Dollars and Dentists: PBS Frontline investigates America's dental health crisis

In America, in the 21st century, people still die of toothaches and dental neglect. "Dollars and Dentists," the latest investigative documentary hour from PBS Frontline, explores America's broken dental care system and reveals how the pressure for profit leaves the poor and under-insured at risk.

As host Miles O'Brien reports in the film, more than 100 million Americans don’t go to the dentist because they can’t afford it. Many end up financially devastated and in severe pain. Some, including children, even die.

The film focuses on two companies whose practices raise questions: dental chain Kool Smiles, which treats children on Medicaid who might not otherwise receive care. Critics say Kool Smiles takes advantage of patients, pushing for more extensive treatment than standard, in an effort to rack up more billing. The firm's practices are under examination by federal and state authorities. And other chains, like Aspen Dental, offer credit cards and payment plans to help low-income patients finance care. But the cards, issued in dentists’ offices, are offered at what many consider to be predatory financing rates, in a pressured sales approach.

Watch the full hour-long documentary here.

Boing Boing editor/partner and tech culture journalist Xeni Jardin hosts and produces Boing Boing's in-flight TV channel on Virgin America airlines (#10 on the dial), and writes about living with breast cancer. Diagnosed in 2011. @xeni on Twitter. email: xeni@boingboing.net.

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inkfumes

Ill affirm this… I need about 12 thousand $$ worth of dental work to repair a broken bridge, instead of fixing it I am living with the pain and discomfort. Payment plans are unavailable or unaffordable. I know someone that just travelled to mexico to have work done, bids from American dentists were in the 15k area, in Mexico the work ran about 3K and the dentist had equipment and facilities that were more modern than the local dentists.
- Antinous / Moderator
  
  I know a lot of people who go to Mexico for dental care. It’s a day trip and can save a fortune.
  - niktemadur
    
    Fun fact: the wildest college parties I went to in Guadalajara were courtesy of the orthodontists. Dentists drinking cane alcohol with Squirt Soda in one room, dentists fucking their brains out in the next.
dioptase

It’s an old stat, but a few years ago it was estimated that a new dentist needed to invest $500,000 to begin a new practice. That kind of investment requires some serious cash flow to pay off. That fits with what I’ve noticed. New dentists push for more procedures than old, established dentists.
Chesterfield

Last year I spent a little over $10,000 on an implant for a tooth that I broke. I also developed a cavity under a crown that I had on a molar that resulted in the tooth being extracted. The implant for that tooth is going to cost even more because they have to build up bone for the implant. So, in two years, I will have spent around $22,000 on two damaged teeth. Ugh.
- rattypilgrim
  
  I feel your pain. No, I really do. Same thing happened to me with an implant. What a racket! And don’t get me started on all the x-rays you’ll be subjected to.
Ness Creighton

I’ve got a broken molar with a root canal in it that I cannot get a crown for, and four wisdom teeth that need to be extracted that I cannot have done (all 4 are broken). Why? Because apparently 3 fillings, a cleaning, and an emergency root canal capped my “amount” for the year for my insurance (1500$). I’m a PhD student, so the only reason I HAVE dental insurance is through my husband’s job, and I can’t afford to have the work done without the insurance. So yeah. This is a massive problem.
IronEdithKidd

I’m not going to be very happy when my current dentist inevitably retires within the next decade (or less). I have a couple chipped teeth he won’t bother with because there’s no need. A new dentist will pounce on that kinda thing because all s/he sees is a $1500 billing.
mccrum

If you don’t read that first sentence and wonder where we have gone horribly awry as a society, you are part of the problem.

Seriously, death from dental neglect? The system is broken. We might as well have people dying from dysentery on the Oregon Trail here.

Out of curiosity, does anyone know Canada’s rate of dental issues with their universal health care?
- http://twitter.com/dichotoman Max Meyer
  
  I can’t definitively speak for the rest of the provinces but dental’s not covered in Ontario. I’m out a few thousand dollars over the past few years due to some wisdom tooth & root canal fun.I believe I was told that once upon a magical time dental was covered under the Ontario Health Insurance Plan but conservatives did that in.
  - mccrum
    
    Well, that totally sucks. I was hoping there would be some kind of statistic I could review and determine there were less people dying of dental problems because there was zero cost for preventative maintenance.
    
