It began with a toothache. Tori Pence, 23, could feel the hole that had suddenly developed on her tooth, and she couldn't stand either hot or cold food. The bespectacled girl with electric-blue hair had worked a string of odd jobs and hadn't seen a dentist for at least five years.
When she finally got in to see one, she needed a root canal. And fillings for 15 cavities.
"Dentally speaking, I am healthy now," says Pence, who lives in Lansdowne and has been making monthly visits to the University of Pennsylvania's dental clinic for almost a year. "But I still have seven more [cavities] to go."
Pence is one of the estimated 132 million people in the United States without any sort of dental insurance. It's an endemic problem among the unemployed, the poorly paid, and those without medical insurance.
While the national health-care act passed in spring will increase the number of people eligible for medical insurance, its effects on dental will be mixed.
The law increases coverage for children, and will eventually cover more adults under Medicaid, the joint state-federal health plan for the poor. But adult dental services are often hard to find: Less than one-third of dentists in Pennsylvania and New Jersey participate in Medicaid.
Many people don't see the value in preventive dental care - or they dread it - and postpone routine checkups. That is, until it becomes too painful to chew or a front tooth is chipped.
In Philadelphia, geriatric dentist Ann Slaughter says many elderly patients she has examined at inner-city senior centers haven't seen a dentist for up to 15 years.
But "oral health is intimately connected to overall health," she says.
Periodontal disease can cause or worsen heart conditions, strokes, and respiratory illness.
It can be perilous for diabetics. Germs from gum disease can make them more prone to complications, says Slaughter, an assistant professor at the University of Pennsylvania School of Dental Medicine and a member of the city Board of Health.
More than 200 diseases of the mouth can also cause problems elsewhere in the body. The plaque on teeth can travel into the blood and contribute to hardened arteries, a risk for heart attack.
In 2000, Surgeon General David Satcher called dental and oral diseases a "silent epidemic" facing the nation.
"We're in 2010, and we haven't made many advances," Slaughter notes. "That's the sad part."
One problem is the many gaps in dental insurance, which unlike medical insurance, was never intended to completely cover anything.
For those without insurance, the median price for a root canal in Philadelphia is $862, according to a survey that dentists use to price procedures. A crown can cost as much as $1,200.
And while 172 million Americans under 65 have private health insurance, just 45 million of them have any sort of dental plan, according to the National Center for Health Statistics.
In Pennsylvania, 40 percent of the entire population of adults and children lacks dental insurance, according to the Pennsylvania Dental Association.
Medicare has substantial holes as well. It covers health care for virtually all seniors and some younger people with permanent disabilities. But it doesn't pay for routine dental care.
When people turn 65, says Slaughter, "those with disposable incomes pay out of pocket or they keep their dental insurance."
Medicare does cover dental procedures that are connected to a larger medical issue. A surgeon won't perform an open-heart operation on a patient who has a mouth abscess, for example, until a dentist has treated the problem.
Medicaid poses its own challenges. There are 508,000 recipients in Philadelphia, but many of the adults aren't eligible for dental because they aren't permanently disabled or fail to meet other criteria.
Those who are eligible can have a hard time finding a dentist.
"Just because you have insurance doesn't mean you have access," says Laval Miller-Wilson, the executive director of the Pennsylvania Health Law Project.
Pennsylvania has some of the lowest reimbursement rates in the country, according to a recent report by the Pew Center on the States. Pennsylvania's Medicaid program reimbursed dentists 53 percent of what they customarily charge. The national average for Medicaid is 60.5 percent.
New Jersey had among the nation's lowest reimbursement rates until recently, but now pays 103 percent of the customary fee, according to the Pew Center, which nevertheless gave the state an F on its dental report card due to other limitations of coverage for the poor. (Pennsylvania also got an F.)
Miller-Wilson says some dentists' aversion to Medicaid is about more than money. The paperwork is cumbersome. And broken and late appointments are common among the poor.
Instead of accepting Medicaid, "many dentists say they would rather treat patients during free clinics or pro bono," says Rob Pugliese, spokesman for the Pennsylvania Dental Association.
Lack of increased funding for Medicaid dental services is a major reason the American Dental Association opposed the health-care bill.
In 2014, when the new law enables millions more Americans to join Medicaid, many advocates wonder if there will be longer lines to see dentists as well as doctors.
"The health-coverage bill is going to exacerbate the current supply problem," says Miller-Wilson, adding that the state of dental care now may foreshadow what is to come.