Prevalence

Oral disease is prevalent in the United States. The prevalence of dental caries (i.e., “cavities”) in primary (baby) teeth was 23.3% among children ages 2-5 years and 52.1% among children ages 6-8 years in 2011-2016.²

The prevalence of dental caries in permanent teeth was 17.4% among children ages 6-11 years, 56.8% among adolescents ages 12-19 years, 89.9% among adults ages 20-64 years, and 96.2% among adults age 65 years and over in 2011-2016.²

Approximately 2.2% of adults ages 20-64 and 17.3% of adults age 65 and over are estimated to have lost their natural teeth in 2011-2016.²

Morbidity and Mortality

Untreated oral disease can affect appetite, interfere with ability to eat, and lead to poor nutrition. Periodontitis (i.e., “gum disease”) and dental caries lead to pain, impaired sleep, impaired academic performance, missed school and workdays, and decreased employability.³ Left untreated, dental infections may lead to abscess (a severe infection) that may lead to life-threatening sepsis (the body’s extreme response to an infection). Poor oral health may also be associated with other chronic diseases, such as diabetes and heart-related conditions.⁴

Cost

Oral diseases—which range from cavities and gum disease to oral cancer—cause pain and disability for millions of Americans and cost taxpayers billions of dollars each year. Research estimates that employed adults collectively lose more than 164 million work hours due to oral health problems or dental visits.⁵ People with visibly damaged or missing teeth can also face decreased opportunities for obtaining work. In addition, oral disease complications can undo the benefits of costly medical treatments covered by Medicare and Medicaid, such as heart valve replacement, radiation therapy, and hematopoietic stem cell replacement.⁶

Effective Care for Oral Health

Fluoride has an important role in preventing and treating the most prevalent oral disease condition: dental caries. Community water fluoridation makes fluoride available to all community members, regardless of their age, demographic characteristics, income, or insurance status. Drinking fluoridated water reduces the risk of developing cavities by approximately 25%.⁷ An analysis conducted in 2016 estimated that adding fluoride to community water systems saves $6.5 billion per year by preventing the direct costs of dental caries and indirect costs of treating them.⁷

Oral health professionals can also apply fluoride varnishes and dental sealants, which are also effective ways to prevent cavities. Dental varnishes can prevent one-third of cavities in both primary and permanent teeth.⁸ The U.S. Preventive Services Task Force recommends that primary care providers prescribe oral fluoride supplements when children lack access to community water fluoridation and apply fluoride dental varnishes for all children up to 5 years. Dental sealants have been shown to reduce cavities in permanent molars by 80% 2 years after being applied, and they continue to protect against 50% of cavities 4 years after application.⁹

If cavities develop, they can be treated with noninvasive procedures to stop caries progression and remineralize teeth, in addition to relying on fillings or tooth extraction. Modern dental practice also includes improved techniques and materials for restoring teeth and performing dental implants.³

Beyond preventing and treating cavities, dentists and other oral health professionals can address risks traditionally associated with overall health. People who smoke are 3 times as likely as nonsmokers to lose all their teeth.¹⁰ HPVⁱ-associated oral pharyngeal carcinoma is now more prevalent than HPV-associated cervical cancers. Thus, dental visits may provide people with opportunities to receive screening for tobacco and illicit drug use, tobacco cessation counseling, and HPV vaccination.¹¹

Oral diseases are also exacerbated by diabetes, a prevalent chronic disease that often occurs with cardiovascular health conditions. Economic analyses conducted in 2014 estimated that the U.S. healthcare system could save up to $100 million if dental offices provided screening for diabetes, high blood pressure, and high cholesterol and, if needed, referred patients for treatment.¹²

Opportunity #1: Fluoridating Community Water Systems

Fluoridated water protects teeth and reduces cavities by about 25% in children and adults. Community water fluoridation has been shown to save money both for families and for the U.S. healthcare system by preventing cavities.¹³ Data from CDC show that public health efforts to fluoridate community water systems expanded in the latter half of the 20^th century, but these efforts have slowed in recent decades.

Figure 3

Percentage of population served by community water system that received fluoridated water, 2018.

• In 2018, 63.4% of people in the United States received fluoridated water and 73.0% of people with access to community water systems received water with the recommended amount of fluoride.¹⁴ The percentage of the population served by community water systems that received fluoridated water varied by state (Figure 3).
• The percentage in 2018 was similar to values reported in 2008, when 64.3% of the population received fluoridated water and 72.4% of the population with access to community water systems received optimally fluoridated water.
• The percentage of people with access to community water systems who receive optimally fluoridated water remains below the Healthy People 2030 target of 77.1%.

