July 26–It began with a toothache. Tori Pence, 23, could feel the hole that had suddenly developed on her tooth, and she couldn’t stand either hot or cold food. The bespectacled girl with electric-blue hair had worked a string of odd jobs and hadn’t seen a dentist for at least five years.

When she finally got in to see one, she needed a root canal. And fillings for 15 cavities.

“Dentally speaking, I am healthy now,” says Pence, who lives in Lansdowne and has been making monthly visits to the University of Pennsylvania’s dental clinic for almost a year. “But I still have seven more [cavities] to go.”

Pence is one of the estimated 132 million people in the United States without any sort of dental insurance. It’s an endemic problem among the unemployed, the poorly paid, and those without medical insurance.

While the national health-care act passed in spring will increase the number of people eligible for medical insurance, its effects on dental will be mixed.

The law increases coverage for children, and will eventually cover more adults under Medicaid, the joint state-federal health plan for the poor. But adult dental services are often hard to find: Less than one-third of dentists in Pennsylvania and New Jersey participate in Medicaid.

Many people don’t see the value in preventive dental care — or they dread it — and postpone routine checkups. That is, until it becomes too painful to chew or a front tooth is chipped.

In Philadelphia, geriatric dentist Ann Slaughter says many elderly patients she has examined at inner-city senior centers haven’t seen a dentist for up to 15 years.

But “oral health is intimately connected to overall health,” she says.

Periodontal disease can cause or worsen heart conditions, strokes, and respiratory illness.

It can be perilous for diabetics. Germs from gum disease can make them more prone to complications, says Slaughter, an assistant professor at the University of Pennsylvania School of Dental Medicine and a member of the city Board of Health.

More than 200 diseases of the mouth can also cause problems elsewhere in the body. The plaque on teeth can travel into the blood and contribute to hardened arteries, a risk for heart attack.

In 2000, Surgeon General David Satcher called dental and oral diseases a “silent epidemic” facing the nation.

“We’re in 2010, and we haven’t made many advances,” Slaughter notes. “That’s the sad part.”

One problem is the many gaps in dental insurance, which unlike medical insurance, was never intended to completely cover anything.

For those without insurance, the median price for a root canal in Philadelphia is $862, according to a survey that dentists use to price procedures. A crown can cost as much as $1,200.

And while 172 million Americans under 65 have private health insurance, just 45 million of them have any sort of dental plan, according to the National Center for Health Statistics.

In Pennsylvania, 40 percent of the entire population of adults and children lacks dental insurance, according to the Pennsylvania Dental Association.

Medicare has substantial holes as well. It covers health care for virtually all seniors and some younger people with permanent disabilities. But it doesn’t pay for routine dental care.

When people turn 65, says Slaughter, “those with disposable incomes pay out of pocket or they keep their dental insurance.”

Medicare does cover dental procedures that are connected to a larger medical issue. A surgeon won’t perform an open-heart operation on a patient who has a mouth abscess, for example, until a dentist has treated the problem.

Medicaid poses its own challenges. There are 508,000 recipients in Philadelphia, but many of the adults aren’t eligible for dental because they aren’t permanently disabled or fail to meet other criteria.

Those who are eligible can have a hard time finding a dentist.

“Just because you have insurance doesn’t mean you have access,” says Laval Miller-Wilson, the executive director of the Pennsylvania Health Law Project.

Pennsylvania has some of the lowest reimbursement rates in the country, according to a recent report by the Pew Center on the States. Pennsylvania’s Medicaid program reimbursed dentists 53 percent of what they customarily charge. The national average for Medicaid is 60.5 percent.

New Jersey had among the nation’s lowest reimbursement rates until recently, but now pays 103 percent of the customary fee, according to the Pew Center, which nevertheless gave the state an F on its dental report card due to other limitations of coverage for the poor. (Pennsylvania also got an F.)

Miller-Wilson says some dentists’ aversion to Medicaid is about more than money. The paperwork is cumbersome. And broken and late appointments are common among the poor.

