Ever wonder why dentistry operates separately from other fields of medicine?
What goes on inside a person’s mouth—the bacteria, cavities, and gum disease—can have a big impact on overall health, but dental care and coverage has long operated in its own sphere.
The answer to why this is involves a bit of drilling into the history of dentistry, even centuries back, and an examination of the state of the profession today.
1601 Walnut Street: a window into the world of dentistry
About 193,000 dentists work in the U.S. according to the National Dental Association, and unlike their peers in the medical field, the majority operate out of small, independent practices.
For 30 years, Claire Sparano has managed a dental office on the 7th floor of a building on 16th and Walnut street, near city hall in Philadelphia. It’s one of more than 40 independent practices listed in that same building. Some just focus on kids, others specialize in oral surgery or root canals. There’s a cash-only “boutique” across from Sparano’s office.
Hers takes some dental plans, but not all. She spends a lot of time behind the checkin desk, figuring out how it all works for the practice, Coleman and Turner, and for patients.
“They think they have one type of coverage, half the time they find out things weren’t covered that they thought they had,” said Sparano.
Prices for procedures are also part of the conversations with patients coming in and out.
Seated in the waiting area across from what’s perhaps a signature of dental offices, a fish tank containing a big goldfish, is Thorne Holder. He’s hoping to finally get his mouth fixed.
“I’m in a lot of pain,” Holder said, pointing to his right premolar. “There was a root canal there, the enamel has broken off around it, and it’s in serious pain.”
Holder, a former pro-soccer goal keeper, went for a while without insurance. He had some discount work done through a college sports program, but he couldn’t afford the crowns. He never got them. Holder signed up for insurance on his own two years ago, but he couldn’t fine a place that would accept it, he recalled.
Now some of his teeth are falling apart. The pain has been psychological, too.
“You know, this is my smile. This is what people see. They don’t see my body. I mean, I’ve got a great body, but they see my smile first!” he said. “It could depict how much you feel about your hygiene. I feel a bit like my defense is down, like I can be misinterpreted. I feel like before somebody hears me speak they might think that I can’t.”
Dental benefits 101: medical insurance “reversed”
Holder now has coverage through his wife’s work, so he’s feeling optimistic as he waits to get called back for his visit. Behind the front counter, meanwhile, Sparano juggles between patient calls and those checking in and out.
“It’s stressful,” she said, specifically referencing when young adults come in with individual dental coverage for the first time or when older adults change plans after many years. “Because I’m working with a lot of disappointed people until we finally get educated together on what needs to be done.”
Sparano says that stress comes in part because the way dentistry and dental coverage work can be a shock to patients. It’s not like health insurance, which is generally there for emergencies.
What if you get really sick or are in an accident?
That’s when a person banks on coverage really kicking in.
“That catastrophic quote-un-quote coverage that medical plans are designed to provide, it’s a little bit reversed with the typical dental plans in the market,” said Marko Vujicic, head of the American Dental Association’s Health Policy Institute.
The majority of dental plans cover cleanings and other preventive work like x-rays, but when a person needs more complicated dental care—ie: implants, crowns, bridges and surgery—dental, in general, only covers up to a certain amount. Then the patient is on the hook for the rest.
For that reason it may be misleading to refer to most dental plans as insurance.
“Dental insurance is really just a dental benefit of $1,000 to $2,000. Some lucky people get $3,000 a year,” said Sparano. “And there are set limits on everything.”
As patients’ care gets more complicated, so too does their share of cost, explains Sparano. For example, lots of dental plans might cover 100 percent of the cost of a cleaning, 80 percent of the cost of fillings, and 50 percent of the cost of major work, up until that maximum, as it’s called, is reached. Then patients pay for the rest out of pocket.
Sparano, who gets so many questions from patients that she’s drafted an explainer for patients that even breaks down the costs for cleanings for self-pay patients, adds that those purchasing individual dental plans, such as through the Affordable Care Act’s online Marketplaces or the AARP, are often surprised to learn that some of the plans include a waiting period—anywhere from six to 18 months—before it will cover any portion of the cost of needed care, beyond a cleaning.
Dental coverage can also function more like a discount or coupon club, by giving patients reduced rates on services.
Those discounts can be significant.
“Like our normal fee for a molar root canal would be $1,600,” said Mary Tevis, an office manager for a practice on the fourth floor of the 16th and Walnut building. “The majority of our negotiated rates would be $900, so a patient rate would be based on $900 versus $1,600.”
The ADA has this breakdown for the differences in how dental works compared to medical.
Medical plans cover needs and treatment that are:
An insurable risk
Dental plans cover needs and treatment that are:
About 205 million Americans, or 64 percent of the population, have dental benefits according to the National Association of Dental Plans’ Joint Dental Benefits Report on Enrollment for 2014. Most have coverage through an employer, which determines the level and scope of benefits for employees. About a quarter have Medicaid or Tricare.
Those with individual plans mark a small but growing portion of the pool, now that coverage is available as an optional benefit for adults through the Affordable Care Act’s online Marketplace.
The separation of dental from medical: a rift that dates back centuries
“By in large dentistry is very unique that they even carved out a separate insurance from the rest of the body,” said Dr. Andrew Spielman, an associate dean at New York University’s school of dentistry who also teaches courses on the history of dentistry.
