How Widespread Are Oral Health Disparities?

Oral health in the United States has improved in many ways over the past few decades, yet these gains are not shared equally. Significant differences in dental disease rates and access to care persist across various socioeconomic, racial/ethnic, and geographic lines.

These disparities not only affect the health of teeth and gums but can also shape broader physical well-being, work and school performance, and quality of life.

Below is a data-driven examination of these oral health gaps, the underlying factors, and some of the consequences that arise when certain groups cannot maintain good oral health.

Key Statistics at a Glance

• Income and Decay: Among preschool-age children (2 to 5 years), 18% in low-income households have untreated cavities, compared to 7% in higher-income homes.
• Racial/Ethnic Cavities: Among working-age adults, 40% of non-Hispanic Black adults have at least one untreated cavity, nearly double the 21% rate among non-Hispanic White adults.
• Rural vs. Urban: As of 2019, 66.7% of urban adults (18 to 64) had a dental visit in the past year, versus just 57.6% of rural adults.
• Dental Insurance Gap: Approximately 27% of U.S. adults (about 68.5 million people) lack dental insurance, nearly three times the percentage who lack medical insurance.

Income Level and Oral Health

Income level is one of the most reliable predictors of oral health outcomes and access to dental care.

People in lower-income brackets face higher rates of tooth decay, gum disease, tooth loss, and many other dental problems, often because they cannot afford preventive or early treatments.

• Childhood Decay Prevalence
  • Preschool-age children from low-income families have a significantly higher incidence of untreated cavities (18%) compared to higher-income households (7%).
  • Adolescents aged 12 to 19 from low-income backgrounds show nearly double the rate of untreated tooth decay (14% vs. 8%) compared to teens in more affluent families.
• Periodontal Disease
  • Serious gum disease (periodontitis) affects about 60% of low-income adults over age 30, double the rate (30%) in higher-income adults.
  • This pattern indicates a lack of early intervention in economically disadvantaged communities, increasing the risk of tooth loss and complications.
• Tooth Loss
  • Low-income older adults experience full tooth loss (edentulism) at more than twice the rate of wealthier seniors (around 30% vs. 12%).
  • Missing multiple teeth is also far more common in lower-income groups, reflecting the cumulative effect of delayed or foregone treatments over a lifetime.
• Utilization of Care
  • Dental visit rates steadily rise with income. Recent data show roughly 20 to 30% of the poorest adults visit the dentist annually, compared to nearly 50 to 60% of the highest-income groups.
  • For children in low-income families, preventive visit rates have declined by about 10% in recent years, partly due to cost barriers and limited coverage or access.

Racial and Ethnic Disparities in Oral Health

Racial and ethnic background significantly influences one’s oral health risk and care experience. Minority populations, especially Black and Hispanic communities, consistently show higher levels of decay, gum disease, and tooth loss.

• Childhood Caries
  • About 70% of Mexican American children (ages 6 to 9) have experienced tooth decay, versus 43% of non-Hispanic White children.
  • Disparities in sealant use exacerbate this gap: children in minority or low-income schools often have less access to school sealant programs.
• Untreated Cavities in Adults
  • 40% of non-Hispanic Black adults have at least one untreated cavity, nearly double the rate among non-Hispanic Whites (21%).
  • Older Black and Mexican American adults are 2 to 3 times more likely to have untreated decay than their White counterparts.
• Tooth Loss
  • Roughly 16% of Black adults report having lost six or more teeth because of decay or gum disease, compared to 12% among White adults.
  • Periodontal disease is also more common and more severe in certain minority groups, contributing to higher tooth loss rates over time.
• Self-Rated Oral Health
  • In national surveys, minority groups consistently rate their oral health more negatively than Whites. For instance, 17% of Black and 16% of Hispanic respondents have expressed embarrassment about their teeth, exceeding the White rate of 14%.

Historic inequities in health infrastructure, provider availability, and educational resources continue to drive these gaps.

