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Oral History: Why Your Dental Work Isn't Covered by Medical Insurance

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Oral History: Why Your Dental Work Isn't Covered by Medical Insurance

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I was at the dentist recently for a toothache. He snapped some X-rays, gave my mouth a quick lookover, said I appeared to have cracked the tooth (likely from my severe TMJ) and would need a root canal. He forwarded me to an endodontist. The endodontist discovered I had a strange mass in my jaw that appeared unrelated to the cracked tooth. He put me on antibiotics to prevent infection and forwarded me to an oral surgeon, who confirmed the mass was harmless. Now I'm going back to the endodontist for the root canal, and then back to the dentist for the crown. I have spent over $500 and about eight hours in dental chairs to get this far. It will be thousands more dollars and dozens more hours before I solve this problem. None of it is covered by medical insurance.

I should have gotten dental insurance, right? That's what I kept telling myself, until I actually looked into the dental plans for which I qualify (more on that in a moment). But the real question here: Why is dental not covered under medical insurance? The same may be asked of vision, but at least there if you have a serious eye problem (like glaucoma or cataracts) you go to an ophthalmologist, which is covered by medical. Such isn't the case with dental.

The oral cavity is a gateway to your body. A lot of stuff in the mouth can indicate kidney disease, heart disease, diabetes, HPV, cancer, etc.

The partition between dental and medical makes little sense given that "oral health is directly related to general health," says Dr. Gary Glassman, an endodontist based in Toronto, Canada who also practices in the U.S. "The oral cavity is a gateway to your body. A lot of stuff in the mouth can indicate kidney disease, heart disease, diabetes, HPV, cancer, etc. Your dentist can be your first line of defense."

The Barbaric History Of Dentistry

Despite it being a plainly medical issue, oral health has always been an outlier. Until the 1800s, dentistry was the domain of barbershops, practiced in the same chair and usually by the same guy who shaved your beard.

"How would you feel if you went to your hairdresser and they pulled your tooth or lanced your abscess?" asks Dr. Glassman.

It's so bizarre and frightful an image that it's almost comical, but the history of our teeth and jaws being treated as something as incidental as our hair and nails still haunts us.

"Dentistry has always had a disconnect to medicine," says Dr. Michael Tischler who specializes in reconstructive dentistry and the implant editor for Dentistry Today. "In 1840 dentistry was proposed as a medical specialty to the University of Maryland in Baltimore and rejected."

We may have since greatly evolved in how we regard and understand dentistry, but we haven't embraced it as a primarily medical issue; if we had, it would be covered under medical insurance, or at least, things like a root canal would be, because if you need a root canal and don't get one, you could end up with all kinds of lethal problems that lead to hospitalization. It is rumored that Queen Elizabeth died from blood poisoning as a result of an untreated tooth infection. That was a long time ago, but hey, it happens.

Why isn't a health problem so serious it can be deadly, not considered medical? To an extent, it's because it's not that common to end up in the hospital as a result of a tooth or gum problem — not if you're keeping up with preventative dental care.

The Insurance Game of Risk

"The reason dental is separate from medical is that the nature of the risk is fundamentally different as is the deferability of the care," says Dr. Adam C. Powell, president of Payer+Provider Syndicate, a management advisory and operational consulting firm focused on the managed care and healthcare delivery industries. "If you're having a heart attack you'll go to the ER right away. Dental problems can often wait and unfortunately often do. The problem may deteriorate, but often it's not necessarily life-threatening."

Yes, dental problems often do wait. Mine is waiting until my next paycheck (or three). But the argument that dental problems are less severe than "medical" ones doesn't quite hold up, not when you look at the numbers of ER visits for which dental-related problems account.

"More than 800,000 annual ER visits arise from preventable dental problems," says Dr. Allena Willis Kennerly, an orthodontist. Dr. Glassman adds that this year alone 50,000 people will be diagnosed with oral cancer, adding, "Probably 10,000 of those people will die, but these are things that if caught really early can be better treated, before they spread and metastasize."

