All I Want from Health Care is My Two Front Teeth

He came into urgent care with a nasty dental abscess. Cheeks swollen, a look of pain on his face, he struggled to open his mouth wide enough for me to look inside. The smell of his mouth could have knocked over a raccoon.

He needed that tooth pulled right away. So I arranged to get him some antibiotics (which he also needed right away) and called over to the dental clinic to arrange an appointment.

“Is he 100% service connected?” the clerk asked.

“No,” I replied, wondering what that had to do with the care of this grizzly Vietnam War veteran.

“We don’t cover dental care for our patients unless they are 100% service connected,” she explained.

I am proud to have worked in the V.A. health care system for more than 15 years. With a modest budget, relative to Veterans needs, the V.A. does an amazing job of caring for its population. But because of tight budgets, the V.A. must make difficult decisions about what care to offer to whom – what health problems deserve physical therapy, for instance, and how long patients should have to wait for things like hip replacements.

One of the difficult decisions the V.A. has made is to reduce dental benefits for their veterans. The V.A. is not alone in making this tough call. Dental care is often the first thing states trim when they are trying to balance Medicaid budgets.

From a purely medical standpoint, many dental problems do seem far less important than other conditions. Consider my most recent dental problem – I lost one of my front teeth due to trauma. I quickly realized how unnecessary the tooth was, biologically speaking, since I could still bite down on anything I would normally want to eat – crunchy bread-sandwiches, big juicy apples.

I had no pain, and no other medical symptoms. In fact, if you measured the cost and benefits of replacing my tooth, it would come out as a complete waste of money. High cost (several thousand dollars for an implant) and almost no medical benefit.

But sometimes medical costs and benefits don’t capture the entire picture. Losing a front tooth can have pretty noticeable social costs.

I was eventually going to replace my missing tooth with an implant. But for about five months I wore a removable “flipper.” I wore it when at work, doing television interviews, and teaching. But wearing that flipper drove me crazy, so I went “toothless” whenever possible. Walking the dog around our neighborhood with a missing tooth, I’d meet someone and notice the double take when the person recognized that I had a hole in my head. I’d feel the social distance created by my “condition,” a distance that I would try to bridge (not always successfully) with humor. People get freaked out by people who are missing teeth.

Imagine I am a Medicaid enrollee, in no position to joke about my condition, even embittered because I cannot afford a replacement tooth. Everyone I meet notices first and foremost, my damn mouth. How is that going to help my self esteem?

Now, hoping to get myself a job and get off Medicaid, I head out on a job interview. You are my prospective new employer. I have just one question for you: would you hire this guy?

Photo of Peter Ubel with front teeth missing

Of course you wouldn’t. Which causes me to wonder: Does it make any sense to lop off an entire category of health services, like dental care, without thinking about the medical and social benefits such services provide?

We pay for reconstructive surgery for people with relatively minor facial injuries. Isn’t a missing tooth worthy of coverage too?

Moreover, some dental care is as necessary for good health as is most medical care, like pulling out rotting teeth that lead to serious infections. It is short sighted to deny patients coverage for such problems, simply because they fall into a broad category of care that we’d like to curb.

Some dental care services clearly deserve low priority relative to other health-related services. Whitening yellowed teeth, for example, is a purely cosmetic procedure that doesn’t deserve social subsidization. But excluding the entire panoply of dental care services strikes me as indefensible. After all, we don’t exclude all ophthalmologic services just because Lasik surgery is a cosmetic procedure.

When seeking out ways to save money on health care, we should look more carefully at which dental services deserve coverage, rather than dismissing the entire category of care. Such a blunt dismissal of dental care feels like cutting off our front teeth to spite our faces.

Peter Ubel, M.D., is the Jack O. Blackburn Professor of Marketing at Duke University’s Fuqua School of Business and a professor of public policy at Duke’s Sanford School of Public Policy. He is author of Free Market Madness: Why Human Nature is at Odds with Economics—and Why it Matters (Harvard Business Press, 2009). His blog is www​.PeterUbel​.com; 919–660-7700.

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  1. Fred Hapgood says:

    Any specific bit of cost reduction can be opposed. But what would you do if you were trying to make $100 of appropriation cover $150 worth of procedure? “Cut something else,” I guess you might say Is it fair to ask you what? Maybe not. But
    if not then it is hard to know whether cutting whatever we would need to cut to finance
    the reentry of dental care into the list of covered procedures might not end up
    doing even more damage.

  2. […] to identify services they can trim from their Medicaid budgets. Some states (as I wrote about here) are cutting dental coverage for Medicaid enrollees. Others are cutting hospice care or transplant […]

  3. Steve Flori says:

    This is a very strong argument. Indeed dental care deserves a lot more consideration than numerous policy makers are willing to give it now. But, I wish your argument had centered around the medical benefits of dental care i.e the alleviation of pain and infection that are a result of effective dental coverage. I know that you present this point when you describe an anecdote containing one of your patients, but when one discuss the “social/cosmetic benefits,” as you do, it gives some detractors the ammunition to argue against the inclusion of dental care as part of comprehensive coverage.

    On that note, PBS’s “frontline” also, not too long ago, did a segment on this topic (“Dollars and Dentists”) and the pain and suffering depicted among some of those interviewed was quite unsettling.

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  1. […] to identify services they can trim from their Medicaid budgets. Some states (as I wrote about here) are cutting dental coverage for Medicaid enrollees. Others are cutting hospice care or transplant […]

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