With five broken teeth, three cavities and a painful gum abscess spreading to her sinuses, Patty Kennedy knew she had to get in line early for a free dental clinic held last month in San Jose, Calif.
The 53-year-old woman from Modesto, nearly 100 miles away, was counting on the care to repair not only her smile and her worsening health -- but also her chances of getting a job.
"I'd love to work at a grocery store as a cashier. I'd even go for bagger," said Kennedy, who camped out overnight at the CDA Cares clinic sponsored by the California Dental Association Foundation. "At this point, I'd do whatever."
But like many of the more than 2,200 people who showed up for the 5:30 a.m. clinic on May 18 and 19, Kennedy knew that bad teeth translate into poor employment prospects, even for the best workers.
"I really don't smile a lot," said Kennedy, whose husband, Lucas, also 53, lost his job five years ago when California's construction economy tanked. "I know that when you have a job, you want to have a pleasant attitude and you've got to smile and be friendly."
Lack of access to dental care is a particular problem in California, where budget woes virtually eliminated access to the state's Denti-Cal program in 2009, leaving an estimated 3 million poor, disabled and elderly people without oral health services. In 2012, CDA events provided about $2.8 million in free care to nearly 4,000 people.
But barriers to dental services are a problem nationwide, with more than 47 million people in the U.S. living in places with difficult access to care, according to the Federal Health Resources and Services Administration, or HRSA. Low-income adults are almost twice as likely as those with higher incomes to have no dental care in the previous year, according to a 2008 study by the Kaiser Family Foundation.
Provisions of the Affordable Care Act, which take effect in 2014, guarantee dental care for children, but not for adults. And without such care, adults already struggling to get by find that obvious dental problems – teeth that are missing, discolored, broken or badly crooked -- make their situation even harder, said Susan Hyde, a dentist and population scientist at the University of California at San Francisco.
In America, most people – including employers – make instant judgments based on appearance, including someone's smile and teeth.
"If you want to portray someone as being wicked, they have missing front teeth. If they're ignorant, they have buck teeth," she said. "Even from a very early age, we associate how one presents their oral health with all kinds of biases that reflect some of the social biases that we have."
Those views can prevent potential employers from recognizing potential assets, said Lindsey Robinson, a dentist and current president of the California Dental Association.
"If they have a job that requires them to interact socially with the public, it's almost impossible for them to get that job," she said. "Customer service jobs, good entry-level jobs, they're not available to people who lack the basic ability to smile, to function, to chew properly."
The problem is partly based on appearance, but also on the health effects of poor dental care, which have been linked to heart disease, diabetes and stroke. Acute dental conditions cost nearly two days of work per year per 100 people in the U.S., the Centers for Disease Control and Prevention finds. Even employed adults lose more than 164 million hours of work because of oral health problems or dental visits.
"When you're sick and you don't feel good, you can't do anything," said Kennedy, who had suffered with no care for five years. "Your appearance and your countenance suffer."
The problem is also embarrassing, she added.
That makes anyone less likely to have the energy to job-hunt -- and to be less likely to land the position, Robinson said. But research also shows that when people are offered dental care, their chances of employment go up.
Hyde co-authored a 2006 study in which researchers offered interventions to nearly 400 welfare recipients with severe dental problems. Thirty percent had horribly receding gums, 85 percent were missing one or more teeth, 84 percent had one or more teeth decaying in their mouths, Hyde recalled. "One man told me, ‘I get my wife to chew my food for me first.'"
But when they were offered dental services, the patients flourished, she said. Those who completed their dental treatment were twice as likely to get jobs or move off welfare than those who didn't finish treatment, the study showed.
That is the goal behind programs like CDA Cares, said Robinson. The foundation sponsors one or two events in different parts of the state each year.
"They go from broken-down, infected teeth or no teeth at all to feeling great about themselves again," she said.
Patty Kennedy had her five broken back teeth pulled, X-rays taken and a dose of antibiotics that cleared up her abscessed gum and infected sinuses.
"I felt like I was treated with such dignity and respect and kindness and courtesy," she said.
Now that she feels better both emotionally and physically, she may be up to the task of job-hunting, Kennedy said. She only hopes that others in her position can get help, too.
"There were a lot of people who absolutely didn't have any teeth," she said. "They needed some serious work done."