Brad Bolman

Antisocial Dentistry


ISSUE 98 | TEETH | JUL 2021


Artwork by Mithu Sen

In December 2019, I put on a parka, a set of fleece-lined boots and walked to my union’s basement headquarters to sign in for picket duty and march through a blizzard. The HGSU-UAW strike of graduate workers at Harvard, which lasted twenty-seven days, was motivated by a variety of concerns: lack of a third-party grievance procedure to adjudicate harassment cases, long-standing pay inequities between graduate workers across the university’s campuses, and enough others to fill multiple issues of the union’s zine. But as picketers chatted during the breaks between circular marches and warmly repetitive chants, I found conversations turning over and over to an issue of universal dissatisfaction: we don’t even get dental.

Harvard provides health insurance to incoming doctoral students. Speaking generously (which the insurance isn’t particularly), the plan covers some of what’s needed. Dental insurance, however, is offered separately, an additional $792 each year (the current rate)—assuming you have no dependents, each of whom raises the cost by nearly $700. The plan covers cleanings, but more expensive procedures (which most are) can still run to hundreds or thousands of dollars; so costly that multiple international students described flying home to Asia, the Middle East, or Europe for cheaper dental care. Many others simply go without it. Meanwhile, the police officers who guarded our protests—tax and university dollars happily at work stopping us from keeping Fedex drivers from crossing the picket line—receive full dental coverage as part of their own union negotiated benefits.

As journalist Mary Otto notes in Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America (2017), roughly one-third of Americans today lack dental coverage. Studies show that those with insurance are more likely to visit the dentist and receive necessary care than those without, and those who lack health insurance are more likely to lack dental coverage too. Dental health problems can escalate into larger health issues, with the vicious cycle pulling millions into its orbit. While the 2010 Affordable Care Act lowered the number of uninsured Americans, its effect on dental care was far more limited, which is why so many found Bernie Sanders’ insistence on Medicare for All including dental so appealing.

The strike didn’t get us dental. Instead, Harvard agreed to a “Dental Fund” that guaranteed a modest reimbursement on co-pays or deductibles for grad students. In negotiations, the university insisted that providing dental insurance to all students was far more complicated than it seemed. With a second contract now on the table, the union is once again asking for it, complications regardless.

***

While dental coverage can seem more complicated than other forms of health insurance, the reasons for this hardly withstand basic scrutiny. Our mouths and teeth are parts of a larger body: we don’t purchase separate foot or clavicle insurance.

In 1840, dentists Horace H. Hayden and Chapin A. Harris were refused teaching positions by medical faculty at the University of Maryland and responded by founding the Baltimore College of Dentistry, the world’s first dedicated dental school. That “historic rebuff” served as a key set piece in the histories dentists tell about themselves, a kind of primordial trauma repeatedly drawn upon to explain the separation between medical and dental training.

Our inability to easily access dental care is a consequence of this history, together with the struggle to define knowledge of the mouth as a specialized area of medical expertise. Coinciding with the mouth’s arbitrary division from the body and dentistry’s resistance to cooptation by the medical field, American dentists waged a nearly century-long battle to keep themselves and their profession free to practice beyond the control of a socialized state healthcare system. Their successes fighting the perceived threat of communism helped to guarantee that dental insurance remained distinct from health insurance more broadly, enshrining “dental” benefits as a key union negotiating target ever since the 1960s.

In other words, rotting teeth⁠, when not our own fault (you’ll notice at the dentist that it nearly always is⁠) are simply the price of freedom.

***

The story continues in the years immediately following the Great Depression. Drawing inspiration from European advances in socialized healthcare, Franklin Delano Roosevelt moved to implement a national health insurance program in the United States. The American Medical Association, which first formally denounced “compulsory” health insurance in 1921, was vehement in protest against any movement toward “state medicine.” Although dentists were initially more ambivalent, aware of dentistry’s limited accessibility to Americans during the economic crisis, organized members of the profession supported the AMA’s resistance, declaring state dentistry “wrong in principle” and “disastrous in practice.”

