THE STATE OF DECAY
Part 1: Peroxide and pliers for those too poor to pay
First in a series of four parts.
FORT GAY — In the end, it came down to this: hydrogen peroxide, 150-proof moonshine, wire pliers and two teeth that shrieked with pain. Click to watch slideshow
With no money or insurance to pay to fix her aching teeth, Deborah Crites, 50, took matters into her own hands. Crites numbed herself with moonshine and pulled two of her teeth with a pair of wire pliers, she said.
Deborah Crites, 50, couldn’t sleep at night. Her face was swollen like a grapefruit. She was losing weight — 15 pounds at last count. She couldn’t slurp down soup her teeth hurt so much.
Crites called a dentist first, but the price of extractions — $100 per tooth — was out of the question. She had no private dental insurance, no Medicaid, no paycheck.
So one night last fall, after drinking beers with a friend at The Wildcat II tavern here on the banks of the Big Sandy River, Crites descended into the depths of her garage apartment below the bar and took matters into her own hands.
She rubbed her gums with hydrogen peroxide, swigged a pint of moonshine and retrieved the orange-handled pair of pliers from her kitchen drawer.
“You just wiggle it and jerk it right out,” explained Crites, who would later have all of her remaining teeth extracted by a dentist.
Crites is one of an estimated 260,000 West Virginians who have suffered through pain and now live without teeth.
West Virginia has the highest percentage of older adults without any teeth in the nation.
Nearly 43 percent of state residents ages 65 and older are living without teeth, according to the National Oral Health Surveillance System. That’s double the national average.
West Virginia has a higher percentage of toothless older adults than impoverished countries, such as Madagascar, Gambia, Cambodia and Indonesia, according to the World Health Organization.
Tooth loss isn’t just a problem that affects West Virginia seniors.
Among all ages, nearly one of every three West Virginians — more than 580,000 people — has lost six or more teeth because of disease or decay. Nearly 15 percent of West Virginians are living without any teeth at all.
“The old philosophy is don’t go to a dentist,” said Barbara Hughes, a dental hygienist who works in clinics in Southern West Virginia. “We don’t need to be taking people’s teeth out. We need to be saving them.”
State health officials have acknowledged they have done little to improve oral health among older West Virginians. They’ve launched no initiatives. No money has been distributed to address the problem in recent years.
Health officials say we should not define West Virginia’s oral health status based on tooth loss. The statistics are misleading, they say.
Adults ages 65 and older make up 15 percent of the state’s population. West Virginia has a higher percentage of seniors than all but four states.
Even though the state hasn’t tried to improve oral health among older adults, the percentage of West Virginia seniors without teeth has dropped by 5 percent since 1992, though the numbers have increased slightly in recent years.
“You’ve got to look at the total picture,” said Phil Edwards, who directs the state’s Division of Infant, Child and Adolescent Health. “These people age 65 and older grew up in a different West Virginia than what we have now. There are more dentists. More people have [dental] benefits.”
Not everyone is as optimistic as Edwards about West Virginia’s oral health future. Consider:
- West Virginia has one of the lowest percentages of adults who visit the dentist at least once a year.
- Medicaid, the state-administered health insurance program for the poor, will pay only for tooth extractions for adults ages 19 and older in West Virginia. It won’t pay for teeth cleanings, fillings, crowns, dentures or any other dental procedures. Medicaid does pay for dental services for children — a federal mandate.
- Medicare, the federal government’s health insurance program for seniors, pays for no dental services whatsoever.
- West Virginia has the second-lowest number of older adults in the nation with dental insurance — the No. 1 factor in determining if someone sees a dentist. Only 14 percent have insurance that covers dental services.
- West Virginia has high rates of smoking and smokeless tobacco use — two habits that contribute to poor oral health. The state has the highest rate of spit tobacco use in the nation and the third-highest percentage of smokers.
Studies have shown that poor oral health isn’t a problem confined to the mouth. Decay and infections in teeth have been linked to other health problems: heart disease, diabetes, pneumonia, stroke, and premature and low-birth-weight babies.
Seven years ago, former U.S. Surgeon General David Satcher declared oral health disease a “silent epidemic,” saying those who suffer the worst are poor Americans and the elderly.
The description is especially apt in West Virginia.
Spend time at dentists’ offices in rural West Virginia, and you’ll see people with swollen faces, toothaches, gaping cavities, painful abscesses, lip cancer, gum infections, teeth rotted black with decay and molars cracked off because of an unsuccessful attempt at do-it-yourself dentistry.