Opportunity #2: Reducing Financial Barriers to Accessing Oral Healthcare Services

Fluoride varnish and dental sealants can protect teeth independent of community water fluoridation. Although these services can be delivered in school settings, most people receive them during a dental visit. For many Americans, the cost of dental services is a more important barrier to accessing services than the cost of medical care.

Figure 4

People unable to get or delayed in getting needed dental care or medical care due to cost, by age, 2019.

• In 2019, 14.3% of the population reported cost as a reason for being unable to get or delayed in getting needed dental care (Figure 4), which was higher than the 8.8% of people who reported cost as a barrier to getting needed medical care.
• The percentage of children ages 0-17 years for whom cost was reported as a barrier to receiving needed dental care was approximately one-third that of adult groups.

While health insurance can mitigate the cost of healthcare services, health insurance plans often carve out separate coverage for certain types of care, including care for dental, vision, and hearing conditions. Thus, even when people have health insurance, they may still lack coverage for dental care and thus lack access to needed services. This distinction has relevance for understanding how different public health insurance programs have influenced healthcare delivery and oral health outcomes over the past two decades.

The Medicaid program and the Children’s Health Insurance Program (CHIP) have provided comprehensive coverage of dental care for all enrolled children since 1998. Medicaid treats dental care coverage for adults as an optional benefit, which a growing number of states have begun to offer in recent years. In 2018, immediately prior to the period shown in Figure 4, most states covered only limited benefits, such as coverage for tooth extractions and emergency services, six states covered no dental services, and only a few states offered comprehensive dental coverage.¹⁵

As of August 2022, 25 states plus the District of Columbia met the American Dental Association’s definition of offering “extensive” dental benefits, and only 3 states offered no dental benefits in their Medicaid plan. Traditional fee-for-service Medicare does not cover dental benefits outside a few exceptions, and Medicare Advantage plans vary widely in the types and comprehensiveness of services.

Figures 5–11 show that the percentage of people with private dental insurance has not changed but the percentage of people with health insurance coverage, including public health insurance coverage, has increased. They also show that access to dental services and outcomes have mostly improved for segments of the population for whom public insurance consistently covers dental services.

Figure 5

Percentage of people with any period of private dental insurance during the year, by age, 2006-2019.

• There were no statistically significant changes in the percentage of children and adults with private dental insurance between 2006 and 2019 (Figure 5). Between 44% and 63% of people reported having private dental health insurance.
• Rates of having private dental insurance were lowest for children ages 0-17 years, higher for adults ages 18-44 years, and highest for adults ages 45-64 years.

Figure 6

Percentage of people with any period of uninsurance during the year (top) and percentage of people with any period of public insurance only during the year (bottom), by age, 2006-2019.

• The percentage of uninsured children decreased after implementation of the CHIP Reauthorization Act from a peak of 20.1% in 2008 to 9.9% in 2019 (Figure 6, top). The percentage of uninsured adults decreased after implementation of the Affordable Care Act (ACA), from 36.1% (ages 18-44 years) and 23.6% (ages 45-64 years) in 2013 to 23.7% (ages 18-44 years) and 14.6% (ages 45-64 years) in 2019.
• An increase in public health insurance coverage among all age groups (Figure 6, bottom) corresponded with the decrease in uninsurance shown in the top chart.

As shown in Figures 1 and 2, the percentage of children ages 5-19 years with untreated dental caries has decreased since 2001 and the rate of young adults ages 18-44 seeking emergency care for dental conditions has decreased since 2016. The improved outcomes occurred even though access to private dental insurance did not change (Figure 5). They also appear to coincide with the period when Medicaid/CHIP, which includes a dental benefit, expanded coverage for children, but not with the ACA’s health insurance expansion for adults (Figure 6).

Figures 7 to 11 reinforce the concept that inclusion of dental coverage in Medicaid/CHIP was linked to improved oral health outcomes for children. They show that disparities for these outcomes narrowed significantly for children in low-income households and for children in racial and ethnic minority groups between 2002 and 2019. In contrast, improvement in disparities for these outcomes among adults was more modest.

Figure 7

Children ages 2-17 years (top) and adults age 18 years and over (bottom) who had a dental visit in the calendar year, by ethnicity, 2002-2019.

