Dentistry is less scientific and more gratuitous than people think (2019)

The operation is just too slick from a business POV. As someone familiar with SaaS or in general this kind of recurring business model, you can sense all the little operational policies and procedures designed to increase your LTV.

It's a well-oiled machine. Without fail, the hygienist recommends cleaning not once every 12 months or even every 6 months, but every 3 months. When pressed on why, eventually they'll admit it's how nice it feels to have clean teeth and how important your smile is - but NOT strictly necessary for health.

This particular dentist also will shut down and take their entire staff to a resort for a week every winter if the team "hit their targets" for the prior year. That's the literal phrase they used to explain the trip. When I asked what those targets were, the person turned bright red.

So dentistry has a trifecta of factors that will encourage dark-patterns: (1) a true health-related reason for going both preventatively and to deal with problems; (2) a cosmetic / vanity-related reason (white teeth), and (3) the air of higher-educated medical authority.

Wrap that all in a lucrative recurring business model and of course it's going to lead to people taking advantage or at least overpaying for what they really need.

Just writing all this out made me realize I shouldn't be going to my current dentist! Thanks OP. :)

Dentistry is practiced as a business focused on maximizing revenue. Dentists are routinely coached to deploy sales tactics to increase their treatment acceptance beyond what is needed. If you walk into a dental office, you need to protect yourself from being abused. A second opinion unfortunately puts you in the same position, but now with a new dentist who will play into the narrative of only needing to monitor your condition for a while.

The business of dentistry is unfortunately antithetical to conservative treatment, which is almost always in the interest of the patient, because it results in significantly lower patient lifetime value.

I used to know a few dentists. One was a conservative, family dentist with a small home office in a small home (and a mountain of savings). He had a good rep bc he earned it. The other two had a bit more extravagant lives, and they earned it through specialization (and in my opinion, probably a little bit of this article).

What consumers should be most concerned about is the end of family practices, and the start of corporate 1800-DENTIST/Supercuts for dentists. Issues like this article are the norm, and instead of a local dentist to seek resolution with, you’re doing the equivalent of filing a Jira ticket with a faceless insurance conglomerate.

This is the trend the industry is going bc of the costs and difficulty of owning a practice. If you can, I recommend finding a young dentist who has recently bought into a home office partnership, and stick with them until corporate dentistry takes over. It is the only way to consistently avoid situations like this article.

At the time a had a small tooth ache so I was planning to visit a dentist to check it. I was living in Switzerland, where dentist costs are very high, but I was about to go on holiday to Tenerife, where prices are much lower. So I checked on the Internet and chose the dentist with the best reviews near my holiday resort. When I was there and had explained my problem, the dentist said he'd like to do a full check of my teeth. He did that with a little camera so I could see my teeth on a screen as well. Next he went past all my fillings. I had quite a few of them, and for every one of them his comment was the same: 'decay'. He said they were old, or didn't fit properly, so around the edges decay had started. And indeed the image on the screen showed some brown edges. In the end he offered to replace all of them with some modern alternative. The treatment would cost a couple of thousand euro and would take my entire holiday week.

I didn't entirely trust him so I said I needed some time to think about it. Back in Switzerland I went to my usual dentist. I didn't tell him about the Tenerife episode but just explained about my complaint and asked him to check. He concluded that there was not really any problem, it might be my gum was infected and this gave me some pain. Then I told him the diagnose of his colleague in Tenerife. I expected that he would be shocked but he wasn't: he asked how much the guy was charging and just said it wasn't a bad price.

I then told the story to a friend whose both parents were dentists. He wasn't surprised either and he explained like this: he said dentists were like car mechanics. When a car mechanic is checking your engine and some parts were a bit worn out, some would say they should be replaced, but others would say they are still working so let's only replace them when they break.

It's 5 years later and all those 'decayed' fillings haven't given me any problem so far. But maybe I was just lucky? I'm completely confused now.

My wisdom teeth grew in about 15 years ago and have sat comfortably behind my molars since.