“When they pull their own, they usually never get the whole tooth out,” said Dr. Dan Brody, a dentist who extracts dozens of teeth a week at clinics in Wayne, Cabell and Lincoln counties. “Sometimes, we have to go in and cut the rest of them out. I’m willing to bet there are people in Third World countries with teeth not this bad.”
‘I didn’t feel a thing’
Joyce Collier tried to talk Deborah Crites out of pulling her own teeth. She really did, but Crites already had made up her mind.
“I said, ‘Oh, my God. That’s so crazy,’” recalled Collier, Crites’ longtime friend. “I thought she was only going to make an attempt, but she did it.”
Collier and Crites were at the Valley Health dental clinic one morning last winter. Crites sat back in a dentist chair, recounting to Brody the night she yanked out her teeth, proud of her handiwork.
“I didn’t feel a thing,” she said.
Crites had since qualified for a state “medical card” through the Medicaid program. More of her teeth were hurting. She wanted a professional to take them out this time.
Crites had lost count of how many teeth she had left. She reckoned at least five had been extracted by dentists. Other teeth had decayed, deteriorated and fallen out on their own.
“Had some knocked out by my ex-husband, too,” she said.
Brody counted the last of Crites’ teeth. Eleven. They all were coming out that day.
Crites’ oral health problems are shared by thousands of other low-income West Virginians.
Sixty percent of older adults in the state who earn less than $15,000 a year have lost all their teeth because of disease and decay. Ninety percent of that same group has lost six or more teeth.
Compare those numbers to West Virginians who make more than $50,000 a year. Among that group, only about 10 percent have lost all their teeth, according to the Centers for Disease Control and Prevention.
Crites traveled with a construction crew for 18 years, building houses and restaurants in West Virginia, Tennessee, Michigan and Ohio. She never had health or dental insurance. The money she made was to “keep you going.”
Now, months after celebrating her 50th birthday, she would have the last of her teeth extracted.
“You’re looking at some ugly teeth,” she said.
Brody gave Crites three shots of a local anesthetic to numb her mouth. He picked up a pair of forceps.
“I’m just going to rotate it,” he said. “OK, honey, this might pinch a little bit. These eye teeth can be trouble.”
Crites didn’t flinch.
With the last of Crites’ teeth out, Brody slipped a wad of gauze into her mouth. A dental assistant handed her a list of instructions.
“Stay off the moonshine today, OK,” Brody added. “That will make you bleed more.”
Crites mumbled, “Uh, huh,” the gauze soaked red with blood. She gave Brody a thumbs-up sign, then drove home with Collier to her apartment under the bar.
Tooth loss: a problem for all ages
Brandy Taylor doesn’t like to go to the dentist. Never has. Never will.
But the 28-year-old’s tooth was aching. Brandy kept calling her mother in Florida. She was crying on the phone.
So her mother finally grabbed her bags, traveled to West Virginia and saw to it that her daughter saw a dentist.
In January, the two made their way to the Fort Gay dental clinic, where Brody diagnosed the problem as an abscessed tooth.
“I’ll tell you this: I don’t want to be here,” said Taylor, her mother sitting beside her in the operatory. “I don’t like the dentist.”
Two weeks earlier, Taylor’s face swelled. She took some antibiotics. That seemed to help for awhile, but the pain came back, sharp, throbbing.
“She’s cried about it for the last two months,” her mother said. “I don’t think anything hurts like a toothache.”
Taylor, a former mental-hospital worker, has six brothers and sisters. Everyone except her and her 44-year-old sister has false teeth. Her oldest brother had 31 teeth pulled in one day, she said. He was 40 years old at the time. Taylor said she has friends in their early 20s who have lost all their teeth because of gum disease.
Across the state, about 7 percent of West Virginians ages 25 to 34 have lost six or more teeth, according to the West Virginia Behavioral Risk Factor Surveillance System. That percentage climbs to 18 percent among people 35 to 44.
In interviews with the Sunday-Gazette Mail, some people said they believed tooth loss was inevitable with aging, unaware that teeth, with proper care, can be expected to last in good condition for a person’s entire life.
Brody used a root pick to loosen Taylor’s tooth. He twisted and pulled until it snapped out, then sanded the bone with a metal file.
Taylor quickly exited the chair.
