North Carolina Voices: Understanding Poverty; The Trouble with Teeth: Dental Care and the Problems of Poverty

This is The Trouble with Teeth, a special documentary as part of North Carolina Voices Understanding Poverty. I'm Kevin Wolf. For most of human history, losing your teeth was considered inevitable just a part of life, and so was the suffering that went along with it. Europeans, in medieval times, prayed to a saint they believed could take away their tooth pain, and long before there was dentistry, there were tooth pullers who wandered from village to village taking out terrible teeth. By the 19th century, the people with the worst teeth were the wealthy. They could afford to eat lots of sugar. Tooth loss was still common in the United States 50 years ago. Half of Americans had lost all of their teeth by the time they turned 65. But today, dental disease is almost entirely preventable. It's really become a disease that's very heavily concentrated in a small segment of the population.

Most people who lose their teeth are poor. Some of these people are in their 20s, early 30s, and they're losing their teeth already, and that's a shame. Usually it comes down to cost. How much does it cost to say the two verses take the tooth out? And just finding a dentist to take the tooth out can be a challenge. Emily Hanford reports in the trouble with teeth, dental care, and the problems of poverty. Sheila King's Barry Burt is taking out her dentures. I have a denture bath cup, which I fill with hot water, and get the adhesive off my dentures. That's the bottom lower denture plate. That's the top one.

Sheila got these dentures four years ago, and they're falling apart. This top one has been broken and repaired so many times that I can't. I pray it won't break. Sheila lost her first tooth when she was 17. It had a big cavity, and the dentist pulled it. By the time she was 46, she had only three teeth left in her mouth. That's when she got dentures. It's a dark spot in my life going through losing my teeth, because it's interesting. I did have a perfect set of teeth at one point in my life. It seems like it was so long ago, I hardly remember when it was, but I did, and did not understand how important my teeth were.

Until I was losing them. Sheila says she felt embarrassed and inferior, walking around with a snaggle tooth grin, and she couldn't chew her food very well. My mouth would just hurt. My gums, the roots down to the root of my teeth, were just aches. It would be alright for a while, but it was tooth by tooth, that it did that, and it would start to hurt, and then after a while it would be loose. And sometimes I just had to pull the tooth. Was that loose that I could pull it? Do you know why you lost your teeth? I had gum disease. And she wasn't getting any treatment. Sheila says she rarely went to the dentist for checkups or cleanings, never went when she was growing up. We didn't go to the dentist. Because we didn't go to the dentist.

My grandparents didn't go to the dentist. And my mother, even after she married a man in the military, didn't go to the dentist. Dentist is money. It's like buying a new dress or something. You don't have no money to buy a new dress. You got to pay the rent. And you got to pay the light bill, and your teeth only become a priority when you get a toothache and lots of people live like that. A lot of people do avoid the dentist, rich and poor alike. Government surveys show about one-third of Americans don't go on a regular basis. But a closer look at the data shows people who suffer most from dental problems are poor. Having children living at or near the federal poverty line are five times more likely to have cavities than middle and upper income children. Poor adults are more than four times as likely to have destructive gum disease.

And people who are poor are much less likely to get treatment and much more likely to lose their teeth. Seventy percent of people over the age of 65 who have less than fifteen thousand dollars of income a year are missing most of their natural teeth. It's almost exactly the opposite for older adults with more than fifty thousand dollars a year. Seventy-three percent of them still have most of their teeth. The state of oral health in America was much different fifty years ago. Fifty years ago, almost everyone had a lot of tooth decay. They considered that normal, they considered that part of life. Dr. Rebecca King is chief of the North Carolina oral health section. A lot of teeth when people had problems had to be pulled. That was really the only, only avenue that they had to take care of teeth. But by the 1950s, a revolution in dentistry was underway. There are two things you want in a toothpaste.

The first is protection from the K, the second is good taste. No other toothpaste offers better protection against the K, and no other taste as good as new formula eye panna with W.D. 9. After the 1950s, the invention of fluoride toothpaste, the discovery that fluoridated water could significantly improve oral health and increasing affluence, all combined to put attention on the importance of pretty healthy teeth. That's fine, Billy. But remember, there are four rules you can follow to help take care of your teeth. Well, I know what they are, Dr. Williams. Well, what's the first one, Jack? Is it your dentist twice a year? Right. South Carolina had a traveling puppet show that taught children the rules of good dental health. The state's resources have always been devoted primarily to children and prevention. In fact, the legislature requires the state to focus on children, Dr. Rebecca King. By the time adults reach adult-hilled, their dental problems are severe and very expensive. So, if you're going to work on prevention, you have to do it before the disease gets there,

which means children and the younger the better. The state does not have any programs for adults who need affordable dental care. Private dentists rarely provide reduced-cost care or let people pay in installments, and in parts of rural North Carolina, there are no dentists at all. Some county health departments have dental clinics, but a lot of them treat only children. There are community health centers where adults can find some dental services, but you might have to travel a long way to get what you need. Warren County, North Carolina, is just off Interstate 85 near the Virginia border. There's a clinic here called HealthCo. They come from Oxford, they come from Riley, they come from Richmond, they come from everywhere. Natasha Hicks Williams is the receptionist at HealthCo. It seems like they would find somewhere closer, but I guess it's the cheapest place. HealthCo is officially known as Vance Warren Comprehensive Health Plan.