• The percentage of children ages 2-17 who had a dental visit in the calendar year increased by 16.3% (from 49.1% to 57.1% of the population) between 2002 and 2019 but there was no statistically significant change for adults (data not shown).
• The data indicate improved access and narrowing disparities in access to dental services between Black and Hispanic groups and White groups (Figure 7).
• Between 2002 and 2019, the percentage of Black children with dental visits increased from 37.1% to 46.2%; and the percentage of Hispanic children with dental visits increased from 33.8% to 49.7% (Figure 7, top). The percentage of White children with dental visits increased at a slower rate, from 52.2% to 59.3%.
• During this time, the disparity between Black and White children in the percentage with dental visits decreased by 13.2% and the disparity between Hispanic and White children decreased by 47.8%.
• The percentage of Black adults with dental visits increased from 25.5% to 30.8%, and the percentage of Hispanic adults with dental visits increased from 24.6% to 28.9% (Figure 7, bottom). The percentage of White adults showed no statistically significant change (going from 46.2% to 46.8%).
• The disparity between Black and White adults in the percentage with dental visits decreased by 22.7% while the disparity between Hispanic and White adults in the percentage with dental visits decreased by 17.1%.
• Similar trends were seen for children and adults in Asian and multiple-race groups. Sample sizes for American Indian or Alaska Native and Native Hawaiian/Pacific Islander groups were too small to produce statistically reliable data and thus were not analyzed.

Figure 8

ED visits for dental conditions per 100,000 population, by median income of patient’s ZIP Code, 2016-2019.

• Between 2016 and 2019, the rate of ED visits for a dental condition decreased 6.1%, from 515.4 to 484.1 visits per 100,000 population for people who live in low-income counties (the 25% of counties with the lowest median household income). It decreased 11.5%, from 236.3 to 209.1 visits per 100,000, for people who live in not low-income counties (Figure 8).

Figure 9

Children with untreated dental caries (upper left) and adults with untreated dental caries (upper right and bottom), by race/ethnicity, 1988-2018. Note: This chart uses data previously reported in the 2019 Health, United States report. The estimates shown (more...)

• Racial and ethnic disparities were narrowing for untreated dental caries among children ages 5-19 years, while disparities in untreated dental caries for adults ages 20-44, 45-64, and 65+ years showed no statistically significant changes (Figure 9).
• The percentage of children ages 5-19 years with untreated dental caries decreased for Black, Hispanic, and White groups between 1988-1994 and 2015-2018 (Figure 9, upper left). Between 1988-1994 and 2015-2018, the percentage decreased from 33.9% to 15.7% for Black children and from 19.4% to 11.9% for White children. Between 2011-2014 and 2015-2018, the percentage decreased from 21.7% to 14.1% for Hispanic children. There were no statistically significant changes in the percentage of Asian children with untreated dental caries.
• There were no statistically significant changes in the percentage of adults ages 20-44 years with untreated dental caries for any race or ethnicity between 1988-1994 and 2015-2018 (Figure 9, upper right).
• There were no statistically significant changes in the percentage of adults ages 45-64 years with untreated dental caries for any race or ethnicity between 1988-1994 and 2015-2018 (Figure 9, lower left).
• There were no statistically significant changes in the percentage of adults age 65 years and over with untreated dental caries for any race or ethnicity between 1988-1994 and 2015-2018 (Figure 9, lower right).

Figure 10

Children (top) and adults (bottom) who had a dental visit in the past year, by household income-to-poverty threshold ratio, 2002-2019.

• From 2002 to 2019, the percentage of children ages 2-17 years with a dental visit increased from 33.0% to 42.5% in households with income less than 100% of the poverty threshold (“poor”), while the percentage of children with a dental visit grew at a slower pace (from 67.2% to 70.3%) in households with income at or above 400% of the poverty threshold (“high income”) (Figure 10, top).
• From 2002 to 2019, there was no statistically significant change in the percentage of adults age 18 years and over with a dental visit in either income group: 24.2% in 2002 to 24.8% in 2019 for households with income less than 100% of the poverty threshold and 57.2% in 2002 to 57.8% in 2019 for households with income at or above 400% of the poverty threshold (Figure 10, bottom).
• Although the percentage of children with dental visits increased in poor households, narrowing the gap between children in poor and high-income households, children in poor households remain significantly less likely to have a dental visit than either children or adults in high-income households.