    You know, instead of just trusting the common sense.
- Edith Lebel
  
  In Quebec, dental’s not covered by universal health care for adults, but I think it pays for basic maintenance for kids below the age of 12.
- Mantissa128
  
  But you don’t understand. As long as we keep spending money to kill brown people, we are safe!
http://twitter.com/Fishamatician Jamie walker

I really dont understand the american attitude to health care, It seems most would rather give money to an insurance company that will do its best to wriggle out of paying for treatment rather than hand the government a small amount to ensure universal health care. One quote i heard recently on the radio was ” Why should I pay to help other people”.

We might not all have gleaming white Hollywood smiles but we dont die of toothache either. Our NHS dentists charge the following and if you want veneers etc you can pay (usually) the same dentist extra to do it.
Its by no means a perfect system but it does provide a safety net and is generally a good service.

Band 1 course of treatment – £17.50 or $27This covers an examination, diagnosis (including X-rays), advice on how to prevent future problems, a scale and polish if needed, and application of fluoride varnish or fissure sealant.

Band 2 course of treatment – £48.00 or $75This covers everything listed in Band 1 above, plus any further treatment such as fillings, root canal work or removal of teeth.

Band 3 course of treatment – £209.00 or $352This covers everything listed in Bands 1 and 2 above, plus crowns, dentures and bridges.Its
- howaboutthisdangit
  
  The American attitude is dictated by the big money interests, and enforced by knee-jerk reactionaries who consider it unpatriotic to even consider a different way of doing things.
  
  Do you have room for one more over there?
  - millie fink
    
    What a humane, civilized society you’ve got there.
    
    Here in the U.S., ordinary people are hog-tied and fleeced by a profit-driven system that most of us think is okay (indeed, “the best health care on earth”) because we’ve been so thoroughly inundated with messages telling us to trust the “efficient free market” and to distrust “inefficient big government.” Facts don’t matter when they’re up against powerfully propagandized ideology.
    
    Edit: As an American myself, I meant to reply to Jamie walker.
- Tynam
  
  I was about to say exactly this, but Jamie said it better. Americans, next time someone’s telling you how bad we have it in Europe, point at this post.
  
  (And it’s not just the NHS; it’s everything. I have private care with the best dentist I ever met. It costs me significantly less than £250 a year, for everything – and I’m a high-risk patient. My first day there was an emergency visit, uninsured, with one tooth snapped in half and six others needing filling, repair or sealing. Total cost about £750. Not nothing – but cheap at the price.)
  - millie fink
    
    Sounds great.
    
    Brings to mind, though, ideas (stereotypes?) about a lot of Brits having bad teeth. Anyone know if there’s any truth to that common conception, and if so, why hasn’t their cheap, readily available dental care system long ago flung such rumors into the rubbish bin of history?
    - Antinous / Moderator
      
      The UK took decades to recover from WWII. Dentists were doing procedures with no pain control for so long, Brits became very reluctant to go to the dentist. I have friends who tell horror stories about dental visits in the 1970s.
    - Purplecat
      
      The “Bad British Teeth” meme generally comes from a couple of things:
      1. British dentistry, thanks to its less commercial nature concentrates more on function than form. Without the extensive advertising and focus on selling the “perfect smile”, people are satisfied with teeth that would be considered unacceptable in the US.
      2. It’s a long running meme. The first time lots of Americans saw British people and formed opinions of them was back in WWII, before the NHS and universal health care started up here. Teeth were probably legitimately bad back then.
      3. As the article says, the people in the US with the bad teeth are poor, and hence ignored by the media.
      - millie fink
        
        Thanks A & P, very helpful, that all makes great sense.
- mccrum
  
  ”One quote i heard recently on the radio was ” Why should I pay to help other people”. ”
  
  One thing I hear over here is about how we shouldn’t apologize for our country for one reason or another. This is especially true when a politician (typical President) publically apologizes to another country directly.
  
