Can our teeth predict inequality?

How bad dental care can lead to lower wages, worse health, and lower life expectancies

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Americans who do not receive proper dental care are far more likely to die early, develop heart conditions, and earn less money. For communities that have no dentists, this can often be a hidden factor leading to tremendous inequalities that the US is not properly addressing. 

Brush your teeth, save your heart

Oral health is a strong indicator of overall well being — People with poor oral hygiene disproportionately have higher rates of diabetes, cardiovascular disease, and other chronic conditions. WIthout dentists or dental care, communities die younger and have lower incomes as we will show. There is a proven direct link between the number of teeth a person has and how long they will live, particularly later in life. This isn’t just true in the US. One study conducted in Japan revealed that individuals aged 80 without any natural teeth faced a significantly higher risk of cognitive impairment and mortality compared to those who still had 20 or more teeth. Another study looking at a million people found that tooth loss had a strong correlation with heart attacks and heart disease. 

Dentists are often the first line of defense for several diseases such as oral cancer, heart disease, diabetes, and autoimmune diseases. But for the 63 million Americans living in ‘dental deserts’ (i.e. regions where individuals do not have access to dental care either because there are no dentists or costs are too high), this lack of care can spell disaster. A staggering 67% of those dental health professional shortage areas are in rural communities. 

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America’s most vulnerable communities are often most at risk of receiving inadequate dental care, which exacerbates other healthcare challenges. 

• Immigrant communities:One study found that non-citizen immigrants have substantially poorer oral health than US natives. 

• Black communities: It’s been found that the highest death rates for oral cancer are among non-Hispanic Black and non-Hispanic white people. 

• Low-income communities: Periodontitis, gum disease with bone loss, was 2x as common among adults with low income compared with adults who had higher income. Provisions of the Affordable Care Act, which take effect in 2014, guarantee dental care for children, but not for adults

• Low-income children: Children aged 2 to 5 from low-income families are 3x more likely to have untreated cavities compared to children from higher-income families.

The root cause of that root canal

Bad teeth can create downward spirals of inequality that can be hard to bounce back from. Several studies have found that people with bad teeth are less likely to be hired as employers “make instant judgements based on appearance.” With fewer job prospects, individuals will have fewer funds to obtain the dental care they require, making them lose even more teeth. 

Understanding these inequities in oral health is complex, as they may worsen existing conditions or develop simultaneously. Factors such as a diet rich in sugars, smoking, and limited access to dental and healthcare due to financial constraints contribute to these disparities. Gum disease not only appears to worsen blood pressure but also interferes with medications used to treat hypertension, as revealed by the National Health and Nutrition Examination survey. 

Dr. Larry Hill, executive director of CincySmiles dental clinic program, said “it’s hard to understand how dental care has been overlooked by state legislation, federal measures and insurance companies alike, when the small area of the mouth makes so much of a difference in overall health.” Addressing these disparities requires a comprehensive approach that considers the interconnectedness of oral health with overall health outcomes and the social determinants influencing access to care.

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Cost is one of the biggest barriers to accessing dental care. Oftentimes individuals do not have dental insurance, but rather pay out of pocket on an as-needed basis. The portion of the population without dental insurance (27%) is almost 3x as high as those without health insurance (9.3%). Medicaid frequently does not cover the expenses of root canals or crowns, procedures that could preserve teeth, yet it will fully cover dentures once the dental issue has progressed beyond early intervention.

Sugar is destroying your teeth

Sugar and teeth are mortal enemies. Young adults in the U.S. consume on average 17 teaspoons of added sugar every day, more than 2-3 times the recommended amount for men and women respectively according to the American Heart Association. Americans consume more than 100 pounds of sweeteners on average each year, or the equivalent of eating about a bowling ball of sugar every month. 

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Children lose about 34 million school hours because of unplanned dental care, and adults lose over $45 billion in US productivity due to untreated dental disease. 

Mississippi and Florida have the worst dental care

In 18 states, more than 1 in 4 adults consume a soda or a sugary drink every single day. 1 in 3 adults say they do not consume any fruit in a day. Mississippi is the worst state for soda consumption, with 2 in 5 adults (40%) saying that they consume soda daily. Tennessee follows closely behind with roughly the same statistics. 1 in 4 residents in both states say they consume no vegetables daily. 

