Policy Forum
Jan 2022

Health Equity Needs Teeth

Eleanor Fleming, PhD, DDS, MPH, Julie Frantsve-Hawley, PhD, and Myechia Minter-Jordan, MD, MBA
AMA J Ethics. 2022;24(1):E48-56. doi: 10.1001/amajethics.2022.48.



People who are poor or members of communities of color face inequitable oral disease burden. Continued separation of dental and oral health from general medical care exacerbates inequity and forces members of underserved communities to seek nontraumatic dental emergency care in hospital emergency departments. This trend is unnecessarily costly and results in antibiotic prescriptions and pain management that are neither restorative nor responsive to patients’ primary complaints. Value-based approaches to health care need to unify mouth care with general medical care, motivate medical-dental interprofessional practice, promote oral disease prevention, and support restorative dental care. Value-based approaches to health care must also innovate fiscal structures (eg, payment models, data sharing) to improve health outcomes for everyone.

Weekend Mouth Pain

Imagine it’s Saturday evening at 6 pm, and you find yourself in pain—a pain not from a hurt foot or shoulder, but a throbbing, radiating pain in your mouth that feels as if your head and ears are on fire. You cannot sleep or eat. Previously, the pain was dull and only bothered you when you ate something sweet or cold. But now, at 6 pm on a Saturday, you find yourself in extreme pain and unable to function. While you are employed, your minimum wage job does not provide dental insurance and you live in a state that does not provide comprehensive, adult dental benefits through Medicaid. Consider also that when you saw your physician 3 months ago for your check-up to renew your blood pressure prescription, you mentioned the tooth bothering you. It is likely that your physician did not examine your mouth or refer you to a dentist for care. You thought the tooth could wait! To make things worse, because of your lack of dental coverage and your inability to pay for the out-of-pocket expense of dental care in a private practice office, you do not have a dental home to call for an emergency appointment. The last time you saw a dentist was at a charity dental event in the local college’s gymnasium several years ago. In the United States, where should you go and what should you do?

Fragmented, Biased Oral Health Care

Perpetuating the separation of medicine and dentistry affects how costs of services are paid, how clinicians are trained, and where their practices are located.1,2,3,4 Yet the mouth has essential roles in overall health.4,5 Our quality of living—the ability to eat and speak—depends upon the health of our teeth, gums, and mouth.5 Research shows that health system fragmentation contributes to poor health outcomes, engenders patient and clinician dissatisfaction, results in biased treatment planning, perpetuates racism and inequity, and supports an ineffective reimbursement system.2,6,7,8,9,10,11

Members of poor and marginalized groups bear an inequitable oral disease burden.10,12 Across age groups and dental conditions, non-Hispanic Black, Hispanic, and American Indian and Alaska Native individuals have worse clinical outcomes and self-reported perceptions of their oral health, as well as lower adoption of evidence-based preventative services, than non-Hispanic White individuals.13,14,15,16,17,18 Similarly, individuals living below 200% of the federal poverty level have more untreated dental caries and fewer permanent teeth than those living above that threshold.13,19 The underlying causes of inequity are rooted in structural racism.20 Antiracist practices and a focus on social and political determinants of health have been proposed as ways to support health equity.21,22,23 However, changes in practice and focus alone only scratch the surface of deep-seated inequity; lasting change could come from reimagining health care delivery streams, integrating medical and dental services, and implementing a reimbursement system that emphasizes value and patient-centered outcomes. Moreover, changes in payment structures might incentivize interprofessional practice and equity across the health sector.

Financially Unbalanced

Having medical but not dental insurance is a reality for many Americans.3 While the Affordable Care Act has lowered the percentage of the US population that lacks health insurance, especially among people with low income and people of color,24 many insurance gaps—especially for adults—have not closed. In 2015, 1 in 3 US adults had no form of dental benefits coverage.25 In 2017, 9.5% of US adults were unable to access dental care due to cost as compared to 7.4% of US adults who were unable to access medical care due to cost.26 Improved access to dental coverage results in better health care utilization. For adults with lower incomes living in states that expanded Medicaid to include adult dental benefits, the number of people who reported having a dental visit in the past year increased 7.2 percentage points.27

Although the Affordable Care Act increased access to dental care for some adults through Medicaid expansion, hospital emergency departments (EDs) are still the only access point for dental care for many adults.In 2012, there were more than 2 million ED dental visits that incurred $1.6 billion in expenses, with an average cost of $749 per visit.28 National average costs for fillings on permanent teeth and extractions to erupted teeth are less than one-fifth the cost of the average ED dental visit.28,29 In an ED, common treatments for nontraumatic dental problems are nonsteroidal anti-inflammatory drugs, opioids, or antibiotics.30 None of these treatments addresses an underlying dental problem, and each incurs unnecessary costs.31