Strategies to reduce these racial disparities include strengthening community dental clinics in underserved areas, providing culturally competent care, and tackling coverage gaps.

Geographic Variation: Urban, Rural, and Regional Differences

Where a person lives powerfully affects oral health status. Rural communities and certain regions of the country face pronounced challenges relative to urban areas.

• Utilization and Self-Rated Health
  • As of 2019, only 57.6% of rural adults had a dental visit in the past year, compared to 66.7% of urban adults.
  • About 34% of rural residents consider their oral health “fair” or “poor,” compared to 27% in urban areas. Rural seniors show higher rates of missing or decayed teeth.
• Provider Shortages
  • Up to 79 million Americans live in Dental Health Professional Shortage Areas (DHPSAs), with 67% of these shortages in rural locations.
  • Many rural counties have fewer than 25 dentists per 100,000 people, whereas urban centers often exceed 35 to 40 dentists per 100,000.
• Regional Disparities
  • Southern states typically have the fewest dentists per capita, correlating with high tooth loss and gum disease rates.
  • The Northeast and West Coast generally feature better access to care, partly due to larger provider networks and wider adoption of preventive measures like water fluoridation.

These geographic gaps reflect a combination of distance, poverty rates, and workforce distribution. To address them, policymakers and clinicians pursue solutions such as mobile dental units, teledentistry consults, and incentives for dentists to practice in underserved areas.

Dental Insurance Status and Access to Care

Unlike most medical care in the U.S., dental coverage is often separate, and many Americans lack it entirely. Insurance status powerfully influences who can afford regular check-ups and treatments.

• Coverage Rates
  • As of 2023, about 27% of adults (68.5 million people) have no dental insurance, a percentage nearly three times that of uninsured medical patients.
  • Around one-third of Medicare beneficiaries lack dental coverage altogether, and many states offer only limited adult dental benefits through Medicaid.
• Utilization Patterns
  • 85% of adults with dental insurance see a dentist at least once a year, compared to 64% of those without insurance.
  • Among uninsured working-age adults, the prevalence of untreated cavities is about 43%, versus 18% among privately insured peers.
• Medicaid Gaps
  • State-by-state variability in Medicaid adult dental benefits leaves many low-income adults without comprehensive coverage.
  • Even those who are covered may struggle to find a dentist willing to accept Medicaid due to low reimbursement rates. Only about 33% of licensed dentists actively treat Medicaid patients each year.

Without adequate insurance, people often wait until the pain becomes unbearable, raising the likelihood of expensive and invasive procedures. Efforts to include comprehensive oral health benefits in public programs are ongoing, but large coverage gaps remain.

Education Level and Oral Health

Educational attainment plays a dual role in oral health, influencing both economic opportunities (and thus insurance) and health literacy.

• Tooth Loss by Education
  • Complete tooth loss is over three times as common in seniors with less than a high school education (about 33%) compared to those who pursued education beyond high school (9%).
  • Even among younger adults, lower levels of education correlate with more missing, decayed, or unfilled teeth.
• Preventive Service Use
  • Adults with some college education are nearly twice as likely to have regular dental check-ups compared to those without a high school diploma.
  • Health literacy (knowing the value of preventive steps like flossing and early intervention) is higher among more educated populations, reinforcing better oral care habits.
• Oral Health Literacy
  • People with limited literacy may not understand the significance of symptoms (e.g., bleeding gums) or the importance of timely treatment, leading to avoidable complications.
  • Education campaigns that employ plain language and culturally tailored messaging can help reduce these literacy-based disparities.

Because education influences health behaviors and job prospects (including access to employer-based benefits), it strongly shapes oral health trajectories from childhood through old age.

Language Barriers in Dental Care

Communicating effectively in a dental setting can be a major obstacle for the 25.9 million U.S. residents with limited English proficiency (LEP).

