• A Dane Passed By

The not-so-white smiles of rural Nevada

Updated: Dec 10, 2018

In Nevada they have a governor with a big, shiny smile. A Colgate smile is what we would call it in Denmark because it is one of those with an impressive white set of teeth that he confidently flashes on all official pictures.

If you have never been to the United States, this may be the way that you picture an average American. At least that is what I subconsciously did, when I arrived here first time, after having spent way too much time in my teenage room in Denmark watching tv-series like Full House, Glamour and Beverly Hills 90210 on my 12” screen, and also noticing supposedly ordinary people in advertisements for American products where the seller forgot or was too lazy to change the face of the American product to a more casual, Scandinavian kind of person.

Nevada governor Brian Sandoval and fellow politicians after signing a bill.

Like the big, white smile is the center of all official pictures of the governor in Nevada, the Colgate smile was to me the very center of being ‘all American’.

Now, after having spent time in rural Northern Nevada, I can safely say that my (dated) perception of ‘all American’ is not for all Americans.

In rural Nevada, a Colgate smile is a sign of wealth. Not necessarily that you are a millionaire with a mansion and gold watch, but just that you are wealthy enough to exercise the expensive hobby: going to the dentist once in a while.

After having spent a month here, what surprises me and makes me go ‘huh?’ when I stop to talk to a random person in the grocery store or at the gas station, is no longer a set of dark brown teeth, a few missing teeth here and there or even a mouth without anything but gums.

What surprises me now, is when a person displays a somewhat healthy looking set of teeth.

In other words, bad teeth simply seems to be the norm.

Before I elaborate, here are a few numbers from the non-profit organisation Oral Health Nevada, which shows that a lot of Nevadans are off to a bad start.

*47% of kids have experienced tooth decay when they begin in school

*In 3rd grade that number has risen to 64%

*A little less than a third of the total number of 3rd graders live with untreated tooth decay

*Only 37% of low-income children 0-20 years of age have had a dental visit

*Just 20% from the same group has received dental treatment

If you want to see some more graphic results of those numbers 20-30-40-50-60 years later, take a look at my blog post from this fall, where I talked to people who only get to go to a dentist when the free, mobile clinic Remote Area Medical shows up in the neighbourhood (oh, and before you leave this blog post, I will tell you that for all the astonishing and remarkable work the mobile clinic does, it is not the answer to rural Nevada’s problems).

This March Oral Health Nevada served lunch to the local legislators. This is probably the only place where nobody thinks twice about eating next to a picture like the one on the poster, as one participant noticed.

So what the hell is going on with teeth in Nevada, where the governor is smiling but a lot of voters keep their mouths shut or choose to stay in their homes simply out of embarrassment?

There are of course multiple reasons but here but I will focus on where it all begins, the children, and only elaborate on two core issues.

The first one is the one that seems most obvious: access. Two of the rural counties in Nevada do not have any dentists, and four counties (25% of all counties in Nevada) do not have any dentists who treat residents with Medicaid. I will not get too far into the latter but in short, the federally sponsored Medicaid is the only way for poor Americans to get treatment.

I stay in the rural county, Lyon County, which has 52.000 inhabitants, and here they have five dentists in total and only two of them accept Medicaid. Furthermore, depending on where you live as a cash-strapped resident in this county with at least 16,5% of the population below the poverty line, the round trip to a dentist ranges anywhere between 40 and 100 gash-costly miles (60 to 170 kilometers).

Not surprisingly, a lot of residents – which includes their children – choose not to go, and according to the private non-profit organisation Healthy Communities Coalition (HHC), 5 out of 10 screened students suffer from untreated tooth decay. In some schools that HCC go to for screenings, the percentage of students who needs a follow-up is 100. That is: one hundred percent.

Some of my work from the fall (when I wrote about Remote Area Medical) was used in March to illustrate the dental situation for Nevada’s legislators. Here is a 100x60cm poster with a picture of the main character Kathleen next to her personal budget.

