The Affordable Care Act has no teeth. That is not to say enforcement won’t be strict—by all accounts, it will. No, the law literally has no teeth. Dental coverage was all but ignored in the sweeping health-care overhaul.

So while more Americans will likely gain access to medical care when the law goes into effect next year, the number that can afford a visit to the dentist for a filling, root canal or checkup may actually decrease, industry officials say.

The health reform law requires consumers to buy a health plan that covers everything from seeing a psychologist to the full cost of breast pumps—but there are no such mandates for dental coverage, or requirements that insurers pay for the care of most Americans’ pearly whites.

The law does include some provisions for children’s dental services as an essential health benefit, stipulating coverage of medically necessary orthodontia. But it includes no additional coverage for adults, according to American Dental Association president Robert Faiella. While employers who provide health benefits often pay a portion of the costs of dental coverage, fewer of them contribute to dental insurance even when it is offered to employees.

“The ACA really falls short on adult coverage in dentistry,” says Faiella. “The dental side is not really addressed.”

In fact, adult dental coverage in general has suffered in the past decade, while more children have received benefits, according to the ADA. The percentage of adults going to the dentist has also dropped, from 41% in 2003 to 37% in 2010. Adults’ declining dental health has also led to a disturbing trend, Faiella says: The number of emergency room visits for dental problems nearly doubled to more than 2 million between 2000 and 2010, according to ADA research.

The uninsured will likely continue to take their toothaches to the E.R., Faiella says. “We’re concerned about it because the law does not draw attention to the fact that oral health is very critically involved in overall health.”

The federal Department of Health and Human Services says the Affordable Care Act includes a systemic plan to improve the nation’s oral health, including expansions of children’s dental coverage and new health plans that will cover both dental and medical care, according to an HHS spokesperson.

Indeed, the closest the law comes to mandating dental coverage is requiring small business employees who enroll their kids in their company health plan to also enroll them in ACA-certified dental coverage—whether or not their employer contributes to the cost. But because many of those adults will have to pay extra for those enhanced pediatric dental plans—with monthly premiums rising as much as 57%, from $35 to $55—surveys by the National Association of Dental Plans indicate that half of them will drop their current coverage for themselves.

It is a classic one-step-forward, two-steps-back scenario, says NADP executive director Evelyn Ireland: While 5 million children might gain dental insurance through the law, 10 million to 12 million adults could lose it, “for a net loss of coverage in the overall population,” she says. “This is one of those predictions that we really hope we’re wrong about.”

The law’s rules about children’s dental coverage seem to be backfiring in other ways, oral health experts say. On some insurance exchanges, dental plans will be sold separately, so consumers who purchase a health plan can decline to add dental for their kids without facing a penalty. (If the exchange does not offer stand-alone dental plans, the medical plans are required to cover children’s dental services.) “Because it’s not a required purchase, fewer private [dental] plans will be purchased,” Faiella says. “That is what we’re concerned about.”

Dental health advocates were also disappointed that services such as cleanings and sealants were omitted from the Health Department’s final list of children’s preventive benefits that insurers must cover at no cost to patients. But insurers must fully pay for fluoride supplements if a pediatrician prescribes them, according to the rules.

Adding to cost concerns, insurance officials expect that federal subsidies for exchange-based health plans won’t factor in whether the plans include dental or not, leaving no extra money for people who have to buy it separately. “It could be that consumers, even if they purchase dental, aren’t going to get any subsidies,” Ireland says. “It is a really odd kind of situation where they’re going to be oversubsidizing some consumers and undersubsidizing others.”

The exchanges will also sell adult dental plans, though the government is not providing subsidies for them. But consumer health advocates hope that more adults will buy them for themselves, in addition to coverage for their children, especially if the plans turn out to be more affordable than the options currently on the market. “We don’t know yet if families will decide not to pick it up because it doesn’t end up being affordable,” Booth says.

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