Over an ear­ly Sep­tem­ber week­end in 2017, some 850 vis­i­tors showed up to the Uni­ver­si­ty of Mary­land (UMD) bas­ket­ball are­na in Col­lege Park. But the atten­dees weren’t there to watch a game, they came to receive free den­tal care through Mis­sion of Mer­cy, which holds sim­i­lar events across the coun­try to pro­vide one-off den­tal ser­vices to any­one who needs them.

Dental inequality is even more extreme in America than inequality in other areas of healthcare.

Many of the atten­dees queued up in the UMD gym were there not for rou­tine tooth-clean­ings, but instead were suf­fer­ing from severe den­tal prob­lems requir­ing inter­ven­tions like painful extrac­tions. As Mary­land den­tist Dr. Jacob Nix explained, these treat­ments were like­ly long over­due, but had been put off because the patients had no access to den­tal care. ​“I doubt that many of them had been wait­ing on that day just to save a few dol­lars,” said Nix.

As debates over health­care reform have tak­en cen­ter stage dur­ing the 2020 Demo­c­ra­t­ic pri­ma­ry, oral health has received sig­nif­i­cant­ly less atten­tion. But with near­ly one-third of non-elder­ly adults lack­ing den­tal cov­er­age — and Medicare for All bills in the House and Sen­ate includ­ing pro­vi­sions for den­tal care — the incor­po­ra­tion of oral health into a broad­er vision for uni­ver­sal health­care is emerg­ing as a dis­tinct social jus­tice issue.

If the silo­ing of health and den­tal care in the Unit­ed States now feels like a giv­en, it’s by no means nat­ur­al. The sep­a­ra­tion began back in 1840 at the Uni­ver­si­ty of Mary­land-Bal­ti­more, not far from where hun­dreds of work­ing-class peo­ple would receive den­tal pro­ce­dures in a gym­na­si­um near­ly two cen­turies lat­er. When two founders of the then-recent­ly formed Amer­i­can Soci­ety of Den­tal Sur­geons were alleged­ly refused per­mis­sion to teach den­tistry at the UMD-Bal­ti­more med­ical school, they estab­lished their own instead, begin­ning a tra­di­tion that per­sists today.

While both den­tists and med­ical doc­tors adamant­ly opposed nation­al health insur­ance plans dur­ing the Tru­man admin­is­tra­tion in the 1940s, med­ical insur­ance became a stan­dard ben­e­fit for work­ers and was expand­ed to more mar­gin­al­ized pop­u­la­tions through the enact­ment of Med­ic­aid and Medicare in the 1960s. Mean­while, den­tal cov­er­age remained rel­a­tive­ly lim­it­ed. While the pas­sage of CHIP in 1997 and the Afford­able Care Act in 2010 even­tu­al­ly expand­ed basic den­tal cov­er­age to most chil­dren, broad swaths of the Amer­i­can pub­lic still go with­out ade­quate den­tal care.

As a result, den­tal inequal­i­ty is even more extreme in Amer­i­ca than inequal­i­ty in oth­er areas of health­care. Twice as many chil­dren lack den­tal cov­er­age as con­ven­tion­al health cov­er­age. Some 800,000 ER vis­its a year stem from den­tal issues, many of which could be avoid­ed with rou­tine man­age­ment. More Amer­i­cans report finan­cial bar­ri­ers for den­tistry than any oth­er type of health­care. Those who do have den­tal cov­er­age are hard­ly spared: most plans cap annu­al ben­e­fits at around $1500 — an amount eas­i­ly exceed­ed by a sin­gle den­tal emer­gency — and near­ly 50 per­cent of den­tal care nation­wide is paid for out-of-pocket.

Those dis­par­i­ties in access have a pro­found impact. As per­fect teeth have become a cod­ed class mark­er, some 30 per­cent of low-income adults avoid smil­ing with their teeth. But the issue runs even deep­er. ​“I think there’s this per­cep­tion that it’s just aes­thet­ic,” explained Meg Booth, Exec­u­tive Direc­tor of the Children’s Den­tal Health Project. ​“We have to dis­pel this notion that oral health is only about the appear­ance of your teeth. It’s actu­al­ly about dis­ease, and the rest of your body.”

