When I was in my 30s and a dentist told me I needed a few crowns, I decided to skip the expensive devices because of my meager paycheck. Besides, my teeth weren't hurting.
Years later, I am paying the price in pain and costlier dental work. One of the damaged teeth that needed a crown distorted my bite, making a minor jaw-joint problem even worse.
Unfortunately I'm far from alone. The price of dental care is steep for many people financially, physically and even socially, according to Marko Vujicic, chief economist and vice president of the Health Policy Institute at the American Dental Association.
Vujicic said that the majority of emergency room dental visits were for infections that could be handled in a dentist's office. Overall, emergency room dental visits cost $1.9 billion yearly, 40 percent of which is public money, according to his institute's analysis of data from the Agency for Healthcare Research and Quality.
"I'm comfortable calling that highly wasteful," Vujicic said. "That's a very inefficient way to spend dollars."
When Angela Lombardi, who lives in Bensenville, Ill., put off getting fillings because of the cost, the pain kept mounting and her teeth kept deteriorating. Eventually she had to have five teeth pulled at a county clinic, where the fee was low.
But that wasn't the end of her pain. At age 32, she had difficulty chewing food and was too embarrassed to smile because of the unsightly gaps between her remaining teeth.
"Gosh, I had so many teeth pulled because of not having enough money to go to the dentist to get them treated," said Lombardi, now 39. "When I got them pulled, there's this empty space and it's ugly. . . . You can't chew, you can't smile."
Lombardi finally found help at Midwestern University College of Dental Medicine in nearby Downers Grove, where she will get a bridge and crowns for about $3,000.
The dental school, where care is provided by students, charges a third to a half of the fees charged by private dentists. "We want our students to have as robust an education as we can provide, and lower fees help attract and facilitate acceptance of treatment plans," said Melisa Burton, Midwestern's assistant dean of clinical education.
More people are avoiding dental care because of the cost than other types of health care, according to a study in Health Affairs that was led by Vujicic.
The study showed that adults ages 19 to 64 said they were more likely to forgo dental care because of cost than children or seniors (12.8 percent of non-elderly adults compared with 7.2 percent of seniors and 4.3 percent of children).
Nearly a quarter of adults with incomes below the poverty line said they did not receive dental care because of cost. Even people with dental insurance were avoiding getting their teeth fixed because of cost, according to the study.
People also said they didn't get the dental care they needed because of fear, inconvenient locations or appointment times, and trouble finding a dentist who takes their insurance. Cost, however, was the main reason.
Vujicic said public health programs don't seem to take account of the connection between oral health and overall health. Medicaid includes dental coverage for children and some states expanded Medicaid coverage under the Affordable Care Act, but 22 states do not offer dental care for adults via Medicaid while others offer varying degrees of coverage. Marketplaces created under the ACA offer dental coverage in separate plans.
"You and I understand the mouth is connected to the body, that bacteria in the mouth affects bacteria in the body, but policy doesn't," Vujicic said. "There is emerging and new evidence showing the link between chronic disease and oral health." Oral care can help reduce overall health-care costs, research has found.
Vujicic advocates more insurance coverage, both public and private, for oral health. He said that adding dental coverage under Medicaid for the 22 states without it would cost $1.4 billion to $1.6 billion annually, but some of that would be recouped from fewer emergency room visits for oral care.
Jason Grinter, a dentist in Rockford, Ill., sees many patients who have gone without consistent dental care. He said the state's Medicaid program has been a big help to patients in Illinois, covering fillings, dentures, extractions and, in some cases, root canals and crowns.
Grinter said he sympathized with patients who couldn't afford dental care or dental devices such as partial dentures, which aren't included in Illinois Medicaid for adults. He also said private insurance often caps benefits at around $1,000 per year, a ceiling that has not kept pace with dental costs.
"We're all struggling, and a lot of times it's a difficult conversation between the patient and dentist because there is the [financial] barrier," Grinter said. "Not that someone is trying to price-gouge, but the price in my lab is $500 to $600 for a removable denture. . . . If you want to add some time and materials, it's going to get up there in price."
Often families will make sure their children get to the dentist, Grinter said, but tight budgets mean the parents won't do the same.
"They will bring their kids to the dentist three or four times to get all the treatment that is needed," Grinter said, "but they're not willing to do that for themselves."
Forgoing dental care in adulthood can mean even worse health problems in old age, according to Amber Willink, an assistant scientist at the Johns Hopkins Bloomberg School of Public Health in Baltimore. And Medicare does not cover dental care (or vision and hearing care).
"There's that cumulative effect of put it off, put it off, put it off. . . . It's only going to be that much worse and that much harder to manage and treat," Willink said. "We're talking about people who are having trouble eating because of their dental issues."
As for Lombardi, she is looking forward to the day when she can smile again. The university care helped, and then her boyfriend stepped in with a Christmas present.
"He told me, 'Your gift is I'm going to help you get your teeth fixed,' " she said.