Studies show bad teeth prevent otherwise qualified candidates from getting jobs or promotions. Although the U.S. is on the cutting edge of innovations in dentistry, many Americans have poor oral health and crooked or missing teeth and don't go to the dentist because they don’t have insurance and can’t afford to pay out of pocket for care.

Earlier this year, the managers at a Salt Lake City counseling office were struggling to fill a position at their front desk. They'd blazed through a string of potential candidates sent by a staffing agency, but none had the qualifications they were looking for. And then the agency sent a candidate named Shelly (not her real name), a 35-year-old mother of three who'd re-entered the work force because her husband was laid off.

“Everyone in the office loved her, ” recalls Miriam Brown, who also worked the front desk. As a temporary employee, Shelly was pleasant to work with, competent and kind to the patients. “We all told our boss to hire her because she was so great."

Instead, management hired someone else.

At a staff meeting, Brown asked her manager why Shelly wasn’t hired permanately. The response shocked everyone in the room. The office manager said Shelly had bucked and crooked teeth. “He said it wasn’t the image we wanted to project at our clinic,” Brown said.

This is not an isolated incident. Studies show bad teeth prevent otherwise qualified candidates from getting jobs or promotions. Although the U.S. is on the cutting edge of innovations in dentistry, many Americans have poor oral health and crooked or missing teeth and don't go to the dentist because they don’t have insurance and can’t afford to pay out of pocket for care. The scope of the problem is widespread: close to half of Americans are without dental insurance, according to data from the Department of Health and Human Services.

Limited access

Access to dental care in America is limited in two basic ways. First, many don’t have access to insurance, and second there is a shortage of dentists who are willing to treat the poor.

About 130 million Americans, 43 percent of the population, have no dental coverage whatsoever, according to a 2012 report from the U.S. Senate Subcommittee on Primary Health and Aging. The data show that although spending on dental services amounts to just under 5 percent of total health care expenditures, 44 percent of dental bills are paid for directly out of patients' pockets.

This sheds some light on why low-income families are more likely to suffer from compromised oral health: they don’t have the wiggle room in their budgets to pay for dental services. Instead of heading to the dentist when they experience tooth pain or injury, they go to the emergency room.

A study published in the Annals of Emergency Medicine found that in 2009 more than 800,000 patients visited emergency rooms across the country seeking treatment for preventable oral diseases.

The poorest Americans, recipients of Medicaid, are eligible for dental benefits, but many report difficulty finding a dentist willing to see them. Many dentists don’t accept patients on Medicaid because the reimbursements don’t cover the cost of doing business, according to a representative from the Washington State Dental Association, who said that on average, 60 percent of dentists' fees are eaten up by overhead. "I can't afford to do Medicaid," said Cesar Sabates, president of the Florida Dental Association.

In fact, only 20 percent of the nation’s practicing dentists provide care to people with Medicaid, and of those who do, only a small percentage devote a substantial portion of their practice to serving the poor, according to the report by the U.S. Senate Subcommittee on Primary Health and Aging. This helps explain why only 38 percent of children on Medicaid received dental services in 2009, according to Bernard Sanders, who authored a 2012 Senate report on the American dental crisis.

Compromised health, crooked impressions

Public health officials are quick to point out that dental issues are medical issues. An example of the high cost of neglected dental care is the death of Deamonte Driver of Maryland. The 12-year-old boy died in 2007 from an infected tooth. Although he had Medicaid, his mother was unable to find a dentist in their area who would see her children and accept their coverage, and by the time his aching tooth got any attention, the abcess had spread to his brain. An $80 tooth extraction could have saved his life.

As Driver's story illustrates, dental checkups can detect the signs of microbial infections, immune disorders and some cancers. The phrase “the mouth is a mirror” underscores information about general health that comes from examining oral tissues.

Poor oral health may also interfere with vital functions like breathing, swallowing, eating and speaking, which further compromise the well-being of the afflicted. For example, without teeth to chew, it can be difficult to get adequate nutrition.

There is a social cost of going without dental care, too. Numerous studies show a strong correlation between appearance and income. Research by Daniel Hamermesh, professor of economics at the University of Texas, found that better than average looking people earn 5 to 10 percent more than average looking people, who earn 5 to 10 percent more than below average looking people. “Teeth are an important component of physical appearance,” Hamermesh said.

In an effort to isolate the economic value of teeth, Sherry Glied and Matthew Neidell of Columbia University School of Public Health looked at the link between fluoridation and income. “Childhood access to fluoridated water leads to better teeth,” Glied said. Glied and Neidell found that women who grew up in communities with fluoridated water earn 4 percent more than similar women who did not.

But income isn’t the only thing impacted by the appearance of a person’s teeth. Researchers have noted pronounced negative associations with crooked, discolored and decaying teeth. Approximately 40 percent of respondents to a 2012 study by Kelton Research said that they would not date someone with crooked teeth. And about 73 percent said that people with straight teeth are more trustworthy.

When Israeli researchers digitally manipulated the teeth on the subjects in photographs and asked people to give their first impressions, they noted similar patterns of discrimination against people with poor oral health. People with crooked, discolored and missing teeth were judged to be of limited intelligence, low class, bad parents, less professional, less physically beautiful and lacking social skills.

Improving access

Currently, low-income and minority families experience more oral disease, yet they receive less care, according to Bernard Sanders, author of a 2012 Senate report on the dental care crisis in America. "It is our ethical and moral imperative to commit to providing access to dental care for all, both to improve health and to reduce overall costs,” he wrote.

Sanders advocates introducing a new work force model by adding dental therapists, the dental equivalent of a nurse practitioner, to the system. More than 50 countries around the world, including Canada, Great Britain and New Zealand, use dental therapists. Minnesota is the only state where dental therapists are authorized to practice. "I am trained to the level of a dentist, but trained to do fewer things," said Minnesota's first registered dental therapist, Christy Jo Fogerty, in a Frontline documentary, "Dollars and Dentists," that aired earlier this year.

Preliminary studies suggest dental therapists substantially increase access to dental services and provide high quality, lower-cost care, according to Sanders. Analysis by the Pew Research Center found that private practice dentists who add dental therapists to their teams would maintain or improve their bottom lines.

Still, the American Dental Association is fiercely opposed to the proposal. Lobbying efforts by the organization have successfully blocked the expansion of the dental therapist model to other states.