Florida is the worst state when it comes to dental health coverage, with 65 of the state’s 67 counties deemed ‘Dental Health Professional Shortage Areas’ affecting 7.1 million Floridians. Nationally, there are 60 dentists per 100,000 people, while in Florida it is just 51 per 100,000 people. Some Florida counties have just 1-10th the national average at 6 dentists per 100,000 people. Imagine waiting in line with 16,000 other people to see the only dentist nearby!

“Floridians are more desperate than ever to find dental care in their communities.. In just one year, the number of individuals living in dental shortage areas grew by more than a million,” shared Dr. Frank Catalonotto, president of Floridians for Dental Access.

When speaking with Dr. Brittany Davis, DDS, she gave two examples of low-income individuals dealing with severe medical concerns originating from unaddressed oral health needs. She shared with us a story of an older man who had lost all of his teeth and his diet consisted solely of liquids, smoothies, and mashed potatoes. This inevitably led to worrisome nutrient deficiencies, causing other health complications. Dr. Davis said, “it took many weeks and multiple appointments to fabricate his new pair of dentures. The day I was able to deliver his final set, he cried and said he had been without hard food for so long. To celebrate, he was going to go straight home and cook himself a steak!” 

Another patient was a middle-aged man from The Bronx who had not been to the dentist since childhood due to financial hardship. He eventually made an appointment with a student dental clinic to receive a check-up for reduced cost. Dr. Davis told us, “when he came in for his initial visit, he had no pains or concerns. However, it was immediately apparent that there was a suspicious lesion on the side of his tongue. We biopsied the spot and it came back positive for squamous cell carcinoma. This is a devastating cancer that is highly aggressive and has poor life expectancy if not quickly caught and treated. Thankfully for this patient, we were able to intervene just in time.” 

The Path Forward

Dental care cannot be a second thought for our healthcare system. We have data-driven solutions for improving oral hygiene that can help improve life expectancies, reduce costs overall for the healthcare system, and support the communities most at-risk of having issues with their teeth. 

• 👩‍🏫 Roll out cavity awareness programs in low-income schools: Dental cavities are the most common chronic disease in children, and one in five elementary school children have at least one untreated cavity. A NYU study that targeted 7,000 students in low-income communities found that programs like giving students toothbrushes and toothpaste, helping parents schedule twice annual appointments, and educating people on healthy tooth habits helped reduce cavities by 50%. 

• 🍩 Decrease sugar intake: While this idea is not novel, its importance cannot be overstated. There is significant concern regarding high sugar consumption due to its links to obesity, heightened risk of non-communicable diseases, and poor oral health that calls for policy level action. Taxing sugar drinks in five US cities aims to reduce purchases, with a recent study showing successful outcomes despite mixed emotions.There’s been a 33% drop in sugary drink purchases after a sugar-sweetened beverage tax was implemented indicating potential health and cost-saving benefits. Scaling these policies could be a beneficial option. Some food for thought: should we regulate sugar? Experts contend that while tobacco, alcohol, and diet are crucial behavioral risk factors in chronic diseases, governments regulate only two of them to safeguard public health. 

• 🪢 Integrate dental care with primary medical care: I do not understand why we treat teeth as though they are somehow separate from the rest of the body. I understand why we have specialists who cover different domains, but putting dental plans and medical plans as separate causes headaches for patients, doctors, dentists, and the medical field at large. Co-locating doctors and dentists could at least help ensure that when people visit primary care physicians they could also get their teeth checked. In 2009, the World Health Organization advocated for the integration of dental care into primary medical care services. Estimates for Medical Dental Integration (MDI) put the cost savings at hundreds of millions to billions annual. If you run an MDI center or know someone who does (especially in Florida), let us know!

Investing in oral health today directly contributes to the wellbeing of our future. Taking care to reduce sugar intake, enhance awareness among children, caregivers, and families in low-income areas, and integrate dentists into wellness initiatives, have the potential to transport Americans out of dental deserts and bridge the existing gaps between oral and medical care. These measures have the potential to be life-changing for many Americans.