Yves here. I suspect that there are at least some who will read this post and regard the poor state of dental health in Appalachia as mainly the result of bad lifestyle choices (too much sugary foods and drinks, smoking, opioid addiction, etc). It’s hard to overstate the impact of something the author skips over: that many don’t drink fluoridated water at the critical juncture, when adult teeth are forming.

We had something of a natural experiment in my family. I’m the oldest child. I didn’t get fluoridated water at the right age. My brothers did. Despite obviously eating the same diet as kids, my becoming vigilant about my weight in my teens (which among other things meant cutting out sweets) and always seeing the dentist on schedule, while one of my brothers has become obese and eats sugary foods daily, I have a mouth full of dental work while my brothers have hardly any fillings. I joke that when I visit the dentist, I am going for a semi-annual assessment. Even with relentless maintenance, fillings eventually beget larger replacement fillings. So imagine what it’s like for people with vulnerable teeth who can’t get good care.

By Anna Sanford, an editorial assistant at AlterNet’s office in Berkeley, CA. Originally published at Alternet

Mountain Dew, the carbonated fluorescent-green soda that Willy the Hillbilly declared “will tickle your innards” in a 1966 commercial, has long been a staple of Appalachia. It was officially developed in Knoxville, Tennessee, in the mid-1900s, but it has ties to the wheat and rye distilled by Irish immigrants who settled in the region as coal miners during the previous century. Today, coal has left Appalachia, as have a host of other industries that brought economic opportunity. Mountain Dew, however, remains culturally significant. Sarah Baird, a writer who grew up in Eastern Kentucky, recently wrote about the importance of the drink to her sense of identity, saying, “It’s not just a beverage—it’s a portable sense of home.”

In a region long undergoing a cultural and economic crisis, Appalachia’s thirst for Mountain Dew is perhaps the lesser of many evils. Opioid addiction, smoking, chewing tobacco, lack of access to municipal water systems, and the necessary preoccupation with getting food on the table over worrying about nutritional value are also having an enormous effect on people’s teeth. The soda is ruining teeth, in an epidemic known as “Mountain Dew-mouth.” The acid causes erosion and the sugar abets decay.

“I would see a lot of kids who had a mouth full of rotting teeth,” Dr. Edwin Smith, a traveling dentist who drove his mobile dental truck for 12 years throughout Kentucky, told CNN last September. “They were in pain, and they’d be hurting at school.”

In Kentucky, the state with highest proportion of adults under 65 without teeth, Smith has witnessed the extremes of Mountain Dew-mouth—toddlers with baby teeth filled with cavities, kids who won’t brush their teeth because of inflamed gums, and teenagers who have pulled out their own rotting teeth with pliers.

Other forces are at play. Hundreds of prescription medications, as well as chewing tobacco and cigarettes, cause dry mouth, preventing the natural flow of saliva and making teeth more susceptible to decay. Use of these substances is rampant in Appalachia; a single Kentucky county filled prescriptions for over 2 million doses of painkillers last year, which is about 150 doses for every man, woman and child. Kentucky is also the state with the most smokers, followed closely by West Virginia, according to a Gallup study. On top of that, without municipal water systems, people rely on well water, which is unfluoridated—or they drink more Mountain Dew to quench their thirst. Nearly half of the people in Kentucky, and 25 percent of the national population, depend exclusively on well water, posing a threat to natural resources as well as people’s teeth.

With 26 percent of preschool-age kids suffering from tooth decay and 15 percent of young adults extracting a tooth because of erosion, Mountain Dew-mouth in Appalachia has created one of the worst dental health problems in the United States according to a legal brief by Priscilla Harris, an associate professor at the Appalachian College of Law. Nonetheless, the factors that contribute to poor dental health are not simply Mountain Dew; they are not even specifically linked to Appalachia. Noxious substances merely exacerbate a national problem that is affecting every region of the United States. Bad oral hygiene could be significantly remedied through the American health care system; that is, if the United States adopted a holistic approach to health care. However, as it stands now, dental care is treated separate from health care, launching an epidemic that weighs heaviest on those who need it most—the rural poor.

Dental health is essential to overall health, and serious and sometimes fatal illness can result from untreated oral conditions. A problem as common as gingivitis (excess plaque) can result in serious health problems such as heart disease, diabetes, or cancer. Yet throughout the United States, from remote areas of Alaska and across the contiguous 48, poor people struggle to get access to regular dental care, relying on charity clinics and hospital emergency rooms. According to the federal government, more than 50 million Americans live in areas officially designated as Dental Health Professional Shortage Areas, and must travel hundreds of miles to get help. A suburb of Washington, D.C., could have one dentist for 350 residents, while Dickenson County, Virginia, has one dentist for every 15,468 residents.

The distinction between dental care and health care extends to insurance. Medicaid, the joint federal-state health care program that provides health coverage for 72 million people, reckons dental benefits as optional for adults, leaving it up to states to decide. It was not until the Affordable Care Act passed under President Obama in 2010 when Medicaid gave dental care to children under 19. Medicare, the federal health care program that covers 55 million seniors and disabled people, has never included insurance for routine dental services.

While Medicaid, as the medical safety net for the poor, should provide help for those with dental needs who cannot afford to pay, only 15 states offer full dental benefits and five states offer nothing at all, as reported in a study by Pew. However, even in the states that do offer dental benefits, poor patients have difficulty getting appointments. As an isolated industry, dentistry has remained private and unencumbered by the brunt of market forces. Dentists cannot turn away patients based on “race, creed, color, sex, or national origin” according to the American Dental Association’s Principles of Ethics and Code of Conduct; however, dentists can turn away patients based on their ability to pay. In order to cover high overhead costs, pay back dental school bills and earn an income, many dentists refuse to treat people on Medicaid. In 2013, only 34 percent of general dentists accepted Medicaid patients, according to Pew.

