Essay/Fairness & Equality

Poor teeth

If you have a mouthful of teeth shaped by a childhood in poverty, don’t go knocking on the door of American privilege

Sarah Smarsh

Photo by Bruce Gilden/Magnum

is a journalist covering class in America. Her book In the Red, on the working poor and her upbringing in rural Kansas, is forthcoming from Scribner. 

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3,500 words

Edited by Pam Weintraub

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I am bone of the bone of them that live in trailer homes. I grew up next to Tiffany ‘Pennsatucky’ Doggett, the hostile former drug addict from the prison TV drama Orange Is the New Black. I know her by her teeth.

Pennsatucky – a scrappy slip of a woman menacing, beating and proselytising to fellow inmates – stole the show during the first season of the Netflix prison series. But amid an ensemble cast of similarly riveting, dangerous characters, it was her grey, jagged teeth that shocked viewers into repulsed fixation. She was the villain among villains, a monster that fans loved to hate; ‘Pennsatucky teeth’ became a pejorative in social media.

Actress Taryn Manning’s gnarly, prosthetic teeth startled viewers because, by and large, poor characters in TV and film are played by actors whose whitened, straightened, veneered smiles aren’t covered up. It’s hard to think of characters besides Pennsatucky through whom heinous teeth convey rather than lampoon the physicality of the poor. The first that comes to mind is the derelict serial killer in a movie actually called Monster (2003); as with Manning, Charlize Theron’s Oscar-winning transformation generated astonishment with fake teeth.

In my life, Pennsatucky and her teeth are entirely familiar. She’s the slurring aunt who passed out in our farm’s swimming pool while babysitting me, and later stole my mom’s wedding band to buy the drugs that dug grooves in her cheeks. She’s the step-parent whose brain, organs and teeth corroded over the years and now lives in a mobile-home park with my construction-worker dad.

But Pennsatucky’s teeth aren’t just ‘meth teeth.’ They are the teeth of poor folk, of the young grandma who helped to raise me and for decades worked from diner to factory line to a desk job as a probation officer for the county court system in Wichita, Kansas. She was just 35 when I was born, so I knew her as a radiant thing; at the downtown courthouse, where I tagged along – babysitters are expensive – attorneys turned flirtatious near her green eyes, long limbs and shiny, natural-blonde bob. Then at night, in her farmhouse or the tiny brick house we fixed up in a rough Wichita neighbourhood, I watched her take out her teeth, scrub them with a rough brush, and drop them into a cup of water with a fizzy tablet.

‘Brush your teeth and don’t eat too much candy,’ she’d tell me. ‘You don’t want to end up like Grandma.’ She’d widen her eyes and pop her dentures forward so that they bulged from her lips, sending me giggling. In the early 1970s, a dentist had pried every one of her teeth, too far gone or too expensive to save, from her 20-something skull. She’s 69 now and has worn false teeth for more than 40 years.

‘I had bad teeth all my life. They were straight and looked OK, but I always had toothaches,’ she tells me when I ask how she ended up with dentures. As I was growing up, the story fluctuated – she was in a car accident, her natural teeth just fell out, and so on. ‘I was excited to have them, knowing I would never have another toothache. Now I think it was pretty stupid, but at the time it was really painful, and I thought I was doing the right thing.’

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More than 126 million people in the US – nearly half the population – had no dental coverage in 2012, according to the US National Association of Dental Plans. In 2007, the New York State Dental Journal reported that while only one-tenth of general physician costs were paid out of pocket, nearly half of all dental costs were settled directly by patients. This reflects spending by the uninsured but also those sharing costs with coverage providers; most plans cover routine cleanings but leave patients to pay for 20 to 50 per cent of fillings, crowns and other big-ticket visits. For those who can’t afford to pay that difference, treatment is delayed and teeth continue to degrade.

But expense isn’t the only barrier to dental care. Those on Medicaid find that few dentists participate in the programme due to its low payout. And more than 45 million people in the US live in areas, often rural or impoverished, with dentist shortages, according to the US Department of Health and Human Services. Medicare, as a general rule, doesn’t include dental.

In the past year, the Affordable Care Act, or ‘ObamaCare’, has changed many lives for the better – mine included. But its omission of dental coverage, a result of political compromise, is a dangerous, absurd compartmentalisation of health care, as though teeth are apart from and less important than the rest of the body.

it wasn’t sugar that guided our dental fates. And it wasn’t meth. It was lack of insurance, lack of knowledge, lack of good nutrition

About a decade ago, at the age of 50, my dad almost died when infection from an abscessed tooth poisoned his blood and nearly stopped his heart. He has never had dental insurance and has seen a dentist only a handful of times when some malady became unbearable. In 2009, according to the US Agency for Healthcare Research and Quality, dental issues caused about 936,000 emergency-room visits and almost 13,000 inpatient hospital stays. Many of these patients had low incomes and dental coverage that restricted care to emergencies or wasn’t accepted by accessible dentists.