Interprofessional Practice

Integrated medical-dental care has proved successful, most notably for diabetes and hypertension prevention and management, tobacco cessation, prenatal care, and care of people living with HIV.32,33,34,35,36,37 Interprofessional practice supports whole-person care, allowing medical, dental, and other health-focused practitioners (eg, nutritionists and therapists) to optimize care planning collaboratively. When oral health was part of well-child-visits, non-Hispanic Black, Hispanic, and American Indian and Alaska Native children received earlier dental interventions and better preventive services.38,39 Integrating oral health care with periodontal disease treatment and prevention also supports health of patients with diabetes.11,40,41

To facilitate interprofessional practice, health service delivery must express equity and value and be financed to support workforce diversity. With a focus on prevention rather than disease management, value-based payment models can support medical-dental integration by streamlining operations and supporting clinicians practicing at the top of their licenses (ie, the highest level of skill that a clinician is licensed to practice).42,43,44 Medical-dental integration requires regulation and reimbursement structures that establish shared language, forge agreement on measurable outcomes, and incentivize technology use (eg, electronic health record information exchange and interoperability) that reinforces value and seamless interprofessional operations, especially referrals. Technology should also enable data collection that would facilitate assessment of services’ impact and return on investment and support population health management.35

Value-Based Care Is Integrated

Value-based care is a comprehensive term that refers to care that seeks to improve health outcomes efficiently via transformations in care delivery, data and analytics, and financing. Value-based oral health care seeks to prevent dental diseases and improve oral health outcomes with a focus on the quality of care as opposed to the quantity of restorative procedures.45,46 Equitable health care can only occur in an integrated system of value-based care that supports transformations in prevention, treatment, payment models, and data and analytics to deliver patient-centered care and improve population outcomes.47,48 Public and private insurance programs can be restructured to bundle payments, incentivize prevention and health promotion, and create flexible payment options for health services delivered outside of the clinic via telehealth and home-based care. Payment transformation that occurs through alternative models that incentivize prevention and optimal health lends itself to improved health systems outcomes, especially if the health system works to focus not on disease interventions but on the upstream, localized, and systemic causes of disease.49

To facilitate interprofessional practice, health service delivery must express equity and value and be financed to support workforce diversity.

A key example of value-based oral health care is the Medicaid services provided by the largest dental accountable care organization (ACO) in Oregon. Delivering services to approximately 284 000 members of the state’s Medicaid program, this ACO offers a unique approach to oral health care by incentivizing prevention over surgery, community-based care, and population health management.50 This value-based approach resulted in improved outcomes compared to national Medicaid samples: in 2015, 20% of children enrolled were assessed for caries risk compared to 0.1% of children in a national Medicaid sample; 85% of services provided to children were preventive or diagnostic compared to 77% of services in a national Medicaid sample; the need for restorative and surgical services for children enrolled dropped from 21% in 2011 to 15% in 2016 while the national Medicaid sample experienced no reduction over the same period; 17% less on average was spent to treat children and 21% less on average to treat adults than spent by Medicaid to treat children and adults in a national sample.50

Additional examples of value-based care include integration of oral health care with practices such as pediatric primary care and dental homes for pregnant women.50,51 Continued evaluation and appropriate change management will be necessary to overcome foundational bias and discrimination, both interpersonal and institutional.52,53 Moreover, health policy based on social justice can reduce inequity, address social determinants of health, and prevent some emergencies.54

While these changes to create a more equitable model of health care delivery may occur within the systems of payers, work is also needed to ensure that this new, integrated system functions as a social justice practice.54 Addressing racial inequities and discrimination within health care has been described as a “wicked” problem because this problem is complex, has multiple stakeholders, and is tough to solve.20,44 We contend that separating oral health care from medicine is another contributor to that wicked problem.34 The current dental care system is not designed to address social disparities, rarely considers determinants of health, and does not address the inequities it causes.19,20,21 Therefore, an integrated system of medicine and oral health care must bring attention to disparities and build policy, practice, and research solutions to support equity.

Improving population health must be grounded in a shared value of social justice.54 There must be parity in the payment models for private and public insurance. Additionally, value-based reimbursement programs can address the social risk factors of a community by incentivizing providers and plans to improve health outcomes of those with social risk factors and thereby contribute to creating a more equitable and efficient system of health.55 With fair and adequate reimbursement, the integrated health team of medical, dental, and other clinicians can democratize the patient experience and focus on improved health outcomes for all patients. Ultimately, interprofessional, value-based care encourages the wellness and health of communities in addition to the treatment and care of the individual by focusing on population-based outcomes.