With limited benefits through Medicaid and no benefits through Medicare, in order to receive insurance, people must purchase private plans or employer-provided plans. Most dental insurance limits annual benefits to between $1,000 and $1,500 per person—this cap has hardly changed since the mid-’80s, despite inflation. Employer-provided plans—assuming the patient has a job and the job offers a plan—can exceed $500 a year or more and do little to ease the burden when other concerns take priority. So millions of Americans go without dental insurance.

More than a third of Americans do not have dental coverage, according to a Washington Post article. Appalling already, the state of dental care in America faces even greater challenges with the threat of the Trump-backed American Health Care Act currently being debated in the Senate after passing in the House at the beginning of May. The ADA has reported that Obamacare’s requirement to provide dental care for children under 19 will be rolled back, and the 5.4 million adults who gained coverage under the Medicaid expansion will lose all dental benefits.

Without insurance, people often go years without seeing a dentist. Toothaches are the most common problem, causing lack of sleep and difficulty eating. With time, a toothache can become another entity entirely. Germs collect, white blood cells accumulate, pus escalates, and suddenly a swelling, debilitating dental carbuncle has taken residence in one’s mouth.

Dee Matello, a small business owner and mother of three in Laurel, Maryland, had not been to a dentist in nine years. To compensate for the cracked molar on the left side of her mouth, she had simply learned to chew on the right side. Like many Americans without dental insurance, it was not until Matello heard a free dental clinic would be held in the town of Salisbury, just 20 minutes away from her home, that fixing the cracked tooth seemed like a possibility.

“It’s always bothering me,” Matello told the Washington Post as she waited outside the Wicomico Civic Center in Salisbury. Over the course of two days, among the reclining chairs and portable dental equipment that had been erected on the civic center floor, 116 dentists provided $1 million worth of care to 1,165 patients, many of whom had traveled across state lines to endure long lines and the bitter cold as they waited for treatment. After getting an x-ray and having the tooth extracted—a procedure that would have cost from $600 to $800 in a regular dentist’s office—Matello left the clinic, wondering why people who work hard and put faith in their government for help are obligated to endure such demeaning treatment.

At the University of Maryland dental school, a team of researchers explored the effect of toothaches in poor Maryland adults like Matello: 44.3 percent of their respondents reported having experienced more than five toothaches in the past 10 years. Nearly half said that their most recent toothache had caused them the worst pain possible and interfered with many aspects of their daily lives. When initial strategies to remedy their pain, such as nonprescription medicines, failed, many resorted to seeing a dentist.

For Americans who do not have health insurance and need dental treatment immediately, the emergency room remains the only option. However, this poses a significant problem because, in the eyes of the American health care system, the mouth is separate from the rest of the body. So even though hospital visits for dental problems cost an enormous amount to the health care system as a whole—an estimated $2.7 billion over a three-year period according to one major study—people rarely receive the treatment they need.

Dr. George Kushner, the director of oral and maxillofacial surgery at the University of Louisville in Kentucky, explained that he sees ER patients with dental pain on a daily basis. “I take out teeth every week that could have been saved with restorative work,” he told a reporter for USA Today. The vast majority of doctors lack the knowledge and tools to treat dental ailments. They offer the services they can, provide prescriptions for painkillers and antibiotics, and recommend a dental clinic for a follow-up. However, clinics are often too crowded to meet the demand. Thus, patients leave the ER with no long-term solution for treatment.

Though pain and discomfort are unfortunate enough, lack of dental care presents other, more enduring problems. While millions of Americans suffer because of their teeth, another portion of America supports a $110 billion-a-year dental industry, investing in procedures such as gum contouring and spending up to $2,000 on a single veneer. As the wealth gap continues to increase, teeth represent the dividing line between the classes.

Glimmering pearly whites have long been a symbol of social and financial success in America. Consider what every movie star, news anchor and television personality has in common: not height, weight or ethnicity (though there is certainly an enormous amount of room for more diversity). All share an enviable smile—gleaming, bright white, smooth, ovular teeth.

In a country where significant value is placed on a perfect smile, bad teeth prevent economic mobility. The predominant jobs of the working class—waitressing, housekeeping, nursing, etc.—are in the service sector, yet these jobs are hard to come by without a certain degree of oral health. A study published in the Nation Bureau of Economic Research found that a missing tooth can result in a loss of $720 of earnings (and 178 million people are missing at least one tooth).

As she waited to have teeth removed at a free clinic in Jonesville, Virginia, Emma Marsee told Mary Otto, the author of Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America, that people only want “a healthy-looking individual” taking care of them. In areas where jobs are scarce, a person’s financial security depends on her teeth. For 10 years, Otto researched and conducted interviews about oral health in America, traveling across the country attending beauty pageants and clinics, talking to dentists and patients alike. In her book, she writes:

In the way that they disfigure the face, bad teeth depersonalize the sufferer. They confer the stigma of economic and even moral failure. People are held personally accountable for the state of their teeth in ways that they are not held accountable for many other health conditions.

Regardless of cultural influences—Mountain Dew-mouth or not—the dental health epidemic in America is rooted in the historical and political legacy of an unequal system. Without access to preventative measure like regular oral checkups and teeth cleanings, as well as comprehensive care, America’s poor fight an uphill battle, involving increased health risk, social stigma and reinforced economic disadvantage.