Figure 11

Children (left) and adults (right) with untreated dental caries, by household income, 1988-2018. Note: This chart uses data previously reported in the 2019 Health, United States report. The estimates shown are spaced at irregular intervals. Income is (more...)

• Between 1999-2002 and 2015-2018, the percentage of children with untreated dental caries decreased from 31.9% to 18.7% among households with income less than 100% of the poverty threshold (Figure 11, left). During the same period, the percentage of children with untreated dental caries decreased from 8.9% to 5.2% in households with income at or above 400% of the poverty threshold. The disparity between children in poor and high-income households narrowed by 41.3%.
• Between 1988-1994 and 2015-2018, there were no statistically significant changes in the percentage of adults with untreated dental caries for any age group or income level (Figure 11, right).
• During the same years, there were no statistically significant changes in disparities between poor and high-income adults in any age group.

Opportunity #3: Reducing the Distance Needed To Access Oral Healthcare Services

Although dental insurance may reduce cost-related barriers to accessing oral healthcare services, it may not ensure people can access oral healthcare services if the services are far from where they live or if available oral healthcare providers do not accept insurance. Lack of healthcare providers, geographic isolation, and lack of adequate transportation are frequently cited barriers to healthcare services in rural communities,¹⁶ which is also true for oral healthcare.

Increasing urbanization of the population has been associated with less financial stability among rural hospitals, hospital closures, and loss of access to the services they provide. The Government Accountability Office (GAO) documented 101 rural hospital closures from January 2013 through February 2020. Of these, 17 had offered oral healthcare services. The GAO estimates that the median distance people in the communities served by these hospitals needed to drive to access oral healthcare services increased from 2.4 to 36 miles.¹⁷

Rural communities also face greater challenges recruiting and supporting oral healthcare professionals. “Health Professional Shortage Area” (HPSA) is a designation HRSA assigns to areas that lack key types of healthcare practitioners, in order to prioritize support for those communities. HRSA has identified 7,018 geographic areas, population groups, and facilities as “dental HPSAs.”

Nearly three-quarters of dental HPSAs are in areas classified as rural or partially rural.

Figure 12

Dental Health Professional Shortage Areas in the United States and territories, 2022. Note: HPSA scores are developed for use by the National Health Service Corps to determine priorities for the assignment of clinicians. Scores range from 1 to 26 for (more...)

• As of June 30, 2022, HRSA estimates that only 31.4% of dental HPSAs have met their need for practitioners, and an additional 11,694 dental professionals are needed to remove the remaining HPSA designations.¹⁸
• Figure 12 shows the distribution of counties with dental HPSAs. As of June 30, 2022, 4,692 of 7,018 (66.9%) dental HPSAs are classified as rural, 281 (4.0%) are classified as partially rural, and 2,044 (29.1%) are classified as nonrural.

Medical Expenditure Panel Survey data indicate that children and adults who live in micropolitan (“small town”) and noncore (“rural”) areas (i.e., nonmetropolitan counties) are less likely to have had a dental visit in the past year than similarly aged people who live in metropolitan locations (Figure 13).ⁱⁱⁱ

Figure 13

Children who had a dental visit in the calendar year (top) and adults who had a dental visit in the calendar year (bottom), by location of residence, 2019.

• Children in noncore (53.6%) and micropolitan (55.5%) communities were less likely to have a dental visit than children in large fringe metropolitan areas (59.6%) (Figure 13, top).
• Adults in noncore (40.1%) and micropolitan (42.5%) counties were less likely to have a dental visit than those in large fringe metropolitan areas (46.6%) (Figure 13, bottom).

Figures 14 and 15 show trends for insurance coverage and dental visits for children and adults in metropolitan and nonmetropolitan locations between 2002 and 2019. They suggest value in having dental insurance coverage in this population but also hint at barriers unrelated to insurance coverage.

Figure 14

Overall percentage of people with private dental insurance (top), 2006-2019, and overall percentage of people with no insurance or public health insurance (bottom), by location of residence, 2002-2019.

• For metropolitan communities, the percentage of people with private dental insurance coverage decreased from 55.2% to 51.9% between 2006 and 2013, followed by a steady rise from 51.9% to 59.7% between 2013 and 2019 (Figure 14, top).
• For nonmetropolitan communities, a similar but delayed pattern in dental insurance coverage emerged, with a relatively rapid rise from 43.8% to 52.4% between 2016 and 2019.
• Overall, the percentage of people in metropolitan communities with public insurance rose from 16.6% to 26.5% and the percentage of uninsured people decreased from 25.3% to 16.9% between 2002 and 2019 (Figure 14, bottom).
• During the same period, the percentage of people in nonmetropolitan communities with public insurance rose from 20.2% to 32.4% and the percentage of uninsured people decreased from 26.2% to 19.3%.

