The Divide in Dental Health Outcomes

Going without dental care increases the risk of tooth decay, gum infection, tooth loss, and associated pain and discomfort. Other serious consequences of poor oral health include increased risk of cardiovascular disease, pregnancy and birth complications, pneumonia, and endocarditis (a life-threatening inflammation of the lining of the heart).

Permanent tooth loss that is not due to injury is most often the result of untreated tooth decay or gum disease. In 2024, according to the CDC's Behavioral Risk Factor Surveillance System (BRFSS) Survey, 41% of U.S. adults (age 18+) reported that one or more of their permanent teeth had been removed because of tooth decay or gum disease. This rate varied by income, with 46% of respondents below the ALICE Threshold and 37% of those above the Threshold reporting tooth loss due to tooth decay or gum disease.

There were also differences in the share of U.S. adults (age 18+) who had lost six or more teeth because of tooth decay or gum disease: 13% of all adults, 17% of adults below the ALICE Threshold, and 9% of those above the Threshold. At the opposite extreme, respondents above the Threshold were more likely to say they had not had any teeth removed (63%, compared to 53% of adults below the Threshold).

The figure below shows the number of teeth removed due to tooth decay or gum disease, for all respondents and for those below and above the ALICE Threshold. Use the tabs at the top of the figure to see the percentage of respondents who have lost one or more teeth by income status and race/ethnicity, and by income status and age (includes all available groups with a large enough sample size to report).

Affordability as a Barrier to Dental Care

Nationally, 27% of adults (age 18+) spent more than $500 out-of-pocket for dental care in 2024.

When people lack dental insurance or when dental costs aren't fully covered by insurance, cost can drive people to delay or go without needed care. According to the 2023 Federal Reserve Board Survey of Household Economics and Decisionmaking (SHED), dental care was the medical treatment Americans were most likely to forgo due to cost (19% of respondents), followed by visiting a doctor or specialist (15%), filling a prescription (10%), and seeing a mental health provider or counselor (9%). In the U.S., a substantial 30% of SHED respondents below the ALICE Threshold reported that during the prior twelve months, there was a time when they needed dental care but went without because they could not afford it, much higher than the rate for those above the Threshold (10%).

The figure below shows the percentage of respondents who went without dental care due to cost, for all respondents and for those below and above the ALICE Threshold. Use the tabs at the top of the figure to see the percentage of respondents who went without care due to cost by income status and race/ethnicity, and by income status and age (includes all available groups with a large enough sample size to report).

Dental Insurance: The separation of medical and dental services across the U.S. has wide-reaching implications for dental health access, outcomes, and insurance coverage. Notably, dental insurance policies outline the maximum amount the insurance company will contribute, whereas health insurance plans detail the maximum amount the insured party would pay. Also, health insurance provides some protection against catastrophic medical costs, but dental insurance does not. Nationally, 26% of adults did not have dental insurance in 2024. Because dental insurance is not included in many private or public health plans, rates of medical insurance coverage are three times higher than dental coverage rates nationally.

Access to dental insurance increases with income. Nationally in 2024, 38% of adults with an annual household income of less than $30,000 lacked any dental insurance, including Medicaid (income eligibility and asset limits for Medicaid vary substantially by state). As household income rose, the rate of adults without dental insurance fell — to 32% of adults in households earning $30,000 to less than $60,000; 21% of adults in households earning $60,000 to less than $100,000; and 17% of adults in households earning $100,000 or more.

For adults who do have dental insurance, the majority have private coverage (most through an employer, but some self-purchased).

The next most common forms of insurance are public dental plans under Medicaid, which vary by state. Thirty-four states' adult Medicaid dental benefits are defined by the ADA's Health Policy Institute as "Enhanced", meaning they offer a comprehensive mix of services with a per-person annual maximum benefit of $1,000 or more (or no spending limit). Eight states offer "Limited" Medicaid coverage, which includes diagnostic, preventive, and minor restorative procedures and a per-person annual benefit cap of less than $1,000; another eight states provide only "Emergency" care for the relief of pain and infection; and one state, Alabama, has no Medicaid dental services for adults.

And since most state Medicare plans (for adults age 65 and over) do not cover routine cleanings, fillings, tooth extractions (removals), or items like dentures and implants, older Americans must purchase Medicare Advantage plans or opt for other private plans to ensure dental coverage. These plans vary substantially in several regards, including coverage of different types of services, cost-sharing levels, and caps on expenditures.

Although plans differ, dental coverage is generally limited to basic and preventive care. For more substantial interventions like crowns, root canals, and oral surgery, patients are generally charged copayments and there is a maximum annual benefit that the dental plan will pay (typically $1,000 to $2,000). And the most expensive types of care — orthodontics, dentures and bridges, and management of acute infections — are often not covered initially or at all.

Lack of access to dental care and insurance can add financial and health burdens to communities and hospital systems as well. For example, the use of Emergency Departments (EDs) for non-traumatic dental conditions is far more expensive than average dental care and increases the workload for ED staff.

Community Factors That Affect Oral Health

Broader community and economic factors — like having dental providers close to home, work arrangements that enable the scheduling of routine care, and community-based programs — can help promote good oral health.

In the United States, there were 48,858,129 households with no or low access to dental providers within 30 minutes of their home in 2023. (Low-access areas are those in the bottom two quintiles for access nationally, as reported by the ADA Health Policy Institute.) This includes 20,430,752 households below the ALICE Threshold — 38% of all households below the Threshold.

Proximity to providers was substantially lower for households in rural areas than for those in urban areas. Nationally, 87% of households in rural areas (21,087,826) had low access to dental providers, compared to 27% of households in urban areas (27,491,563). Differences between rural and urban areas persisted across income levels: In rural areas, 90% of households below the ALICE Threshold and 86% of those above had low access; in urban areas, 27% below and 27% above had low access.

However, living in close proximity to a dentist is not enough to ensure that oral health needs are met. For example, work arrangements such as working multiple jobs, long shifts, or lack of paid time off can make it difficult to prioritize or find time for routine care (especially at dental clinics that only offer appointments during standard work hours). Other barriers include lack of transportation and low participation of dental care providers in public programs, largely due to low reimbursement rates and high administrative burden.

In addition to addressing issues like transportation and Medicaid provider participation, states and municipalities can contribute to better oral health outcomes with a wide range of community-based programs and interventions, including increasing the availability and affordability of fresh, minimally-processed, low-sugar foods; implementing school dental sealant programs; and maintaining optimal levels of fluoride in water.