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It was in 2000, in his landmark report "Oral Health in America," that U.S. Surgeon General David Satcher warned of a silent epidemic of oral disease in America. In spite of some efforts made since to address its underlying causes, the epidemic persists today.

In covering this epidemic, it is important to keep in mind that the burdens of disease weigh most heavily upon poor children and racial and ethnic minorities of all ages, who are most likely to go without the care needed to prevent and treat tooth decay, periodontal disease, tooth loss, oral cancers and other diseases of the mouth.

Of particular concern is dental decay, or caries, a chronic, progressive and largely preventable disease caused by bacteria.

By the time they complete their teen years, more than half of American children have experienced tooth decay, according to the National Health and Nutrition Examination Study or NHANES.

The impact is serious. Untreated oral disease can result in pain, dysfunction, and even death. Preventable dental conditions were the primary diagnosis in 830,590 visits to emergency rooms nationwide in 2009, a 16 percent increase over 2006 according to a 2012 study.

While dental care is financed and delivered separately from other types of health care, oral health is intimately connected to systemic health. Even so, many Americans live in communities that lack dentists. Nearly 50 million Americans are living in 4,552 areas designated as dental health professional shortage areas by the U.S Department of Human Services' Health Resources and Services Administration, or HRSA. (To find out if you are working in such an area, please see the data section of this core topic.)

Millions more people in the United States have trouble paying for care. The Kaiser Family Foundation estimates that more than a quarter of Americans under the age of 65 lack private dental insurance.

Thirty million children are entitled to dental benefits under Medicaid, the federal-state health care program for the poor, but only a minority of the nation’s dentists accept Medicaid. Only 35 percent of the young – from newborn to age 20 enrolled in Medicaid for any period in 2009 – received a preventive service, according to a 2011 report by the Centers for Medicare and Medicaid Services.

The Pew Center on the States estimates than 17 million poor children go without dental care each year.

Poor adults are not entitled to dental benefits under Medicaid. Dental coverage varies from state to state, is often extremely limited, and may be reduced during times of fiscal austerity.

Medicare, the federal health care program for the elderly does not cover routine dental care. One quarter of all adults over the age of 65 have lost all their teeth, according to the Centers for Disease Control and Prevention.

Public health officials stress that preventive measures are key to fighting oral diseases but they are not available to all Americans.

Community water fluoridation, hailed as one of the great public health accomplishments of the 20th century, has been shown to reduce the risk of decay in children and adults. Yet only 64 percent of the population has access to fluoridated water, according to the Institute of Medicine. Fluoridation is strongly opposed by some groups who see it as a form of forced medication or a violation of personal freedom.

Dentists are not evenly distributed across the country. Most are in private practice, and serve more affluent communities, while poorer urban and rural places more frequently go without care. It would take nearly 10,000 additional providers to address the current shortage, according to HRSA. Federal and state efforts to explore strategies to expand care are under way.


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