It's been around since the 1970s, offering medical and dental care. The clinic runs on government and private grants, plus the money patients pay based on their income. Marie Jones is here with a toothache. I had one to break off in the back about a year ago and last week it got infected. Marie used to have dental insurance, but found out the hard way that it only paid for cleanings. I did not know what it covered until I went to the dentist about two months ago and the dentist told me it would cost me $6,000 to get my mouth fixed and my insurance would not cover it. She dropped the insurance and now has none. The majority of people who come to this clinic are like her, they pay out of pocket. Even though Marie works two jobs, her income is low enough that she pays just $25 per procedure, the lowest level on the fee scale. Marie is eager to have her aching tooth out today, but she's hoping eventually she can

get a new one, an implant. Just feel good when you can smile and people say you have such a beautiful teeth and they are so even, they are so white, it makes you feel good, it makes you want to just keep showing it, it makes you want to just keep showing it, you know. Dr. Kirby Ransom is the dentist of health code today. Dr. Ransom pulls out Marie's tooth. When it's over he gives her some advice. What I would recommend is that you come back and get an exam done and get a cleaning because right now you're in an early, combative state of gum disease, and if you have some nail we can actually help you save the rest of your teeth. He also tells her she should stop smoking because it's making her gum disease worse. Once Marie is gone, Dr. Ransom's assessment of her situation is not as optimistic.

Looking at her mouth she's probably going to need gum surgery where they actually reflect her, doing what's called a flap, hoping that that's going to basically stop the disease from progressing. Ransom says this could cost her up to $1,500 and she can't have it done at health code. So if she could come up with the money she'd need to find a pariodontist and there aren't any near here. She'll probably end up losing her teeth for the simple fact that she doesn't have the finances to pay for it. And to replace those lost teeth with implants like Marie was hoping, that would cost her $2,500 or more per tooth. Ransom says he understands the problems of people like Marie. Growing up myself in a rural area, one of the main things was dental care. He says people who were missing teeth had a hard time getting jobs and that's why he works here one day a week to help out. He says he'll stay until health code finds a full-time dentist. The clinic's been looking for more than a year.

Health code CEO Charles Worth says it's hard to recruit dentists to a poor rural county. It's typical of anyone who's professional coming here in a sense that what do you have to offer? We don't have a lot of other activities that may interest someone who's coming with the family, the school system may not be up to what they're used to where they may be coming from. And the salary is low. Worth says he could pay up to $125,000 a year for an experienced dentist. But dentists in private practice in the United States make an average of $173,000. Dr. Kirby Ransom isn't interested in the health code job full-time. He has his own practice where he sees mostly patients who have private insurance. But he's thinking about taking some Medicaid patients. Medicaid is the government insurance program that covers many poor people. Ransom says he'd take just children, though. No adults. I guess I have more of a heart for the kids in their situation versus the adults.

Ransom says he sometimes sees adults at health code who come in with a mouth full of problems and then drive away in a fancy car. And that bothers him. Ransom and other dentists point out that it's not that expensive to take care of your teeth. If you brush and floss, eat healthy foods and you don't smoke, you can prevent almost all dental disease. There would be a lot less need for a place like health code if everyone just took better care of themselves. Dr. Rob Dordy is the director of a county-run dental clinic near Greenville in the eastern part of the state. When he talks about the work he's doing with low-income patients to his private practice colleagues, he says they bring up personal responsibility a lot. I hear them saying that they want to encourage maturity among our patients, especially the low-income patients. In other words, they need to suffer some consequence for making the bad choice of not taking care of their mouths. And they need to not just suffer the pain, but also pay the high cost of making that bad choice.