  That said, I’d like to go on record and apologize to you, directly and sincerely, for having to hear that total dumb ass on the radio expounding beliefs that make no sense in either a moral or logical manner.
  - http://twitter.com/Fishamatician Jamie walker
    
    Apology accepted on one condition. Could you ask your fellow americans if they could start using the perfectly good H on the word Herbs while on tv, it drive me nuts. I will of course return the favour on any letter we drop :)
- Amanda Smith
  
  Come on people….NO ONE dies from a toothache. Unless they shoot themselves to stop the pain. What PBS is trying to avoid specifying is that an infection that may have begun in the tooth spreads to the brain specifically or the heart (causing infective endocarditis)….then and ONLY THEN can a tooth cause death. And that would be in the rarest of occasions.
  - Antinous / Moderator
    
    Or the infection tracks to the neck, erodes the jugular or carotid and they bleed to death out their mouth. I’ve witnessed it at close range.
  - cdh1971
    
    It’s not rare Amanda.
    
    The long-term damage to the heart is even more frequent, and then there is t he stigma attached to having even yellow teeth, not to mention rotting teeth, or missing teeth.
    
    And, no, tooth pain is not some sort of sign of sloth or divine disfavour, or ‘making bad choices’.
    
    I would say that maybe you should listen to less right-wing radio, but sadly, I find this lack of empathy and lack of critical thinking too common among the the so-called millennials, regardless of professed creed.
    
    Yikes…you might need to Google what right wing radio is, ’cause when you think ‘wing’ you think yummy buffalo wings and when you think right – well, you have to look that one up.
    - cdh1971
      
      I have a tightness in my chest. I think this might be the big one!…
      - niktemadur
        
        Elizabeth!
  - http://pulse.yahoo.com/_6LOJDBXCDHL5MVQQRLOCCJ35AY alexb
    
    Or they have mouth cancer and it goes unnoticed until it’s too late. Whereas it’s one of the things that a regular dental check up is designed to spot.
  - donovan acree
    
    Yes they do Amanda. I was almost one of them. My (ex) dentist had me on the same antibiotic for 4 weeks trying to treat and infection. In the end, I had to go to a surgeon and have a piece of my infected jaw and some infected ganglia removed. The surgeon estimated I had 72 hours before it would have been too late – and this is what you get if you HAVE insurance.
  - Shane Curtis
    
    You are incorrect in that assumption. Just as one example, look up Ludwig’s angina. I treat patients with serious, acute dental infections every single day.
- http://pulse.yahoo.com/_6LOJDBXCDHL5MVQQRLOCCJ35AY alexb
  
  These people who feel “why should I pay to help other people”, where do they think their insurance permium goes? Does it go to a special fund just for them? Or does some of their premium go to helping other people? Do they not understand that some of other people’s premiums go to helping them when it’s their turn to need help?
  This is socialist health care, but in the US you pay your premium and the biggest chunk goes to the private company that provides the care. In Europe the premium goes into the social pot.
  - http://www.facebook.com/csismeiro Carlos Sismeiro
    
    The system is changing for the worse in Europe right now.
    
    I personally live in one of the countries facing strong austerity measures (Portugal) and literally people have died.
    There are not enough ambulances, there are less maternities, even though we have chronic lack of doctors for what we need our chief of government decided loads had to be fired and told them to emigrate (by the way Germany seems to be using this as a great way to get cheap specialist almost by the bus load).
    
    The whole government and state and what not are supposed to be a cooperative effort by the people for the people and it is supposed to lose money – it has a cost to make the country, any country, a better place. The idea of choosing based solely on cost effectiveness and on profitability is what destroys the weak tissue that holds a society together.
    
    In all “western” countries we must react to the destruction being done, because the heavenly “each man for himself” place that many politicians seem to be aiming for looks too much like the world of the “Mad Max” film series or the “The Book Of Eli”, and I think most people who want that will actually hate it when we get there.
sarahnocal

I don’t understand how, with all of the advances that have been made in health care, the treatments, transplants and miraculous cures, why we still have such problems with our teeth and why dentistry has hardly changed in hundreds of years . It doesn’t make any sense.
- hymenopterid
  
  It makes sense if you consider that dental insurance is slow to cover a lot of new treatments. So even if you find a dentist that has the new equipment, you’l have to pay out of pocket to get them. This is why, in 2012, a lot of our patients are still getting acrylic and amalgam fillings when we have a cool CNC milling machine that will mill out a custom filing out of ceramic while you wait. We’ve had that machine for about four years, and most peoples’ insurance still won’t cover a filling made by it.
  
