The Dental Divide: How Race And Insurance Affects Your Oral Health

Having good oral health isn't just about strong teeth and gums. It can affect our socio-emotional and psychological health, along with our general wellbeing. Four out of ten middle-aged adults in the US report that dental issues cause pain, problems with eating, and missing out on work. For kids, it can affect school participation and overall development.¹ ²

Furthermore, oral health can play a key part in affecting the rest of our body too.³ If you think about it, the mouth is actually the gateway to your respiratory and digestive systems. So whatever bacteria is found orally can move downward to other organs and potentially cause disease.³

Despite the importance of taking care of our oral health, not enough American adults are following the recommended guidelines of seeing a dentist every 6 months (twice a year). According to the Centers for Disease Control and Prevention (CDC), a 2019 survey found that only 64.9% of adults in the US visited a dentist over the previous year. In contrast, people in the Netherlands visit the dentist an average of 3 times a year.⁴ ⁵ Furthermore, a 2019 survey found that only 30% of the US population floss daily, and about the same percentage of people brush their teeth less than twice a day.⁶ ⁷

According to experts, there are many reasons for oral health neglect. And this includes social, biological, and cultural reasons. But data collected over the years show that certain groups of people are disadvantaged when it comes to receiving appropriate oral health care. It seems that wealth, race, and insurance have a part to play in it.⁸

The oral healthcare divide

Socioeconomic disadvantages: Getting oral health care is expensive

One of the biggest barriers to receiving oral health care is cost. For many people in both the developing and developed world, it's relatively expensive to get oral health treatment. And in many cases, it's usually not part of universal health coverage (UCH) schemes. According to the World Health Organization (WHO), dental treatment works out to be about 5% of people's total health expenditure for those in high-income countries. And forms about 20% of their out-of-pocket health payments.⁹

It's no wonder that a survey by Health Affairs involving 14,962 American adults showed that cost is the most cited reason for not visiting the dentist within the previous year.¹⁰

What this means is that lower-income households are also most likely to leave oral issues unchecked. According to the American Dental Association (ADA), 36% of those from low-income brackets (versus 18% in the high-income range) have cavities that are left untreated.

Those earning less than $30K annually are also twice as likely as those earning above that to have had all their teeth removed.

The situation is even bleaker in the majority of low to middle-income countries. Most of the governments in such areas aren’t able to provide oral health care to the vast majority of their population — or have preventative services in place to stop oral diseases from developing.⁹

Uninsured people are less likely to seek oral care

Another oral health inequality comes in the form of dental insurance access. A 2014 survey conducted by the American Dental Association asked 4,014 participants if they intended to visit a dentist within the next year. Only 43.7% of those who were uninsured said 'yes'.

This percentage was much higher for those who were either privately insured or under Medicare and Medicaid schemes (86.2%, 71.6%, and 72.6% respectively).

Furthermore, the number of those without dental insurance is growing. It was estimated that approximately 25% of US adults (or 74 million people) do not have dental insurance. When COVID-19 hit in 2020, job losses were at their peak and this left more than 16 million people without dental insurance from employers. While it's expected that a certain proportion of these people will take up some form of private or government plans, many are expected to remain uncovered. This is why it's expected that those without dental insurance may rise to 82 million in the future.¹¹

So why exactly aren't people getting dental insurance? For many, cutting back on costs is the primary reason. And fueling this decision could be the perceived lack of value from dental insurance. While The Affordable Health Care Act was meant to make health insurance more financially equitable, the benefits do not seem to have extended to oral health.¹¹ ¹²

Although for children it's considered an essential health benefit, insurers are not required to provide dental coverage for adults. This means out-of-pocket expenses remain relatively high for dental procedures — even when insured. One survey involving 50,077 Americans found that there are more significant cost barriers to accessing dental care compared to other forms of healthcare (e.g. medical care or mental health care) across all types of insurance groups.¹³ ¹⁰

Racial differences exist too

Even from a young age, oral health disparities can be clearly seen for racial minorities. According to data collected by the CDC between 2011-2016, 33% of Mexican Americans and 28% of non-Hispanic Black children aged 2 to 5 years old had cavities. This is compared to 18% of non-Hispanic White children of the same age.¹³

Black and Hispanic adults between 20-64 years old are also far more likely to have untreated tooth decay compared to Whites (42%, 36%, and 22% respectively).

Non-Hispanic Black or Mexican American seniors aged 65 years and older are also 2-3 times more likely to have unaddressed cavities compared to non-Hispanic White adults in the same age group.¹⁴ ¹³

There are many contributing factors leading to racial inequality in oral health care access — including cost. But another prominent reason is the overall mistrust that ethnic minorities have towards the healthcare system in general.¹⁵ A survey conducted by researchers from Emory University found that 81% of African American respondents agreed with the statement “You'd better be cautious when dealing with health care organizations”, while only 36% of White respondents agreed. African Americans were also more likely to report that medical racism exists in the system.¹⁶

Having a health practitioner that is of the same race as an ethnic minority patient could help to break down some of these barriers. But again, African American and Hispanic dentists are underrepresented in the dentistry workforce.¹⁷

Racial disparities have also been noted in terms of oral health literacy (OHL) — one's ability to receive and process basic health information. One study found that a higher percentage of African American participants had low OHL compared to Caucasian participants. And this was correlated to poorer oral health outcomes (like more missing teeth).¹⁸

The consequences of poor oral health

While many might not think much about a toothache, the impact of poor oral health can be far-reaching.

Currently, 3.5 billion people around the world are affected by oral diseases and the global cost to the economy is estimated to be $544 billion.

The most common oral health issue is tooth decay (or dental caries).

