Challenges in American Dentistry: A Call for Reform

Two hundred years ago, your dentist was your barber or your blacksmith. Extractions were done with pincers and tooth keys. Post-extraction infections could be fatal. Things have, blessedly, improved since then. But dentistry still remains largely separate from the rest of the American healthcare system, treated more like a trade than an aspect of medicine, despite growing evidence and awareness that oral health and overall health are connected. 

Being split off from traditional medicine has done dentistry a disservice. The field has a paucity of academic research compared to traditional medicine. Funding for the National Institute of Dental and Craniofacial Research (NIDCR), the main federal agency funding dental research, is only a small fraction of the budget given to the National Institutes of Health (NIH) as a whole. The number of peer-reviewed dental journals is far smaller than it is for fields like cardiology or oncology, and fewer dental schools are attached to major research hospitals. The separation has also led to fewer interdisciplinary studies, leaving gaps in research on how oral health affects overall health.

Patients feel the effects of the split, too. For some patients, going to the dentist can feel more like going to a mechanic than to a medical professional. (Though those critical voices are louder than their statistical representation would suggest: dentists repeatedly poll near the top of all professions for trust and ethics; in 2023, they polled slightly higher than medical physicians, though still nearly 20 percent lower than nurses.)

Part of the discrepancy comes from differences in insurance. Dental insurance functions more like a discount plan. Its low annual coverage caps—usually between $1,000 and $2,000—mean patients pay out-of-pocket for most major procedures. While traditional health insurance covers catastrophic expenses, dental insurance prioritizes basic care like cleanings and fillings. A root canal is one of life’s more unpleasant experiences, and paying out of pocket for it doesn’t hurt it any less. 

“The biggest challenges in American dentistry are affordability and access,” says Julie Reynolds, DDS, MS, an assistant professor of preventive and community dentistry at the University of Iowa College of Dentistry and Dental Clinics. “Americans are much more likely to have financial barriers to dental care than other types of healthcare.”

Those financial barriers disincentivize many Americans from seeking out the dental care they need. In 2022, 43 percent of adults identified cost as a reason they’re likely to avoid dental care, up from 38 percent the year prior (CareQuest Institute for Oral Health). That’s even though 55 percent reported some type of oral health problem. 

Dental services are the most likely health service to be delayed (KFF). But delaying treatment means conditions are likely to worsen, resulting in poorer outcomes. And dental insurance is not mandatory under the Affordable Care Act, despite numerous studies showing oral health and overall health are linked. 

In traditional medicine, Medicare and Medicaid provide a broad safety net for access and affordability. In dentistry, coverage is inconsistent and often inadequate. Dr. Reynolds points out that in 2021, there was a nearly 20 percentage point gap between the proportion of children with private dental insurance who had a dental visit that year and the proportion of children with Medicaid who did (ADA). That gap is twice as large for adults. 

“These challenges are particularly concerning given that dental disease is the most common chronic disease in childhood and affects the vast majority of Americans by adulthood,” Dr. Reynolds says.

Traditional Medicare only covers oral health in limited, “medically necessary” procedures. Dental coverage through Medicaid is state-by-state and drastically underfunded, leading to low reimbursement rates, thus causing more dentists to opt out of the program. In 2021, the Build Back Better Act (BBBA) originally included a proposal to expand Medicare to cover dental, vision, and hearing benefits—but the dental coverage was ultimately cut from the final version.

“We have to get people into coverage,” says Bailey Reavis, manager of government relations for Families USA, a nonprofit and nonpartisan advocacy organization focused on healthcare affordability and access in the US. “And once we get them into coverage, we have to make sure it’s actually affordable and accessible.”

Families USA’s Oral Health for All campaign is aimed at making comprehensive dental care a guaranteed benefit in public health programs. They push for Medicare to include routine dental services, and they also advocate for Medicaid to provide mandatory adult dental benefits in every state. 

“The campaign seeks to break down that silo that exists between oral health and medical care,” Reavis says. “You shouldn’t need separate insurance.”

Integrating dentistry into a comprehensive care plan like Medicare would help guide the rest of the market. In traditional medicine, many prices are dependent on what Medicare pays; dentistry would benefit from a similar baseline of costs. It would help address another challenge in American dentistry: the rise of corporate consolidation.

“The dental industry, similar to many areas of medical and behavioral healthcare, is seeing significant consolidation right now, with major growth of large group practices and private equity-backed corporate chains,” Dr. Reynolds says. “This trend has the potential to present opportunities by having economies of scale that can weather financial challenges, but also has the important risk of putting profit over ethics and high-quality patient care. This segment of the delivery system will need significant oversight in order to avoid that risk.”

Corporate consolidation occurs when large dental chains, often backed by private equity, buy out independent dental practices, centralizing ownership under a few major companies. This shift prioritizes profit-driven models, which can lead to higher costs, reduced patient care quality, and pressure on dentists to meet financial quotas. It also contributes to fewer independent practices, less competition, and reduced access to care in rural or underserved areas.

“We know that rural Americans are less likely to visit the dentist than those who live in city or suburban areas, and that’s something that’s really exacerbated by consolidation across healthcare,” Reavis says. “We know that when healthcare markets consolidate, it impacts rural health centers, whose providers often close when they are targeted by large corporate health systems and private equity—sometimes because the land that they are on is so valuable, and not because of anything to do with the practice itself.”

Expanding Medicare and Medicaid dental benefits could counter some of these effects by creating a more stable reimbursement system, ensuring that patients don’t have to rely solely on private dental chains for care. If Medicaid covered comprehensive adult dental care nationwide, more independent and community-based providers could thrive rather than leaving the market due to financial pressures. It wouldn’t counter the effects of consolidation completely, but it’d be a start.

“Policy changes related to financing and coverage would be most likely to have a positive impact on oral health in America, including increasing reimbursement and minimizing administrative burden for dental services in Medicaid, ensuring comprehensive coverage in Medicaid for people of all ages, and reducing cost sharing,” Dr. Reynolds says. 

It’s not a hard sell. In 2024, a national poll found that 92 percent of national voters support adding a dental benefit to Medicare. The survey also found broad support for adult Medicaid dental benefits. The results are encouragingly bipartisan: 85 percent of respondents who voted for Trump in both 2016 and 2020 and 99 percent of those who voted for the Democrat candidate in those two elections said they would like to see a dental benefit added to Medicare.

Dentistry has come a long way since the barber’s chair. It should continue to scooch closer to the doctor’s office. The last Congress had three hearings on oral health. Dentists and advocates remain hopeful that a major policy change is achievable. 

“Making oral health more affordable is overwhelmingly popular,” Reavis says. “People want it, Congress has started paying attention, and the momentum is there. The challenge is making sure it actually happens. I’m hopeful that it’s closer than we think.”