• Lower Utilization
  • Even when controlling for insurance status, non-English speakers are significantly less likely to seek preventive or routine dental care.
  • Among Asian Americans who do not speak English at home, irregular dental visits can exceed 45%, much higher than among English-proficient individuals.
• Communication Challenges
  • Without adequate interpretation services, crucial home-care instructions, treatment options, or medication guidelines may be misunderstood.
  • Miscommunication raises the risk of poor outcomes, including failing to complete antibiotic courses or neglecting post-treatment care.
• Provider Availability
  • Many private dental offices do not offer on-site interpreter services. Some rely on patients’ family members, which can introduce privacy and accuracy issues.
  • Community health centers are more likely to have multilingual staff, but overall access remains uneven, especially in rural and suburban LEP populations.

Bridging language gaps through interpreters, bilingual providers, and translated educational materials is key to ensuring LEP patients receive equitable, high-quality dental care.

Cultural Influences on Oral Health Behaviors

Cultural beliefs and traditions can shape attitudes toward when and why to seek dental services, as well as daily habits that impact teeth.

• Preventive vs. Reactive Care
  • In some communities, a dental visit is reserved for acute pain, not routine check-ups. Delaying care often leads to advanced decay or infections.
  • Surveys among African American elders have shown strong associations between “pain” and dental care needs, meaning painless issues sometimes go ignored until later stages.
• Traditional Remedies
  • Certain cultures rely on clove oil, salt rinses, chewing sticks (miswaks), or other practices as first-line treatment for pain. While these can offer temporary relief, they may postpone professional diagnosis.
  • Beliefs like “baby teeth don’t need care” or “losing teeth is normal with age” can undermine the value placed on early interventions.
• Dietary Habits
  • Cultural diets high in sugary beverages or betel nut chewing can raise caries risk. Conversely, some traditional diets low in processed sugar can be protective if maintained.
  • When immigrants shift to more Western diets without adjusting oral hygiene practices, cavity rates can spike.

Cultural competence in dentistry (acknowledging and respecting these beliefs) can improve trust and engagement with recommended preventive measures.

Dental Provider Availability and Access to Care

Provider shortages in certain regions or among specific populations are a root cause of oral health disparities.

• Health Professional Shortage Areas
  • Over 7,600 dental HPSAs, covering about 79 million people, are recognized nationwide. Many of these areas lack enough dentists to handle local needs.
  • The shortage is especially acute in rural zones, inner cities, and high-poverty regions.
• Dentist-to-Population Ratios
  • Urban areas can exceed 60 to 80 dentists per 100,000 people, but some rural or lower-income places fall below 25 per 100,000.
  • Southern states often have lower dentist density, contributing to elevated rates of tooth loss and gum disease.
• Specialty Services
  • Access to endodontists, pediatric dentists, orthodontists, and other specialists is even more limited in underserved areas.
  • Patients in remote towns may need to travel hours for complex procedures, delaying treatment and worsening outcomes.

Programs offering loan repayment for dentists who practice in high-need settings, or expanding mid-level provider roles (like dental therapists), aim to mitigate these critical provider shortages.

Treatment Completion Rates Across Populations

Beyond the initial dental visit, completing a recommended treatment plan is another major hurdle, especially for financially stressed or marginalized patients.

• Cost-Related Dropouts
  • Low-income patients may start a root canal but never return for the permanent crown if they cannot afford it. This partial treatment can lead to tooth fracture or reinfection.
  • High rates of untreated cavities in uninsured groups (over 40%) reflect not just a lack of diagnosis but also incomplete follow-up.
• Demographic Differences
  • Studies show Black and Hispanic patients are more likely to end up with tooth extractions over root canal therapy, implying incomplete or less costly interventions.
  • Children in low-income households or with inconsistent transportation are less likely to finish multi-visit treatments like orthodontics.
• Clinic Factors
  • Understaffed safety-net clinics might have minimal appointment reminders or follow-ups, leading to high no-show rates.
  • Poor communication or a sense of being rushed can discourage patients from returning, ultimately resulting in untreated conditions.

Improving follow-through requires strategies such as case management, streamlined same-day treatments, or integrated care programs that reduce the burden of multiple visits.