I saw a new dentist for a routine cleaning “intro package” where she suggested that I have the wisdom teeth removed. I asked her why should I have a surgery for this since I never had problems with them. She said it was a good idea because they were “more likely to develop a cavity” because they are farther back and harder to brush.

So basically she was pushing me pay thousands of dollars to have a serious surgery to avoid the risk of developing a cavity because I might not know how to brush teeth that I have had for 15 years and never had a cavity on.

I wonder how many people just decide “guess I need this surgery”

The root canal itself was quick, relatively painless, and not super expensive after insurance. But he couldn't do a crown, apparently that's only a dentist thing. Since my previous dentist closed his office, I asked for a recommendation and he gave me a referral.

The referred dentist did the crown just fine but the price gave me sticker shock: about 4x as much as the root canal itself, after insurance! It basically wiped out my HSA account for the year. When I went back for a general checkup and cleaning, the same dentist said they found SEVEN cavities. Which was a little mind-blowing since in the decade previous, my old dentist only filled ONE cavity and always complimented me on the state of my teeth.

I asked how much it would cost out-of-pocket to address the cavities and they gave a number somewhat north of $200. Oh, that's not so bad to have a bunch of cavities filled. Oh sorry, nope, that's the price PER CAVITY. I asked what I was doing wrong because I _had_ been flossing and brushing every day and got a very hand-wavy answer. I was in a literal state of shock so made an excuse about my schedule being full for the next couple weeks and beat a hasty retreat. After the root canal and crown, I literally couldn't afford to have seven cavities filled.

Fast forward a year and I finally find another dentist for a cleaning and evaluation and to tackle at least the worst of those seven cavities. You want to know how many cavities he found? None. None at all.

In all seriousness, fraud is rampant, and cash pay or low regulation fields like dentistry can easily take advantage of patients and their health literacy.

In ophthalmology, you hear of “laser” cataract surgery, “floaterectomies”, telling patients they need cataract surgery well before they are symptomatic, dry eye treatments.

Hell, in cardiology there have been multiple cases of fraud uncovered where doctors were putting pacemakers and defibrillators in people that didn’t even need them!

Maybe I’m jaded, but when there exists such a profit incentive, we as healthcare providers struggle to “do no harm”. I’m lucky to be surrounded by mentors and other doctors that try and exemplify the moral behavior patients expect in healthcare, but imagine if I had a mentor early on like Dr Lund in the article..

So, there are dentists who aren’t in it just for the money. It is anecdotal, but so is the article. For that matter, the bad dentist was caught by a good dentist.

Also, I miss my dad.

However, this whole thing would be more informative and impressive if they had gone after the elephant in the room. Aspen Dental overtreats more than the rest of the dentists in USA put together. They are a "large health-care organization with substantial oversight... and standardized treatment regimens", but that oversight and standardization is geared entirely toward convincing every patient to get at least ten crowns. Aspen Dental are also large enough to hire lots of lawyers, so Atlantic isn't going to touch that with a ten-foot pole.

- Using flouride toothpaste.

- Using a combo of bad-bacteria-killing mouthwash and flouride mouthwash (especially before bed).

- Eating or finishing meals with tooth-protective foods.

- Chewing xylitol [0] gum or mints. Xylitol is a sugar-replacement (with a lower insulin response) found in plants . I think Epic Dental has the most reasonably priced stuff that I would trust.

Her routine is here [1]. I think her suggestions are reasonable. She has a product line, but you can use generic products that fit her guidelines. Just match up the ingredients.

Also, a couple good points in the book Breath by James Nestor:

- We have malformed mouths and teeth because we don't do enough serious chewing. Think bread/mac and cheese/peanut butter vs carrots/steak/celery.

- Mouth breathing is bad. Your mouth dries out and this assists tooth problems. You can solve this while sleeping by taping your lips together.

[0]: https://en.wikipedia.org/wiki/Xylitol

[1]: https://issuu.com/zellies/docs/zellies-cmcsbooklet?mode=wind...

I just had my yearly checkup and the dentist again noticed few small inactive cavities and said we should just monitor them like last year.

Not a good criteria for choosing a dentist. My dentist is a 4 hour drive away. I moved 10 years ago and I prefer the inconvenience over the risk that someone else will be selling me treatments I don't need.