  Gee, it’s almost as if Delta doesn’t want to cough up the cash. One of the reasons this is a rip-off is that the average consumer doesn’t have the information to determine if the dental plan they’re purchasing is going to be adequate when they need it.
  - sarahnocal
    
    I guess the question is Why are we still getting cavities? Where is the vaccine?
    - Antinous / Moderator
      
      A vaccine that gets you to produce antibodies on the outer surface of your teeth? Wouldn’t that require a mouth full of pus?
    - erx
      
      1) there have been many advances in dentistry over the past hundred years, and dentistry is probably the most advanced medical subspecialty there is. Dentists can pull out all of your teeth and replace them with implants that a layperson can’t distinguish from real teeth, and no other specialty can make that claim. However, that stuff is really expensive. It used to be that dentists just pulled teeth if they went bad, and that was really cheap.
      
      2) we eat lots and lots of sugar, and people in the past didn’t.
      
      3) There is a vaccine-like strategy for cavities that was developed by a company called Oragenics. Basically, cavities are initiated primarily by a bacterium called streptococcus mutans, which makes lactic acid that eats through tooth enamel. The guy behind this (I think his name is Hillman) deleted the gene that makes lactic acid from the genome of strep mutans, then replaced it with an analogous gene from a harmless bacterium and also added a gene that caused his strep mutans to outcompete the cavity-causing strep mutans. The idea is that people would get their mouths cleaned out really well, gargle with an antibiotic rinse to kill as many strep mutans as possible, then recolonize their mouths with his non-cavity-causing strep mutans, which would then kill off the last of the cavity-causing ones. One of the big problems is that strep mutans is one of the bacteria that can cause infection of your heart valves if it gets into the bloodstream (which happens all the time while eating or brushing your teeth), and I think there was a lot of concern that the modified bacteria might be more likely to cause that, which would obviously be bad. It’s a cool idea though. Last I heard they were still in initial testing, so maybe there were bugs to iron out.
- donovan acree
  
  I just wonder why our mouths are not covered with normal health insurance. Why are we being gouged for this one type of health issue?
  - Antinous / Moderator
    
    It’s not just teeth. California just forced insurers to cover treatment for autism. Mental health coverage is still spotty. Reproductive services were and remain a fight for coverage. The list goes on.
kcmpls

Even when people have good health insurance in the US, like me, it often comes with no or terrible dental insurance. My dental insurance provides free preventative care (which is great), but only play 80% up to $1000 for anything else each year. Last year I had to split my root canal and crown into two separate years to get them mostly paid for. And I have “good” benefits by American standards (thanks to my union!).

When did dental and health get split? And why? We don’t have special insurance for our feet, why for our mouths? It is all so very weird.
- xzzy
  
  Because tooth decay is considered preventable, and if you get a cavity it’s your own damn fault for not brushing enough.
  
  Bonus option: Cavities are inevitable and insurance companies can’t make money covering things they know they’ll have to pay out for.
- millie fink
  
  We don’t have special insurance for our feet, why for our mouths?
  
  I have little doubt that it’s because we’re stuck with a profit-driven system, and teeth care costs a lot more than foot care. Costs that, in such a system, can be more readily shifted onto “the health care consumer.”
  - Antinous / Moderator
    
    teeth care costs a lot more than foot care.
    
    People with ingrown toenails can require a lot of foot care. Some insurance policies limit podiatric visits to a certain number per year.
    - millie fink
      
      No doubt, though of course, I meant the cost in general to the business interests to which most Americans are prey.
  - donovan acree
    
    Why do you say tooth care costs more than foot care? The foot is arguably a more complex system. Heck, toenail removal costs $250 to $1,200 vs a tooth extraction costing $50 to $150. Yet, podiatric treatment is covered.
http://twitter.com/tburtonwood tom burtonwood

best health care system in the world. ; )

i once had a dentist tell me if i’d come in to see in 10 years prior he could bought a new BMW, and spent the rest of the appointment cooing over this goldmine that he saw me for. needless to say i didn’t go back.
deckard70

The death of “Angel” actor Andy Hallett from a tooth infection which spread to his heart should have been a wake-up call that health insurance should not treat dental care as something outside of medical care. All health plans should include dental care. It is only natural – our bodies are one, there is no division between our jaws and the rest of our bodies.
- jimh
  
  There is a division however, between how the insurance industry views human beings and how anyone with the slightest amount of compassion views them. I had a dentist tell me that insurance will approve a full set of dentures almost without fail. That is, pulling all your teeth, and giving you false ones.
  