Motivating Equity

Although advertisers suggest that white teeth and a perfect smile are the standards of a healthy mouth, oral health actually entails a functional dentition; the ability to open one’s mouth, chew, and speak; gums that do not bleed; and a mouth free from both pain and disease. Far too often, patients face excruciating pain with no dental coverage, cannot afford to pay out of pocket, and have no clue where to access treatment. For non-Hispanic Black, Hispanic, and American Indian and Alaska Native people, this is not simply an access issue: it is a matter of social injustice. Clinicians, payers, communities, policymakers, employers, and other decision makers must collectively decide to promote justice. We recommend adoption of value-based models that incorporate interprofessional practice and reimbursement mechanisms that are integrated with value-based care. Stakeholders must unite and advance research to transform health care. After all, who knows when it will be 6 pm on Saturday and you will be the one in pain…. Where will your help come from?


  1. Otto M. Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America. New Press; 2017.

  2. Vujicic M. Our dental care system is stuck. And here is what to do about it. J Am Dent Assoc. 2018;149(3):167-169.
  3. Mertz EA. The dental-medical divide. Health Aff (Millwood). 2016;35(12):2168-2175.
  4. Simon L. Overcoming historical separation between oral and general health care: interprofessional collaboration for promoting health equity. AMA J Ethics. 2016;18(9):941-949.
  5. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. Accessed January 30, 2021. https://www.nidcr.nih.gov/sites/default/files/2017-10/hck1ocv.%40www.surgeon.fullrpt.pdf

  6. Mofidi M, Rozier RG, King RS. Problems with access to dental care for Medicaid-insured children: what caregivers think. Am J Public Health. 2002;92(1):53-58.
  7. Patel N, Patel S, Cotti E, Bardini G, Mannocci F. Unconscious racial bias may affect dentists’ clinical decisions on tooth restorability: a randomized clinical trial. JDR Clin Trans Res. 2019;4(1):19-28.
  8. Cabral ED, Caldas AF Jr, Cabral HA. Influence of the patient’s race on the dentist’s decision to extract or retain a decayed tooth. Community Dent Oral Epidemiol. 2005;33(6):461-466.
  9. Chisini LA, Noronha TG, Ramos EC, et al. Does the skin color of patients influence the treatment decision-making of dentists? A randomized questionnaire-based study. Clin Oral Investig. 2019;23(3):1023-1030.
  10. Watt RG, Daly B, Allison P, et al. The Lancet Oral Health Series: implications for oral and dental research. J Dent Res. 2020;99(1):8-10.
  11. Simon LE, Karhade DS, Tobey ML. Oral health status of hospitalized patients with type 2 diabetes. Diabetes Spectr. 2020;33(1):58-65.
  12. Bastos JL, Celeste RK, Paradies YC. Racial inequalities in oral health. J Dent Res. 2018;97(8):878-886.
  13. Lin M, Griffin SO, Gooch BF, et al. Oral health surveillance report: trends in dental caries and sealants, tooth retention, and edentulism, United States, 1999-2004 to 2011-2016. Centers for Disease Control and Prevention; 2019. Accessed November 16, 2021. https://www.cdc.gov/oralhealth/pdfs_and_other_files/Oral-Health-Surveillance-Report-2019-h.pdf

  14. Fleming E, Afful J, Griffin SO. Prevalence of tooth loss among older adults: United States, 2015-2018. National Center for Health Statistics data brief 368. June 2020. Accessed November 16, 2021. https://www.cdc.gov/nchs/data/databriefs/db368-h.pdf

  15. Phipps KR, Ricks TL. The oral health of American Indian and Alaska Native children aged 6-9 years: results of the 2016-2017 IHS Oral Health Survey. Indian Health Service data brief. April 2017. Accessed November 16, 2021. https://www.ihs.gov/doh/documents/Data%20Brief%20IHS%206-9%20Year%20Olds%2003-30-2017.pdf

  16. Eke PI, Borgnakke WS, Genco RJ. Recent epidemiologic trends in periodontitis in the USA. Periodontol 2000. 2020;82(1):257-267.
  17. Weatherspoon DJ, Chattopadhyay A, Boroumand S, Garcia I. Oral cavity and oropharyngeal cancer incidence trends and disparities in the United States: 2000-2010. Cancer Epidemiol. 2015;39(4):497-504.
  18. Borrell LN, Taylor GW, Borgnakke WS, Woolfolk MW, Nyquist LV. Perception of general and oral health in White and African American adults: assessing the effect of neighborhood socioeconomic conditions. Community Dent Oral Epidemiol. 2004;32(5):363-373.
  19. QuickStats: prevalence of complete tooth loss among adults aged ≥ 65 years, by federal poverty level—National Health and Nutrition Examination Survey, United States, 1999-2018. MMWR Morb Mortal Wkly Rep. 2020;69(37):1334.