For American dentists, who proactively distinguished themselves and their profession from its practice in England and Russia, socialized health insurance could never be the answer. Historian Alyssa Picard cites a Los Angeles dentist in 1933 who noted, “One hasty glance into the mouth of any person coming to us from any country in the world which ‘enjoys’ state or insurance dentistry is all a dentist needs to determine its ‘blessings.’” Opposition from the AMA made the issue politically toxic: when national health insurance was considered for FDR’s Social Security Bill of 1935, his allies feared that inclusion of the measure would doom the entire spending package. New York Senator Robert F. Wagner Jr. followed with a proposal in 1939, the “National Health Act,” but it was shelved as focus turned to the Second World War.

In the aftermath of the conflict, debates over national health insurance reemerged, this time colored by the burgeoning Cold War narrative of American capitalism standing firm against encroaching Soviet state socialism. Harry Truman, a hawkish voice against communist influence, nevertheless remained committed to a universal and comprehensive health insurance system which he introduced in 1945. The AMA once again stood against the bill, this time supported more actively by the American Dental Association. Carl O. Flagstad, Chairman of the ADA’s Committee on Legislation, insisted that compulsory insurance would interfere with the dentist’s “primary objective” of preventing disease by overtaxing a limited profession and refocusing American dental care around “repair.” On the other hand, the smaller National Dental Association, which formed in response to the ADA’s refusal to admit minority dentists (a practice that survived until 1965), supported Truman’s plan: for the NDA and its members, national intervention promised to resolve many challenges created by restrictive and racist local licensing systems that discriminated against minority dentists.

Truman’s first attempt stalled, but after winning surprise reelection in 1948, he once again raised calls for a national insurance program. Although Picard cites support among dentists treating low-income populations, leaders of the ADA were even more aggressive the second time around in fighting what they understood as the Red march against their profession. New ADA President Clyde Minges argued that “compulsory” insurance was a “political” rather than “scientific” solution to the problem of dental disease, one that would harm Americans. Wyoming Senator Lester C. Hunt, a Democrat and dentist, helped lead opposition to Truman’s plan and proposed a voluntary “compromise” bill, with support from the AMA and ADA, that would cover only “catastrophic” healthcare costs. So fearful were doctors and dentists of national health insurance that they even resisted the Truman administration’s efforts to form a Department of Welfare (the future Department of Health, Education, and Welfare) because it was thought to “give impetus to a compulsory health insurance program.”

Dentists with sparkling smiles lobbied Congress against health insurance, and mounted a massive campaign of public persuasion, advertising in newspapers across the country. The Nevada State Dental Society proclaimed in the Reno Evening Gazette in 1950 that “Suffocating Socialism at home, like communism overseas, threatens the America we cherish.” “We Salute… American Medical Progress,” the ad concluded. “The Voluntary Way is the American Way!” A full-page bulletin from Iowa’s Cerro Gordo County Dental Society declared that Great Britain had found its experiment with socialized dentistry “unsatisfactory,” but “In The United States You Can Still Choose Your Dentist!” “For How Long?” it continued, ominously.

***

Central for these and other arguments was the stark individualization of patient and mouth. Your dental care and treatment were for you to decide—which also implied that failures were your responsibility. This emphasis supported two larger trends in twentieth-century dental care traced by sociologist Sarah Nettleton: the alienation of mouth and teeth from the body and the often punitive control exercised over individual patients.

In the first case, dentists fought to maintain their professional autonomy and resist more powerful, and better organized medical groups by insisting on the exceptionality of the mouth and its teeth. Such arguments were initially leveraged to win respect and privilege for a profession that was, in the early twentieth century, still derided for its over-reliance on painful extraction and limited anesthetics. In the centuries prior, dentists put on carnivalesque performances to attract patients, with loud music partly meant to distract from their screams. If dentists wanted to maintain their professional autonomy, guaranteeing the ability to license and run small but profitable private practices, they needed to make the mouth into something cared for in a radically different way from the rest of the body. After all, why couldn’t one’s yearly physical checkup include a brief teeth-cleaning as well?

However, the second process was in some ways more insidious. Dentists embraced the surveillance of patients, and disciplinary strategies that reinforced what many, following Michel Foucault, have described as “responsibilization.” Tooth-brushing was discussed as a personal practice and obligation: twice daily, after waking and before sleep, ideally supplemented with floss. Although fluoridation campaigns acknowledged environmental threats to the mouth, dentists invested most heavily in public education campaigns to shape the conduct of individual brushers. Visits to the dentist included interrogation about the frequency and efficacy of brushing—an experience that, not unintentionally, leaves a thick residue of guilt. This psychic toll falls heaviest on the poor and working class, as “bad teeth” impact not only employability, but establish a relationship with the mouth as one of abject financial obligation.

