’s not class, it’s bottled water

    Exactly. Bottled water has no fluoride.

    I think the dentist’s are in cahoots with bottled water companies.

  30. “And this happy little fellow is the gouger”

    No one else get the title? One of the best.

    Don’t these poor people realize their options? “These pre-date stainless steel so you can’t get them wet”

  31. asharak,

    I think some people are more prone to tooth decay that others.

  32. So the justification for licensing, at least as far as the ADA goes, is to ensure that dentists don’t have too much competition.

    This is the only reason for all State required professional licensing.
    I am not one to usually call my fellow citizens
    Stupid Fucking Morons but the epithet applies to anyone who thinks the requirement is primarily to “protect the public”.

  33. All I can say is that one look around at a legal conference will confirm that the state bar sure isn’t in the business of keeping people out of the practice of law because they aren’t smart enough.

  34. “Lisa needs braces… dental plan… Lisa needs braces… dental plan…”

  35. You’re all anti-dentites.

  36. Good link, Kwix, I was going to post the exact same thing about the rural Alaska health care access. What a sham.

    To summarize: The ADA doesn’t want practitioners who are “unqualified” to work in the remote villages of Alaska and the government enforces it. However, because they artificially have kept dentists’ pay so high and rural Alaska cannot afford dentist, there are no dentists out there. So everyone’s teeth just rot…

    Not bad for a group who is “…committed to the public’s oral health…” (from the ADA mission statement)

  37. It’s hard to think of a more obvious class signifier than bad teeth

    Rubbish. I grew up relatively poor but Medicaid took good care of my teeth. True, I never got the braces I needed but that doesn’t mean I had “bad teeth”. The health of your teeth is partly a function of cultur…

    I think some people are more prone to tooth decay that others.

    …and partly genetics. I have nasty, cavity-ridden teeth despite reasonably good toothbrushing and reasonably regular visits to the dentist. Whereas my ex had like two cavities and hadn’t seen a dentist in 10 or 15 years.

  38. I suspect the health of your teeth may also be a function of exposure to sunlight and/or sufficient vitamin D. I grew up in the US and had lots of cavities. My kids grew up in Puerto Rico and NO CAVITIES ever. The oldest got braces and when they came off – STILL no cavities.

    BTW, growing up I brushed my teeth just as often as they did – twice daily – and I’d say they probably ate more sugar than I did.

  39. I always wondered why dental schools were closing, seemed like the profession attracted a lot of students. Guess I wasn’t cynical enough.

  40. Speaking of protectionism….

    My father-in-law is a dentist in PA. He and his wife want to move somewhere warm. Problem is he wants to keep practicing. There are only a handful of states that will accept his PA licensing. Other states require him to retake the licensing exam, and apparently it is quite difficult to pass these exams if you are coming in from another state in states where people are trying to move to (AZ, Florida etc). It’s well known in the dental community that this is done to protect local dentists from competition and to make it very difficult for out of state dentists to practice in those states.

  41. Killer fact: hunter-gatherers studied all over the world have straight, white, uncrowded teeth and essentially no cavities. These folks have never seen a toothbrush, drunk flouridated water, or visited a dentist. But their diets are basically devoid of starch and sugar, while rich in meat with its natural fat.

    It should surprise no one that a population growing fatter by the second is also suffering declining dental health. Bad diet is at the root of both.

  42. joe

    This has nothing to do with insurance. At all. No way.

    My firm offered a Dental Plan some years ago. I elected to not take it.

    Over the years since then my dental bills (out of pocket, including regular checkups, two root canals and a three-crown-bridge) have not come close to what I would have paid in “premiums”.

    joe, if you want to talk about the lack of a welfare scheme to pay for poor people’s medical and dental bills I’ll listen. But, please, stop calling it “insurance”.

  43. “The dirty secret is that being a dentist isn’t really that hard. Filling a cavity is about as complex as refinishing a coffee table. Yet, dental school is nearly impossible to get into and a license to print once you get there. We really don’t need people with elite intelligence to be dentists. Further, most basic dental care like cleaning and filling in small cavities can and should be done by trained dental assistants.”