This separation from medical insurance goes deep into the history of the field itself, Spielman explains. Up until the 1700 and 1800s, dentistry was mostly in the background.
Teeth were an anomaly, and given the severity of tooth pain, they had “a very special status,” with magical powers associated with them.
Plus, unlike bone, “teeth do not regrow or fuse. They seemed to be inert, almost dead, and therefore no one really bothered with it,” said Spielman. “So it was pretty much where medicine gave up on teeth and said, ‘this is something that we don’t deal with.'”
It became more of a craftsman’s trade. Barbers, surgeons, wigmakers, even blacksmiths would perform dental work.
“You have this group of individuals who pretty much pick up a plier and pull teeth without much training or instruction,” said Spielman, adding that there were some informal apprenticeships. “So it was really a free for all type of thing.”
In 1728, the Frenchman Pierre Fauchard, considered the father of modern dentistry, published a book that set dentistry apart as a separate specialty and science.
In the 1840s, the first dental school then opened in Baltimore, signaling a formalization of the profession. For a variety of reasons, including resistance from the medical school, the dental school was separate.
Spielman says with that and the opening of many more dentals schools thereafter, dentistry has pretty much followed its own course, sticking to its surgical heritage.
The emergence of commercial dental benefits
Fast forward several decades: during World War II, health insurance really took off in the U.S. It became a way for employers to attract workers within the confines of federal wage controls. Those plans, however, didn’t include dental benefits.
That started surfacing separately in the post war boom.
“There really wasn’t much coverage before then,” said Ireland, with the American Association of Dental Plans. That’s the main trade group for dental plans.
During that time, toothpaste companies and the dental groups started advertising the importance of oral health.
“It was interesting in the ’60s, there also began to be a focus by manufacturers of toothpaste on getting people to the dentist,” said Ireland.
Some dental groups, mainly on the west coast, created their own prepaid dental plans that by the 70s joined in as part of the bargaining deals for employee benefits.
But remember, health insurance was about having coverage for the worst case scenarios. Dental plans were different, focusing on covering basic cleanings and fluoride services.
“Because the two dental diseases – cavities and periodontal or disease gum disease – are largely preventable,” said Ireland.
The idea, she says, was to avoid the need for high cost care like implants, dentures and crowns. And again, as a person’s tooth complications increased, so too did their share of the cost.
For the most part, that’s the way coverage has worked to this day.
Ireland says the industry’s focus on prevention is a good thing, pointing to ADAP surveys finding that most people aren’t maxing out their coverage.
NYU’s Andrew Spielman, however, sees dental coverage and the $1,000-1,500 average coverage cap, as a joke. Dentists, he says, never had a real incentive to join the medical model, especially as they watched their doctor peers lose their independence and join bigger health systems, as health insurers gained more power.
“I think it was a self preservation sort of thing,” he said. “Keeping dentistry out of managed care, and keeping them separate, so they can still ensure a good living.”
Medicare, the public benefits program for seniors, does not cover dental, but it is required for children with medicaid, the public health benefits program for low income and disabled individuals. In some states, like Pennsylvania, medicaid includes dental benefits for adults.
Looking ahead: merging the mouth back with the body
Nowadays, the mouth has been merging back with the body, thanks to science.
“I’ve been practicing for nearly 30 years, and a tooth has never walked into my office by itself, it’s always attached to somebody,” said Dr. Matthew Messina, a consumer advisor with the American Dental Association who has a private dental practice in Cleveland.
Messina says the field is increasingly realizing that the traditional oral health approach may need some rethinking because of the growing recognition of the mouth’s role in a person’s overall health. That means more communication with doctors and looking out for other health issues that manifest in the mouth, like diabetes and heart disease.
“The dentist can be the first person to see so many problems, so we’re trying to put it back together,” said Messina. “But traditionally, it’s the fact that physicians and dentists were trained in separate schools that sort of divided the process.”
That isolation of dentists is also starting to change.
“There is essentially a look back,” said Dr. Burton Edelstein, a professor at Columbia University’s College of Dental Medicine, referring to the world’s first dental school in Baltimore. “And saying maybe things should not have been so separate.”
Some dental programs, such as at NYU, cross train with nursing and other specialties as part of their education. Inside community some health centers, dentists are practicing side by side with doctors. It’s becoming more integrated in some children’s health initiatives, too, and it’s an essential benefit for children under the Affordable Care Act.
There’s also more recognition that dental costs are making care prohibitive for some people. An Urban Institute Survey released in October found that even those with dental coverage are foregoing care. About one in five adults between the ages of 18 and 64 reported having unmet dental needs because they couldn’t afford the services, the study found.
“The fact that people who have the coverage still indicate significant financial barriers to dental care suggests to me that the model may need some rethinking,” said the ADA’s policy analyst, Marko Vujicic.
Although optional, some medical plans available through the Affordable Care Act are starting to include dental.
Edelstein, who also founded the Children’s Dental Health Project and teaches health policy, says the fact that in some instances a person can get dental coverage through a medical plan marks “a major change.”
The federal government is also moving toward rewarding providers for keeping patients healthy, through new reimbursement models. That may further incentives for dentistry and medicine to connect.
But even though the fields are moving closer together in some ways, for longtime dentists like Messina, it’s hard to imagine that the fundamental ways dental coverage works in the private market will dramatically change anytime soon.