Being unable to smile because of embarrassment of the look of your teeth is a horrible experience that is all too common considering the technology and level of care that is now available. Many people claim that they have put off going to the dentist because of fear and cost. This is incredibly unfortunate as we all deserve to feel confident enough to smile.

Fifteen years ago this spring, Surgeon General David Satcher issued a call to action to address what he called America’s “silent epidemic”–the growing incidence of dental disease in this country.

Unfortunately, we as a nation have not made much progress over the last decade and a half. Just last weekend, thousands of people lined up to get charity dental care at the California state fairgrounds in Sacramento. Some had spent the night waiting in line.

Similar events will be held from coast to coast in the coming months, including at the Wise County, Virginia, fairgrounds near where I grew up. Seeing thousands of people waiting hours in the rain to get free dental and medical care in barns and animal stalls a few years ago changed my life. I realized that some of those people could have been relatives. I quit my job a few months later to become a patient advocate.

In his landmark 2000 report, “Oral Health in America: A Report of the Surgeon General,” Satcher wrote that while the United States had made great strides in other areas to improve the health of Americans, “there are profound and consequential disparities in the oral health of our citizens.”

Those disparities persist, according to a survey conducted by Wakefield Research and released last week by the Children’s Dental Health Project, a Washington-based independent nonprofit organization. Not only that, but lack of access to affordable dental care has spread to the middle class.

It doesn’t have to be this way. In fact, there are initiatives in three states that are making a difference, and advocates in Vermont are hoping their state will become the fourth this year.

Nearly four of 10 adults surveyed said either they or a family member had delayed seeing a dentist during the last year because of the out-of-pocket costs they would have had to pay. And a third of those adults said they or a family member currently have a toothache or other problem with their teeth or gums that should be addressed.

The CDHP survey showed that, as in 2000, members of racial and ethnic minorities continue to suffer disproportionally.

Thirty-four percent of blacks and 36 percent of Hispanics said their teeth are in such bad shape that they’re embarrassed to let others see them.

It is not just the poor who are now foregoing regular dental care. The researchers found that a surprisingly large number of relatively affluent Americans said they, too, are self-conscious about their teeth.

One in five of those surveyed with annual incomes of $75,000 or higher answered “yes” when asked if they “sometimes avoid smiling or do other things that make it harder for people to see what your teeth look like.”

When asked if during the past 12 months they or another family member had delayed seeing a dentist because of the out-of-pocket costs they’d have to pay, 26 percent of people making $75,000 or more said they had. Also answering “yes” to that question were 38 percent of people with household incomes of $35,000 to $74,999, and almost half (46 percent) of people with incomes of less than $35,000.

The problem of lack of access to dental care affects every state, from the largest to the smallest.

A December 2014 report by the California state auditor found that more than half of the children enrolled in that state’s program for low-income children (Denti-Cal) were not getting regular dental care. It also found that 32 of California’s 58 counties have dental access problems because of a shortage of dentists.

On the other side of the country, the Vermont Department of Health recently estimated that low-income children in that state are more than twice as likely to experience untreated tooth decay. As a consequence, many of them wind up in hospital emergency rooms–the most expensive place to get care–when the pain becomes unbearable. The state’s Medicaid program reported spending $2.5 million of taxpayers’ dollars annually to treat emergency tooth decay problems for children under the age of 6.

As in California, Vermont officials and healthcare providers say there simply are not enough dentists to meet the need, or at least not enough who are willing to see Medicaid patients.

“I can tell you that access to oral health care is the single largest problem facing our patients,” Peter Youngbaer, director of the People’s Health and Wellness Clinic in Barre, told Vermont Public Radio in February. He said that 44 percent of the patients who visited the clinic in 2014 had not seen a dentist in at least five years. Many of them said they had never seen a dentist.

To alleviate the problem, several patient and consumer advocacy groups are hoping Vermont will follow Maine’s lead in permitting mid-level dental providers to practice in the state. Maine last year became the third state in which mid-level dental therapists can practice. Alaska and Minnesota are the other two so far.

