PAYING THE PRICE:
WHEN DENTAL CARE IS A LUXURY
A day inside a free dental clinic shows how the nation's most vulnerable are paying the price for unaffordable care.
Photographs by Karen Fucito; Story by Maria DaSilva-Gordon
This project was
made possible by a grant from CareQuest Institute, a national nonprofit that aims to improve the oral health of all.
5 YEARS. 8 YEARS. DECADES.
At HealthLink Dental Clinic in Hatboro, Pennsylvania, it’s common to see first-time patients who have gone years without seeing a dentist. The free clinic serves low-income working adults and veterans in Bucks and Montgomery counties who do not have dental insurance.
By the time they walk through HealthLink’s doors, they are often experiencing costly and painful issues that could have been avoided with preventive care.
They are not alone.
A recent report from United For ALICE, the research engine of United Way of Northern New Jersey, exposes the oral health gap facing struggling households nationwide. ALICE and the Dental Divide reveals that for families in poverty and ALICE® (Asset Limited, Income Constrained, Employed) — households living paycheck to paycheck — dental care is often out of reach.
Across the country, families struggling to cover essentials are less likely to receive regular dental care, more likely to lose teeth to decay or disease, and too often forgo treatment because of cost or lack of nearby providers.
The nationwide divide in dental care access and outcomes can be seen in free clinics like HealthLink.
Over the course of five hours, staff and volunteers performed cleanings, examined X-rays and made sure patients left armed with an understanding of basic dental care.
And they listened. They heard about the chipped tooth, the filling that fell out and the pain that many had put up with for years.
They saw restaurant workers and landscapers and their spouses; veterans and widowers; young working parents and seniors. While their ages, ethnicities and personal stories varied, they all had one thing in common: tight budgets that push dental care to the back burner.
Here are their stories.
30% of adults in the U.S. struggling to afford the basics had to forgo dental care in the prior 12 months due to cost.”
— ALICE and the Dental Divide
“Intermittent.” That's how restaurant worker Tyler described his dental care before finding HealthLink. He would go for five-year stretches without seeing a dentist. “You've got to shuffle your money around and try to make things [work]," the 34-year-old said. “It's pretty much paycheck to paycheck."
Like other ALICE workers, he's left trying to prioritize the basics. “I need my lights, I need my room and board, after that, it's like, everything else can wait I guess."
Dental care often doesn't make the list. By the time it does, it's often too late for preventive care. After his initial new patient exam, Tyler returned to HealthLink for six fillings.
“If I was regularly going, every six months, it would probably be a lot [better]. Once you push it off for five years...," he said, trailing off.
A 26-year-old landscaper, Vilder said he had not had a cleaning since he was a child. The reason was two-fold: he was never taught basic dental hygiene, and he couldn't afford regular care.
During his visit, Dana McCafferty, HealthLink's part-time hygienist, performed a deep cleaning to remove plaque and tartar from above and below the gum line and smooth out the tooth roots. It's a time-consuming, sometimes painful process — Vilder's jaw was numbed beforehand, and he will need another appointment to complete the treatment.
Afterward, McCafferty taught him how to floss — a small but critical step toward maintaining his oral health.
Once you’ve lost bone, it
doesn’t come back.”
—Dr. Daniel Harmon, volunteer dentist at HealthLink
While Mikerlange has no cavities, no dental pain and a bright smile, the X-rays during his visit tell another story: bone loss.
Although he would try to prioritize his dental care, the 35-year-old restaurant worker said he couldn’t afford regular cleanings. He also had never been taught the importance of flossing.
“Him not getting those cleanings over time was a huge issue for him because he has some bone loss,” McCafferty said. “He has periodontal disease because of that.”
With consistent flossing and regular visits to HealthLink, the bone loss has stabilized.
“You can't get that bone back, but we can keep it at where it is,” McCafferty said. “That's our goal for him.”
Dr. Daniel Harmon has been volunteering at HealthLink since the facility opened its doors in 2001. He's seen how a lack of regular dental care can spiral into something more painful and costly. Patients with gum disease, like Mikerlange, who've ended up with bone loss. Decay that, if taken care of sooner, “would not be a root canal, it would just be a simple filling.” And teeth that cannot be saved by a root canal and need to be extracted instead.
HealthLink does not perform implants or bridge work, so any extraction would likely go unresolved. “We can't restore the tooth that's missing,” Harmon said.
Tucked away off a main road at the end of a long driveway, HealthLink can be found in a one-story complex. Inside is a small waiting and reception area and two rooms where patients receive exams and care. A cozy office space sees staff and volunteers congregate to discuss patient care, talk about their day or grab a quick bite between appointments. Closed on the weekends, the clinic operates five days a week.
HealthLink is entirely supported by charitable contributions. Jenny Salisbury, the clinic’s executive director, said she is always looking for ways to fundraise. But rallying people around dental care as a cause is a challenge.
While everyone can agree that access to medical care is a necessity, she said, that’s not the case when it comes to dental care.
“A lot of people don’t see dental care as a necessity,” Salisbury said. “It’s seen as a luxury.”
46% of U.S. adults struggling to afford the basics reported tooth loss due to tooth decay or gum disease. 17% had six or more of their permanent teeth removed as a result.”
— ALICE and the Dental Divide
John, a veteran who has been with HealthLink since 2020, is missing his back teeth. As a result, he has “extensive wear on his front teeth, reducing the longevity of keeping those teeth,” Dr. Jim Oline, a dentist volunteer, said. “Think of it as an overuse injury.”
HealthLink has been able to repair John's teeth that are broken and jagged due to grinding. The cause of the grinding? “He doesn't have the back teeth [that] he didn't take care of because he couldn't afford to do it,” Oline explained.
