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Susan Inglett’s dental coverage changed just after she got a root canal on one of her top teeth.

It was 2009, and California was in the midst of a budget crisis. To cut costs, Medi-Cal, the state’s health insurance program for low-income residents, eliminated non-emergency dental benefits for adults.

Inglett, 63, of San Diego, needed a crown for that vulnerable tooth, but the state no longer paid for them.

She couldn’t afford one on her own, so she went without it. After that, she had three other teeth pulled because the dental services that would have saved them were no longer covered.

“You end up making choices about what you can and cannot afford,” Inglett says. “If a procedure comes up and you simply can’t afford it, and it’s cheaper to yank the tooth, then you take out the tooth.”

Now, Inglett won’t have to choose between fixing her teeth and getting them pulled.

Many of the dental services cut nine years ago were restored on Jan. 1 for her and about 7.5 million adults on Medi-Cal, many of whom had to get their teeth pulled rather than repaired.

Some benefits had been partially restored in 2014, such as fillings and X-rays, but critical treatments remained uncovered, including lab-processed crowns, root canals on back teeth, treatments for gum disease and partial dentures.

Those procedures are now covered.

Medi-Cal is California’s version of the state-federal Medicaid program. All state Medicaid programs must provide comprehensive dental coverage for children, but dental services are optional for adults.

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Almost all states do provide some adult dental benefits, though the scope varies. As of May 2017, 16 states plus the District of Columbia provided extensive adult dental benefits, 17 offered limited dental benefits and the remaining 13 that covered adults did so only for emergency dental care, according to the Center for Health Care Strategies.

Four states provided no adult dental benefits at all.

During budget crises, optional adult dental benefits are among the first to be chopped, says Robin Rudowitz, associate director of the Kaiser Family Foundation’s Program on Medicaid and the Uninsured. (Kaiser Health News is an editorially independent program of the foundation.)

As economies improve, states often move to restore them, Rudowitz says. Seven states, including California, Arizona and Oregon, expanded their dental coverage in fiscal years 2017 and 2018.

But access to actual dental care is a problem for Medicaid enrollees, and a critical question looms in California now that adult dental benefits have been restored: Will there be enough dentists willing to accept the rates that Denti-Cal — Medi-Cal’s dental program — pays for them?

“The vast majority of dentists don’t accept Denti-Cal patients because they can’t afford it,” says Sigmund Abelson, associate dean for clinical affairs at University of the Pacific’s dental school.

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The school operates clinics in San Francisco and Union City that treat about 2,500 Denti-Cal patients a year, he says. Services are provided by students under the supervision of faculty.

Abelson says he believes the overall health of Medi-Cal enrollees will improve now that full dental benefits have been restored, assuming they can find participating dentists.

Oral and physical health are directly linked, and many Denti-Cal recipients suffered from preventable illnesses because they couldn’t get appropriate dental care, Abelson says.

Some ended up in emergency rooms, “many times with acute infections that could have been treated by dentists,” he says.

Patients like Inglett who are missing teeth tended to start eating more processed foods and soft foods, says her dentist, Misako Hirota, who practices in National City, just south of San Diego.

“That in itself creates a lot of other problems,” such as diabetes, obesity and high blood pressure, she says. “It’s all a vicious cycle.”

Among the treatments that were restored this month, Abelson ranks root canals and special cleanings for people with gum disease as two of the most important.

Under the previous rules, root canals on back teeth were not covered. Extractions, on the other hand, were.

Now, all teeth are eligible for root canal coverage, Abelson says.

For patients with gum disease, Denti-Cal also started covering “ scaling and root planing,” which is a deep cleaning below the gum line that can help reduce infections in the mouth, Abelson says.

“Remember, your gums are holding in your teeth,” he says. “There’s no point in fixing a tooth if you have bad gums. You may ultimately lose the tooth.”

Hirota is thrilled that her patients are now eligible for partial dentures. After benefits were partly restored in 2014, enrollees could get only full dentures. That meant any remaining teeth had to be pulled before patients could qualify, Hirota says.

Having dentures “makes all the difference in the world for your confidence, and for your ability to get a job and present yourself in public,” she says.

Inglett is grateful for the changes. If the benefits had not been restored, she would have had to get more teeth pulled. “I am at the point where I would have to keep sacrificing my teeth,” she says.

Inglett already has a dentist who accepts Medi-Cal. Enrollees who don’t might have difficulty finding one.

A scathing report on Denti-Cal in 2016 by the Little Hoover Commission, an independent state oversight agency, noted that just a quarter of California dentists participate “due to its low reimbursement rates and administrative obstructions.” Finding a Denti-Cal dentist in rural counties can be next to impossible.

But state officials say they are engaged in a statewide outreach effort to recruit more dentists and have simplified the enrollment paperwork for providers.

And last year, Denti-Cal increased the rates it pays dentists for hundreds of procedures by 40 percent, a boost that was funded by the tobacco tax, Proposition 56, which voters approved in November 2016.

Hirota’s regular charge for a filling that repairs damage on two surfaces of a tooth is $130. Before the rate hike, Denti-Cal paid her $48, but that grew last year to $67.20, she says.

Hirota believes more dentists may start to accept Denti-Cal patients now, but Abelson is skeptical that the rate hikes will be enough to entice an adequate number of dentists.

To search for dentists who accept fee-for-service Denti-Cal, which is the primary service model for most of the state, visit the Denti-Cal website at http://bit.ly/DCDentists or call 800-322-6384. If you live in Sacramento or Los Angeles County and have managed-care Denti-Cal, email dentalmanagedcare@dhcs.ca.gov or call 916-464-3888.

You can also call your local dental society, which likely maintains a list of dentists in the area who accept Denti-Cal. You can find your branch by visiting the California Dental Association website ( www.cda.org ) and clicking on the “About CDA” tab.

Like University of the Pacific, many dental schools accept Denti-Cal patients, Abelson says. However, they are concentrated in the Bay Area and Southern California, so they won’t be accessible to all Californians.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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