  Because it’s a one time cost. Maintenance is much more expensive over a lifetime. We are profit/loss centers, not people.
- millie fink
  
  Actually, a lot of dogs die that way too.
BrighterSara

Dental care can be so difficult to access and afford for many people across the US. Hat’s off to Frontline for tackling this important issue. With almost half of the population without dental insurance, much more needs to be done to help bring reasonable options for care and treatment that won’t break the budget.

Dental pricing transparency is a significant issue also facing the industry. Procedure prices can vary 400% in the same neighborhood, sometimes within blocks of one another. In conjunction with Empirica research, Brighter recently released a survey on this topic and its impact on the LA area. Uninsured patients are potentially overpaying by hundreds of millions of dollars, with seniors, families, and minorities among those most impacted. For more, check out: http://www.brighter.com/research/price_transparency/los_angeles/

Fear of prices keeps many from seeking out care early on and sticker shock once care is received are gut-wrenching experiences far too familiar to many of us. Brighter.com, a dental savings plan and consumer empowerment tool, is working hard to bring affordable, quality care to the uninsured. Brighter believes in bringing transparency to dental care, letting members compare dentists based on reputation and upfront pricing. We use group buying power to pre-negotiate savings of up to 60% on dental procedures to enable our members to save and make the best dental wellness decision for themselves and their families.
jimh

One dentist that I used to go to had a separate employee that I called the “closer”. He wore a shirt and tie, reminded me of a 20-something car salesman, and came in after the cleaning and the dentist’s exam. He was clearly not a part of the medical staff. His only job was to put the hard sell on you for the services. “You’re going to LOSE THOSE TEETH!”, he once said to me, as he was trying to get me to commit in writing to four crowns.

I didn’t sign, and went to another dentist referred by a friend. I said nothing about the “four crowns” diagnosis I had been given earlier. They x-rayed me at the new place, and it turned out I didn’t need all that work. I had a couple of small cavities to fill.

I shudder to think the amount of healthy tooth enamel they would have removed to install unnecessary crowns, and the associated long-term maintenance involved with replacing them later.
- hymenopterid
  
  The funny thing is that those tactics don’t even work. You might as well bash your head into the wall. We had our best month in 20+ years and most of the charges were for cleanings. No massive restorations or full mouth veneers, just cleanings. There are a lot of old and stupid ideas as far as how to sell stuff in dentistry and how to increase profits. Why on earth would scaring people work in the dentist’s favor? Ugh!
  - jimh
    
    I thought the same thing when I walked out of the office that day, knowing I would never go back whether I actually needed those four crowns or not. I sure wasn’t going to have them done there.
bcsizemo

That last time I had my teeth cleaned (over a year ago…no insurance now) I thought the dentist was going to have an orgasm while checking over everything. Even the dental techs were astounded when they realized I had all 4 wisdom teeth in…
That’s what having 4 teeth removed and 4 years of orthodontics gets you I guess.

The dentist asked me why I even came….I just thought it’d been a couple of years seemed like a good idea to get some X-rays and what not.

Hopefully everything continues to go well. I just worry about my future kids. Don’t worry daddy will be driving the same car we brought you home in through your highschool graduation just so you can have pretty teeth.
- niktemadur
  
  True story: the dentist that fixed my teeth as a teenager in San Diego was the same man who fixed Michael Jackson’s teeth in Los Angeles several years before.
  
  The man’s name was Bud Rubin, and he was a gentle, Carl Sagan-like wizard in his manner. “So… bite down for me… thank you…” His gentle voice and gentle finger pressure just soothed me like a balm. Then his minions did the painful work.
  