During a visit to a veterans clinic several years ago, John spotted an ad for HealthLink. “And, boy, I’m glad I did.”
Prior to HealthLink, the 79-year-old had a dentist, but “it got to the point where I couldn’t afford it,” he said. “I retired and I didn’t have my [dental] insurance anymore.”
Over time, he developed issues that HealthLink was able to address. “As an older person, if you don’t clean your teeth regularly — I’m talking about dental hygienists — you develop problems, and I was developing some problems.”
Without access to free dental care, John admits taking care of his teeth would prove challenging. “I would probably wait until it was probably too late to address issues, and then it would be worse, you know? That’s usually how it works.”
13% vs. 7%. Nearly twice as many U.S. adults who can’t afford the basics had gone five years or more without seeing a dentist. 59% had a visit in the past year, compared with 72% of adults not facing financial strain.”
— ALICE and the Dental Divide
Five years. That’s how long Jenny has lived with the aftermath of being punched in the mouth during a mugging. At first, the pain in her teeth was intermittent but over the last two years, it had gotten bad.
Unable to afford regular care, the 32-year-old restaurant worker has only managed sporadic visits: she had wisdom teeth removed a few years ago, her last cleaning was four years back.
Free dental care spares Jenny an impossible choice — paying to relieve her pain or affording her child's medical and dental insurance.
$440,646
THE VALUE OF THE SERVICES HEALTHLINK PROVIDED TO 939 PATIENTS IN 2024.
The nonprofit performed 2,267 procedures in 2024, a 17% increase from the previous year. Salisbury, HealthLink’s executive director, said they see a lot of root canals.
Other services they provide include oral exams, X-rays, fillings, dental hygiene, simple extractions, crowns and patient education. The clinic does not perform certain extractions such as the removal of wisdom teeth. Instead, they refer patients to someone who will do that pro bono.
Every new patient not only has X-rays taken and their teeth examined, they also have their blood pressure and A1C levels checked.
HealthLink has caught type 2 diabetes in patients who otherwise never would have known, Salisbury said.
A new patient, Guillermo wasn't expecting the blood pressure and A1C checks. He said he appreciated the extra care.
In the 15 years he worked as a manager, Guillermo said he never missed a day of work. Six months into a new job in the food industry, he'd already missed two. Recently, the dental pain he had been experiencing on and off for more than a year became unbearable.
“It was pain every day,” he said.
Lost hours mean lost wages for his family, so the 33-year-old put some money together and found a place he thought he could afford. He was only able to cover the $50 X-ray. Relieving the pain came with a $5,200 price tag. “It was out of my reach,” he said. While he had saved more than $50, that money went to an unexpected repair on his family's only car.
Following his new patient HealthLink exam, Guillermo had a clear plan for next steps. First, he would need all his wisdom teeth removed.
As HealthLink doesn’t perform that procedure, he was referred to an oral surgeon who offers pro bono care. It might be the source of his pain; one wisdom tooth is broken with an exposed root tip. Once he heals from that procedure, HealthLink will tackle other concerns.
“He has broken teeth that are possibly going to need a root canal to be saved,” Jennifer Santiago, HealthLink’s clinic manager, said. Removing the wisdom teeth will offer improved access to those teeth, she said.
Santiago, who also assists dentists during appointments, noted another issue: a significant buildup of tartar. Guillermo will require the time-consuming and sometimes painful deep cleaning an earlier patient received.
38% of struggling households in the U.S. lived in communities with limited proximity to dental care providers”
— ALICE and the Dental Divide
If she had not learned about HealthLink from someone at her church, Laura would have had to go back to a free clinic she had found in New York. Getting there not only requires multiple modes of public transportation, it's also four hours each way, she said. The visit would have meant lost hours — and wages — at the restaurant where the 60-year-old works.
When Laura first came to HealthLink, she was in pain from a tooth she thought would need to be removed. Instead, the plan is to perform a root canal.
“The goal is to save the tooth,” said Santiago, who also serves as a translator for Spanish-speaking patients.
But first, an infection in the tooth needs to clear. During her visit, Laura learned it hadn’t yet — so, for now, the root canal would have to wait.
In 2025, the clinic had to eliminate its full-time dental assistant position and reduce its dentist's hours to cut operating costs. Salisbury and Santiago are now HealthLink's only full-time staff members. McCafferty serves as the part-time hygienist, and Dr. Michelle Sentosa provides care just a few hours per month.
In 2024, the team managed 605 hours of patient care — but the clinic couldn't run without its volunteers.
Eleven volunteer dentists, about 40 dental hygiene students each year, and a dozen administrative volunteers, including board members, help keep HealthLink's doors open.
In 2024, volunteers provided 700 hours of care.
“I can always use more dentists," Salisbury said.
With free access to dental care, HealthLink patients can take better care of their teeth, Oline, the volunteer dentist, said.
“They now have a facility that can help them solve some of their problems, and they’re willing to take care of them,” he said. “And most patients have been very appreciative.”
McCafferty, the part-time hygienist, agreed. Even when patients need aggressive cleanings, they are grateful, she said. “No one ever thanks you after that.”
Kevin, a HealthLink patient for 10 years, expresses his gratitude by occasionally popping by with coffee and donuts for the staff. He even helped assemble the bright orange chairs in the waiting room.
When he arrived as a new patient, it had been three years since he’d seen a dentist. The 32-year-old landscaper had a couple of cavities and needed some fillings. Now, he comes regularly.
“It’s a great help,” he said of the free dental clinic. “They help a lot of people.”