    This is undoubtedly one of the most stupid and definitely the most ignorant post I have ever read on this site. First, let’s dispense with the obvious. Most dentists don’t do cleanings anymore anyway; they are done by hygienists. As for your statements concerning the filling of small cavities, this demonstrates you have absolutely no knowledge of dentistry whatsoever. Who exactly determines if the cavity is small prior to the excavation of the lesion? This requires a clinical examination as well as the interpretation of diagnostic images, usually taken by the assistant. I can think of nowhere that trains assistants in the interpretation of radiographs; the training hygienists receive is rudimentary, at best, in this regard. To train them would result in a substantial increase in time and resources for said training. Furthermore, interpreting x-rays involves far more than just looking at them and saying “ah-ha, a cavity.”; caries detection is often difficult enough in itself though. I daresay any court in the nation would find you negligent if you focused only on cavities at the exclusion of other radiographically-visible pathologies; these pathologies can range from the very benign to the lethal. To be able to detect and then make differential diagnoses concerning possible pathologies requires quite a lot of training; most dental schools require a mininum of 3-4 semesters of general and oral pathology. Also, the detection of pathologies requires a knowledge of healthy dental anatomy and histology to know the appearance of these tissues at health. After all, you can’t know if something is wrong if you don’t know what it normally looks like. It is obvious that additional training would be required for this knowledge as well. Dental assistants do not receive this kind of training (as a matter of fact, many states require no training at all for the title of dental assistant)and dental hygienists only receive the very basics.

    Back to the filling of small cavities. What would happen if there was a carious or mechanical exposure of the pulp during this process? Are you now advocating that dental hygienists be trained in endodontics as well so that they can perform a pulpotomy or pulpectomy on the patient? After all, with pulpal exposure, this is probably the minimum that would be required. And if a pulpal exposure is in doubt, are you going to train them to detect such exposures radiographically in addition to teaching them the myriad of diagnostics tests available to determine if a possible exposure has occured?
    But let us give these supremely-trained super assistants the benefit of the doubt as far as pulpal exposures are concerned. Let us just assume that once the lesion is opened up that it is larger than imagined, without an exposure. Even if the lesion is initially thought to be small enough to require no anesthesia, most patients will demand anesthesia for larger lesions. The individuals administering these shots will require a knowledge of the neuroanatomy necessary to provide adequate anesthesia. There is more to giving a shot than just sticking a needle in someone’s mouth and pressing down a plunger. You have to know which nerve anesthetizes which portion of the mouth you are working on and where that nerve is located. Furthermore, you have to consider which anesthesia to use based on many factors including potential allergic reactions, age and weight (particularly for pediatric patients), whether to use an anesthetic with a vasoconstrictor, usually epinephrine (an important consideration in individuals with hypertension, as well as other conditions). Furthermore you must be able to adequately obtain and interpret a patients health history for many reasons, including the determination if antibiotic prophylaxis is necessary prior to the administration of anesthesia. All these factors require a knowledge, both academic and clinical, that can only be obtained by a level of training no dental assistant in this country receives; very few states allow dental hygienists to administer anesthesia, and none that I know of let them do it absent a dentist. And this is not merely because we want to pad our wallets. They just do not receive the training. And the additional time required for said training would make this whole “let’s have dental assistants do it” argument pointless, primarily because the additional training would increase the cost and lower the availability, both benefits that are assumed will exist once the so-called “dental cartel” is broken.
    Now, let us discuss the actual filling of the cavity. While it may be easy to fill an extremely small cavity, as I made clear above there is no guarantee it will be small once the excavation begins. Larger cavities require much greater skill to excavate and fill as one must take into consideration such factors as potential pulpal exposures, the need for cavity liners, the patient’s dental anatomy and occlusion, the need to maintain contact with adjacent teeth etc. When I attended dental school, I was required to see patients six hours a day, five days a week, for the last two years of my schooling to hone my skills. Knowing the extent of the training received by assistants and hygienists, there is no way in hell I would let them put a drill spinning at 100,000 rpm, at least, in my mouth. As for your implication that all dentists do is fill cavities, that is too stupid to comment upon further. In addition, individuals with bachelors degrees in English would be wise not to pontificate on dentistry and the skills and training required for certain procedures as if they were experts in the field.
    The implication contained within this article that dental assistants (this is particularly laughable) and dental hygienists receive enough training in school to be able to safely intrepret, diagnose, anesthetize and then treat even basic dental problems is absurd to the extreme. Furthermore, as I pointed out above, the increase in the training cost and time involved would simply result in an increase in the price of the services rendered and lower the availability of these super-trained hygienists and assistants. What would be the point? Moreover, there is no such thing as “safe” basic care involving only the filling of cavities. What good is a decay-free smile if the hygienist misses the extremely lethal palatal melanoma or oropharyngeal carcinoma?