  Almost thirty years later, my teeth are still just about perfect. Bud Rubin was a wizard, and don’t try to tell me any different.
John Giotta

Dental coverage is a joke. They’ll pay for cleanings twice a year, but if you need anything more than a cleaning and you’ll be paying through the nose.
http://twitter.com/ethicalcannibal Ethical Cannibal

My husband are like all the other stories here. He’s got terrible teeth from growing up in poverty in the US. He needs two bridges, but it took us twenty years for him to have a job that even half covered the costs. Half covered. That’s with good insurance.

Unlike some of these horror stories, we have a good dentist, that keeps costs low. He won’t even do unnecessary work. I keep asking for vampire fangs longer than the artificial ones I have installed, and he won’t do it because he is more worried about my teeth than the cash I’d hand him. That means he’s a keeper.
Sinchy

I’ve always wondered why dental care was not part of overall health insurance. The private health insurance system treats it as if your teeth had nothing to do with the rest of your body. It’s a bizarre disconnect that ignores the fact that food goes in your mouth and pain in your teeth is often the worst and most common type suffering people go through.
Vickie Kostecki

For a long time, the dental office I go to has had a steady stream of young, recently graduated dentists, join the practice who had to bill anything they could to (presumably) pay off their investment. About twice a year I would have to explain to a new dentist that, no, I did not need a whole new set of x-rays and half my fillings replaced, just because I had insurance.
Jason Wood

Humans will game the system; that’s just how it goes. As far as I can see, there are two main “systems” available as options for health care; the current U.S. system of “hope to hell you get good enough insurance and can keep it” (for ‘basic’ healthcare, you’ll need even better luck for dental), or the “let’s let the government make sure everyone has healthcare” system used in much of the rest of the ‘civilized’ world. So if we accept that people will game the system, which set of negative side-effects seem more acceptable:
1) Many people will suffer poor health, or even death, because of their inability to pay (which is often not even a matter of “laziness,” but of pure blind luck-of-the-draw).
2) Some people will get more than they really “deserve,” such as people getting treatment for health problems that were largely “their fault,” or possibly more treatment than is “strictly necessary.”

How the in the name of the Flying Spaghetti Monster’s Most Wholly (Holy [Hole-y]) Tentacle does the majority of a country decide that #1 is a better option?
http://www.flickr.com/photos/stefan_e_jones/ Stefan Jones

I watched the Frontline episode about an hour ago.

I feel so fortunate to have good dental insurance, and enough money to pay for what it doesn’t cover.
http://www.jimdraws.com Thorzdad

Dental care will get even more expensive and less likely to be covered by insurance now that financial corporations like CareCredit (aka: GE Financial) have gotten their claws into the system. Most of the independent dentists in this area now simply hand you a brochure for CareCredit when they give you the cost estimate for whatever procedure you need.
http://carrierlost.com/ Tonweight

As someone who’s had more than enough work done to know that it sucks and costs too much, I’m at least grateful to have a decent guy doing the work these days. While I still have the “80% coverage” woes, I know that I’m only getting charged for what’s absolutely necessary because my dentist makes it a point to go over what each line-item means.

Still – it would be nice to have a more comprehensive and less predatory system in place. When I needed three broken wisdom teeth surgically extracted, my dentist charged me (well, my insurance company) LESS than the guy before him, who’d extracted the first broken wisdom tooth; AND, he was done – with ZERO pain – in about 45 minutes. Of course, it took the rest of the day for the lidocaine to wear off, but that’s jbust phhhbine bby bbe, dboctbor.

My dentist is a ninja of the mouth.
niktemadur

Funny isn’t it, how naughty dentists always make that one fatal mistake.
Bye for now, keep your teeth clean.
http://www.youtube.com/watch?v=fAe6UEUmaJk
http://germanwotd.com Amelia_G

One of denephews had two gold crowns installed not long after those teeth erupted. Now he’s seven and wearing braces. This can’t be right.
At least dentistry’s cannulas are smaller-gauge than when I was a kid. Thank goodness for that.
- Antinous / Moderator
  
  I had braces when I was in the second grade. Nothing wrong with getting it over with before puberty.