Summary: Teeth Tell the Story

When Sandra smiles, she covers her mouth with her hand. She is 68 with four teeth remaining in her upper jaw. Each extraction followed the same math: a cavity that would have cost $200 to fill became an abscess that cost $150 to extract. She cannot chew meat or raw vegetables. She stopped going to church because she could not eat at the coffee hour without opening her mouth.

When Medicare was enacted in 1965, dental care was explicitly excluded. Sixty years later, the exclusion remains. Approximately 70 percent of Medicare beneficiaries have no dental coverage. Roughly 85 percent of high-income older adults have coverage; roughly 25 percent of low-income older adults do. Medicaid adult dental coverage varies enormously by state: some provide comprehensive benefits, others cover only emergency extractions. Private dental insurance caps annual benefits at $1,000 to $2,000, a limit barely changed since the 1980s. A single crown can exhaust a year’s benefit.

The consequences cascade through the body. Approximately 26 percent of Americans aged 65 and older have lost all their natural teeth, with the percentage significantly higher among the poor, Black, and Hispanic. Untreated dental infections send roughly 2 million Americans to emergency rooms each year. In rare but documented cases, they kill. Tooth loss drives malnutrition as people shift to soft, processed foods. Periodontal disease is associated with elevated cardiovascular risk, worse diabetes control, and emerging links to cognitive decline.

Dental status functions as a visible class marker. Missing or damaged teeth trigger negative judgments about intelligence, competence, and social status. The shame is common and corrosive. Sandra knows her missing teeth are not her fault. She still feels ashamed when she opens her mouth.

Adding comprehensive dental benefits to Medicare would cost an estimated $200 to $400 billion over ten years. The deeper obstacle is conceptual: dental care has been framed as separate from medical care, as cosmetic rather than functional. The framing is medically false. The mouth is part of the body. Oral infections are infections.

Sandra worked, raised children, managed what she had. She did not neglect her teeth. She could not afford them. The exclusion was a political choice. The suffering is the predictable consequence.