American politics operates within the theoretical framework of political liberalism; there is a practical and reasonable consensus on popular sovereignty, the equality of citizens, a free civil society, the rule of law, and basic human rights. There is a sense of justice at work in political liberalism that supports citizens in making seemingly just choices. For the political liberal consensus to operate, this democracy has a complex system of policy making, bureaucracy, and other oversights to protect the individual. Oral health operationalizes political liberalism and its rights of the individual. The practice of dentistry is largely a small business, private practice ownership model. The rules and regulations regarding the practice of dentistry are largely made by its own members, as the deciders of what is and what is not ethical dentistry. While on the surface a profession decides its own ethical rules and practices seems non-harming and perhaps neutral, when these principles and practices are decided in the absence of the consideration of patients and communities, there are consequences. To be sure, when acting in their own professional self-interest and economic self-interest as small business owners, the individualist mindset of dentistry has allowed for disparities to persist, health equity to become illusive, and for a child, Deamonte Driver, to die in this broken oral health care system. Because of these systems-level failures, oral health needs a system-level solution: oral health needs to take on liberatory ethics.
Liberatory ethics, a moral philosophy that calls for questioning existing systems of power and eliminating the roots of oppression, allows for the possibility of individuals and communities to achieve their optimal level of health by creating opportunities for health free from oppression. Juxtaposed to a political liberalism, a liberatory ethic does not assume a neutrality or objectivity that can ignore power and oppression. Instead, it invites critique and considers how decisions, even when made with reasonable consensus, can create and sustain inequities. To be sure, a liberatory ethic allows for seeing how systems like capitalism, patriarchy, and white racial supremacy influence seemingly democratic and just decisions. When considering a liberatory ethic for health, it may mean: eliminating threats of bodily and psychological violence, removing systems that produce and exacerbate poor health such as incarceration, and cultivating a built environment with access to parks and transportation. This liberatory ethic requires health justice, a social ethic of care which unites health care, public health, and the social determinants of health. Applying a liberatory framework to oral health thus means treating the mouth as a part of the body by understanding the social determinants of oral health, nationalizing oral health care, and adopting anti-racist systems and practices.
Oral Health and the Separation of Mouth from the Body
The founding of the first dental school in 1840 set the tone for the separation of medicine and dentistry. Fast forward a century, President Lyndon Johnson signed the Medicare and Medicaid Act in 1965, creating public health insurance programs for the elderly and people with limited incomes. Dental coverage was not included because the American Dental Association (ADA) opposed dental coverage in Medicare. From 1965 to the 2021 debates in Congress on the inclusion of dental benefits in Medicare Part B, the ADA has historically opposed these proposals that could increase access to care for older adults, perhaps because dentistry wanted to remain separate from the health care system. In 2021, the ADA provided the following call to action to its members:
“Write your congressional representative and tell them that you oppose the current legislative proposal being considered by the House committees and urge them to consider alternative approaches that would not only reflect dentistry’s unique delivery of care, but would actually provide oral health care to seniors who need it most.”
For children, it was not until 2010 that the Patient Protection and Affordable Care Act established dental benefits as essential benefits. Two years later, the ADA officially supported dental benefits for children, and in 2025, the ADA provided public comments to the Centers for Medicare and Medicaid Services supporting states in including adult dental services in their Essential Health Benefits-benchmark plans and for “stronger policies with regards to reasonable assurance to ensure individuals and small groups both inside and outside the marketplaces include an offer of adult dental benefits for consumers.” These two position statements mark a shift in perspective for dentistry, and a willingness to place the needs of the public above the preferences of the practicing dentist. In 2027, dental benefits are set to be essential for adults and no longer a state option. However, with the passage of the One Big Beautiful Bill Act this year, the future of dental benefits in Medicaid is uncertain.
Although the field of dentistry has historically positioned itself as separate from the larger healthcare ecosystem, it is an important part of our overall health and wellbeing. In 2000, the first-ever Surgeon General’s Report on Oral Health was published. Oral Health in America described the “silent epidemic” of the nation’s oral health with certain populations identified as bearing disproportionate burden of diseases, worse oral health outcomes, and persistent challenges with accessing care. However, the most revealing statement was the reminder that oral health is key for overall health. In the decades that have passed, however, many oral health disparities have remained entrenched as persistent inequities.
