The importance of oral health for overall well-being cannot be overstated. Yet the US dental delivery system struggles to address effectively the two most common oral diseases (caries and periodontal disease), which are among the most prevalent of all chronic diseases and are largely preventable. This article describes the evolution of contemporary US dental care policy and practice, highlighting the challenges resulting from the dental system’s separation from the rest of health care, and explores the implications of this divide for the future of oral health policy and system reform. It remains unclear whether twenty-first-century dental science, information technology, interprofessional practice, and population health needs can be mounted onto the current nineteenth-century dental care delivery model. At stake is whether reform efforts will lead to a reduction in disparities and the widespread incidence of dental disease, or whether those efforts will maintain a system in which poor oral health serves as a primary marker of social inequality for the next generation of Americans.