The shift toward personal responsibility was, in many ways, simply the obverse of the explicit individualism and anti-communism which shaped the development of the American dental profession. For his leadership against Truman’s bill, Clyde Minges was named the “Dentist of the Half Century” by the Journal of the American Dental Association in 1950 (tellingly for the period, news of the honor appeared in his local Rocky Mount, North Carolina Evening Telegram above an article titled “Jap Communists Call Strike In Reprisal For Rush Trial”). The broader outpouring from America’s dental societies from 1945 onward counterposed “voluntary” care with “compulsory” insurance, rhetorically linking “freedom” to the absence of universal coverage. Pioneered and implemented by the AMA, this approach remains dominant today: freedom to choose one’s dentist is “American,” guaranteed coverage is socialism. There is an almost direct through-line from the dental industry’s resistance to Roosevelt and Truman-era health insurance policies to the sustained fight against expanding dental coverage today. For dentists, the Cold War never ended.

***

When Lyndon Johnson’s Medicare program came up for debate in the early 1960s, the American Dental Association jumped onto the defensive once more. Fritz A. Pierson, a Nebraska dentist and president of the ADA, argued that the federal government should not “assume the additional responsibility of providing health care to persons who can easily afford it,” cautioning that Medicare would “provide health benefits for a segment of the population without regard to the needs of individual beneficiaries.” We all know the argument: free medical care wastefully aids the wealthy—and thus should aid no one. W. Edgar Coleman, president of the Georgia Dental Association, called Medicare “the first step toward socialized medicine.” So central was resistance to Medicare that in 1964 the battle against Johnson’s program was singled out as the ADA’s primary legislative campaign.

Their fight was successful: dental and visual benefits were both excluded from the final Medicare bill; as newspaper question-and-answer sections demonstrated, this decision surprised many Americans who reasonably assumed the policy would cover all routine medical work. In response, the American Dental Association began proactive discussions, supported by the insurance industry and members of Congress, to create and expand private dental insurance. These programs would sit separately from existing medical insurance policies, both because they were created by dentists and because insurers were less certain about how to reimburse the alternative cost structure of dental procedures.

Some glimpsed an unanticipated benefit in the decision to separate dental from Medicare: hard-won union health plans which offered benefits already provided by Johnson’s program could now use money freed up for additional “fringe” benefits such as vision and dental. In 1954, the International Longshoreman’s Union and Warehousemen’s Union-Pacific Maritime Association persuaded dental societies in Washington, Oregon, and California to cover the children of members, ushering in the first union dental plan. Children’s dental needs were considered manageable by both workers and dentists, and after initial successes, the fight for dental benefits became an increasingly prominent part of union contract disputes. “The biggest area for dental insurance now is in unions,” explained Ronald Kotulak in the Chicago Tribune in May 1966, even though “Twelve years ago many experts insisted that no one”—meaning employers—"could support a dental insurance plan without committing financial suicide.” In the final analysis, those initially dire financial concerns proved unwarranted: union dental plans were relatively cost-effective and, when they began to include adult coverage, even reduced the number of sick days lost to toothaches, estimated around 40,000 per year in 1966. As it turned out, a bit of dental coverage was good for the bottom-line.

The exclusion of dental benefits from Medicare had two important, long-lasting effects. On the one hand, it left dental insurance as a key item on the union bargaining block. Dental was something worth striking for and one of the wins often mentioned by the press after major contract negotiations. When a nationwide strike of refinery workers was called in 1980, it was no surprise that a major demand was to widen the health plan to include “prescriptions and dental work.”

More broadly, teeth were further cordoned off from the major national insurance programs, shielding rising dental costs from Medicare’s bargaining power and making public dental insurance appear increasingly impossible to implement. For unions (like my own), the need to win dental had its own downsides, including repetitive fights for benefits that universal coverage could simply guarantee. As union membership continues to decline there are fewer workers able to access union dental packages in the first place, with the high cost of dental insurance restraining most employers from handing over benefits gratis.

