Improving Oral Health Care in America: An Ethical Imperative
Across the United States, seemingly everywhere you look, are stark reminders that in the 21st century, oral health continues to serve as a national symbol of inequity. With millions grappling with preventable oral diseases, the need for systems-level reforms has never been more urgent. I recently returned from a strategic planning retreat for the Coalition for Oral Health Policy (COHP), a nonpartisan research and advocacy organization dedicated to advancing systems-level policy reforms to improve access and equity in oral health care. Despite the immense challenges facing this vision, I left the event in Charlotte more convinced than ever that a more inclusive, accessible, and accountable oral health care system is within reach — if only we dedicate ourselves to comprehensive reform through policy. As I routinely point out to students at the UNC Adams School of Dentistry, this is a collective responsibility — not one merely reserved for the lobbyists, grassroots advocacy organizations, and policymakers themselves, but a moral and ethical imperative for action by providers, community members, funders, academics, and anyone interfacing with the American oral health care system. That is, essentially, to say, everyone.
Oral disease in the United States is not just a public health issue, but a profound reflection of systemic inequities. Dental caries (tooth decay) and periodontal (gum) disease, while largely preventable, remain widespread, disproportionately affecting the most already marginalized populations. In so many ways, these individuals have “fallen through the cracks,” with disparities underscoring a significant gap in our healthcare system. We must commit ourselves to addressing the root causes, not merely the symptoms, and seek comprehensive, policy-driven solutions.
“We must commit ourselves to addressing the root causes, not merely the symptoms, and seek comprehensive, policy-driven solutions.”
In this blog post, I want to issue a call for an all-hands-on-deck approach to oral health policy advocacy. First, however, let’s explore the overall oral health landscape in the United States.
The Landscape of Disparity
It’s been estimated that roughly 80% of health outcomes are driven by non-clinical factors, and that reality is on full display when it comes to oral health in the United States. Oral health disparities in the U.S. are stark, with racial, ethnic, economic, and geographic factors (among others) playing pivotal roles. Communities of color, low-income families, and those living in rural areas bear the brunt of these disparities. According to the Centers for Disease Control and Prevention (CDC), children from low-income families are twice as likely to have cavities compared to children from higher-income households. Similarly, racial and ethnic minorities have higher rates of dental caries, periodontal disease, and tooth loss.
These disparities are structural, the result of profound inequities pervasive throughout our society. The role of the social determinants of health cannot be overstated. Education, employment, housing, transportation, access to healthy foods — these factors influence oral health outcomes, with poor nutrition, tobacco use, and inadequate water fluoridation exacerbating the risk of oral diseases. Moreover, deeply rooted biases in healthcare settings discourage many from seeking care, leading to delayed diagnoses and treatment. Even when racial and ethnic minorities do manage to obtain care, these same forces too often result in undertreatment, overtreatment, or otherwise sub-optimal care, further perpetuating the vicious cycle. This is, of course, to say nothing about racial inequities in socioeconomic status, which frequently render indicated oral health treatments out of reach.
“These disparities are structural, the result of profound inequities pervasive throughout our society.”
The Cycle of Disadvantage
While serving as director of the North Carolina Oral Health Collaborative, we had an opportunity to host author Mary Otto for a special presentation. Otto’s landmark book, Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America, makes clear the connection between oral health and social and economic success in the United States with devastating effect, noting that the consequences of untreated oral diseases extend far beyond the mouth. For children, poor oral health can lead to pain, absences from school, difficulty concentrating, and decreased self-esteem, adversely affecting their academic achievement and social development. Adults face challenges in employment, where visible dental problems can stigmatize and reduce job opportunities, further entrenching the cycle of poverty and marginalization.
The link between oral health and overall health is also well-established, with periodontal disease linked to heart disease, diabetes, and pregnancy complications, just to name a few.
Economic Impacts
The reliance on emergency dental care as a primary treatment method for the uninsured and underinsured represents a significant inefficiency in the U.S. healthcare system, costing over $2 billion annually. This approach places a heavy financial burden on healthcare institutions and underscores a broader systemic failure to proactively address oral health issues. Emergency departments frequently encounter patients seeking relief from dental pain and infections that could have been prevented with early intervention. These visits often lead to temporary fixes rather than solutions to underlying problems, creating a costly cycle of return visits that further strain healthcare resources and divert emergency services from acute medical needs.
