September went out hot in East Tennessee. Caleb didn’t mind; he parked his lawn chair in a shallow pool of shade, clipped a small fan to its arm, lit a cigarette, and settled back to wait. It would be more than 12 hours before the free medical clinic opened its doors. Caleb had read about the clinic online, and that it was best to get there early. Hundreds of people were expected to show up.

Caleb had driven up from Georgia to get a cracked tooth pulled. He’s a lean, hard-looking man with a scar running vertically down from his lower lip, the result of a getting bitten by a dog. His teeth are yellowed, many of them dark brown at the gum line. A few years ago, Caleb paid more than $2,000 to have three teeth extracted by a professional, a price that he considered ridiculous. He works odd jobs but wanted me to know that he isn’t poor: He earns enough to own his house and car. “But there’s nothing in the back pocket,” he explained. Since then he’s resorted to pulling teeth on his own, with a pair of hog-ring pliers that he modified for the job. One time he messed up and crushed an aching tooth, leaving a jagged stump embedded in his jaw; he went after that with a chisel and a hammer. He saved a neighbor $300 recently, he claimed, by pulling a tooth for him. “You know what that cost him? Two and a half shots of Wild Turkey 101.”

On the ground beside Caleb sat Michael Sumers, a fellow Georgian with a long neck and wide, darting eyes. Sumers, who never saw a dentist as a child, hoped to get his remaining 14 teeth pulled. He’s only 46 years old. His mouth has hurt him almost constantly for the last five years, but he hasn’t been able to afford any help. Sumers lives on his disability check, and after paying $700 a month in rent, he doesn’t have much left. “I can’t eat steak without my teeth breaking,” he admitted.

Chicken is what broke one of Jessica Taylor’s teeth. Another two were broken by her ex-husband’s fist, when he hit her in the mouth during a fight. I found Taylor sitting on the ground, her back to a tree, a pizza box beside her. “Now I’m here,” she said, explaining why she’d come to the clinic, “and he’s in hell.”

Over on the far side of the lot, a group of women sat around a small barbecue grill, smoking cigarettes and flipping burgers: Beverly, April, Darlene, and Donna, a woman with a thin face and gray hair scraped back into a ponytail. All of them hoped to get their teeth worked on the following morning when the clinic opened. Beverly smiled, showing me how her two front teeth overlapped. Her parents divorced when she was little, Beverly told me, “and forgot which one was supposed to take care of it.” April, her sister, read about the clinic on Facebook and had been the first to pull into the parking lot that morning. At 9 am, when the clinic staff arrived to set up rows of dental chairs, April was there in a pink T-shirt, waiting on the sidewalk.

Of the countless ways in which poverty eats at the body, one of the most visible, and painful, is in our mouths. Teeth betray age, but also wealth, if they’re pearly and straight, or the emptiness of our pockets, if they’re missing, broken, rotted out. The American health-care system treats routine dental care as a luxury available only to those with the means to pay for it, making it vastly more difficult for millions of Americans to take care of their teeth. And the consequences can be far more profound than just negative effects on one’s appearance. In fact, they can be deadly.

Wealthy Americans spend billions of dollars per year, collectively, to improve their smiles. Meanwhile, about a third of all people living in the United States struggle to pay for even basic dental care. The most common chronic illness in school-age children is tooth decay. Nearly a quarter of low-income children have decaying teeth, well above the national average; black and Hispanic children also experience higher rates of untreated decay. Neither Medicaid nor Medicare is required to cover dental procedures for adults, so coverage varies by state, and both the very poor and the elderly are often left to pay out of pocket. (Tennessee provides no dental coverage to anyone over 21.) In those states where Medicaid does cover dental care, benefits are limited. Even middle-class Americans can’t always afford necessary care, as private insurance often will not cover expensive procedures. Dental coverage improved modestly during the Obama administration, through an expansion of Medicaid and the state Children’s Health Insurance Program under the Affordable Care Act, but access remains patchy and wholly inadequate.