***

The Affordable Care Act’s “individual mandate”⁠—originally proposed by the conservative Heritage Foundation in 1989 as an alternative to universal insurance⁠—does not cover adult dental insurance. Instead, a more limited program of pediatric dental care was implemented as one of the ACA’s ten essential benefits. This emphasis on pediatric care bears a longer history and has been a central rhetorical trope in the ADA’s fight against universal coverage since the 1950s.

In contrast to Truman’s and Johnson’s proposals, dentists recommended more limited interventions from the federal government: support for fluoridation, further funding for community services and research, and additional access to dental care for children. “Extension of community health programs to make dental care available to all children is being urged by the American Dental Association,” noted a short article in Perry, Georgia’s Home Journal in June 1949. In a system of universal coverage, the piece added, “Children would get less attention.”

Why? Justifications were rarely entirely coherent. There aren’t enough dentists, the ADA claimed—but then why not train more and pay them better? Prevention was critical, they insisted—but why was there a tradeoff in the first place? However, the overall point was clear: universal coverage would sacrifice the nation’s children. The same threat reappeared in debates over Medicare in the 1960s, with dentists suggesting that the program would focus too many resources on repair work for the elderly and “inevitably lead to a neglect of the needs of children and others.” When Johnson proposed a secondary program with dental benefits only focused on children, the ADA applauded.

The figure of the Child, as queer theorist Lee Edelman argues, has a powerful effect in structuring political argumentation. “The fantasy subtending the image of the Child,” notes Edelman, “invariably shapes the logic within which the political itself must be thought.”; being against children places one in the moral company of monsters. Despite the obvious paradox that children become adults whose teeth might need repair, the ADA’s masticatory futurism, the rhetorical pitting of children’s prevention vs. adulthood’s repair, has served repeatedly as a final backstop against the encroaching “socialization” of dental. Who, after all, would not want to protect the innocence and teeth of America’s children?

The essentially conservative nature of this vision exacerbates the anxious structure of dental care. Contemporary capitalism, Maurizio Lazzarato reminds us, thrives on the production of indebted subjects, “guilty and responsible in the eyes of capital, which has become the Great, the Universal, Creditor”—and, one might add, in the eyes of the dentist, too. If childhood is the time of preventive dental hygiene, adulthood is left as an extended period of oral dysphoria for many. Cavities, cracks, and other dental abjections, whose repair is often neither covered nor affordable, exist as mementos of the mistakes of the children we once were.

***

Couldn’t all of this have been otherwise? History reveals a multitude of paths not taken, many which might have guaranteed dental coverage to all Americans and left our unions free to fight more important battles. But writing the history of dentistry remains challenging. Books on the topic are few and far between, and the vast majority, filled with linear, progressive historical accounts, have the minty, hagiographic flavor that only industry sponsorship can guarantee. Many are, in fact, published by presses owned directly by dental product companies.

While the history of medicine is a well-established academic field—it has professional associations, university positions, conferences, and prizes—the history of dentistry is distinctly marginal. The Journal of the History of Dentistry is dominated by practitioner accounts, stories of how tools became faster and modern techniques were pioneered. There are about as many books of poetry with teeth in the title as there are comprehensive histories of a field of medical practice that affects the vast majority of Americans at least once every year. And even fewer closely explore the social and political factors that keep dental coverage away from many Americans, as if fear of the dental chair has seized historians as well. It makes sense, in this light, that one of the best recent books, Picard’s Making the American Mouth (2009), was written by a union organizer.

Outside of academic history, our cultural representations of dentists are highly ambiguous and often structured by fantasy: from the overly libidinous (Jennifer Anniston in Horrible Bosses) to the actively malevolent (the torture scene of Marathon Man). Dental websites obsessively curate top-ten lists of the best on-screen dentists, leading to peculiar collections of the good and the bad which demonstrate, more than any particular ideological bent, a desire simply to be seen and acknowledged. Early dentistry’s reliance on carnivalesque performance to attract clients has morphed, in our age of spectacle, into the profession's desperate attachment to its own media representation.