A snapshot of oral health inequities mirrors inequities in other health outcomes. People who are marginalized, have lower socioeconomic status, and live in rural settings generally have higher rates of oral health diseases, including cavities, periodontal disease, and oral cancer. The persistence of oral health inequities has many causes with access to care being a critical structural and systemic barrier. There are unique challenges caused by national shortages in oral health care providers, challenges which continue to be exacerbated by barriers placed on the scope of practice of dental hygienists to practice at the top of their licensure and resistance to growing mid-level providers and dental therapists who are similar to nurse practitioners.
Health Justice and Social Determinants of Oral Health
In addition to the previously discussed social determinants of oral health, such as access to care and workforce shortages, structural and systemic racism creates and exacerbates poor oral health outcomes, impacts clinician decision-making, and contributes to patient’s decision making in delaying care.
For example, the four year and nine month water crisis in Flint, Michican left an urban, majority Black community with water contaminated with lead and Legionella. Without a doubt, the Flint Water Crisis is an environmental health problem. Yet, when analyzing the public health implications, one can argue that the impact on oral health was minimized. To the degree that community water fluoridation is a key oral health concern, it is striking that a search with key terms: “Flint Water Crisis” and “oral health” results in no PubMed results. Two commentaries in the Journal of the Michigan Dental Association focused on rallying “support for fluoride in the water supply.” In these commentaries, the crisis was not framed as an example of structural racism meeting environmental justice in the context of broader oral health. Nor was it discussed as a call for systems-level changes to support oral health in the community. This missed opportunity to frame the crisis as a broader systems-level issue was corrected in the response from community members.
Health justice requires community-informed and led transformative action, as seen in the Flint community’s response to the water crisis. People of all walks of life demanded safe water and justice, organizing themselves around water as a human right, and called out the ways that current systems failed their community. This community practice of health justice could be a reality for oral health, and would require two important steps: addressing privatization and envisioning an antiracist future for oral health.
The Oral Health Problem of Privatization
To the degree that the individual and the private corporation can both have rights and protections reflect a unique political feature of American neoliberalism. Dental care is dominated by individual or group, private practices as opposed to a robust public system of dental care in places like hospitals, local health departments, and community health centers. In fact, 91% of active dentists worked in private practice settings. Because dentists operate within the privatized business model, the solo or group practice decides the types of insurance accepted or not accepted, hours of operation, and the degree to which there are diverse members of the dental team available to patients. The ADA also reports that the few dentists who accept patients with Medicaid coverage for dental care are “more likely to be Black, Hispanic, or Asian; located in majority non-White zip codes, rural areas, or high-poverty zip codes; work in larger practices; and are more likely to be affiliated with a Federally Qualified Health Center (FQHC).”
In addition to an already heavily privatized industry, private equity is currently reshaping the oral health care landscape, with the percentage of dentists associated with private equity doubling in six years. In response, dentists have opposed state legislation that would allow for hedge funds and private equity to operate dental offices because private equity seeks to maximize profits without prioritizing patients and takes away dentists’ autonomy.
Applying an Environmental Justice Framework to Oral Health
Environmental justice centers communities in bottom-up, liberatory efforts to address “the ethical and political questions of ‘who gets what, why, and how much'”; for example, environmental justice clarifies which communities are more subject to toxic exposures, why the level of pollution is rationalized, and how the amounts they are exposed to lead to increased morbidity and mortality. It is clear with environmental justice that the unfair creation and distribution of exposures to toxins and other health hazards are not by accident but by design. The policy and systems-level decisions that undergird the placement of toxic sites, limited built environmental infrastructure, and the localization of poverty map to racism and other systems of oppression. While responding to the harm is part of the remedy, the ultimate solution is removing the exposure which typically requires a structural, systemic, or policy change. Rather than greenwashing corporate practices of pollution by developing “socially responsible business models,” environmental justice advocates for structural solutions that uproot racism and other forms of oppression.