    As for the asinine comments concering the intelligence of dentists, dentistry is like any other profession. Good dentists, as well as other medical specialists, are usually intelligent individuals . Dentists are just doctors that happen to limit their practice to the oral cavity. And from my personal experience, dentists and dental students are easily as intelligent as M.D.s. I know because I have a D.M.D and M.D. and I also have to put up with both to do my job.

    P.S. joe is an apologist for Chavez

  44. “That doesn’t explain people who still get cativites even though they brushed their teeth regularly and stayed away from sweets”

    It is impossible to get a cavity if certain sugars, primarily found in sweets, are not consumed. The initiation of a carious lesion (the technical term for a cavity) absolutely requires the consumption of sucrose.

  45. DR Chavez is a thug (I know he is)

    Then how come my soda drinking kids never got cavities? It really is a mystery to me.

    My mom would only let us have half a bottle of soda a week. I still got cavities all over the place. My kids, on the other hand, would drink that stuff at school all the damn time. Plus plantain chips and empanadillas and God knows what else. No cavities. Very few of their friends had cavities either.

    Plus, there is a strong correlation between oral health and cardiovascular health. So I still suspect consumption of sucrose is necessary but not sufficient for your carious lesions.

  46. I know because I have a D.M.D and M.D. and I also have to put up with both to do my job.

    Holy crap, did you take twelve years and spend $150,000 to go to college? Also, not to impugn the intelligence of dentists, but I think much of this thread has been about the ADA using the government large and small to protect a monopoly on the profession and make sure it stays lucrative.

  47. “My mom would only let us have half a bottle of soda a week. I still got cavities all over the place. My kids, on the other hand, would drink that stuff at school all the damn time. Plus plantain chips and empanadillas and God knows what else. No cavities. Very few of their friends had cavities either. ”

    Genetics and oral hygiene play a factor in determining who and who does not get cavities. Perhaps they have better oral hygiene than you when you were a kid.

  48. “Holy crap, did you take twelve years and spend $150,000 to go to college? Also, not to impugn the intelligence of dentists, but I think much of this thread has been about the ADA using the government large and small to protect a monopoly on the profession and make sure it stays lucrative.”

    It cost way more than that. Also it did not quite require twelve years. After college, it requires 4 years of dental school, 2 years of medical school and 4 years of oral surgery residency, of which 30 months must be spent on the actual surgical rotation.

    I realize that the original article concerned the maintenance of a monopoly. However I was responding to the absolutely idiotic statement made by an individual who clearly has no idea what is involved in the practice of dentistry. Anyone who suggests that filling cavities properly is the same degree of difficulty as finishing a dining room table is an ignorant jackass, plain and simple.

    Furthermore, I was hoping that my lengthy post would dispel the myth concering so-called “simple” irreversible dental procedures and who exactly is qualified to perform them. As I thought I made abundantly clear in my post, dental hygienists and particularly assistants do not receive the training required to make these procedures even remotely simple, particularly when you consider that the unexpected will inevitably arise during one of these procedures. A whole heck of a lot more goes into performing these procedures and providing a MINIMAL amount of care then just doing a little buzz with the drill and sticking in some filling material. It is criminally negligent in pretty much every state to fill cavities and neglect other oral health issues. Again, dental auxillaries are not trained to perform most of that additional necessary work or even recognize the need for it, and the required extra training would increase costs and limit the numbers of practicioners to a degree that it would defeat the purpose, just as I pointed out.
    As I also pointed out to the person who started this thread, there is an obvious misconception as to what is involved in performing dentistry, or it would not just be blithely suggested that an individual with a few months training would be adequately qualified for the purposes of providing care in order to break a supposed “dental monopoly”. Perhaps a solution other than foisting dangerously underqualified practioners on the unknowing public should be suggested. And believe me, the comments have more than proved that most people are absolutely clueless about dentistry and oral health. And like I said before, individuals with a bachelors in English usually have virtually no knowledge of dentistry and its practice and thus should not be snarkily offering definitive policy solutions as if they were an expert in the field.