What I have learned over the years is that your teeth are in a constant state of deterioration and will never be perfect. There is always some treatment that can be medically justified but, often, it doesn't need to be done.

I myself suffer from varying, chronic pain after a pointless visit where two "tiny" holes were drilled.

I think the only way is to stick with one dentists, so they see you as a long-term investment.

funfact: Yelp was inspired by the difficulty of finding good dentists.

Now I'm interested in DIY dentistry. Any pointers?

Inevitably she will retire... Then I need to find another dentist who cares most about dentistry.

The industry is apparently now dense with dentists obsessed with the business of dentistry, or even “dentist lifestyle influencers” who glamorize the business of dentistry to sell products/courses/whatever to other dentists.

When my last cleaning came around, they of course found another cavity. When I was taken in to get it filled, I panicked in fear of the needle and threw up in the chair. They told my mom we'd have to do the procedure on another day. The dental practice did not know that we were about to move to another country, and wouldn't have time to come back. My mom decided to just wait until after the move.

When I was taken to the dentist after moving about the tooth that was meant to be filled, they had no idea what we were talking about. They didn't see anything on the x-rays and said my teeth were fine.

Ever since then I wondered how many of those filling I even needed.

I'd avoided dentists ever since and didn't see one almost 15 years until a couple of years ago when I had a wisdom tooth that needed to be taken out. I was worried that when they'd take a look at my teeth they'd find all sorts of things wrong after all that time. But aside from the wisdom tooth and a tiny cavity that they said could heal on its own, they said my teeth were fine and I didn't need to do anything else except for being better about flossing (which is when I finally got really diligent about it).

(And for the wisdom tooth extraction I specifically found a clinic that specialized in dental phobia. They let me opt for a "Wand" device to do the anesthesia of the tooth instead of a traditional needle. It looks much less like a needle, and the release of the anesthetic is entirely controlled by the device itself and not by the hand of the dentist [though of course the dentist is still the one configuring it]. That somehow made me feel better about the whole thing, since I knew the device would release anesthetic at a stable and "ideal" rate. I trusted it more than a human.)

[0] https://www.goodreads.com/book/show/544354.Nutrition_and_Phy...

At Bristle, we’ve created an at-home oral health test that also pairs you with ingredient recommendations to prevent the progression of oral disease. The goal is to give data around oral health without the misaligned incentives of a practitioner who benefits from your demise.

For my next checkup, I searched and searched for a dentist who spoke in unaccented English I could clearly understand. He checked my teeth and cheerfully told me I needed to have all my lower front teeth removed and a bridge implant. Out of pocket cost: $30,000.

I couldn’t possibly afford this and decided to get a second opinion. The problem is, my insurance only covers one checkup every 6 months. In the meantime I agonized over how I would possibly pay for my extensive dental work, and I managed to find another dentist with whom I could communicate.

I asked this dentist if I needed the $30,000 procedure and she scoffed!

I was instantly furious and gave the Rolls Royce doctor bad reviews on Yelp and Google Maps. I’ve been getting a real-life lesson on the practices described in the article. I plan on sharing it with everyone I know.

I’ve learned from him that over treatment and bad quality work is shockingly common. Part of the reason is how dentistry is taught in this country: people take out very expensive loans for dental school, so they want to start practicing right away while also over-treating to pay down loans. It used to be cheaper and people would apprentice — that is now rare. You see this in medicine too where they pack as many people as possible into a day, who cares if the quality is low per person.

The vast majority of dentists he sues are general dentists. They often don’t have the training and/or equipment to do surgery, and it results in things like drilling into nerves which cannot be undone. A lifetime of burning pain is the consequence. Again: no undo.

My best advice is to always see a specialist, even for a teeth cleaning. They have additional schooling and demonstrate a desire to go deeper in the profession. Prosthodontists will do cleanings, and their inspection will be far more valuable than a general/family dentist. They’ll also know which specialists to send you to for various procedures and won’t attempt to do something outside of their training.

