Oral health is an important but often overlooked component of health and well-being. It affects people’s quality of life and functioning – one’s ability to eat, speak, learn, work, sleep, and socialize with others. Black, Latinx, Native American, poor White, and other marginalized communities are disproportionately impacted by the lack of adequate dental care, barriers to receiving care, and consequent negative health outcomes. This article provides a brief overview on oral health disparities in the U.S., systems-level factors contributing to oral health inequity, and systems-level solutions that promote oral health equity.

The story of 12-year-old Deamonte Driver of Maryland demonstrates how deep systemic barriers and inequities run for low-income families of color. Deamonte died in 2007 as a result of bacteria from the abscess in Deamonte’s tooth spreading to his brain. A simple dental procedure, an $80 tooth extraction, and routine dental care could have prevented his death. His mother, Alyce Driver was unable to find a dentist who accepted Medicaid to treat Deamonte’s toothache. Deamonte’s death brought much needed attention to oral health disparities. His death was a national news story and catalyst for policy action that would expand access to dental care for children. In 2009, Congress reauthorized Children’s Health Insurance Program (CHIP) and required states to provide dental coverage to enrolled children, as well as gave states the option to provide dental benefits to some children who do not quality for CHIP.

Still, Black and Latinx children and adults have higher levels of dental carries or untreated dental disease compared to White children and adults. According to the National Health and Nutrition Examination Survey data from 2011-2016, about 33% of Mexican American and 28% of non-Hispanic Black children aged 2-5 have had cavities in their primary teeth, compared with 18% of non-Hispanic White children.[1] Among adults, 42% of African American adults and 36% Hispanic adults have untreated dental disease, compared to the 22% of Whites.[2] If left untreated dental disease can lead to heart disease, strokes, and preterm delivery in pregnant women. It is important to note that people with intellectual and developmental disabilities also face significant oral health disparities, including a higher prevalence of untreated dental caries and periodontal disease compared to people without intellectual and developmental disabilities.[3]

The direct and indirect cost of this untreated dental disease is extraordinary. Costs includes, $45 billion in lost productivity, lost school hours and preventable emergency room visits, as well as the physical, social and emotional costs of living in often chronic pain and the loss of self-esteem. [4] Good oral health is not just about individual will and behaviors such as brushing, flossing, and eating healthy. Rather, to achieve oral health equity, we must look at the systems that support or impede good oral health.

We must strive for oral health equity because it’s an issue of fairness and justice as well as for its health benefits. Historical marginalization of Black, brown, and other disenfranchised groups has led to disinvested neighborhoods and discriminatory policies and practices. To name a few examples, low-income, communities of color deal with fewer affordable primary health and dental care providers, lack of grocery stores with healthy food, unreliable transportation to get to medical appointments, and discrimination in clinical interactions.

Health systems factors more directly related to oral health outcomes that should be reformed include:

  • Limited adult dental benefits as part of public insurance and the variation among states,
  • Low Medicaid reimbursement for dental care which result in few dentists accepting Medicaid,
  • Restrictions on healthcare professionals who can provide dental care (e.g., advanced dental therapists can provide preventive and routine restorative care at lower cost), and
  • The lack of coordination between primary and dental care.

Society as a whole benefits when oral health disparities are reduced and when we have more healthy productive individuals. So we must address oral health inequities that were both intentionally and unintentionally created by systems and policies.

How to Improve Oral Health Equity

Local and national foundations and oral health advocacy organizations are focusing their efforts on much needed policy and systems change solutions that engage the most impacted communities as strategic partners, decisionmakers, and advocates. The proposed solutions include:

  • Training and empowering historically marginalized communities to be leaders in tackling systemic barriers to good oral health and advocating for high-quality, affordable dental care.  Engaging communities to lead the work ensures a fair, equitable, and sustainable process and outcomes. Also, relationships through informal and formal networks can promote good oral health and overall health.
  • Expanding school-based health centers that provide comprehensive services including dental care, so that students can get dental care where they already spend most of their time;
  • Investing in public health infrastructure for community water fluoridation, which prevents tooth decay, raising awareness about its benefits, and combating misinformation. Although 73% of the US population have access to adequately fluoridated water in 2018, rural populations are less likely to have access to adequately fluoridated drinking water. This is because rural populations tend to rely on untreated domestic water wells. Some communities also actively reject fluoridation in their water system because of misinformation about its safety.
  • Advocating for the expansion Medicaid and Medicare to include a robust adult dental benefit, which has the potential to provide oral health care access to millions of adults;
  • Supporting safety-net partners such as Federally Qualified Health Centers and Community Health Centers in developing, testing, implementing, and elevating patient-centered care models promoting greater collaboration among primary and oral health care providers and value-based care. If proven feasible and effective, these models can be adapted and scaled to ensure that high standard of oral health care is the norm and not the exception in marginalized communities; and
  • Developing a core set of oral health measures to measure progress nationally. A set of standardized oral health measures would facilitate assessment, tracking, monitoring and evaluation of quality improvement needs and intervention strategies, and answer: “To what extent are we achieving oral health equity?”

These strategies seek to transform our oral health and other interrelated systems and policies to make quality oral health care available, accessible, and affordable to all.  Most importantly, it is critical to build power and elevate the voices of historically marginalized communities to drive oral health equity change. We believe that knowledge, assets, and strength lie within communities most impacted by these issues.

[1] Centers for Disease Control and Prevention. (n.d.). Disparities in Oral Health. https://www.cdc.gov/oralhealth/oral_health_disparities/index.htm.

[2]  Dye, B., Thornton-Evans, G., Li, X., and Iafolla, T. (2015). Dental Caries and Tooth Loss in Adults in the United States, 2011–2012. Centers for Disease Control and Prevention, National Center for Health Statistics. https://www.cdc.gov/nchs/products/databriefs/db197.htm

[3] Wilson, N. J., Lin, Z., Villarosa, A., Lewis, P., Philip, P., Sumar, B., & George, A. (2019). Countering the poor oral health of people with intellectual and developmental disability: a scoping literature review. BMC public health, 19(1), 1-16.

[4] Centers for Disease Control and Prevention. (n.d.). Cost-Effectiveness of Oral Diseases Interventions. https://www.cdc.gov/chronicdisease/programs-impact/pop/oral-disease.htm