America's Dental Health Is in Trouble

Time​ Magazine

a day ago

Not long ago, Dr. Suzanne Fournier saw a 16-year-old patient with a swollen face and difficulty breathing. Fournier, a dentist who practices at an urban hospital in Louisiana, had to extract six of the teen's teeth; he was eventually intubated and admitted to the intensive care unit because his airways had closed up.
He survived, but Fournier is worried that there will be more children like him across the country who could come close to death because of the state of their oral health. 'I really worry that someone is going to die because they have an abscessed cavity that develops into an infection, and they won't be able to access care,' she says.
In the U.S., 27% of adults don't have dental insurance, according to the most recent State of Oral Health Equity in America by the CareQuest Institute for Oral Health, a nonprofit that advocates on behalf of better oral health care. That's about 72 million Americans. By comparison, 9.5% of adults don't have health insurance. And though many children can get dental care through Medicaid or the Children's Health Insurance Program (CHIP), low reimbursement rates mean that many dentists won't accept those insurance plans, leading to dental-care deserts across the country. Only about half of all children on Medicaid used any dental service in a year, according to an analysis by KFF.
Now, dentists say they're worried that a perfect storm of public-policy changes could further worsen oral health across the country. Proposed cuts to Medicaid would mean that fewer people will be able access dental care, as federal government staffing purges target places like the prevention division of oral health at the U.S. Centers for Disease Control and Prevention (CDC). What's more, as states including Florida and Utah vote to ban the addition of fluoride to drinking water and other states consider similar bans, dentists say the oral health of children and adults will suffer.
'We are already facing an oral health crisis,' says Melissa Burroughs, director of public policy for CareQuest. 'Medicaid cuts and water fluoridation rollbacks are the two biggest ways in which the oral health crisis is likely to be exacerbated.'
Why dental care is an afterthought
America has long separated dental health from medical health. In most cases, Medicare, the federal health insurance program for older adults, doesn't cover dental care at all. Dental care through Medicaid varies tremendously from state to state, and states are not required to include dental coverage for adults, though they are required to include it for children. People going onto the Affordable Health Care marketplace for health plans can't purchase a dental insurance plan independently unless they also purchase a medical health plan. And subsidies offered to lower-income families on the health marketplace don't apply to dental plans.
Even those people with dental insurance coverage often find that their plans don't cover much outside of a dental cleaning and check-up. About 40% of adults who have health insurance don't get regular dental care, according to one recent survey from the PAN Foundation, a health care advocacy organization.
Not having dental health care can come with major consequences. Tooth decay and gum disease can exacerbate other health conditions and lead to heart disease, low birth weight in pregnancy, and even respiratory disease. Adults who present to emergency departments for tooth pain often end up with opioid prescriptions, which can lead to addiction. If children's teeth hurt, they may have trouble eating, leading to poor nutrition; if they're in pain, they're likely to sleep poorly. The CDC estimates that 34 million school hours are lost each year because of unplanned dental issues.
'You can find lots of studies that find associations between poor dental care and things like pneumonia and diabetes and heart disease,' says Dr. Lisa Simon, an internal medicine specialist who started her career as a dentist and then went to medical school to focus on oral health care. 'But even if you didn't think about any of those things, how important is it to have a central feature in our face look the way we want to, and not live with pain, and be able to take in nutrition?'
Simon practices in Massachusetts, a state with one of the best dental safety nets in the country, and generous Medicaid benefits compared to those in other states. But she still sees people who have ended up in the ICU because of life-threatening sepsis from a tooth infection, patients who can't start chemotherapy because they can't pay to remove their infected teeth, people who won't even let her look into their mouths because they're so ashamed. In Massachusetts, fewer than one third of dentists accept Medicaid, which is close to the national average.
'I have gone down to Haiti nine times, and I have never seen the level of decay that I saw when I worked in Florida,' says Fournier, the Louisiana dentist, who previously practiced in Florida.