Offscreen, however, dentistry remains consistent—and highly conservative. The resistance to expanded government benefits or intervention into dental cost structures remains one explanation for dentists’ taste for Republican politics. Many of the country’s practitioners avoid taking Medicaid reimbursement or placing their practices in low-income areas, maintaining substantial obstacles to equitable provision of dental care, particularly for non-white populations. Despite efforts toward democratization, expensive schooling and high entry barriers to forming a new practice make it difficult for just anyone to become a dentist. Dentistry remains predominantly white and predominantly male (more so than medicine), and most states bar dental hygienists (who are largely female) from cleaning teeth unless employed by a dentist. The ADA has fought aggressively to keep the policy, which protects the existing structure of care, in place. Many who succeed in the field thus quickly find themselves in America’s upper income brackets, catering more and more to seekers of expensive cosmetic procedures. As dentist Brett Wells asked recently:“Is this the Dark Age of Dentistry? Or is it the Golden Age?”

Meanwhile the ADA is now probably more powerful than the NRA, given the latter’s bankruptcy, and dentists have continued to affect national policy in ways their predecessors would never have imagined. Three of the nation’s more prominent Congressmen-dentists—New Jersey’s Jeff Van Drew, Texas’ Brian Babin, and Arizona’s Paul Gosar—voted to overturn the results of the 2020 election, with Gosar leading the fight to decertify Arizona’s results (Idaho’s Mike Simpson and Georgia’s Drew Ferguson, also dentists, voted against the objection). The ADA funded all three during their runs and tends to support Republicans generally: according to OpenSecrets.org, sixty-one percent of dental contributions went to the Grand Old Party in the 2018 midterms. More recently, your dentist was roughly twice as likely to donate to Donald Trump than to Joe Biden.

“Americans may have no identity, but they do have wonderful teeth,” wrote Jean Baudrillard; yet, as journalist Natalie Shure noted in 2019, “dental inequality is even more extreme in America than inequality in other areas of healthcare.” The ADA is not unaware of these challenges, pointing the finger at “poverty, geography, lack of oral health education, language or cultural barriers, fear of dental care and the belief that people who are not in pain do not need dental care.” The fault may not be entirely individual, but the industry’s basic talking points remain largely unchanged and tend to racialize unequal oral health by blaming other languages and cultures. All the while, Medicare for All—including dental—remains off in the legislative distance, leaving most of us to hope that our present and future employers pick a health plan that “includes dental.”

They usually say no.

***

A few years ago, I taught a winter course on the history of teeth at Harvard. Inspired in part by a love of Valeria Luiselli’s The Story of My Teeth (2013) (my own involves falling teeth-first into a wooden stove during a preschool nap period), six other grad students and I spent two weeks reading about dentistry, watching clips containing dentists, and bemoaning our experiences in the dentist’s office.

One of the most exceptionally strange books I read in preparation was dentist Sydney Garfield’s acid history, Teeth, Teeth, Teeth: The Incredible World of Teeth (1969). The book’s inner back cover, an illustration of a tooth rocket blasting into space, offers only a glimpse of its many wonders. Immediately after a section on animal teeth, Garfield concludes with a rambling bit of speculative fiction about a future overrun by cloned teeth and disappearing dentists. “Physicians and dentists who had the M.D. and D.D.S. degree will be almost forgotten like the witch doctors of old,” he muses. Instead, “The new professional doctors of human welfare will have degrees like D.P.F.P. and D.I.H., Doctor for the Planning of Future Perfection and Doctor of Infinite Happiness.” A small cadre of Doctors of Emergency Repair will remain, too, caring “for those that never seem to avoid accidents” (one can hope, in the absence of copays, deductibles, or anything of the sort). Ever humble, Garfield admits that he “cannot envision the future to be.” But to his credit, and unlike many professional colleagues, he was willing to imagine a world without his kind, where oral health is universal and emergency repair remains available as necessary.

That future is certainly one worth fighting for. Collective struggles for health justice shouldn’t shy away from dental out of a belief that it is a marginal, fringe concern. Our teeth are deeply rooted within our lives and health, but afflicted all-too-often by the burden of guilt and atomized responsibility that are noxious by-products of America’s peculiar brand of dental anti-communism. However, union fights over dental benefits have exposed the necessary linkage between agency in our workplaces and control over the treatment of our bodies. By pressing for guaranteed dental coverage, we can free our unions from endlessly spinning their tires over teeth and stop employers from using treatments for cavities and fillings to keep us in jobs we hate. Rather than the exclusive privilege of deep pockets or an arena for intergenerational competition, healthy teeth should be everyone’s due. We deserve nothing less.

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