When twelve-year old Deamonte Driver died because of an untreated cavity, his death was a tragedy for his family and community, and reflected a deeply broken oral health care system. His death was “for want of a dentist.” The Driver family was given dental insurance through Medicaid but no access to dental providers who accepted it. To apply the environmental justice framework, what they received was insurance that was impossible to use, why no dentists accepted this insurance as a function of organized dentistry resisting comprehensive dental benefits in public health systems, and how many services were rendered inaccessible such as preventative care, dental homes, and emergency services. When the majority of dentists work in private practices, do not participate in Medicaid dental programs, and challenge the reimbursement rate through Medicaid, marginalized dentists at FQHCs who are already disproportionately underrepresented in the workforce are left to treat the majority of Medicaid patients. Because dentists may choose to practice in areas based on factors like the geographic distribution of active dentists, population median income, the number of FQHCs with dental services, and student loan burden, dental shortage areas emerge and even accessing care with non-Medicaid insurance becomes a herculean task.
The question of “who gets what, why, and how much” leads us to conclude that certain communities are forced to deal with greater structural risk for oral diseases. For example, diet and nutrition inform one’s risk for cavities. However, Black and Brown, low-income, disabled, and homeless communities are often confined to built environments with food apartheid, leading to forced consumption of more processed foods and sugar-sweetened beverages. The increased life stressors associated with poverty, disability, and homelessness can lead to increased tobacco use, and the environment may also have more tobacco and smoke shops leading to greater prevalence of tobacco use, driving the risk for oral cancers and periodontal disease. Finally, the community water that is fluoridated may be perceived as unsafe, leading people to drink more bottled water, which is not fluoridated, and miss the cavity prevention benefits from the community water. The built environment may also be one in which the community water is contaminated leading to more bottled water consumption.
An Antiracist Future for Oral Health
Applying a liberatory ethics framework to and integrating lessons learned from environmental justice in oral health enables us to build an antiracist future for oral health. This antiracist future looks like an oral health system that centers racial equity and addresses racism as a foundational problem to oral health inequities as ethical and professional responsibilities. Some solutions include better support for the integration of medicine and oral health, interprofessional practice with value-based payment models, and comprehensive dental coverage in public health insurance programs. In treating the body holistically and centering whole-person health care, the health services delivery system must shift its focus from treating the progress of disease to preventing disease. With a focus on prevention, wellness, and health promotion and equitable, bundle payment models in public and private insurance, there are opportunities to reduce these persistent health inequities and improve population-level health.
Additionally, to support the workforce that is needed to address inequities in oral health outcomes, “robust student loan forgiveness programs for Black, Hispanic, and American Indian/Alaska Native dentists” are needed along with strengthened accreditation standards for humanistic dental education practices, and the removal of barriers at admissions that preclude growth in diversifying the profession. Workforce models should also include the expansion of dental therapy and growth in mid-level oral health care providers. Improving access to dental care through comprehensive dental benefits in public insurance is also necessary.
The antiracist future for oral health may also include strengthening the dental public health infrastructure. Whereas 91% of dentists work in private settings, an antiracist oral health delivery system would include more of those dentists working in hospitals, community health centers, schools, and other public settings. A systems-level intervention would also support oral health care being co-located with healthcare and the training and practice mechanisms for healthcare providers to provide oral health assessments and preventative treatments, such as a fluoride varnish. While in some pediatric settings this occurs, from a lifespan perspective, the practice is limited to children. To ensure optimal oral health for all people and across the lifespan, it is critical to have the health care workforce able to deliver preventive care and also restorative treatment. Such care should be with the healthcare providers patients prefer and in the settings where they want to receive care. An antiracist future for oral health must consider that it is the communities and patients that oral health care providers serve that should have a voice in determining the oral health delivery system.
Authored by Eleanor Fleming
Eleanor Fleming (she/her/hers) is a board certified public health dentist, a trained political scientist, and a CDC trained epidemiologist. Her scholarship and thought leadership focus largely on oral health, antiracism, health justice, and all of the words that will get government funding terminated. A proud Southerner, she longs for an oral health future where courage leads to solutions and health is a right and not a commodity.
Art Credit: Mural by Ernest Shaw