About a year ago, I was told by a dentist (in a larger clinic) I needed to have gold filling in my molars (because gold is least reactive, better than ceramic and gets the dentist a pretty penny). I was quoted ~$500 after the insurance. Also suggested was some SMILE UV procedure to whiten the enamel. I was reluctant as well as mortified. The whole convincing act sounded more like a sales pitch. I went to a second dentist, who runs his own singularly run establishment (the current one in question) and he flatly told me 'no'. My teeth were in good shape mostly (minus some coffee stains & a cavity). Since it was about closing time, he sat me down over a quick bite & went through the dental physiology - and why he considered it pointless. In the end, he added since I was on insurance I had nothing much to lose monetarily, but by doing Dentist A's suggestions, I was primed to keep visiting every few years for fixes. He had nothing to gain by turning me away. That was a huge confidence booster. Honesty was a huge factor in getting my trust.

It opened my eyes to the fact that the vaunted & strictly regulated Japanese health care has its share of bad apples too. Dental treatment is a money spinner even in Japan. Although, mostly operating assiduously and in good faith, we need to still look out for some bad actors. (I have another terrible story - but it pertains to opthalmologists)

Bonus: Since he turned out such a nice guy I get him souvenir candies (ironic!) from wherever I go traveling. And he cauterizes my sporadic canker mouth sores without ever charging a dime :)

Around 10 years ago, during one of the dentists appointment, my wife had to perform an x-ray scan of the whole mouth. Besides the stuff dentist wanted to confirm, he found out that she has her wisdom teeth grew in a little problematic direction that might become painful in very short time and suggested to remove them before that happens.

That said, such operation would require narcosis. Both of us are very skeptical when someone wants to do something for us that requires putting us into that state so we've gone to another dentist to get another opinion.

Turned out, that other dentist said that he don't see any problem with my wife's wisdom teeth and warned us, that the operation other dentist suggested was very dangerous and had high probability that it could break some jaw nerves very easily which could lead to partly face paralysis.

So yeah, 10 years has passed and my wife has never experienced any pain caused by her wisdom teeth - maybe got lucky or maybe that 1st dentist was just plain wrong.

But in the end I've always tend to be warned and while having any doubts, it's worth to spend some money just to double check if suggested treatment is really good for us (or necessary).

I'd never had a filling before, so this was a very big deal for me. The dentist had time, so he just did it right after my cleaning. The only word I have for how I felt was raped. I don't use that lightly. It was emotionally traumatic to have someone pressure you like that, not give you a clear choice, and violate your body.

I kept going there just because I was lazy, and I went on a day the dentist was out of the office, so the hygienist just showed him the xrays. When he found another one several years later, I got a second opinion. He said it was something a more aggressive dentist might go after, so the diagnosis wasn't outright wrong, but probably overly aggressive.

Never went back to the first dentist. 7 years later, it's still fine. I suspect most of my fillings were the same story.

My current dentist probably overtreats with 4 cleanings per year, but I'd rather pay for the extra cleanings.

The biggest innovation in the last 50 years are titanium dental implants (very expensive) and the use of ceramic and acrylic (more expensive) over the insane amalgam fillings with mercury. And yet, many dentists still put the health hazard of amalgam with mercury in people's mouths (like it's a tradition) or do root canals which keep dead toxic teeth in mouths too. If you want less toxic options, then you must pay for much more expensive procedures.

I developed this theory after finding one the 'old fashioned' way, through reviews and word of mouth, and he convinced me I had six cavities and I let him drill and fill two of them before I got a second opinion. Turns out I had no cavities, and didn't need the first two filled either; just a few spots to watch.

Ex. Recently France sentenced one dentist to 10yr for doing procedures that were not needed (same combo root canal + crowns): https://www.lefigaro.fr/faits-divers/c-est-un-carnage-un-anc...

My pet peeve is about the number of x-ray my dentist performs. Every time, everything is fine. Feels like the sole reason, is that my insurance pays for me to be radiated once a year.

Without discounting any of the bad experiences people have had here: I've been going to the same dentist for 30 years. He never suggested teeth whitening to me, even though I obviously could have benefitted from it, and did when I explicitly asked for it.