“The farther I can stay away, the better off I am,” she said. “I’m going to get them all taken out and get false ones, and the hell with toothaches.”
Medicaid pays only to pull teeth
Robert Abbott’s tooth had been aching for months.
He had health insurance through Medicaid, so he called a dentist in his hometown of Williamson to set up an appointment.
An office employee told him they would take the Kentucky medical card, but not West Virginia Medicaid, he said. Abbott said he offered to chip in $5 or so to make up the difference between what West Virginia reimburses dentists for extractions through Medicaid compared to Kentucky.
Abbott was out of luck. He was in pain, and no one would help him.
With no money or insurance to pay to fix her aching teeth, Deborah Crites, 50, took matters into her own hands. Crites numbed herself with moonshine and pulled two of her teeth with a pair of wire pliers, she said. .. “If he got rid of all of his teeth, he’d be fine,” said Abbott’s fiancée, Bobby Barker, during a visit to the Fort Gay dental clinic last winter. “A lot of his problem is his teeth.”
Even if Abbott had gotten in the door at a West Virginia dentist’s office, his only option would have been to have his teeth extracted. That’s the only dental procedure for which West Virginia Medicaid will reimburse dentists.
In Kentucky, adult Medicaid recipients can get their teeth cleaned and cavities filled. Extractions are a last resort. Across the border in West Virginia, having your tooth pulled is the only option.
West Virginia is one of 20 states that offer only emergency dental services, which means just extractions, under Medicaid.
Four states, including Pennsylvania, offer full dental work — dentures, fillings and crowns. Eleven states, including Kentucky and Ohio, offer limited dental services. And 16 states, including Virginia, offer no dental benefits at all for poor people who have Medicaid insurance.
West Virginia adult Medicaid recipients — nearly 20 percent of the state’s population — haven’t had full dental services since 1993.
That year, state lawmakers cut the program after costs rose from $4 million to $64 million in 18 months. The average Medicaid payment per dentist increased to more than $100,000 a year, up from $10,000. Some dental practices raked in more than $500,000 a year.
Lawmakers screamed waste. They alleged that unscrupulous dentists were gouging the system, performing unnecessary and expensive procedures.
Dentists argued they were just serving more people, that they were just making up for years of neglect. The number of dentists willing to take on new Medicaid patients doubled.
In 1993, more than 74,000 West Virginia Medicaid recipients received dental services, up from about 1,000 people when the state would only pay for emergency services related to “pain and suffering.”
State legislators didn’t back down. To this day, West Virginia’s poorest adults can have an aching tooth pulled when they see a dentist, but nothing else.
As it turned out, Abbott needed five aching teeth pulled.
By the time he got to the Fort Gay clinic, he was working as a cook and cashier at Long John Silver’s in Williamson. With a $150-a-week job, he no longer qualified for Medicaid. A Catholic charity group in Mingo County agreed to pay his bills.
Abbott’s pain had become unbearable.
“Just a little pick and sting,” Brody said. “It’s going to make you feel a whole lot better in a minute.”
Brody gave Abbott four shots of a local anesthetic called Lidocaine. The X-ray showed that Abbott’s teeth had unusually long roots. It would be difficult to pull them out.
“You’re going to hear a big cracking noise,” Brody said, grabbing Abbott’s tooth with a pair of forceps. “You’re going to hear a big pop. Don’t be alarmed. A little bit of twisting.”
One by one, Brody wrested the teeth from Abbott’s mouth, holding them up, pointing out the black rot and yellow calculus that had infected Abbott from tooth to nerve to bone.
Abbott was gagging. His hand was shaking.
“Come to papa,” Brody said. “Come to papa. Oh, so close. Let’s see if we’re living right. Don’t worry, I won’t get my knee up on your chest.”
Brody called for suction, and his assistant used a tube to suck the blood out of Abbott’s mouth.
Abbott lapped his tongue across his gums. He asked Brody about the “rough spots.” Had he missed any teeth?
“I got all the teeth out,” Brody said, writing a prescription for an antibiotic. “I assure you of that. You’re feeling the bone. You’ll feel like a brand new man, partner.”
The dental assistant, Becky Atkins, gave Abbott post-extraction instructions: No spitting, solid food or soda pop for 24 hours. No drinking through a straw. Atkins gave him a handful of extra gauze.
Abbott lifted himself out of the chair. He stopped and stared at the tray where five bloody teeth lay amid a scattering of metal dental instruments.
