Cracked tooth, cracked system: Why U.S. dental care needs pulling 

To have a bad tooth quit hurting reminded me how fortunate I am. Being pain-free is not an equal opportunity state of being. Dental care is out of reach for too many Americans, unless we break with our current politics and culture.

 Studying health impacts of disasters for a living, I often think about worst-cases and who bears the brunt in events like a Hurricane Harvey. This outlook became unexpectedly relevant several days ago when I sat in the exam chair of a dentist who specializes in root canals. She had just diagnosed my cracked molar as probably unsalvageable. Breaking in two, the tooth may not even qualify for a root canal — the dental scenario people often dread the most. 


A clinical dilemma existed: Was the tooth already split or just starting to? A mere crack meant maybe keeping my molar; a true split meant losing it. I could choose an extraction now or keep hedging my bets to preserve the tooth: A $230 scan could gauge the crack’s severity. If the findings were inconclusive, then physically opening the tooth for inspection at $470 would determine if a root canal was justified. If so, then $800 more would complete the procedure.  

Later at home, the pain lifted after ibuprofen and antibiotics. I mulled over what the dentist had said upon seeing the shocked look on my face and began to research my slim hope online: The American Association of Endodontists identified five crack “types”: craze lines, fractured cusp, cracked tooth, split tooth and vertical root fractures. With a poor prognosis, a split tooth (my lot?) typically warranted pulling. I dug deeper, searching for studies on new ways to repair hopeless fractures. Few existed; long-term effects were dubious. As the reality of irreversible damage set in, oral surgeons were my next priority. 


My cracked molar had initiated a dizzying spiral of decision-making. But, as my sister-in-law who works as a nurse in a poorly resourced school pointed out, hard up people had one option: Pull the tooth. Insurance, income and education gave me choices. Coverage through my employer made finding care for my cracked tooth easy. Earning a good salary, I could elect a costly scan and procedure to pursue the slender possibility of saving the tooth, even without insurance. Flush and well educated, I could engage with experts about all my alternatives. 

No disaster, my toothache felt like one at first. But for many other Americans, it would be. The National Association of Dental Plans reports that, in 2016, over 74 million had no dental insurance, cutting their chances to prevent and respond to crises like a cracked tooth. Even with coverage, many people put off fillings, crowns and root canals due to high co-pays. Other roadblocks, according to the U.S. Office of Disease Prevention and Health Promotion, are poor awareness about the need for dental care, unavailable dental services and fear of the dentist.  

But dental care is no luxury, and it is not separate from health care. Social status and a good job often hinge on whether a person has a full set of straight, white teeth. Gum infection is linked to elevated risk of cancer, heart disease, dementia, infertility and stroke. Untreated oral disease can kill: In 2007, Deamonte Driver, a 12-year old Maryland boy, died after bacteria from an abscessed tooth infected his brain — something an $80 extraction could have prevented had poverty and interrupted Medicaid coverage not impeded timely care. 

We are now struggling to define the future U.S. dental care system. One vision is the Donald Trump-endorsed move to revive a work requirement for Kentucky’s Medicaid program that provides meager dental benefits to those most in need. Another is the Bernie Sanders “Medicare for All” proposal that would incorporate most dental care. Meanwhile, our culture continues to moralize bad teeth, blaming people — and not skewed life odds — for their toothaches. Shame in part explained my own horror at the initial thought of losing a tooth. 

Resolved to have my molar pulled, if need be, I also want our cracked dental care system yanked and replaced. We can join public health professionals in advocating that U.S. health policy adopt comprehensive dental care as an essential health benefit for both children and adults; then, public insurance programs like Medicare and Medicaid would cover it and private health insurance embrace it. And, as voters, we can back leaders willing to work toward equity in U.S. oral health so everyone has a chance to enjoy and hold onto healthy teeth.  

Monica Schoch-Spana ( a senior scholar with the Center for Health Security at the Johns Hopkins Bloomberg School of Public Health.