In a way, painless dentistry probably increases the profit-seeking. At one time, drilling and other procedures were incredibly painful. Now they're only painful to your wallet.

If you break a finger, the orthopedist doesn't usually give you a finger canal that removes all of the nerves, blood vessels, and bone marrow and replaces it with some kind of resin composite.

Though I guess they are into expensive and horribly invasive hip and knee replacements.

It seems that minimally invasive dentistry is a thing - hopefully it will catch on.

But someone is setting up a practice in my area (South London) that fits with what a lot of people here are seeing: he's opened three surgeries in the immediate area, there's lots of advertising for expensive procedures, and he drives a Lamborghini. All that has got to be paid for somehow.

In my home country of Romania I sometimes almost have to ask my dentist to take my money. Since on check-ups I usually don't need any work done, he just lets me off without payment. This has actually happened to me a number of different times with different doctors.

I don’t think this acquiring dentist asked some basic questions before buying.

“How much was your revenue last year?”

“$900k”

“How many patients did you see last year?”

“1000”

“ok that’s $900 avg per patient. You charge $50 per cleaning, twice a year…holy shit”

Now, also in Italy the Anglo American idea that dentists are not fully medicine has been adopted as well, and at the university there is a path for dentistry alone. And it doesn't make any sense.

It would seem fear and anxiety are actually the dentist's most profitable products.

The total cost to get a new tooth was like $5k. I got an implant done so that a crown could be placed later down the road and I am deferring the crown. And of course, the new dentist is using a similar scare tactic:”act now! The implant might blah blah blah.”

Sometimes, I wonder if dentistry is the world most accepted sham.

You should know that our days are basically spent in an almost PTSD status after having undergone years of abuse by patients in the form of dark, frustrating patterns that repeat every week. These are behavioral patterns that typically leave us in a frustrating and infuriating lose-lose situation through no fault of our own, and they seem ingrained in the general population.

A few examples: in my clinic and those of my colleagues about 75% of african immigrants that book an appointment, and confirm it 2 days before, end up no-showing for the appointment, and don't even answer the phone when we call them. this happens several times a week. I haven't found a solution because I can't just say "you're an immigrant and I won't book your appointment", nor can I make them prepay while holding native residents exempt from this rule. No-showing means I lose a sizable amount of revenue while having to pay the staff for nothing. Example 2: a good percentage (20%?) of those with an infection are given antibiotics, I explain they should come back when the pain has subsided, -usually a few days- to perform the root canal / extraction (which will allow me to use anesthesia effectively - it doesnt work when you have an infection) and they also end up no-showing because "it doesnt hurt any more", without bothering to answer their phone when we call them. They call back 2 months later, in pain, demanding to be seen -today-, at which point my blood is boiling. Bear in mind I explain this at least 3 times during the first appointment. Example 3: randomly, a good patient will turn rogue and decide that the crown I'm doing on her canine "looks too big" or "is too rounded" or some other subjective aesthetic bullshit like that. it's typically a middle-class 50-60 woman. This happened today to me, I showed the crown's thickness to the patient with a measurement tool, it was 0.5 -millimeters- and explained it's physically impossible to make it any thinner. Her answer "it's your problem, I'm not a dentist". These patients will typically then refuse to pay for about 1000$ of work, despite the work being first class, because "they are not happy". This happens randomly and is not predictable despite my best efforts, and is peppered with ridiculous episodes like crying in the chair, calling their husband who will typically back their claims and then start guilt-shaming you with gems like "my wife is so distressed by this. we are both deeply hurt." Example 4: a patient will randomly decide he will try to leave a bill unpaid, and they will adopt every kind of trick and dark pattern in the playbook. Lies, asking to delay the payment so they can stiff me out of 4 fillings instead of just one etc..this happens multiple times a year. Example 5: patients taking impressions for, say, a night guard, after being explained the cost and days it takes to make it. We typically deliver then a week later. They will then call a day before their delivery, when the night guard has already been made, saying "doctor I've decided I don't want it any more, I want to cancel the appointment, k thx bye". That is the average message, and I stress the "k thx bye" part where they make it clear they don't even want a reply and it's all said and done (typically because they think they can buy a 20$ nightguard on amazon instead). They will refuse to pay for the nightguard that's already been made and the laboratory has already billed me.

