My toothache led to a painful discovery: The dental care system is full of cavities as you get older

I had a toothache recently, and it led to an even more painful revelation.

If you were to X-ray the state of oral health care in the United States, especially for people 65 and older, the picture would be full of cavities.

“It’s probably worse than you think,” said Elizabeth Mertz, a professor at UC San Francisco Healthforce Center researcher who studies barriers to dental care for older adults.

Mertz once referred to the porous, gap-filled oral health care system — which isn’t a system at all — as a “chaos.”

But let me go back to my toothache, then I take some painkillers. It had been bothering me for a few weeks, so I went to my dentist, hoping it would get better and preparing for the worst, having had two extractions in less than two years.

Let’s make it a trifecta.

My dentist said the molar needed to be connected due to a cellular disorder called resorption, and the periodontist in his office recommended bone grafting and possibly an implant. The whole process will take several months and cost about the price of an overflowing vacation.

I’m lucky enough to have great dentist and dental coverage through my employer, but as anyone with a private plan knows, dental insurance can’t really be called insurance. Ideal for cleaning and basic preventive procedures. But for complex and expensive procedures — which multiply as you age — you can capture half the cost, if paid at all, with annual payment caps in the $1,500 range.

“The No. 1 reason for delays in dental care,” says Mertz, “is out-of-pocket costs.”

So I wondered if cost-wise, it would be better to drop my medical and dental coverage and switch to a Medicare plan that costs more – Medicare Advantage – but includes dental care options. Almost unanimously, my two dentists advise against that because Medicare supplement plans can be limited.

Getting it all done can be confusing and time-consuming, and no one warns you in advance that aging itself is work, benefits are steep, and the special care you’ll need most – dental, vision, hearing and long-term care – is not included in the basic package. It’s as if Medicare was designed for pranksters like that, and we’re paying the price now as the percentage of people 65 and older explodes.

So what should people do as they get older and their teeth loosen?

A retired friend of mine told me that she and her husband don’t have dental insurance because it’s too expensive and has little coverage, and it turns out they’re not alone. According to some estimates, half of US residents age 65 and older do not have dental insurance.

That’s actually not a bad option, Mertz said, given the cost of insurance premiums and co-pays, as well as caps. And even if you do have insurance, many dentists don’t accept it because reimbursements have stagnated as their costs have increased.

But without insurance, many people simply don’t go to the dentist until they have to, and that can be dangerous.

“Dental problems are clearly associated with diabetes,” as well as heart problems and other health problems, said Paul Glassman, associate dean of California Northstate University’s dental school.

There is another option, and Mertz called it dental tourism, saying that Mexico and Costa Rica are popular destinations for US residents.

“You can get a week’s vacation and dental work and get out earlier than you would have to pay in the US,” he said.

Tijuana dentist Dr. Oscar Ceballos told me that about 80% of his patients are from north of the border, and from as far away as Florida, Wisconsin and Alaska. You have patients in their 80s and 90s who have been coming back for years because in the US their insurance was too expensive, the payments were limited and the out-of-pocket costs were unaffordable.

“For example, dental implants in California are about $3,000-$5,000,” Ceballos said. In his office, depending on specifics, the same service is “like $1,500 to $2,500.” Costs are lower because labor, office rent and other overhead costs are cheaper than in the US, Ceballos said.

As we spoke on the phone, Ceballos peered into his waiting room and said three patients were from the U.S. He handed his cell phone to one of them, San Diegan John Lane, who said he had been traveling south of the border for nine years.

“The main reason is the level of care,” said Lane, who told me he calls himself 39, with “about 40 years of extra time” on the clock.

Ceballos “is meticulous and has facilities that are as clean and sterile and as sanitary as anything you can find in the US,” said Lane, who had driven his wife to San Diego to get a new crown.

“The cost is 50% less than it would be in the US,” says Lane, and sometimes the savings are even greater.

Come this summer, Lane is likely to see even more Californians in Ceballos’ waiting room.

“The proposed funding cuts to the Medi-Cal Dental program will have a devastating impact on our most vulnerable citizens,” said dentist Robert Hanlon, president of the California Dental Assn.

Under the Proposition 56 tobacco tax in 2016, additional reimbursements for dentists were in place, but those increases could be eliminated under the proposed budget cuts. Only about 40 percent of the state’s dentists accept Medi-Cal payments as is, and Hanlon told me that a CDA survey shows that half will stop accepting Medi-Cal patients and many others will accept fewer patients.

“It’s shocking that when the cost of providing health care is so high, the state is considering cutting funding back to 1990s levels,” Hanlon said. “These cuts … will force patients to forego or delay basic dental care, driving completely preventable emergencies in already overcrowded emergency departments.”

Somkene Okwuego, who as a child in South LA was an occasional patient at USC’s Herman Ostrow School of Dentistry, will graduate in just a few months.

I started writing about Okwuego three years ago, after he got an undergrad degree in gerontology, and he told me a few days ago that many of his dental patients are elderly and have Medi-Cal or no insurance at all. She has also worked at a Skid Row dental clinic, and plans to work at a clinic where dental care is free or discounted after graduation.

Okwuego said “fixing the smiles” of his patients is a privilege and improves their appearance, which can help “when they’re trying to get jobs.” When I went to see him on Thursday, he had 83-year-old Jimmy Stewart as a patient.

Stewart, an Army veteran, told me he had trouble getting dental care at the VA and hadn’t seen a dentist in years before a friend recommended the Ostrow clinic. He said he had been discharged and received high-quality rehabilitation care at USC, with work covered by his Medi-Cal insurance.

I told Stewart that there may be Medi-Cal cuts in the works this summer.

He said: “I will be sad.

He and many other people.

steve.lopez@latimes.com