The situation in Nevada is in sharp contrast to my childhood in Denmark. When I had to go to the dentist, I walked out of my class room and into a small court-yard, where I turned right, then left and finally right, before I stood in front of a white door. That was the entrance to what we called the school dentist and the walk for my short legs probably took between four and seven minutes depending on the number soccer balls and other distractions on my way.

Dental care is free for all Danes before they turn 18 years old as long as you choose a dentist that the municipality work with. The dentist is optional so the parents are still free to choose another dentist, but if that dentist does not work with the municipality, the parents have to pay themselves (this, I was told by a professional here, would very likely be a big obstacle in Nevada, since nobody wants to be told what to do or where to go, and, say a person choose a ‘non-municipality-related’ dentist for their child, they don’t want to pay for other people’s access to a dentist. Get it? It’s all about freedom of choice).

According to data from the Danish Health Authority, children aged 7 without cavities in their permanent set of teeth is at 96-97%. Unfortunately, this looks worse when Danes turn 18 where the population with no cavities is down to around 45%.

Percentage of Danish 7-year-olds without cavities in the permanent set of teeth, 1992-2016.

Back to Nevada where not going to the dentist leads to the second issue here: awareness. Whereas the Danish model includes information and education of both child and parents, similar programs in Nevada are either rare or non-existing.

In general, I really like it here in Nevada, and out of the +30 states I have been to over the last ten years, this state is slowly moving towards the very top of all-time favourites. The local ‘live-and-let-live’ doctrine suits my way of thinking and living, and I like that I can’t necessarily tell whether a person is wealthy or not by looking at their house or the way they dress. In Nevada, only you are the expert when it comes to what you (and your family) need and want, and people in general let you live your life accordingly.

Thus, with this next statement, I know that I risk loosing my last local reader (because who knows a child’s needs better than it’s parents, right?). Well, I will risk it anyways:

If you never learned how to take care of your own teeth, you are probably not the best person to teach kids (yours or others) how to brush or take care of their teeth.

If a child wants to be better at running, scoring a touch-down, hitting a home-run, playing the piano or speaking a foreign language, most parents know that the only way is via a professional coach. Maybe I am stretching my point here, but the only difference I see between this and teeth, is that the latter is for everybody and for life.

A woman gets treatment on a basketball court in Silver Springs this September.

On top of all these local factors, or maybe at the very bottom of all these local factors, is the general American health care system. Most people I know had no dental insurance after they, sometimes in their 20’s, said goodbye to their parent’s insurance policy, and according to the National Association of Dental Plans, 114 Americans have no dental coverage at all.

It is simply too expensive.

So, what to do? In Nevada, the concept of a school dentists or any other tax-costly programs are at best far, far out in the future, and the organisations who are trying to persuade politicians to do more are right now focusing on getting funding for a State Dental Health Officer and a State Public Health Dental Hygienist.

Today, most of the dental work in Nevada seems to happen after the damage is done, so the key for the officer and hygienist is prevention with a focus on oral hygiene and what increases the risk of oral disease (smoking, sugar, not brushing your teeth correctly etc.).

Also, the dental health officer and hygienist and their staff are collecting data, so the state can compete for federal funding and grants. For someone outside the United States, this is important to understand because a lot of states (especially states like Nevada with no state income tax and therefore a small state budget) rely on federal funding to sponsor their public programs. But in order to get federal funding, the state needs to bring forth data that backs the need, and right now the poor collection of data in Nevada means, that the state gets less money from Washington D.C. than other states in the Union. Nevada has not received direct federal funds for the State Oral Health Program since the summer 2013.

I am definitely not an expert in this field but I have seen a lot of bad teeth here in rural Nevada, and I do hope that the local politicians understand the need for better dental care, so more locals can flash their own Colgate smiles in the future.

Like news segments on tv, I want to end with a happy story: The man you see on the picture above the headline is Victor, who was sent home from Remote Area Medical’s clinic in September because his mouth would occupy the only dentist the whole day. The local dentist who sent Victor home, though, has since given him free dental help worth more than $8000, and Victor recently said that he now feels confident enough to get out of his little house and help other people in need. Voila.