“You don’t get to take those teeth home,” Atkins said. “Biohazard.”
Dental visits rare in state
Robert Jones tried every old remedy to dull the pain in his tooth: Orajel, saltwater, hydrogen peroxide. He rubbed aspirin directly into the molar. Nothing worked.
Jones called around to find a dentist. He called dentist offices in Boone and Logan counties. They wouldn’t see him, or they told him they would put him on a waiting list. Jones didn’t have insurance, Medicaid or cash.
Jones wound up in the hospital emergency room.
They gave him a pain pill and an antibiotic. Someone told him to call the United Way in Charleston. The agency directed him to a Valley Health dental clinic in Harts where Dr. Brody diagnosed the toothache as an abscessed molar.
It had been years — he couldn’t remember the last time — since Jones had been to a dentist.
“People in my area don’t get dental care,” said Jones, who lives in Hewitt in Boone County. “Routine dental visits are nonexistent.”
Across the state, about 60 percent of residents went to the dentist last year — the fourth-lowest visitation rate in the nation. Among West Virginia’s poorest residents — those who make less than $15,000 a year — only one of every three people saw a dentist — the lowest rate among all states.
Thirty-four of West Virginia’s 55 counties are designated by the federal government as dental health professional shortage areas. One county, Doddridge, has no dentist. Several counties have two or fewer dentists.
Still, dentists and state health officials say an overwhelming majority of West Virginians are within a 30-minute drive to a dentist. Most dentists will take Medicaid patients, they say. In poor counties, they couldn’t stay in business without them.
That won’t help people like Jones. He has applied for Medicaid, but hasn’t been approved. He’s been borrowing money from family members.
“It’s hard to get dental care if you don’t have cash on hand,” he said. “It’s been a very painful situation.”
Jones said part of his molar broke off during a car wreck years ago. He smoked for 40 years. He’s had six heart bypasses.
Growing up, Jones said, dental care wasn’t a priority. His father was a coal miner. The family struggled to survive on $189 a week.
“Food was more important than toothpaste when I was growing up,” Jones said. “If you’re going to have shoes on your feet and food on the table, you’re not going to have toothpaste, brushes and mouthwash.”
At the Lincoln County dental clinic, Brody told Jones the abscessed tooth would have to come out.
After numbing the tooth, Brody grabbed a pair of forceps. “You may hear some cracking, partner,” he warned.
Brody struggled to extract the molar. It had three roots. Only one of every 100 teeth has three roots, Brody said.
A dental assistant handed him a metal root tip elevator, which he used to pry up the tooth. Brody called for a larger pair of forceps.
“There’s still a piece of bone,” Brody said.
Brody twisted and wiggled the molar. At last, the bloody tooth popped out.
Without dentures, a struggle to eat
Deborah Crites couldn’t afford a set of dentures.
Medicaid won’t pay for dentures. A dentist would charge about $1,200. The dental clinics don’t make them. There’s a discount denture store about 50 miles from Crites’ home, but Crites hates traffic, plus she can’t afford the $375 charge anyway.
There used to be a guy who made dentures illegally out of his garage in Fort Gay, she said. He was cheap, did a good job, charged about $100 a plate, Crites said.
“Then he blowed his brains out,” she said.
It’s been three months since Crites had the last of her teeth removed. Her gums are still numb. She can eat only soft food. She pretty much survives on Beefaroni. Forget fresh fruits and vegetables.
Crites misses her favorite — shrimp.
“I can pick it off with a fork a little bit at a time, but it’s not the same,” she said.
No one knows for sure how many West Virginians who don’t have teeth live without dentures. National studies put the number at about 10 percent among older adults. It’s probably slightly higher in West Virginia because of the large numbers of low-income residents.
Crites was smoking a cigarette, sitting at the kitchen table in her apartment where she lives with the former owner of the bar upstairs.
“It ain’t no condo,” she tells visitors. “It’s a hillbilly place.”
They watch large-screen television that’s jury-rigged to a small television because the speaker on the large TV doesn’t work. Heat is spotty in the basement, so she leaves on a gas stove burner to stay warm. She still has the wire pliers. The moonshine jar is empty now.
In a drawer, Crites keeps a photograph of herself when she was a young woman. She guesses she was around 30.
In the photo, she’s dressed up. Her hair is permed. She’s smiling, her teeth white and shiny.
Crites doesn’t smile much these days.
“It’s hard to get help when somebody needs it around here,” she said.