The Vermont Technical College plans to offer a program to train dental therapists, who would work under the general supervision of a dentist and provide a limited scope of services, ranging from preventive care to simple extractions and fillings.

Beth Nolan of Voices for Vermont’s Children told Vermont Public Radio that her organization supports expanding the dental workforce because efforts to recruit more dentists to treat low-income patients have not been successful.

“Without an alternative workforce model for dentistry, low-income patients will continue to be denied access to care,” she said.

Satcher agrees. He has joined a growing number of healthcare professionals advocating for expanding the dental workforce throughout the United States.

“States should explore all options that could expand access to care,” he wrote in a commentary, “including allowing midlevel dental providers such as dental therapists to practice.”

Author’s Note: This blog post is part of a series examining America’s oral healthcare crisis. Be sure to read the previous post, “Why I’m OK Having a Mid-Level Dental Practitioner Work on My Teeth.”


You and Your Teeth Are What You Eat

Diet is a huge factor to oral health that is often overlooked. There are many simple changes that can be made to fight tooth decay and gingivitis. There are certain foods and drinks that are best to avoid and others that can help. Be sure to read the article to find out exactly what you should do to improve your diet and oral health.

You may be able to prevent two of the most common diseases of modern civilization, tooth decay (caries) and periodontal (gum) disease, simply by improving your diet. Decay results when the teeth and other hard tissues of the mouth are destroyed by acid products from oral bacteria. Certain foods and food combinations are linked to higher levels of cavity-causing bacteria. Although poor nutrition does not directly cause periodontal disease, many researchers believe that the disease progresses faster and is more severe in patients whose diet does not supply the necessary nutrients.

Poor nutrition affects the entire immune system, thereby increasing susceptibility to many disorders. People with lowered immune systems have been shown to be at higher risk for periodontal disease. Additionally, research shows a link between oral health and systemic conditions, such as diabetes and cardiovascular disease. So eating a variety of foods as part of a well-balanced diet may not only improve your dental health, but increasing fiber and vitamin intake may also reduce the risk of other diseases.

How can I plan my meals and snacks to promote better oral health?

Eat a well-balanced diet characterized by moderation and variety. Develop eating habits that follow the recommendations from reputable health organizations such as the American Dietetic Association and the National Institutes of Health. Choose foods from the five major food groups: fruits, vegetables, breads and cereals, milk and dairy products and meat, chicken, fish or beans. Avoid fad diets that limit or eliminate entire food groups, which usually result in vitamin or mineral deficiencies.

Always keep your mouth moist by drinking lots of water. Saliva protects both hard and soft oral tissues. If you have a dry mouth, supplement your diet with sugarless candy or gum to stimulate saliva.

Foods that cling to your teeth promote tooth decay. So when you snack, avoid soft, sweet, sticky foods such as cakes, candy and dried fruits. Instead, choose dentally healthy foods such as nuts, raw vegetables, plain yogurt, cheese and sugarless gum or candy.

When you eat fermentable carbohydrates, such as crackers, cookies and chips, eat them as part of your meal, instead of by themselves. Combinations of foods neutralize acids in the mouth and inhibit tooth decay. For example, enjoy cheese with your crackers. Your snack will be just as satisfying and better for your dental health. One caution: malnutrition (bad nutrition) can result from too much nourishment as easily as too little. Each time you eat, you create an environment for oral bacteria to develop. Additionally, studies are showing that dental disease is just as related to overeating as heart disease, obesity, diabetes and hypertension. So making a habit of eating too much of just about anything, too frequently, should be avoided.

When should I consult my dentist about my nutritional status?

Always ask your dentist if you’re not sure how your nutrition (diet) may affect your oral health. Conditions such as tooth loss, pain or joint dysfunction can impair chewing and are often found in elderly people, those on restrictive diets and those who are undergoing medical treatment. People experiencing these problems may be too isolated or weakened to eat nutritionally balanced meals at a time when it is particularly critical. Talk to your dental health professional about what you can do for yourself or someone you know in these circumstances.

Reviewed: January 2012