Figure 15

Children who had a dental visit in the calendar year (top) and adults who had a dental visit in the calendar year (bottom), by location of residence, 2002-2019.

• From 2002 to 2019, the percentage of children with a dental visit increased both for nonmetropolitan communities (from 49.5% to 54.7%) and metropolitan communities (from 49.0% to 57.5%) (Figure 15, top). However, the rate of improvement was faster for children in metropolitan locations, widening a disparity between these groups.
• During this period, disparities between adults in metropolitan and nonmetropolitan communities narrowed (Figure 15, bottom). The percentage of adults with a dental visit increased from 38.4% to 41.6% in nonmetropolitan communities, a small but significant increase, while the change in the percentage of adults with a dental visit in metropolitan communities was not statistically significant.

Viewed together, Figures 14 and 15 suggest a potential correlation between a rise in private dental insurance coverage after 2016 and an increased percentage of adults who had a dental visit during the year in the same years. They also provide an indication that health insurance coverage is insufficient to address disparities between people in metropolitan and nonmetropolitan communities. While measures for children show an overall rise in dental visits in both metropolitan and nonmetropolitan locations, the faster rise in visits in metropolitan areas suggests those who live in nonmetropolitan communities may face barriers unrelated to insurance (e.g., lack of transportation).

Experts have proposed several strategies that could reduce dental workforce shortages and geographic distance as a barrier to receiving high-quality dental care.^16,19,20 These include policies that:

• Prioritize students from rural areas for admission to dental schools, as they are more likely to return to rural areas to practice.
• Establish dental school curricula that emphasize rural dentistry.
• Recruit and retain dentists and other oral healthcare providers through financial and tax incentives, loan repayment/forgiveness, and community development programs.
• Establish programs that integrate oral and behavioral health services into primary care practices, thus enabling primary care providers to offer at least some dental services. As of September 2020, 14 states and several tribal nations had authorized care delivered by dental therapists.²¹
• Enable a wider range of health professional roles to safely deliver oral healthcare services. For example, dental therapists are licensed health professionals who provide preventive and restorative dental care as part of a broader dental care team, comparable to the role performed by physician assistants in delivering medical care.
• Expand capacity to deliver teledental services, including building broadband internet infrastructure and amending licensing regulations to permit teledentistry.

Limited Data for Oral Health Outcomes in Nonmetropolitan Communities

If demonstration projects to expand the rural workforce transition into national initiatives, it will become increasingly desirable to assess their impact on nonmetropolitan (i.e., micropolitan and rural) communities at state and national levels. Currently, the NHQDR has limited capacity to examine trends in this area.

For example, data showing less access to routine dental care services in nonmetropolitan communities raises concern for people who live in these communities. However, it is unclear if persistent disparities in dental visit rates are associated with similar trends for untreated dental caries for people in nonmetropolitan areas since data needed to examine differences in rate of untreated dental caries by location of residence are not available.

Data on ED visits for primary diagnosis of dental conditions by people in metropolitan and nonmetropolitan communities (Figure 16) show that disparities for this measure are narrowing. However, in the absence of corroborating data, it is unclear if this trend represents a desirable outcome (e.g., improved care and less need for emergency dental services) or an undesirable one (e.g., hospital closures leading to less access to needed emergency care).

Gathering data that would allow closer examination of oral health outcomes in nonmetropolitan counties would enhance our understanding of healthcare delivery in these communities and inform programs that seek to serve their needs.

Figure 16

Emergency department visits with a principal diagnosis related to dental conditions per 100,000 population, by location of residence, 2016-2019.

• The trend for people in large central metropolitan areas was statistically similar to those in large fringe metropolitan areas (going from 234.1 to 202.8 visits per 100,000 population in large central metropolitan areas and from 221.6 to 218.8 visits per 100,000 population in large fringe metropolitan counties) (Figure 16).
• The trend for people in medium and small metropolitan counties improved from 382.6 to 339.9 visits per 100,000 population, narrowing the disparity with large fringe metropolitan communities by 24.8%.
• The trend for people in nonmetropolitan counties improved from 482.9 to 442.2 visits per 100,000 population, narrowing the disparity with large fringe metropolitan communities by 14.5%.