  49. For sake of clarity, I’d point out that even though dental care is important, the premise in the study is simply wrong and based on an erroneous NYT analysis of Public Use Data Files.

    http://nchspressroom.wordpress.com/2007/10/11/the-new-york-times-and-oral-health/

  50. Dr CIAT teeth have been around for hundreds maybe even thousands of years. Dentists only a fraction of that. Who took care of the teeth before the ADA? If you look at movies of ancient times you can see that people had nice clean teeth “Gladiator” is a good example.

  51. CIAT,

    Well, I’m glad you spent a quarter of a million dollars and only ten years to be a medical doctor and a dentist! Look, I didn’t disagree with you- the comment you rebutted was pretty damn ignorant. You made good points. You went to a fairly great length to do so. And yes, people with liberal arts degrees don’t have business snarking off about how supposedly easy it is to do [insert highly technical and potentially complicated task here]. But they do possibly (hopefully) have the necessary faculties to analyze policy. Join in on that.

    burma,

    As you pointed out yourself, Gladiator is a movie. I’m sure Russell Crowe has had a lot of expensive bleaching and capping done. I doubt Hollywood would sacrifice leading man sex appeal for the sake of historical accuracy.

  52. Oh, wait- you said after college. So that’s more than ten years. Me count good.

  53. CIAT,

    You’re exactly the kind of self-absorbed thug that libertarians despise.

    Do you know the difference in welding temperatures for Aluminum and Steel? Flux characteristics and requirements?

    Do you know the difference between a ganache and a glasse? How to get carmelization without getting carbonization on a large scale operation?

    Do you know the proper petroleum/macadam ratio for humid climates versus dry?

    Would you have the slightest clue as to how to act in response to your livestock limping on two hooves, but not four?

    You’re a prick because you think that the knowledge you spent your life collecting is so inherently more valuable than the knowledge non-professionals work their whole working lives to perfect that you deserve to extort money from the unwashed with the guns and courts of the govenrment and state houses.

    XON, Esq. . .

  54. “You’re a prick because you think that the knowledge you spent your life collecting is so inherently more valuable than the knowledge non-professionals work their whole working lives to perfect that you deserve to extort money from the unwashed with the guns and courts of the govenrment and state houses.”

    Hahahaha, I laughed my ass off when I read this one. Yeah, I am trying to extort money from people. That’s a good one. Got anymore ridiculous hyperbole you want to throw my way. And I’m a thug to boot. Why don’t you compare me to Hitler and get it over with?

    As for the ridiculous nonsensical properties of metal you were asking about, exactly what do those have to do with anything even remotely connected with this discussion? Absoltuely nothing.
    Evidently you are so stupid, you missed the entire point of both of my posts. Why else would you ask me the following: “Would you have the slightest clue as to how to act in response to your livestock limping on two hooves, but not four?” Somehow such stupidity is supposed to be remotely connected with what I discussed. I will say it again: Hygienists are not qualified to perform the tasks you wish them to perform. I couldn’t give two shits if an idiot like you wants to accept it or not. When you are willing to have a nurse with an associates degree diagnose heart problems then we can discuss having a dental assistant perform dentistry.

    In closing, what is the capital of Madagascar?

    Who fucking cares because it is totally irrelevant to the discussion, moron.

  55. “But they do possibly (hopefully) have the necessary faculties to analyze policy. Join in on that.”

    That is exactly what I am trying to do. The whole crux of the argument here is the notion that assistants and hygienists can perform enough dentistry own their own to allow them to practice independently. As I have tried to demonstrate in my posts, this is just not true. The whole argument the author puts forth quite simply collapses under the weight of this fact. Some jackasses are so touchy, they prefer to call me a thug instead of engaging in the debate.

  56. “….enough dentistry own their own…”

    That should read on their own.

  57. “Do you know the difference in welding temperatures for Aluminum and Steel? Flux characteristics and requirements?

    Do you know the difference between a ganache and a glasse? How to get carmelization without getting carbonization on a large scale operation?

    Do you know the proper petroleum/macadam ratio for humid climates versus dry?

    Would you have the slightest clue as to how to act in response to your livestock limping on two hooves, but not four?”

    Actually, the answer is no to all of these questions. I am not qualified to work in these fields. Thank you for making my point for me.

  58. Is that the reason why there are many dentists who does their job not excellent. It is a scary fact.

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