According to the WHO, 2.3 billion people suffer from decay in permanent teeth, and 530 million children have decay in milk teeth.⁹ ¹⁹

Gum (periodontal) disease is the next most common oral health issue. And in more severe cases, it can result in loss of teeth. It’s estimated that about 10% of the global population is affected by severe periodontal disease.⁹

Oral cancer also affects about 1 in 60 (1.7%) men and 1 in 140 (0.71%) women in the US. Common causes include tobacco and alcohol use. But there is an increasing number of oral cancer cases that are due to a sexually transmitted disease known as human papillomavirus (HPV).²⁰ ⁹

Furthermore, poor oral health has been linked to seemingly unrelated health conditions, including respiratory diseases and diabetes.²¹ Gum disease has also been linked to higher rates of cardiovascular disease, and this connection has puzzled medical professionals for years. Some experts hypothesize that the same bacteria that infects gums can travel to other parts of the body and cause blood vessel inflammation — resulting in heart attacks or strokes.²² ²³

More evidence is needed to confirm this causative effect between gum bacteria and diseases that affect other parts of the body. But it still highlights the need to remember that our oral health is connected to general health. 

How can we fix the oral health disparity?

Public oral health programs

The silver lining to the current oral health care disparity is that are many preventative public health measures that can be taken to reduce the progression of oral diseases in disadvantaged groups. This includes initiatives that promote healthy oral habits like brushing teeth twice a day, flossing before bed, maintaining a balanced diet, and going for regular dental checkups.²⁴

The CDC has also implemented initiatives like school sealant programs. This is where children aged 6 to 11 years old can get dental sealants for free within the school setting. A plastic coating is applied to the back teeth and it can help to reduce the chances of cavities developing. It's estimated that if sealants were provided to 5 million children from low-income households, it could stop 3.4 million cavities from developing over 4 years.

Water fluoridation is another way that the CDC is ensuring that all households have access to enough fluoride to strengthen teeth. And it's been shown to save both the government and individuals money by reducing oral health issues.²⁵

More equitable oral health insurance

As cost is often cited as the biggest barrier to seeking dental treatment, there have been calls for more comprehensive and affordable oral health insurance. This might involve expanding what is covered in dental insurance. Some experts suggest making dental care a compulsory benefit of Medicaid, or classifying it as an essential health benefit. Other suggestions include issuing benefits based on the recipient's level of well-being improvement rather than classifying it according to the number of teeth treated or arbitrary dollar limits — like limiting root canals to front teeth.¹⁰ ²⁶

The rise of dental tourism

Interestingly, people have also been taking matters into their own hands — by going to other countries for dental treatment where the cost of procedures is a fraction of what they would pay in the US. According to one report, these overseas dental procedures can be 40-75% cheaper.²⁷ And this is usually because of the lower cost of labour and business expenditures in such locations.

But while taking advantage of "dental tourism" seems like a logical choice for many people, they also should be aware that it's not without its risks. Going to an overseas oral health professional means that dental standards may not follow US guidelines and long-term follow-up care is uncertain.²⁸

People should not have to resort to going overseas to receive affordable and equitable oral health care. The rise in this trend highlights deeper issues like the classification of oral health in insurance terms and medical racism. Maintaining the health of our mouth is just as important as any other part of our body. The sooner this is reflected in public health initiatives and the way dental insurance is structured, the faster we will be able to close the oral healthcare gap between different segments of the population.

Sources:

1. Disparities in Access to Oral Health Care (2020)

2. An Oral Health Equity Agenda For The Biden Administration | Health Affairs

3. Oral health: A window to your overall health | Mayo Clinic

4. Oral and Dental Health | Centers for Disease Control and Prevention

5. https://stats.oecd.org/FileView2.aspx?IDFile=4cbd825d-6409-4eed-8483-2d5be8524797

6. How Many Americans Floss Their Teeth? | U.S. News

7. 2% of People Don’t Brush Their Teeth & Other Crazy Dental Statistics | Fortson Dentistry

8. Reducing Oral Health Disparities: What can we Learn from Social, Environmental and Cultural Factors? (2017)

9. Oral health | World Health Organization

10. Dental Care Presents The Highest Level Of Financial Barriers, Compared To Other Types Of Health Care Services | Health Affairs

11. A quick look at people without dental insurance | Insider Update

12. Tough Times Prompt Consumers to Cut Back on Their Dental Insurance | Dentistry Today

13. Disparities in Oral Health | Centers for Disease Control and Prevention

14. Dental Health Is Worse in Communities of Color | Pew Trusts

15. Understanding African Americans' Views of the Trustworthiness of Physicians (2006)

16. Medical Mistrust, Perceived Racism, and Experiences of Medical Discrimination Among Transplant Patients (2017)

17. Patients are more satisfied with care from doctors of same race (2002)

18. Relationship between oral health literacy and oral health status (2018)

19. An Economic perspective of the global burden of dental caries | ACFF

20. Key Statistics for Oral Cavity and Oropharyngeal Cancers | American Cancer Society

21. Improving Access to Oral Health Care for Vulnerable and Underserved Populations (2011)

22. Gum disease and the connection to heart disease | Harvard Health Publishing

23. The Influence of Porphyromonas Gingivalis Bacterium Causing Periodontal Disease on the Pathogenesis of Rheumatoid Arthritis: Systematic Review of Literature (2019)

24. Misperception of Oral Health among Adults in Rural Areas: A Fundamental but Neglected Issue in Primary Healthcare (2018)

25. Community Water Fluoridation | Centers for Disease Control and Prevention

26. An Oral Health Equity Agenda For The Biden Administration | | Health Affairs

27. Worth the Trip? A Look at Dental Tourism | Ontario Academy of General Dentistry

28. What Is Dental Tourism? | Colgate

The author, Dawn Teh, is a health writer and former psychologist who enjoys exploring topics about the mind, body, and what helps humans thrive.