‘I notice people’s teeth because mine are so bad,’ Dad tells me during a break from a side job renovating a fraternity house. He has long been the handsome object of crushes, but his teeth have become increasingly askew with time, one of his eye teeth now ragged and long like a rabbit’s for lack of a carrot to file it down. ‘Nutrition affects teeth, right?’

I point out that Gatorade, which he favours when he splurges on a bottled beverage, is full of sugar. But it wasn’t sugar, heaps of which are sucked down daily by the middle and upper classes, that guided his and my grandma’s dental fates. And it wasn’t meth. It was lack of insurance, lack of knowledge, lack of good nutrition – poverties into which much of the country was born.

My family’s distress over our teeth – what food might hurt or save them, whether having them pulled was a mistake – reveals the psychological hell of having poor teeth in a rich, capitalist country: the underprivileged are priced out of the dental-treatment system yet perversely held responsible for their dental condition. It’s a familiar trick in the privatisation-happy US – like, say, underfunding public education and then criticising the institution for struggling. Often, bad teeth are blamed solely on the habits and choices of their owners, and for the poor therein lies an undue shaming.

‘Don’t get fooled by those mangled teeth she sports on camera!’ says the ABC News host introducing the woman who plays Pennsatucky. ‘Taryn Manning is one beautiful and talented actress.’ This suggestion that bad teeth and talent, in particular, are mutually exclusive betrays our broad, unexamined bigotry toward those long known, tellingly, as ‘white trash.’ It’s become less acceptable in recent decades to make racist or sexist statements, but blatant classism generally goes unchecked. See the hugely successful blog People of Walmart that, through submitted photographs, viciously ridicules people who look like contemporary US poverty: the elastic waistbands and jutting stomachs of diabetic obesity, the wheelchairs and oxygen tanks of gout and emphysema.

Upper-class supremacy is nothing new. A hundred years ago, the US Eugenics Records Office not only targeted racial minorities but ‘sought to demonstrate scientifically that large numbers of rural poor whites were genetic defectives,’ as the sociologist Matt Wray explains in his book Not Quite White: White Trash and the Boundaries of Whiteness (2006). The historian and civil rights activist W E B du Bois, an African American, wrote in his autobiography Dusk of Dawn (1940) that, growing up in Massachusetts in the 1870s, ‘the racial angle was more clearly defined against the Irish than against me. It was a matter of income and ancestry more than colour.’ Martin Luther King, Jr made similar observations and was organising a poor-people’s march on Washington at the time of his murder in 1968.

Such marginalisation can make you either demonise the system that shuns you or spurn it as something you never needed anyway. When I was a kid and no one in the family had medical or dental insurance, Dad pointed out that those industries were criminal – a sweeping analysis that, whether accurate or not, suggested we were too principled to support the racket rather than too poor to afford it.

My baby teeth were straight and white, and I wasn’t obese – an epidemic among poor kids that hadn’t yet taken hold in the 1980s – but I had plenty of ‘tells’: crooked bangs, trimmed at home with sewing shears; a paper grocery sack carrying my supplies on the first day of school while other kids wore unicorn backpacks; a near-constant case of ringworm infection (I kept a jar of ointment on my nightstand year-round); the smell of cigarette smoke on my clothes, just as cigarettes were falling out of favour with the middle and upper classes; sometimes, ill-fitting clothes, as when the second-grade teacher I revered looked at my older cousin’s shirt sagging off my shoulder and said: ‘Tell your mother to send you to school in clothes that fit you.’ In fifth grade, a girl noticed my generic, plastic-smelling, too-pointy boots – a Kmart version of the black leather lace-ups that were in fashion – and for weeks hounded me before and after school, kicking dirt on my shins and calling me Pippi Longstocking.

I had moments of cool clothes and good haircuts, too, and I was a confident child who earned friends and accolades. But I still think of the boy who handed me a dessert cup from his lunch box every day when a mix-up in the free-lunch programme left me without a meal card for months.

He pulled from my skull the greyed tooth, cracked perfectly down the middle

Common throughout those years was a pulsing throb in my gums, a shock wave up a root when biting down, a headache that agitated me in classrooms. While they looked OK, my baby teeth were cavity-ridden. Maybe it was the soy formula in my bottle when they were growing in, or the sugary cereals to which my brain later turned for dopamine production in a difficult home. Maybe it was because our water supply, whether from a rural well or the Wichita municipal system, wasn’t fluoridated. But richer teeth faced the same challenges. The primary reason my mouth hurt was lack of money.