  20. Smith PD, Wright W, Hill B. Structural racism and oral health inequities of Black vs non-Hispanic White adults in the US. J Health Care Poor Underserved. 2021;32(1):50-63.
  21. Came H, Griffith D. Tackling racism as a “wicked” public health problem: enabling allies in anti-racism praxis. Soc Sci Med. 2018;199:181-188.

  22. Patrick DL, Lee RS, Nucci M, et al. Reducing oral health disparities: a focus on social and cultural determinants. BMC Oral Health. 2006;6(suppl 1):S4.

  23. Dawes DE. The Political Determinants of Health. Johns Hopkins University Press; 2020.

  24. Garfield R, Orgera K, Damico A. The uninsured and the ACA: a primer. Kaiser Family Foundation; January 2019. Accessed February 28, 2021. https://files.kff.org/attachment/The-Uninsured-and-the-ACA-A-Primer-Key-Facts-about-Health-Insurance-and-the-Uninsured-amidst-Changes-to-the-Affordable-Care-Act

  25. Health Policy Institute. Dental benefits coverage in the US. American Dental Association; 2015.

  26. National Center for Health Statistics. Table 29: delay or nonreceipt of needed medical care, nonreceipt of needed prescription drugs, or nonreceipt of needed dental care during the past 12 months due to cost, by selected characteristics: United States, selected years 1997-2017. Centers for Disease Control and Prevention; 2018. Accessed on June 23, 2021. https://www.cdc.gov/nchs/data/hus/2018/029.pdf

  27. Elani HW, Sommers BD, Kawachi I. Changes in coverage and access to dental care five years after ACA Medicaid expansion. Health Aff (Millwood). 2020;39(11):1900-1908.
  28. Wall T, Vujicic M; Health Policy Institute. Emergency department use for dental conditions continues to increase. American Dental Association; April 2015. Accessed January 30, 2021. https://mediad.publicbroadcasting.net/p/wusf/files/201802/ADA.pdf

  29. American Dental Association. Action for dental health: bringing disease prevention into communities. December 2013.

  30. Roberts RM, Bohm MK, Bartoces MG, Fleming-Dutra KE, Hicks LA, Chalmers NI. Antibiotic and opioid prescribing for dental-related conditions in emergency departments: United States, 2012 through 2014. J Am Dent Assoc. 2020;151(3):174-181.e1.
  31. Sun BC, Chi DL, Schwarz E, et al. Emergency department visits for nontraumatic dental problems: a mixed-methods study. Am J Public Health. 2015;105(5):947-955.
  32. Owen C, Hilton I, Thompson P. Integration of oral health and primary care practice: Integrated Models Survey results: embedded dental providers. National Network for Oral Health Access; October 2019. Accessed January 30, 2021. https://nnoha.org/nnoha-content/uploads/2019/10/NNOHA-2019-Integrated-Models-Survey-Results.pdf

  33. Jeffcoat MK, Jeffcoat RL, Gladowski PA, Bramson JB, Blum JJ. Impact of periodontal therapy on general health: evidence from insurance data for five systemic conditions. Am J Prev Med. 2014;47(2):166-174.
  34. Glurich I, Schwei KM, Lindberg S, Shimpi N, Acharya A. Integrating medical-dental care for diabetic patients: qualitative assessment of provider perspectives. Health Promot Pract. 2018;19(4):531-541.
  35. Acharya A, Cheng B, Koralkar R, et al. Screening for diabetes risk using integrated dental and medical electronic health record data. JDR Clin Trans Res. 2018;3(2):188-194.
  36. Fox JE, Tobias CR, Bachman SS, et al. Increasing access to oral health care for people living with HIV/AIDS in the US: baseline evaluation results of the Innovations in Oral Health Care Initiative. Public Health Rep. 2012;127(suppl 2):5-16.
  37. Neumann A, Kumar S, Bangar S, et al. Tobacco screening and cessation efforts by dental providers: a quality measure evaluation. J Public Health Dent. 2019;79(2):93-101.
  38. Achembong LN, Kranz AM, Rozier G. Office-based preventive dental program and statewide trends in dental caries. Pediatrics. 2014;13(4):e827-e834.
  39. Tiwari T, Rai N, Brow A, Tranby EP, Boynes SG. Association between medical well-child visits and dental preventive visits: a big data report. JDR Clin Trans Res. 2019;4(3):239-245.
  40. Taylor GW. Exploring interrelationships between diabetes and periodontal disease in African Americans. Compend Contin Educ Dent. 2011;22(3, theme issue):42-48.
  41. Fleming E, Singhal A. Chronic disease counseling and screening by dental professionals: results from NHANES, 2011-2016. Prev Chronic Dis. 2020;17:E87.