She and other dentists worry that looming Medicaid cuts would exacerbate the problem; when state budgets are tight, dental care is often one of the first things to go. Massachusetts, for instance, cut Medicaid coverage for adult dental care in 2010 in the aftermath of the Great Recession; dental-related visits at a safety-net hospital increased 14% in the two years after the Medicaid cuts.
Fluoride bans are worrying dentists
Fournier recently testified before the Louisiana House of Representatives about Senate Bill 2, which sought to make it more difficult for localities to add fluoride to their drinking water. (In Louisiana, only about 38% of people are served by community water systems that fluoridate their water.)
The bill was voted down in committee, but bills to restrict access to fluoride have been introduced in other states, including North Carolina, Massachusetts, Ohio, and Nebraska, according to CareQuest. Bills to ban the addition of fluoride in public drinking water have already passed in Utah and Florida. Some local counties have already voted in 2025 to ban fluoride independently.
They are likely influenced by the Make America Healthy Again movement, led by Robert F. Kennedy Jr., Secretary of the Department of Health and Human Services. He has called fluoride a 'dangerous neurotoxin' and has said he wants the CDC to stop recommending fluoridation. In May, the FDA announced that it was trying to remove ingestible fluoride tablets from the market.
Dentists predict long-term and costly health problems if communities continue to remove fluoride from the water. One recent study published in JAMA Health Forum found that the elimination of fluoride from the public water supply would be associated with a 7.5% increase in tooth decay and cost about $9.8 billion over five years. Places that have taken fluoride out of their water supply have seen an increase in dental problems; in Canada, for instance, Calgary removed fluoride in 2011, saw a significant increase in cavities, and is now reversing course and adding fluoride back in.
Dr. Jeff Otley, a practicing dentist in Florida's panhandle, says he noticed when his region stopped fluoridating its water in 2014. He saw an increase in the number and severity of cavities in kids. The recent ban on fluoridation in Florida is going to affect kids and adults, he says, especially because Florida's Medicaid program offers barely any benefits for adults. 'We are going to have more disease, larger cavities, and some of these kids are going to have to go to the hospital because their cavities are going to be so bad,' he says.
Out-of-reach solutions
Oral health advocates say that in recent years, the country had been making some progress in improving access to dental care. For instance, a bill introduced in the Senate in March would require Medicare to cover dental, vision, and hearing.
And some states have, in the last few years, expanded Medicaid benefits to cover adult dental services. This can end up saving money in the long run; when Colorado chose to expand Medicaid adult dental benefits under the Affordable Care Act, one safety-net provider saw a 22% decrease in tooth extractions, according to CareQuest. When states increase how much dentists can be reimbursed through Medicaid, more dentists sign up as Medicaid providers, which has been shown to increase children's dental visits.
But advocates say they're worried that all of this progress is now going to be reversed, and that oral health in the U.S., especially for children, is going to suffer.
'I think we're at this balancing point where if we can keep things moving forward, there is the real opportunity for millions of people to get dental care,' says Simon, the Boston doctor and dentist. 'But we've seen this before—anytime there's a budget shortfall, dental care is the first thing on the chopping block.'
The irony of this to many dentists is that providing people with preventative care can actually save states money over time. Children on Medicaid who received fluoride treatments saved between $88 and $156 each for their state programs, one study found. Water fluoridation is another preventative policy that saves money: In 2024, the CDC estimated that providing communities with fluoridated water for one year saves $6.5 billion in dental treatment costs and leads to 25% fewer cavities.
But some of these preventative ideas aren't likely to go far, says Amy Niles, the chief mission officer of the Pan Foundation. 'In this country, we don't always embrace the importance and value of preventative care to prevent disease later on,' she says.
Fournier, the Louisiana dentist, is relieved that her testimony and that of other medical professionals helped persuade Louisiana legislators to ditch the fluoride bill. But she still chafes at a health care system that makes it so hard to provide preventative care for oral health.
'Our goal is aligned with RFK Jr.'s, which is to make Americans healthy,' she said in her testimony. But, she says, America doesn't seem interested in waging a war on the No. 1 chronic disease in children: tooth decay.