I could go on for hours and cite about 40-50 of these patterns that we see day in and day out, they put you in a very frustrating position where choice 1 is bad and choice 2 is even worse (say, suing the patient for collections as option 1 and taking a direct loss as option 2).

It almost got me burned out and I know several colleagues who either have burned out, or completely changed profession because of the widespread lack of basic respect and fairness from patients.

This happens while, as someone else said, you're in xxx,xxx$ debt, so you can imagine being told unfairly that you have to eat a 1000$ loss for something that's not your fault, tends to make you want to scream. I know I went home shouting in my car more than once asking what I did wrong to be subjected to this bullshit day in and day out.

It's a incredibly abusive profession and it has a very high suicide rate (at like 3x the average for other professions, this is true for most medical professions by the way). And I won't even talk about the physical toll it has on you because I don't mind working 8 hours even in uncomfortable positions, but seeing the way people lie, cheat and try to blame-shame you tends to take away all faith in humanity. So yes, there are bad dentists just as there are bad -anything-, but there are also bad patients. I guess I just wanted to vent and let you see the other side of the coin...we say "no good deed goes unpunished" and it's true indeed

Fair warning, this is a long post with a lot of buildup of my own experience with the dentist. The relevant part is the last couple paragraphs but context is all before.

A few years ago I had horrible dental anxiety. Enough so that I would have a fight or flight moment just sitting in a chair. When I was young (baby teeth coming out age) I had been told that I was going in specifically so some teeth could be loosened so they would come out naturally. That did not happen, they pulled them outright and that forever broke my trust. They even had to use those sizer like clamps to keep my mouth open (the ones that sit on your tongue, not the nice cheek ones we have now) I was lied too, and at a young age. Maybe they though I would be less scared but it hurt my trust going forward. But basically I did not go to the dentist after that point unless my parents dragged me... and I put up enough of a fight both getting there and in the chair that they gave up. I wasn't a brat, I had no issue with the doctor... I was just scared out of my god damn mind. Once I became an adult I didn't go to the dentist for... 6 or so years.

I even chipped a tooth and the idea of going the dentist scared me so much that I was desperately looking for some "secret" solution to grow back the tooth... as an adult. But I even ignored that.

Finally my wisdom teeth happened. And they hurt like hell, but they actually came in fine. But they got a cavity because while the teeth themselves came in, fitting brush between them is another story. I was in horrible pain and I could not let it go any longer. I was still scared shitless but... pain is quite the motivator.

I remember the first Dentist I went to. It was a big chain (I don't know if national but there are a lot of them. I called them and explained my situation. I stressed that I had a lot of dental anxiety and why. They reassured me that they had someone who specialized in this. So I get there... explain again why I have anxiety. He proceeds to do the examination without tools, just taking a look at things. He does the X-rays. And then right as we are about to leave, he takes one of the tools and quickly scrapes one of my teeth (with no warning)... I have not wanted to run out of a place quicker in my life. It wasn't a necessary scrape, I am convinced he did it to be like "See this isn't too bad" He completely ignored WHY I had anxiety. I was not happy... It isn't the tools it was the being lied too. The tools never bothered me (that's partially a lie, if I had to see the open mouth clamps that they used when I was young I would probably scream).

Finally I found another dentist. Slightly more upscale to be honest, but there were some basic things they did that tremendously helped me... like before I ever came in the dentist called me to chat to see how I was handling the pain, to make sure I was comfortable with what the appointment (to be clear this was not his assistant, but the actual dentist). I got to meet him on my terms, home on my couch. When I finally got there I never felt rushed, I was told I could come in early and just sit in the chair if I needed (not sit back until I was ready). I was checked on by various people during this time, but when he finally came in for the actual appointment I was laying back in the chair... anxious but calm because I got there on my terms.