Dordy says some dentists use this as a way to justify why they don't participate in programs that provide free or low-cost treatment. Dentists like Dordy say too many private dentists see themselves as business people first, not health care providers. Well, if you don't see yourself as a business person you won't be here to provide any health care to anybody for very long, so that's the unfortunate truth. Dr. Cindy Bolton is a general dentist in Readsville. She's also the spokesperson for the North Carolina Dental Society on access to care issues. The Dental Society is a professional organization that represents dentists. Dentism has been charged with encouraging her colleagues to take more Medicaid patients, but it's a hard sell. I was last year paid less than 50 percent of what my fees were to provide care for this patient population, and my overhead to run my business is around 80 percent. It was even worse a few years ago. A class action lawsuit claimed children on Medicaid could not find dentists to treat

them because the reimbursement rates were so low. The lawsuit was settled in 2003 when the state agreed to raise some of the rates. More dentists actively participate in Medicaid now, but it's still only about one in four. When you realize that the state only has so much money that you can't just always say we need increased funding, we need increased funding, you have to do everything that you can do through other venues to try to provide care as well. Like volunteering at free clinics, something Bolton does once a month. Free clinics tend to target the working poor population, people with little money and no insurance, and there is a big demand. This answering machine sits on a bureau in the extra bedroom of Mary Anderson's house. Mary is sitting at a clutter desk wearing shorts and slippers and getting ready to take appointments for the open door dental clinic of Alamance County.

The only way to get an appointment is to call it exactly 10am the day you want to come. It wasn't always done this way. It used to be you would show up at the clinic to get your name on a list. That didn't work. People would end up fighting each other in the parking lot. It got really ugly. Don't clinic, this is Mary. What do you need to have done? Treatment at open door is free. Your income must be below 200% of the poverty level. You have to be an adult and you can't have any insurance even Medicaid. The point is to provide service to people who have no other options. Mary says a lot of the patients are former factory workers. These people that have worked for 10, 15, 20 years, all of a sudden their jobs are gone. Their health insurance, their dental insurance, everything is gone. And they're trying to hang on to their house or their car. OK, we'll see you tonight at 5.30.

Thanks. Bye-bye. Mary says the phone rings day and night. But once tonight slots are filled, she turns off the ringer and lets the answering machine take over. Thank you. Have a nice day. The clinic opens at 5.30 pm. There are 18 people on the list. One of the first people at the reception desk is a woman who is not on the list. She begs to be seen. We have to call that number to make an appointment. Unfortunately, I don't like appointments at all. And I'm sorry about that. This is not a thank you very much. Pam Myrick is the receptionist. She's a volunteer. And so is everyone else who works here, including the dentist who started this clinic, Dr. Steven Slaught. He sees a world full of people who desperately need dental care and he's trying to do something about it. All right. What do we got? We got that one in this one. Well, let's see if you can save that one. Let's go ahead and get this one out.

All right. That was a pretty important thing. Tonight is Extraction Night. That means pulling teeth. One of the patients is an inmate from the Alamance County jail. He's in an orange jumpsuit and shackles escorted by a sheriff. He has a tooth pulled. The patient sitting next to him, David Butler, can't resist a comment. I tell you what the problem is, they got everything switched around backwards because I, like a guy, I was in jail about 18 years ago and I had to go to the dentist for something. And I mean, I went to the dentist within a week, had everything done and no problem. You never said, never heard nothing about it, you get home, whether you have time if you got the money or not, you got to wait and all this kind of stuff is hard to, hard to see the dentist. Best thing to do is go to jail, you get teeth. But in fact, if Steve Slott's open door clinic were not here, the jail would have nowhere to send its inmates for dental care. The local hospital refers patients here too, so does the homeless shelter. Okay, we're ready to go.

I'm going to do a bunch of homework. Yeah, I try to say, but I try to get a feeling down on that, I'm 13, I have to do feelings that you're going to have to call and see if you can get in. Home, but yeah, I'm third. Thank you. It's Thursday now, Restoration Night, and that means feelings. Things move more slowly because dental students do the work. There are six of them here tonight, and it's not easy for Dr. Slott to sit back and let them learn. Just keep going, you've got to get to the care, yeah, all right, so just go ahead and get to the care, yeah, and we'll see what's there. Okay. Dr. Slott sees the future in these students. He hopes they'll keep treating low-income patients after they graduate. It takes more time for me to deal with the dental students in the clinic and I see less patients at the clinic, but to me it's worth it if we can get them to go out and take them because it's thousands, maybe tens of thousands of people over their career. He's not just hoping they'll volunteer in free clinics like this one. He's hoping they'll work in one full time, or start one, or at least take Medicaid patients

in their private practice. In his own private practice, Dr. Slott sees mostly patients on Medicaid. In fact, he's the only dentist in the county who accepts adults on Medicaid at his office. I don't have a whole lot of excess money, but that's not the point. The point is that I can make a living at it. A decent living, I've educated my kids and drive decent cars, living in nice house, have what I want, and I'm doing what I want. Dr. Slott makes his point by parking his BMW convertible at the clinic door. Right where the dental students can't help, but notice it. We've added a patient for Dr. Jibriel at two o'clock. People with dental problems who don't find a free clinic like open door, or a place like health co, often end up at the hospital. The director of the dental clinic at UNC Hospitals in Chapel Hill is Dr. Janet Sutherland.

