In early January 2018, I began to have a recurring dream. I’m sitting comfortably at the kitchen table surrounded by friends, when one of my teeth falls out. I reach up to my mouth and out come two, three more. Then, I run to the mirror, only to find my mouth full of jagged shards where my teeth used to be.

The location and people I’m sitting beside vary, but the outcome is always the same. My permanent teeth lie cupped in my palm like a handful of trail mix.

Tooth loss is a common subject of stress dreams. Dream interpreters and psychologists link it to poor self-image, fear of death, and loss of communication or control. My dream began as I packed up my apartment to move across the country for graduate school. I was afraid that uprooting my life would mean losing the community that defined me. Perhaps teeth had become a stand-in for the life I had built. Without teeth—without community—who would I be?

Both biologically and psychologically, our teeth are us, and they determine our futures. Their shape, layout, and imperfections can identify us, fingerprint-style, and serve as a physical record of our experiences, accumulating distinctive layers in response to life events like incarceration and menopause. Our oral health is inextricably tied to our overall health. How our teeth look can determine our social and economic success, and our self-esteem.

It’s strange, then, that our teeth—the hardest structures in our bodies—are so often neglected, by individuals and society. Indeed, they seem to exemplify and exacerbate all the worst aspects of American healthcare.

That starts with preventive care, or a lack thereof: The American Dental Association’s Health Policy Institute estimates that less than half of Americans visited a dentist in 2021. One reason getting people to the dentist is like pulling teeth is because as a society, we just don’t want to pay for it— just 73% of the U.S. population has dental insurance, millions fewer than the 91% with health insurance. And we don’t trust our dentists. Our anxiety about cleanings and treatments lead to avoidance, which leads to elevated pain, which only compounds the problem.

Poor dental care affects the rest of our bodies, too. Nitrate-reducing bacteria that live on the tongue convert nitrate, a compound in leafy green vegetables, into nitrite, a molecule our bodies use to produce nitric oxide, key to lowering blood pressure. There’s evidence that people with preeclampsia, or pregnancy-induced high blood pressure, have fewer of these nitrate-reducing species on their tongues. Frequent tongue brushing, but not antiseptic mouthwash, increases the abundance of these good bacteria.

Chronic inflammation in the mouth, including from persistent infection of the gums and teeth, can stress the heart and lead to increased risk of clogged arteries and heart attacks. Gum disease-related microbes that enter the bloodstream have been linked to inflammatory diseases like lupus and rheumatoid arthritis.

Tooth decay, lupus, and rheumatoid arthritis are more common among people of color, and lower socioeconomic status has been shown to correlate with worse treatment outcomes. The ways we care for our mouths, then, may aggravate existing disparities—and the landscape for dental care is fraught.

According to the CareQuest Institute, a nonprofit aiming to increase equity in dental care, 93% of people living in poverty need dental care they aren’t getting. For many, it’s simply too expensive. A 2022 study from researchers at the American Dental Association found only about a third of dentists treat Medicaid patients. (Dentists are often paid less for treating patients on Medicaid.) In another ADA study, nearly 17% of adults reported that the cost of treatment prevented them from receiving dental care, more than twice the rate reported for other medical treatments. This cost barrier affects more than 1 in 5 Black patients and 1 in 4 Hispanic patients.

Unless something changes, these broad health disparities seem likely to get worse.

Dental science is advancing rapidly—with researchers testing gene therapy strategies to regrow teeth in humans and attempting to transplant oral microbiomes to cure infections—but it won’t deliver itself to patients. Manufacturers first introduced sealants—plastic coatings dentists apply to the grooves of the teeth to prevent cavities—in 1967. These treatments are effective; for children with a history of aggressive cavities, who are at higher risk for infection and tooth pain and extraction, they could be a particularly promising solution. But insurance often doesn’t cover sealants, so they don’t get used.

Many patients remain wary of dentists trying to upsell them. Some researchers have argued that implementing so-called value-based care in dentistry, rather than a fee-for-service model, will be a critical first step in getting people into the clinic willingly. The existing fee-for-service reimbursement means dentists don’t get paid for maintaining health but for fixing problems. It incentivizes surgical procedures over preventing cavities and bolsters the perception that dentists’ goal is to sell us something. Value-based care proponents also aim to build patient trust by actively involving patients in decision-making and, critically, considering how oral health is interrelated with overall health.

The four and a half years following my recurring nightmares were, ironically, the longest I’ve ever gone without seeing a dentist. While I visited the student health clinic for primary care check-ups, they didn’t do dental, and the idea of hunting for a dentist that would accept my insurance as I juggled classes and research for my PhD was daunting. The few clinics I called in those years never got back to me. Talking to my classmates, it’s clear that’s true of many in my community—and we’re some of the lucky ones. Graduate students in STEM fields typically receive higher stipends than students in the humanities, though many are still rent-burdened and without the disposable income to pay for expensive dental procedures. I’m lucky enough to have dental insurance, but across universities and graduate programs, dental coverage is not a given.

Now, at the cusp of graduating and facing the stress of changing communities once again, I’m daydreaming not of tooth loss but of regrowth. Changes to our oral health don’t need to have endless ripple effects on our appearance, identity, and overall health. Instead, maybe we can design a healthcare system that we can all trust to keep us healthy from the mouth down.