Access to Preventive Dental Programs

Wide-ranging preventive measures, from water fluoridation to school sealant projects, have proven effective at lowering decay rates, but not everyone benefits equally.

• Community Water Fluoridation
  • About 72.3% of those on public water systems have fluoridated tap water, leaving more than a quarter without this protective measure.
  • Rural residents relying on private wells or small water systems are far less likely to benefit from fluoridation, driving up cavity rates.
• School Sealant Programs
  • Dental sealants on back molars can prevent up to 80% of cavities in those teeth. However, only about 32% of Black children (ages 6 to 11) have sealants, compared to 44% of White children.
  • Under-resourced school districts may lack funding for in-school sealant clinics, missing a key window for prevention.
• Preventive Visits
  • 39% of low-income adults get an annual cleaning, compared to 70%+ among high-income earners.
  • Many Medicaid-enrolled children still do not receive recommended annual preventive services, often due to limited dentist participation or low program awareness.

Strengthening these preventive programs, especially in high-need areas, could reduce the need for costly restorative treatments later and narrow the persistent oral health gap.

Emergency Dental Service Utilization Disparities

Relying on hospital emergency rooms for non-traumatic dental conditions is a stark indicator of unmet preventive and routine dental needs.

• Costly ER Visits
  • Dental-related ER visits in 2018 exceeded $2 billion overall. Most problems seen in the ER (abscesses, severe decay) are preventable or manageable earlier in a dental setting.
  • Despite the high price, ERs typically only offer pain relief or antibiotics, not definitive dental treatment.
• Who Goes to the ER for Dental Care
  • Uninsured, publicly insured, and lower-income individuals make up a large share of these ER visits.
  • Black adults are about 2.5 times more likely than other racial groups to go to the ER for dental issues, reflecting deeper gaps in routine access.
• Revolving Door Effect
  • Without a referral to a dentist who will accept them or the funds to pay many patients cycle back to the ER when pain returns.
  • This pattern drains healthcare resources, with the average dental ER visit costing about three times more than a comparable office appointment yet offering poorer outcomes.

Reducing ER reliance calls for expanding safety-net clinics, increasing dentists' acceptance of Medicaid coverage, and improving patient navigation to timely outpatient treatment.

Cost Barriers to Dental Care

Financial constraints are the top-cited reason people delay or skip dental visits in the United States.

• Skipping Care
  • In a 2022 survey, over half of adults with a dental problem did not seek professional care, with 1 in 4 citing cost as the primary reason.
  • Even among insured individuals, nearly half have at some point avoided or postponed a recommended dental treatment because of out-of-pocket expenses.
• Low-Income Households
  • Up to 60% of adults in poverty admit postponing or rejecting dental care due to cost, versus under 5% of higher-income adults.
  • This disparity perpetuates a cycle where minor issues worsen until they require emergency or more invasive (and expensive) procedures.
• Seniors
  • 62% of Americans over age 65 lack any dental insurance, leaving many to pay out-of-pocket on fixed incomes.
  • Average annual out-of-pocket spending for a Medicare beneficiary using dental services can exceed $800, making comprehensive treatments like implants or dentures unaffordable.
• Treatment Choices
  • Higher-income patients often opt for root canals and crowns to save a tooth, while lower-income individuals, facing high costs, may settle for extractions.
  • Dental care ranks as the most commonly skipped type of health service due to cost, a unique challenge given the separation of dental from broader medical coverage.

Reducing oral health disparities requires addressing these cost hurdles through expanded public coverage, higher Medicaid reimbursement rates, or innovative financing models.

Transportation Barriers and Dental Care Utilization

Another major obstacle is simply getting to a dentist, especially in rural settings or for disabled or elderly individuals.