A man is in the emergency room with a swollen face and infected teeth. The emergency room physician calls Dr. Sutherland to find out what to do. Turns out the man wants to be put to sleep before his teeth are pulled. And I told the doctor, we don't do general anesthesia, but if he is a severe enough phobic, we do IV sedation. And the first thing the doctor said, well, he didn't have the money to pay for it. This patient is probably out of luck. He's going to have to come up with some way to pay for the sedation and the extraction of his teeth, or else he's not likely to get either. A recent national study showed that when people show up at emergency rooms with dental problems, they usually leave with pain medication and good advice, get to a dentist. But you're not likely to find a dentist after you leave if you couldn't find one before you came.

Kim Marks is the dental clinic manager. She says the clinic gets about 50 calls a day from people who need dental care and have no way to pay, but this clinic is not set up to help them. We're here to treat sick persons, persons who, if they had a million dollars, couldn't be treated in an outside dental practice. People treated in this clinic are already sick, and it usually has nothing to do with their teeth. He has hep C, AIDS, and his blood, kind of, under 200 hemophilia, eggs, scaradosis. The clinic dentists are meeting to go over their patients for the day. All of these patients need good dental care to stay healthy. Some of them have conditions like diabetes that can cause problems with their teeth and their gums. Others, like certain cancer patients, need to have bad teeth taken out before they can have surgery or radiation. Still others have diseases or conditions that make it particularly hard for them to find a dentist, like Marty Rhodes, who was HIV-positive.

They asked if they could turn out, you used to smoke a mix. Like a fish. King pear. Yeah, I can tell. You got a brown tongue. I'll put it in. Hmm. I'm quitting. You better. Marty lives in rocking him about two hours away. Dr. Sutherland says having a compromised immune system makes it that much more important for him to get good dental care, because untreated infections in the mouth can spread to other parts of the body. Sutherland says for her patients in particular, it's impossible to separate oral health from general health. They'll have the medical problems, then they'll have the oral health problems. And then you get into this vicious cycle of there's a dental problem that's really exacerbating the medical condition. Clinic manager Kim Marks. It's almost like our health care has taken care or looked at other parts of our body, but they've disregarded the mouth totally.

And there's increasing evidence that rotted teeth and untreated gum disease could have serious consequences for overall health. Dr. Steve Offenbacher is co-director of the Center for Oral and Systemic Diseases at UNC Chapel Hill. The concept that is emerged is that the oral cavity is a reservoir for these bacteria and these germs which can spread to other parts of the body and therefore can have multiple effects in different organ systems. Offenbacher says there is strong scientific evidence that untreated gum disease can cause some women to deliver their babies early. Other research shows people who have untreated gum disease are at higher risk for heart attack and stroke. It's not clear yet if the gum disease is causing those problems, but Offenbacher is currently overseeing a large study to try to find out. And he says if you want to avoid gum disease, simply brushing and flossing your teeth is probably not enough. You need a dentist to scrape the plaque off every once in a while. And if you do end up with gum disease, there's expensive treatment or there's the cheaper

route having your teeth taken out. For a lot of poor people, this is still the only option. Paula King's Berry Burt is moving, boxes, papers and trash bags are piled high around her living room. Tomorrow, the mortgage company is coming to take the house. It's not Sheila's house. It belongs to her uncle, but he doesn't want it anymore and she can't afford to buy it and the mortgage is more than the house is worth. Sheila has been thinking about moving to Florida to live with her son, but her car just broke down and she owes several people money. And I don't want to leave without paying them, so you know, when things like the car need to be fixed, comes up, I got to fix the car, complications, set me back even further.

So for now, new dentures are on the back burner. And I make the best out of it because there was a time when I needed them and I didn't have them at all and I managed to live until I got them. Sheila went to health co-recently to find out what new dentures would cost, more than $1,000. Dentures are the only item not subject to the sliding fee scale. People sometimes feel that what is best for her is just out of reach. The real improvement will lie in my grandchildren. That my sons and their spouses will make sure that their children have good dental care. Because the sons could take the same approach that I took which was we only deal with that

if it becomes a prop and it's unfortunate that we don't know of what it means until we've passed the point where we can actually do something about it. The trouble with teeth was produced by Emily Hanford and edited by Deborah George, production assistance from Anthony Hayes and Sally Council. North Carolina Voices, Understanding Poverty, is a production of North Carolina Public Radio WUNC. Executive producer of North Carolina Voices is Emily Hanford. Support for the series comes from the AJ Fletcher Foundation, the Center for Documentary Studies at Duke University, Doug and Peggy Abrams, the Julian Price Family Foundation, Hoppen Taylor P.A., the Michael and Laura Brader Arrahe Foundation, and the North Carolina

Humanities Council. More information about North Carolina Voices is at WUNC.org.