  42. Varnum J. Value-based care: four key competencies for success. Health Catalyst. March 20, 2018. Accessed January 30, 2021. https://www.healthcatalyst.com/insights/value-based-care-key-competencies-success/

  43. Spiro A. Challenging paradigms: practising at the top of your license. Health Manag. 2017;17(3):206-207. Accessed June 23, 2021. https://healthmanagement.org/uploads/article_attachment/hm-v17-i3-spiro-paradigms.pdf

  44. Greiner AC, Knebel E, eds; Institute of Medicine. Health Professions Education: A Bridge to Quality. National Academies Press; 2003.

  45. Boynes S, Nelson J, Diep V, et al. Understanding value in oral health: the oral health value-based care symposium. J Public Health Dent. 2020;80(suppl 2):S27-S34.
  46. Frantsve-Hawley J, Mathews R, Brown C. The wicked problem of the oral health care system. J Public Health Dent. 2020;80(suppl 2):S5-S7.
  47. Martin A, Kirby H, Ayers G, Kelly A, Riley A, Boucher S. Demonstration of payer readiness for value-based care in a fee-for-service environment: measuring provider performance on sealant delivery. J Public Health Dent. 2020;80(suppl 2):S50-S57.
  48. Clary A, Hanlon C, Mention N. Integrating oral health into Oregon Medicaid’s coordinated care model: lessons for state policymakers. National Academy for State Health Policy; September 2017. Accessed February 17, 2021. http://www.advancingstates.org/sites/nasuad/files/DentaQuest-Brief.pdf

  49. Anderson AC, O’Rourke E, Chin MH, Ponce NA, Bernheim SM, Burstin H. Promoting health equity and eliminating disparities through performance measurement and payment. Health Aff (Millwood). 2018;37(3):371-377.
  50. CareQuest Institute for Oral Health. Advantage Dental’s approach: a model for better health, better access and better value. December 2018. Accessed October 11, 2021. https://www.carequest.org/system/files/CareQuest-Institute-Advantage-Dental-Approach-White%20Paper.pdf

  51. Kanan C, Ohrenberger K, Bayham M, et al. MORE Care: an evaluation of an interprofessional oral health quality improvement initiative. J Public Health Dent. 2020;80(suppl 2):S58-S70.
  52. Lee JT, Polsky D, Fitzsimmons R, Werner RM. Proportion of racial minority patients and patients with low socioeconomic status cared for by physician groups after joining accountable care organizations. JAMA Netw Open. 2020;3(5):e204439.

  53. Yasaitis LC, Pajerowski W, Polsky D, Werner RM. Physicians’ participation in ACOs is lower in places with vulnerable populations than in more affluent communities. Health Aff (Millwood). 2016;35(8):1382-1390.
  54. Gostin LO, Powers M. What does social justice require for the public’s health? Public health ethics and policy imperatives. Health Aff (Millwood). 2006;25(4):1053-1060.
  55. Office of the Assistant Secretary for Planning and Evaluation. Social risk factors and Medicare’s value-based purchasing programs. US Department of Health and Human Services. Accessed August 23, 2021. https://aspe.hhs.gov/topics/health-health-care/social-risk-factors-medicares-value-based-purchasing-programs

Editor's Note

Background image by Lauren Beatty.


AMA J Ethics. 2022;24(1):E48-56.




The authors thank Michael Monopoli, DMD, MPH, MS and Sean G. Boynes, DMD, MS.

Conflict of Interest Disclosure

Dr Fleming is a consultant for the CareQuest Institute for Oral Health and reports receiving funding from DentaQuest. Dr Minter-Jordan reports that her employer, the CareQuest Institute for Oral Health, is a majority owner of DentaQuest, a national dental benefits company. Dr Frantsve-Hawley had no conflicts of interest to disclose.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.