Indeed, poor oral health has been linked to heart dis­ease, Alzheimer’s and oth­er seri­ous ail­ments. In her 2017 book Teeth: The Sto­ry of Beau­ty, Inequal­i­ty, and the Strug­gle for Oral Health in Amer­i­ca, jour­nal­ist Mary Otto tells the sto­ry of 12-year-old Dea­monte Dri­ver, whose untreat­ed toothache even­tu­al­ly devel­oped into a dead­ly infection.

Poor oral health has also been linked to poor school per­for­mance and absen­teeism among chil­dren. This dan­ger­ous sta­tus quo high­lights just how odd it is that teeth have been arbi­trar­i­ly sequestered from oth­er body parts when it comes to Amer­i­can health­care. As San­ta Fe, New Mex­i­co den­tist Dr. Daniel Bor­rero put it, ​“We have teenagers who are devel­op­ing gum dis­ease and we ask them, ​‘Do your gums bleed when you brush?’ And they say, ​‘yes.’ But if your fin­gers were bleed­ing, you wouldn’t just say that casually!”

While includ­ing den­tal care in a Medicare for All sys­tem would deliv­er more patients, the cur­rent sys­tem of deny­ing den­tal care pro­vides plen­ty of mon­ey. On aver­age, den­tists make near­ly as much as physi­cians, while typ­i­cal­ly work­ing few­er and more pre­dictable hours. Sim­i­lar­ly, den­tists are more like­ly to have auton­o­my over their jobs and work in inde­pen­dent prac­tices, where­as physi­cians are increas­ing­ly employed by con­sol­i­dat­ing health­care com­pa­nies. Few­er than 40% of den­tists cur­rent­ly accept Med­ic­aid, and the pro­fes­sion leans con­ser­v­a­tive.

It’s no sur­prise, then, that the pow­er­ful Amer­i­can Den­tal Asso­ci­a­tion (ADA) oppos­es Medicare for All, and stands as a for­mi­da­ble ene­my in the fight for uni­ver­sal health­care. As Maine leg­is­la­tor Richard Mal­a­by said of the ADA to the Wash­ing­ton Post, ​“I put their pow­er right up there with the NRA…dentists do every­thing they can to pro­tect their inter­ests — and they have money.”

While Physi­cians for a Nation­al Health Pro­gram is com­prised of some 20,000 doc­tors sup­port­ing Medicare for All, few (if any) den­tists are mem­bers. While Bor­rero sup­ports sin­gle-pay­er health­care and Nix describes him­self as ​“open to it,” they both strug­gled to think of many col­leagues who embraced the idea — as did oth­ers in the den­tal pro­fes­sion whom I spoke to for this sto­ry. The excep­tion was den­tal students.

“Per­son­al­ly I feel that if you are more inter­est­ed in accu­mu­lat­ing exces­sive wealth than in pro­tect­ing the health of your com­mu­ni­ty, then you prob­a­bly should­n’t be in any type of health care in the first place,” one den­tal stu­dent explained, who asked not to be iden­ti­fied in order to speak can­did­ly. ​“I feel like sin­gle pay­er is a far more equi­table solu­tion than expect­ing den­tists to nego­ti­ate with insur­ance com­pa­nies for what they can charge patients. Every­one needs teeth!”

If den­tal stu­dents are more like­ly to join a coali­tion of sin­gle-pay­er sup­port­ers than their more expe­ri­enced pro­fes­sion­al coun­ter­parts, they’ll be in good com­pa­ny. As Meg Booth tells it, over a decade after she began work­ing on the issue of access to ade­quate den­tal care, it’s final­ly begin­ning to coa­lesce as a major polit­i­cal issue: ​“I think kids’ groups, and Medicare groups, and social jus­tice groups at the grass­roots lev­el are all try­ing to edu­cate the pub­lic on a more fun­da­men­tal lev­el that oth­er peo­ple besides den­tists care about this,” she said. She’s hope­ful they’re becom­ing vocal, con­spic­u­ous con­stituents for uni­ver­sal den­tal care: ​“There are peo­ple who see the impact in their com­mu­ni­ties and states.”