Dental Insurance Is Like 'Triple A For Your Mouth'

Now, let's say you do have dental insurance. That's certainly more favorable than the alternative, but it's hardly ideal. If you undergo a serious procedure, you'll likely still be left with a hefty bill.

"Dental insurance, unlike medical, is not regulated and it tends to be very constrained," says Powell. "The annual maximum benefit is not that high, and there's usually some sort of deductible."

And it's a relatively new type of insurance, with Dr. Bobbi Stanley, a dentist, noting that it was first introduced some 60 years ago. "Dental work was a fee for service agreement until the mid-50's when dental insurance was introduced in California," says Dr. Stanley. "[Plans] rose in popularity throughout the '60s and had a reimbursement of about $1000."

Inflation may have catapulted the worth of the dollar over the decades, but the reimbursement rate for dental insurance hasn't budged much. "Most dental insurance companies have an [annual] maximum of $1,500.00," says Dr. Anil Dwivedi, a general dentist with a specialty in anesthesiology.

Clearly the purpose of dental insurance is not to cover dire issues, but to prevent them — by encouraging regular maintenance. Dr. Powell likens dental plans to "Triple A for your mouth," highlighting that "it's not like car insurance [which covers catastrophes], but it includes a few free oil changes."

A few oil changes can go a long way (to stick with Powell's disturbingly apt analogy), and preventative care does have a terrifically positive impact on one's oral health. But it doesn't prevent every problem. Take me for example. I need a root canal because I cracked a tooth from clenching and grinding — even though I wear a $600 bite guard at night (which was made for me by a dentist when I had dental insurance, and which was not covered by my dental insurance). Problems like mine are, evidently, not so rare.

"Unfortunately we see extreme situations like this all the time," says Dr. Tischler. "So even though I preach prevention, prevention, prevention, it won't save you from serious dental emergencies. And that is compounded by the fact that while dental insurance will cover preventative aspects of dental care it doesn't always cover major dental procedures for adults. This is something that people need to be aware of from a financial planning standpoint."

Dr. Powell asserts that one major reason dental plans tend to be so minimal in what they cover, is because people don't want to shell out higher premiums.

"If [dental plans] were more inclusive, that could be a problem because then premiums would be higher, and if premiums were higher, plans would be less appealing to people," says Powell. "I buy the dental plan because it's a good rate and it's cheaper than paying directly out of pocket. If it started covering these high claims it would not be $400 a year dental plan, it would be a $700 a year plan, and then I wouldn't buy it."

The Case To Merge Medical and Dental

There are still a lot of people not buying dental insurance, even when many plans costs less than a Netflix subscription. No judgments, people, I'm in the same camp.

"Some 74 million Americans had no dental coverage in 2016," says Dr. Tischler. "The dentally uninsured rate has increased to about four times the medically uninsured rate — even with dental coverage expansions. In part, this is due to the lack of dental coverage in traditional Medicare. Those over 65 may still have coverage through an employer, be able to purchase individual dental coverage or obtain dental coverage as a supplemental benefit through a Medicare Advantage plan; however only 52.9 percent reported having dental coverage on the 2016 NADP consumer survey while virtually 100 percent of seniors have medical coverage under Medicare."

Dentists are trying to decrease the separation between dentistry and medicine because we are doctors of oral medicine.

It doesn't look like interest in dental insurance will pick up in 2017, but someday we might not have to worry about it. There is a glimmer of hope that dental will eventually be covered under medical in the future.

"It's widely accepted that dental and medical are separate, but the gap is closing as we move forward," says Glassman. "Dentists are trying to decrease the separation between dentistry and medicine because we are doctors of oral medicine."

There's also the mounting data that the healthcare industry could benefit from covering dental as part of medical. Consider those 800,000 ER visits per year for dental-related problems. Wouldn't more people get the preventative dental care if it were covered by their medical insurance? Couldn't medical insurance companies ultimately save oodles of money on emergency care if the problem were nipped in the bud free of charge?

Dr. Glassman certainly thinks so.

"It would be more affordable for medical insurance to include basic dentistry," says Dr. Glassman. "Not only would it save a lot of lives, it would save a heck of a lot of money."

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