Once, around third grade, an upper molar that had menaced beyond all – the worst toothache I ever had – finally rotted so thoroughly that it cracked in half while still in my jaw. Mom took me to the dentist, somehow. The pain was tremendous, he explained, because the pulpy nerve at the tooth’s centre was exposed. He pulled from my skull the greyed tooth, cracked perfectly down the middle, and let me take it home. For years, I kept the two pieces in a tiny jewellery box, sometimes taking them out and joining them like interlocking sides of the heart-shaped friendship necklaces I coveted.

Around that time, I had my jaw X-rayed for the first time. The results were grim.

‘You might as well start saving for braces right now,’ my mom recalls the dentist saying. We were at the outset of a post-divorce period that would include much moving and a slew of partial-coverage dental insurance plans: employer-based, which would be cancelled with Mom’s regular job switches, and variations on state-funded, poor-kid programmes in between. Each time the policy changed, Mom had to find a new dentist who would accept our coverage. Then we’d ride out a waiting period before scheduling a cleaning or filling. My dental records were often lost in this shuffle, as was the case with my general health files in doctors’ offices and school districts – I got a new round of shots just about every year for lack of immunisation records on file.

There would, of course, be no saving for braces.

It took years to find out whether the X-raying dentist’s pessimistic prediction would come true. My baby teeth were slow to fall out, their replacements slow to grow in. But at some point came the unequivocal, surprising verdict: my teeth grew in straight.

I don’t just mean straight enough. I mean 99th-percentile straight. I mean dentists call hygienists over to take a look.

‘Doesn’t she have pretty teeth?’ they say, my mouth under hot lamps. ‘Are you sure you didn’t have braces? But you whiten them, right?’

I shake my head no and in the dentist’s chair tingle with the bliss of gratitude. That my environment and genes somehow conspired to shake out a bright, orderly smile is a blessing I can’t explain. But I can tell you what preserved the blessing: me.

When a health teacher said brush your teeth twice a day, I brushed my teeth twice a day. When a TV commercial imparted that dentists recommend flossing daily, I flossed daily. A college room-mate once remarked on the fervour of my dental regimen. After boozy nights, when other kids were passing out, I held on, stumbled to the bathroom and squeezed paste onto a brush. However tired, however drunk, I scrubbed every side of every tooth, uncoiled a waxed string and threaded it into sacred spaces.

Privileged America judges harshly the mouths that chew orange Doritos, drink yellow Mountain Dew, breathe with a sawdust rattle

Poor teeth, I knew, beget not just shame but more poorness: people with bad teeth have a harder time getting jobs and other opportunities. People without jobs are poor. Poor people can’t access dentistry – and so goes the cycle.

If Pennsatucky ever gets out of poverty, it will be thanks in part to a prison-yard fight in the season-one finale, when the upper-class protagonist knocks out her nasty grill; early in the second season, her rotten gums nearly toothless, she blackmails the warden into a new set of teeth. Upon incarceration, Pennsatucky traded meth for ‘born-again’ religious fanaticism, but her new teeth are a harbinger of a more substantive rebirth. If the eyes are the soul’s windows, its door is the mouth – the fence across which pass food, drink, words, our very breath.

Privileged America, ever striving for organic purity, judges harshly the mouths that chew orange Doritos, drink yellow Mountain Dew, breathe with a sawdust rattle, carry a lower lip’s worth of brown chaw, use dirty words and bad grammar. When Pennsatucky gets out of prison, she’ll need respect, rehabilitation, employment. To that end, for all her praying and testifying, Pennsatucky’s pearly gates might be her pearly, albeit prosthetic, whites. She cries with joy in a prison van on the way to get them, and later shows off with an over-the-top smile during laundry duty.

‘You’re acting a little, like, retarded,’ an envious inmate tells her.

‘I’m not retarded,’ she says. ‘I got new teeth!’

When I was a young adult, I learnt I’d been born without wisdom teeth. The dentist told me I was ‘evolutionarily advanced’ since human beings, no longer in the business of tearing raw flesh from mastodon bones, don’t need so many teeth now. So many TV shows, bad jokes and bucktoothed hillbilly costumes in Halloween aisles had suggested that my place of origin made me ‘backwards’, primitive and uncivilised, that the dentist’s comment struck me deeply, just as in fourth grade when I read the word ‘genius’ in a school psychologist’s evaluation notes to my mother and wept on the sidewalk.