Flash forward... and I have for sure had a fair number of operations from them. 3 teeth extractions (2 of them being impacted with each other), 2 of my wisdom teeth came out, 2 root canals, several crowns and I don't know how many cavities at this point. I also had to have a deep cleaning and now I go in for a cleaning every 3 months to manage that. There is that voice in the back of my mind that wonders if it was all necessary. If I actually need to go in every 3 months. But I find myself reluctant to think about that because I know that... if it wasn't for them I would not be working on my teeth at all. I strongly feel like if I tried to go somewhere else, my anxiety would not be as bad but a lot of my comfort now is tied to my relationship with them.

I know horror stories like what is outlined in this article are nothing new and we have heard things like this before... but I wish this particular industry was better.

A lot of the problems are the result of misaligned incentives. While it's applicable to almost all of healthcare, it's especially prevalent in dental. Providing high-level what I've seen with the understanding that I am talking about the worst outcomes of our care model and certainly not hitting all of the problems. That said, I have met many more dentists who genuinely care about their patients than those who don't - and I truly believe that is the norm.

*Payers* Dental insurance is glorified discounting. Medical insurance provides annual out-of-pocket maximums (deductibles) where anything you pay beyond that is covered by the insurer. Dental insurance is the opposite. There is an annual maximum the insurer will cover (usually ~$1500) and anything beyond that is covered by the patient. In both cases there are some covered services (medical: checkups, some tests, etc. dental: X-rays, cleanings, etc.) but the second you have something even marginally serious your insurance SHOULD kick in. The problem with dental is that it doesn't. I've spoken with people that had to defer necessary procedures for a year because insurance could only cover half - so 1/2 this year and 1/2 next year.

The problem with this model is that while medical insurance is (theoretically) more incentivized to keep costs low since they will have to pay for major care, dental insurance has a natural ceiling. Yes, if you need $5k of dental work the insurer "suffers" - but it's maxed out for whatever your coverage limit is. There's not a severe financial downside to extensive care.

*Providers* Complimentary to the model of dental insurance is a fee-for-service (FFS) model for care. What this means is that providers are paid based on services. In other words, a provider makes more money doing a cavity filling than not having to do one because they kept you healthy.

The extreme opposite would be a model where a dentist was financially penalized every time you needed a filling - you can imagine how the relationship and role of the provider would change.

Something that gets overlooked, but is important to call out, is that the system for becoming a dentist doesn't help. There are 4 years of dental school. When you graduate, you're likely $XXX,XXX in debt. On top of that, private practice is still extremely prevalent in dental care - so add another $XXX,XXX in debt. Plus the cost of the equipment you need. This isn't an excuse, but its a reality for many dentists. When you combine massive debt and a care model that prioritizes paying for procedures the result is what we see today.

The other problem is that this misalignment means providers have to make personal/ethical choices around care. Sometimes those choices mean performing unnecessary procedures on patients. Sometimes it's the opposite, and the provider takes a personal hit on revenue. So you end up with 5 second-opinions, none of which line up to the others. A provider should not have to choose - or eve consider - ethical responsibility to patients vs. financial stability.

*Patients* We - patients - get shafted in dental care. Our system is incentivized to reactively treat disease over maintaining good health. On average we pay [40% of dental expenditures out of pocket](https://www.carequest.org/system/files/CareQuest-Institute-B...). That's ~4x more than the average for all other healthcare services.

We're left to navigate oral care on our own. Of course you're skeptical when a dentist says you need 10 fillings - they're incentivized to perform the procedures. Would you be as skeptical if you knew the dentist was getting charged $50 for every filling they had to do? Do you think the care model would change if dental insurers suddenly had to pay for your $10k dental procedure instead of you?

Cavities and gum disease - largely preventable conditions - are the most prevalent diseases on the planet. And we're not talking about some complex, mysterious disease. These are microbial infections. We have tools to detect them early and interventions that work (at least work well enough to make a major dent). Misaligned incentives don't motivate anyone to adopt these technologies or encourage preventive care.

Anyway, that's my rant. There are lots of things I didn't cover but I have to get back to work. Linking [my company here](https://www.bristlehealth.com/) to minimize self-promoting but provide some more info.

This is an American thing. In Europe if a wisdom tooth doesn't hurt, you don't remove it.