Dental care is healthcare by any biological measure, but in the United States it has been treated as something separate for nearly two centuries. Your teeth and gums are part of your body, infections in your mouth can worsen chronic diseases, and poor oral health sends people to emergency rooms at a cost exceeding $2 billion a year. Yet dental coverage is carved out from medical insurance, excluded from Medicare, and optional for adult Medicaid recipients in many states. The split is a product of history and policy, not science.
Why Dental and Medical Care Separated
The divide traces back to 1840, when the state of Maryland chartered the Baltimore College of Dental Surgery as the first formal dental school in the country. This happened, notably, after the medical department at the University of Maryland reportedly refused to include dental education in its curriculum. From that point forward, dentistry developed its own schools, its own licensing boards, and its own professional identity.
Throughout the 19th century, there was genuine debate about whether dental education belonged inside medical schools or in independent institutions. Practical arguments won out: medical schools were unwilling to supply the physical space and expensive equipment dentists needed, and they resisted treating dental faculty as true colleagues. Some dentists pushed back on integration too, insisting that “dentistry is altogether too large to be made the tail end of the kite of medical practice.” Others worried that staying separate would reduce them to mere carpenters. That tension was never fully resolved. Instead, it hardened into two parallel systems of education, practice, and insurance that persist today.
How Insurance Keeps Them Apart
Medical insurance and dental insurance work on fundamentally different models. Medical plans cap what you pay out of pocket each year, then cover costs beyond that limit. Dental plans do the opposite: they cap what the insurer will pay, typically setting a dollar limit on annual coverage. Once you hit that ceiling, you’re responsible for everything else. Orthodontic coverage, when included at all, usually has a separate lifetime maximum instead of an annual one. This structure means dental insurance functions more like a discount plan than true insurance against catastrophic costs.
The Affordable Care Act reinforced this split. It requires marketplace health plans to cover ten categories of essential health benefits, and pediatric oral care is one of them. But routine dental services for adults are explicitly excluded from that list. Starting with plan years beginning in 2027, insurers will be allowed to include adult dental services in marketplace plans, but they won’t be required to.
What Federal Programs Actually Cover
Traditional Medicare flatly excludes dental care. Under Section 1862(a)(12) of the Social Security Act, Medicare does not pay for services related to the care, treatment, filling, removal, or replacement of teeth. The only exception is when a dental procedure requires hospitalization because of the severity of the procedure or the patient’s underlying medical condition. For the roughly 67 million Americans on Medicare, this means routine cleanings, fillings, extractions, and dentures come entirely out of pocket unless they purchase a separate dental plan.
Children fare better. Medicaid covers dental services for all enrolled children through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. This isn’t limited to emergencies. States must provide, at minimum, relief of pain and infections, restoration of teeth, and maintenance of dental health. Every child must be referred to a dentist on a regular schedule, and if a screening reveals a condition that needs treatment, the state must cover it regardless of whether that service appears in the state’s Medicaid plan. States running separate Children’s Health Insurance Programs (CHIP) are also required to include dental coverage that prevents disease, restores oral health, and treats emergencies.
For adults on Medicaid, coverage varies wildly by state. Roughly 19 states offer extensive dental benefits for adults, while about 12 states limit coverage to emergency-only care. The rest fall somewhere in between, covering some preventive or restorative services but with significant restrictions. Where you live determines whether Medicaid will pay for a routine filling or only pull a tooth that’s already causing acute pain.
The Biological Case for Integration
The mouth is not sealed off from the rest of the body. Gum disease, specifically the chronic infection called periodontitis, has well-documented links to cardiovascular problems and diabetes. The connections run through at least three pathways. First, bacteria from infected gums enter the bloodstream, triggering inflammation in blood vessel walls and contributing to the buildup of arterial plaque. Second, inflammatory molecules produced in diseased gum tissue spill into the bloodstream and provoke a bodywide inflammatory response, which damages blood vessels over time. Third, this same systemic inflammation can impair how the body produces and responds to insulin, worsening blood sugar control.
The relationship with diabetes is particularly striking because it runs in both directions. Poorly controlled blood sugar makes gum disease worse, and untreated gum disease makes blood sugar harder to control. A study of 154 patients with type 2 diabetes and periodontitis found that basic gum treatment, scaling and cleaning combined with oral hygiene instruction, lowered their average blood sugar marker (HbA1c) by about 0.7 percentage points over 12 months. Patients who started with the worst oral health saw reductions of 1.31 percentage points. For context, reductions of that size are comparable to what some diabetes medications achieve. Treating a mouth infection improved a metabolic disease.
What Happens When Dental Care Is Left Out
When people can’t access routine dental care, they end up in hospital emergency rooms. In 2017, dental-related ER visits cost more than $2 billion nationally. Emergency departments can prescribe antibiotics and painkillers, but they generally can’t perform the extractions, root canals, or restorations that would actually solve the problem. Patients leave with temporary relief and often return. This is one of the clearest examples of how separating dental from medical care creates costs without improving health.
The burden falls disproportionately on adults who are uninsured, underinsured, or living in states with emergency-only Medicaid dental coverage. A toothache that a $200 filling could resolve instead becomes a cycle of ER visits, missed work, and worsening infection.
Efforts to Reconnect the Two
A growing number of health systems are trying to bridge the gap. One model, called MORE Care, embeds oral health services into primary care visits at community health centers. Across 29 primary care sites in four states, the program increased preventive fluoride treatments from 25% to 40% of eligible patients and boosted oral health risk assessments from 47% to 77%. In Ohio, participating clinics saw a tenfold increase in oral health services during well-child visits and generated hundreds of referrals connecting patients to dental care. Later phases of the program showed that integrating dental and medical care reduced the need for surgical dental procedures, catching problems earlier when they could still be treated simply.
These programs demonstrate something that the science already supports: when dental care is treated as part of routine healthcare rather than a separate system, people get more preventive services, fewer problems escalate, and the overall cost of care drops. The mouth has always been part of the body. Policy is slowly starting to catch up.