Having straddled a class divide and been wrongly stereotyped on both sides of it, throughout my life I’ve found peace in the places and things that don’t evaluate my status: nature, animals, art, books. ‘I sit with Shakespeare,’ wrote du Bois in The Souls of Black Folk (1903), ‘and he winces not.’ Social disadvantage and hazard engender what he called ‘double consciousness’, the ever-present awareness of more than one self. For du Bois, his most challenging two-ness in the wake of slavery was to be educated and black – a tension of socialisation still at work, to be sure, as President Barack Obama’s raw first memoir attests. Today, for me and millions of people in the US living on one side of a historic income gap, the defining double consciousness is to be educated and poor.

The latter, for many of those who suffered losses after the economic collapse of 2008, is a terrifying new identity, its horror projected on to Pennsatucky’s serrated mouth and hard to reconcile with the Americans they thought they were. But in my academic and professional ‘climbing’, I learnt early and often that one doesn’t leave a place, class or culture and enter another, but rather holds the privilege and burden of many narratives simultaneously.

Friends who know my background sometimes kid me when I’m drunk and misconjugate a verb or slip into a drawl, or when, thoroughly sober, I reveal a gross blind spot in the realm of book-learning (if, say, the question involves whatever one learns in sixth grade, most of which I spent playing in red dirt outside a two-room schoolhouse near the Oklahoma state line). They smile at the pleasure I take in scoring solid furniture from yard sales or, once, for expressing delight over a tiny cast-iron skillet, a miniature version of the pan my grandma once used to fight a drunken stepfather off her mother. I enjoy the kidding and feel appreciated when they recognise the true clichés that weave my story.

But here’s the thing: wealthy people use cast-iron skillets and bad grammar, too. It’s just not their narrative and thus passes without remark. I’ve observed fellow journalists, the same ones who made trailer-park tornado survivors famous for a loose grip on the past participle, edit dumb-sounding quotes by city commissioners to suit the speaker’s stature. And while I took the education I wasn’t given through libraries, encyclopedias and my former stepfather’s New Yorker subscription, plenty of members of the middle and upper classes refuse or lack the ability to seize the opportunities handed them. It can be useful to acknowledge the cultural forces that carve us, or edifying to indulge in the tropes of our assigned narratives, but true distinctions of character, intelligence, talent and skill exist at the level of the individual, not of the class – or the ethnicity, the gender, the sexual orientation, the religion and so on. To claim otherwise, as we’ve discovered across time and countless persecutions of our own doing, is at best an insult and at worst an excuse for enslavement and genocide.

the liberal proponents of Occupy Wall Street are often the same people who think Southerners are inbred and Walmart shoppers slovenly miscreants

In Thomas Harris’s best-selling crime-novel series, the FBI consults the imprisoned serial killer and mastermind psychiatrist Hannibal Lecter in its search for ‘the Tooth Fairy’, a family-slayer who bites his victims with dentures made from a mould of his grandmother’s distorted, razor-sharp teeth. Years after that manhunt, the FBI again turns to Lecter for help; this time, the refined sociopath – a former philharmonic orchestra board member and mannerly purveyor of his victims’ flesh – finds it more interesting to analyse the agent than the latest case.

‘You know what you look like to me, with your good bag and your cheap shoes?’ he asks the young agent Clarice Starling – who comes from the same place as Pennsatucky but whose intellect, health, grit and ambition, presumably, landed her on the right side of the prison bars. ‘You look like a rube. A well-scrubbed, hustling rube with a little taste. Good nutrition’s given you some length of bone, but you’re not more than one generation from poor white trash, are you, Agent Starling? And that accent you’ve tried so desperately to shed: pure West Virginia. What is your father, dear? Is he a coal miner?’

Lecter’s condescending soliloquy from a cell decorated with sketches of the Duomo cathedral in Florence – a place Starling surely hadn’t heard of when she left her family sheep farm for the FBI Academy at Quantico – hits home but doesn’t derail her. His most famous line – the aggressive posturing about fava beans and good Italian wine – happens when Starling sends a psychological evaluation through the glass and tells him to look at his damn self. We should do the same in the US, where the liberal proponents of Occupy Wall Street are often the same people who think Southerners are inbred and Walmart shoppers slovenly miscreants with no social awareness.

A century ago, du Bois wrote: ‘The problem of the 20th century is the problem of the colour line.’ The problem of the 21st century is that of the class line. For the American Dream to put its money where its mouth is, we need not just laws ensuring, say, universal dental care, but individual awareness of the judgments we pass on people whose teeth – or clothes, waist lines, grocery carts, or limps – represent our worst nightmares.

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