“This approach ... underscores a broader systemic failure to proactively address oral health issues.”
Moreover, untreated dental conditions have a profound impact on children's education, with those suffering from poor oral health being significantly more likely to miss school. This absenteeism disrupts their learning, contributing to academic setbacks and limiting their social development. For adults, oral health issues can hinder workforce participation, particularly in customer-facing roles, and contribute to lower productivity due to increased absenteeism. The cumulative effect of these factors not only affects individual economic stability but has broader implications for the overall economy, highlighting the critical need for systemic change in how oral health care is addressed in the United States.
Geographic Disparities
In rural communities, the scarcity of dental professionals is a stark reality, creating significant obstacles to regular and preventive oral care. This shortage is not merely a matter of convenience but a serious public health issue that can lead to higher rates of oral diseases and subsequent chronic health conditions. The geographic isolation of these areas compounds the problem, often requiring residents to travel long distances for care, assuming such travel is feasible given personal and economic constraints.
Insurance Gaps
The segmentation of dental care from broader health insurance coverage in the U.S. (an extension of our historically siloed approach to dental and medical care) creates an additional layer of access challenges. Many health insurance plans offer limited or no dental coverage, leaving individuals to bear the high cost of dental care out-of-pocket or forgo care altogether. Medicaid coverage for dental services varies widely by state, with some offering comprehensive care and others providing only emergency services or no coverage at all for adults. This inconsistency further exacerbates disparities.
Of course, there are many, many other indicators of the broken oral health care system in the United States. However, as the above exploration makes clear, the true reasons for the current state of dysfunction are fundamentally rooted in the system's design. Therefore, addressing oral health disparities requires a comprehensive approach to achieving systems-level reforms through policy. Only by addressing the root cause, not just the symptoms, can we build a better oral health care system for all.
A Call to Action: The Need for Systems-Level, Policy-Driven Reform
Addressing the disparities in oral health care within the United States requires more than just isolated interventions — it demands a comprehensive, systems-level approach that targets the root causes of inequity. The current system, with its fragmented care and lack of integration between oral health and general health policies, fails to meet the needs of millions of Americans, particularly those from marginalized communities. Expanding dental coverage through both Medicaid and Medicare, and other insurance programs, is a crucial first step in reducing barriers to care. Ensuring that oral health is recognized as an essential component of overall health will help bridge the gap for those who currently lack access to preventive and restorative services.
“Addressing the disparities in oral health care within the United States ... demands a comprehensive, systems-level approach that targets the root cause of inequity.”
Moreover, public health initiatives must be prioritized and adequately funded to support preventive care and education in underserved communities. By focusing on early intervention and regular care, we can prevent the cycle of dental emergencies that burden both consumers and the healthcare system. Community-based programs that address social determinants of health — such as nutrition, education, transportation, and economic stability — are essential for creating a sustainable impact. These programs should be culturally attuned to the specific needs of diverse populations, ensuring that interventions are effective and equitable.
In addition to expanding access and preventive care, fostering innovation in service delivery is vital. School-based care, mobile dental clinics, teledentistry, and other emerging technologies offer promising solutions to reach remote and underserved populations. By bringing care directly to where people are, we can break down traditional barriers such as transportation and geographic isolation, making it easier for individuals to receive the care they need. These innovations, coupled with strategic policy interventions, can significantly enhance the quality and accessibility of oral health services across the nation.
An Opportunity and Imperative for Us All
The transformation of oral health care in the U.S. is not just an opportunity—it is an imperative. Policymakers, healthcare providers, community organizations, and consumers of care must come together to advocate for systemic reforms that will ensure equitable access to oral health care for all Americans. By embracing this challenge, we can create a future where oral health is seamlessly integrated into the overall healthcare system, where disparities are addressed at their source, and where every individual, regardless of their socioeconomic status or background, can achieve and maintain optimal oral health. This collective commitment to equity and justice in healthcare is essential for building a healthier, more inclusive, and supported society.
“The transformation of oral health care in the U.S. is not just an opportunity — it is an imperative.”
Now is the time to act. Each voice, each effort, and each step toward advocacy brings us closer to a reality where oral health is recognized and treated as a fundamental human right. Let us seize this moment to create lasting change that will benefit not only our generation but countless others to come.