• National Estimates
  • Around 5.8 million Americans delay or skip health care every year because of transportation problems, and dental visits are a notable part of these missed appointments.
  • Low-income and minority patients, particularly in rural communities, cite lack of a vehicle, limited public transit, or costs of travel as reasons for failing to see a dentist.
• Rural Obstacles
  • The nearest dental office might be 50 miles away. Even if Medicaid offers non-emergency medical transport, dental visits may not qualify or remain cumbersome to arrange.
  • Roughly 11% of Medicaid enrollees with unmet dental needs report transportation as a primary barrier, separate from any financial issues.
• Urban Challenges
  • Public transit in big cities can still pose problems for parents juggling work and childcare or seniors with mobility limitations.
  • Missed appointments are common in clinics serving lower-income areas, and frequent no-shows can lead providers to reduce scheduling for certain patient groups, perpetuating the cycle.

Mobile dental vans, on-site clinics in schools or senior centers, and tele-dentistry consultations are strategies used to bridge transportation gaps and ensure consistent preventive care.

Variations in Quality of Dental Care Received

Even when two patients enter the same dental facility, their experiences and outcomes can differ based on insurance, race, or socioeconomic status.

• Differences in Treatment Offered
  • Studies show that Black patients (even within the Veterans Affairs system) are less likely to receive root canal therapy and more likely to undergo extraction for similar diagnoses compared to White patients.
  • In private or mixed practices, insurers may cover advanced procedures differently, skewing the options realistically available.
• Communication and Respect
  • Patients from low-income backgrounds often report feeling rushed or judged in certain clinics, reducing their trust and willingness to return.
  • Thorough explanations, shared decision-making, and respectful communication are sometimes less common in busy safety-net settings, impacting follow-up rates.
• Provider-Patient Matching
  • Diverse or bilingual dentists can boost patient comfort, but the dental workforce does not always reflect the local demographic.
  • Cultural competency training for all dentists can mitigate biases and address the unique beliefs or needs of different populations.

Investing in high-quality dental facilities in underserved areas, enforcing consistent standards of care, and improving patient-provider communication can narrow quality gaps that reinforce oral health disparities.

Long-Term Health Consequences of Oral Health Disparities

Poor oral health impacts more than just the teeth and gums; it influences multiple dimensions of overall well-being.

• Chronic Disease Links
  • Periodontal disease is associated with heart disease, stroke, and difficult-to-control diabetes, among other conditions.
  • Disadvantaged groups with higher rates of gum disease thus face compounded risks of serious systemic illnesses and hospitalizations.
• Nutritional and Quality-of-Life Issues
  • Tooth loss limits the range of foods one can comfortably chew, increasing reliance on soft or sugary items that may lead to obesity or malnutrition.
  • Frequent dental pain can result in missed work or school (tens of millions of hours lost annually) and contribute to lower economic stability in already vulnerable communities.
• Self-Image and Mental Health
  • Visible decay or missing teeth often leads to social stigma and embarrassment; some people feel it costs them job opportunities or confidence in daily interactions.
  • Minority groups report especially high rates of feeling judged based on oral appearance.
• Healthcare System Costs
  • Unaddressed oral issues can strain emergency departments, increase overall healthcare spending, and complicate treatments for chronic conditions.
  • Integrating dental care with general health services, sometimes referred to as “medical-dental integration,” could save millions in avoidable hospital visits.

Ultimately, tackling oral health disparities is about more than achieving a cavity-free smile; it is a matter of public health, social equity, and better life outcomes for entire communities.

Over the last several years, it has become increasingly clear that preventing oral health problems involves tackling socioeconomic and systemic challenges. Communities with lower incomes, fewer providers, language barriers, or historically limited resources bear a disproportionate burden of disease, reinforcing existing inequalities.

The first step in bridging the gaps is raising awareness of these trends and identifying specific points of intervention. Stakeholders at every level (federal and state policymakers, private insurers, and local community organizations) can collaborate to expand dental coverage, invest in underserved areas, and develop culturally responsive programs.

In the years ahead, improvements in dental benefit structures, workforce distribution, and patient navigation services promise to reduce the number of children going to school with untreated cavities and adults visiting the ER with raging tooth pain. When everyone can reliably access preventive care and complete necessary treatments, the nation stands to gain in health, productivity, and overall well-being.