When it comes to first impressions, your teeth can determine whether people think you are smart, trustworthy and employable. Despite this, one in four nonelderly adults in the U.S. have untreated tooth decay, and that number doubles for people with low incomes. While the Affordable Care Act expands dental benefits for children, it does little to address what’s being called a dental health crisis among adults.

Harriotte Hurie Ranvig has trouble chewing.

"I cannot chew on the right side of my mouth," she said. "Because there’s extracted teeth on the top and bottom on the right side in the molar area. So the teeth will not strike on that side. If I eat a carrot or something that’s big and hard, it slides in the grove between the teeth, and that’s not chewing!"

To fix the problem, Hurie Ranvig needs a dental implant a new tooth on her lower jaw, but she cannot afford to pay out of pocket. The procedure costs several thousand dollars.

Hurie Ranvig is 67, lives in Somerville, and is blind. She’s been on MassHealth, the state’s Medicaid program for a little more than a decade, and is happy with the coverage … mostly.

"I have got 2 hip replacements in 2005 because I had very advanced arthritis," she said. "I’ve had heart problems and had those taken care of. MassHealth has been superb in every way except for dental."

Currently, MassHealth covers fillings for the most visible six front teeth on the top and bottom, as well as extractions of all teeth. Starting in January, coverage will expand to include fillings of all teeth, but implants will still not be covered nor will dentures, root canals or crowns. Still, it’s a big improvement from several years ago, when lawmakers cut dental benefits almost entirely in 2010.

"We have a long history of separating oral healthcare from overall healthcare," said Nancy Turnbull, an associate dean at the Harvard School of Public Health. "Dental care is a very marginalized issue."

Turnbull says that because dental care is not a federal requirement for Medicaid, it’s often on the chopping block when states are balancing their budgets.

"While budgets are always tight and have been particularly tight over the last few years, the benefits in terms of reduced emergency department use, improving the ability of people to be employable and other really important health consequences, it’s a small investment for the state," she said. "It should be a priority."

Hurie Ranvig agrees.

"Dental health is an integral part in any human’s health," she said. "They’re not just little rocks in our mouth. They’re critical."

So critical, in fact, that poor teeth and gums are linked to some serious health problems including diabetes and heart disease.

​​"The mouth is the unguarded gate to the rest of the

​​body," said Courtney Chelo, the Oral health policy coordinator for the advocacy group Healthcare for All.

"A problem that starts from the mouth doesn’t stay there," Chelo said. "Cavities are actually a bacterial infection and untreated, that can spread and cause much greater harm elsewhere in the body."

And that’s when people go to the emergency room. Chelo says she’s thrilled to see fillings for all teeth restored, but for some people, it comes too late.

"A lot of folks who we work with started off needing fillings, but now need much more intensive treatment," Chelo said.

That’s what happened to Joanne Jijon.

"My teeth have literally fallen apart, crumbled," Jijon said.

Jijon is 62 and lives in Worcester. She’s the mother of three, and used to work as a nurse's aide. In the '90s, she went on disability because of arthritis, and then she had a stroke. Her teeth are in really bad shape. She’s missing several, and many of the remaining ones are misshapen and grey. She says at times they ache.

"My teeth just gradually decayed," Jijon said. "Decay all the way to the point right into the gums. The whole tooth gone, except for like little pieces that might be stuck in the gum. My teeth are too bad to fix, so I have to get them all pulled now."

MassHealth covers extractions, but not dentures, and Jijon says she can’t afford to pay for dentures herself. I asked her what she’ll do about food.

"I’ll have to do what I have to do without teeth," she said.