Not long ago, my dentist referred me to a specialist for a procedure consult. I was shocked by my out-of-pocket cost – the bill was more than I make in a month. And I’m one of the lucky ones – I have dental insurance and a reliable income.

Low-income patients, or those on a fixed income who require extensive procedures, often find themselves in even more difficult situations.

The issue, sometimes called “dental inequality,” has complex health, economic and social implications. Mary Otto’s critically acclaimed 2016 book “Teeth” investigated the oral health care crisis that affects millions of Americans; she noted that lack of dental coverage and poor oral health can have far-reaching and devastating consequences, including patient death.

Dental care is not a luxury – it is essential for overall health. According to the Mayo Clinic, oral health issues can “contribute to various diseases and conditions,” such as endocarditis, cardiovascular disease, pregnancy and birth complications and pneumonia. In 2016, the National Association of Dental Plans reported that there were more than 2 million emergency room visits for dental treatment annually.

I was born with congenital heart defects, and for 30 years have been prescribed prophylactic antibiotics to take prior to dental cleanings because of the possible risk of infective endocarditis. My recent referral was to a periodontist, to treat gum recession with a procedure that involves a gum graft to replace lost tissue. Gum recession, which is found in nearly half the population, is the product of many factors, including genetics, past history of orthodontics and brushing habits.

I still see a cardiologist, and have five cardiac diagnoses listed in my medical chart, so I submitted an inquiry to my health insurance plan coverage for this procedure. I was informed by my health maintenance organization that “the oral surgery benefit under your medical insurance does not cover the services you need. That is always a dental insurance benefit.”

Having already used my dental coverage maximum of $1,500 or the year, I am fully responsible for the cost of the procedure – estimated at $3,743.

That medical and dental care are considered separate in the U.S. health care system owes to an event remembered as a “historic rebuff.” Back in 1840, two dentists requested to add dental instruction to the medical course at the University of Maryland. The request was denied, and a separate dentistry field was founded.

This distinction was then cemented in the early 1900s with the development of U.S. medical insurance, which centered on issues of internal health.

Dental care is still not covered by most health insurance plans. In a 2017 article on New York Times columnist Nicholas Kristof’s blog, Zoe Greenberg quoted dentists and public health officials who argued that this is because of, in Greenberg’s paraphrase, the “ignorance and indifference” of lawmakers and private insurance companies.

According to the Physicians for a National Health Program, 70 percent of seniors lacked dental coverage in 2016, because dental care is not covered by Medicare. The National Association of Dental Plans also reported in 2016 that some 74 million Americans, or about 23 percent of the population, had no dental coverage – approximately four times the medically uninsured rate.

That is simply unacceptable. As we head into a presidential election year in which health care is emerging as a major issue, we must do all we can to include dental care as a health care benefit, to protect and improve the health and lives of all Americans.