Instead of accepting Medicaid, “many dentists say they would rather treat patients during free clinics or pro bono,” says Rob Pugliese, spokesman for the Pennsylvania Dental Association.

Lack of increased funding for Medicaid dental services is a major reason the American Dental Association opposed the health-care bill.

In 2014, when the new law enables millions more Americans to join Medicaid, many advocates wonder if there will be longer lines to see dentists as well as doctors.

“The health-coverage bill is going to exacerbate the current supply problem,” says Miller-Wilson, adding that the state of dental care now may foreshadow what is to come.

Many advocates point to the 2007 death of 12-year-old Deamonte Driver in Prince George’s County, Md., as the impetus for Congress to make sure that dental was included in the basic benefits package for children on Medicaid.

Driver died from a bacterial infection caused by an abscess in his mouth. His mother had been unable to find a dentist who would accept his Medicaid.

Philadelphia’s Slaughter wonders whether “it will take another catastrophe like Driver’s to get policy makers’ attention.”

Even if coverage is broadened, other issues remain.

Pence, the woman with 15 cavities, is in many ways typical of her generation. She was cut off from her father’s health and dental insurance when she turned 18. She ignored her teeth for several years as she worked part time.

Last September, the pain became overwhelming. Following her aunt’s advice, she went to Penn’s dental clinic to get treated at a reduced rate.

In March, she started working a full-time job with benefits. She can now afford yet another fix: the skin graft she needs at the base of her bottom front teeth. Her tongue piercing had worn down the gums so much that “you can see the roots of my teeth,” Pence says.

She has since removed the piercing. She promises to see her dentist regularly in the future.

Reduced-Fee Dental Clinics in Region

Donated Dental Services

717-238-8721

www.nfdh.org (Locations throughout Southeastern Pennsylvania)

Philadelphia

City health centers

Seven of the clinics offer dental services. Call 215-686-1776 for locations, or go to www.phila.gov/health/Services/Serv_DentalCare.html

(Medicaid accepted)

Afton Family Dental PC

215-462-6229

Fairmount Primary Care

Center

215-684-5349

www.dvch.org

Maria de los Santos Health Center

215-291-2509

www.dvch.org

(Medicaid accepted)

Frankford Avenue/Hunting Park/Snyder Dental/Wilson Park Medical Centers

215-229-1390

www.gphainc.org

(Medicaid accepted)

Vaux Family Health Center

215-236-8289

www.qchc.org

(Medicaid accepted)

QCHC Family Health Center

215-227-0300

www.qchc.org

(Medicaid accepted)

University of Pennsylvania School of Dental Medicine Dental Clinic

215-898-8965

www.dental.upenn.edu

(Medicaid accepted)

Ronald McDonald Care Mobile

215-427-8877

(Free for qualified children; Medicaid accepted)

Clinic of Temple University Kornberg School of Dentistry

215-707-2900

www.temple.edu/dentistry

(Senior citizen discount; Medicaid accepted)

Bucks County

Bucks County Health Improvement Project

1-800-347-6803 (Free for qualified children)

Ann Silverman Community Health Clinic

215-345-2410

HealthLink Medical Center

215-364-4247

www.healthlinkmedical.org

Chester County

Community Volunteers in Medicine

610-836-5990

www.cvim.org

(Free)

The Children’s Dental Clinic

610-240-1213

Delaware County

ChesPenn Health Services

610-874-6231; 610-497-2900

Montgomery County

Manor Dental Health Center

215-887-7617

www.manor.edu

Greater North Penn Dental Initiative

1-877-466-7764

(Medicaid accepted)

Norristown Regional Health

Center

610-278-7787

www.dvch.org

(Medicaid accepted)

The Abram and Goldie Cohen Dental Programs Center

610-526-6015

www.harcum.edu

(Medicaid accepted)

Camden County

Camden County College, Dental Hygiene Clinic

856-374-4930

CamCare Health Corporation — East

856-635-0307

(Medicaid accepted)

CamCare Health Corporation — Gateway Center

856-963-8768

(Medicaid accepted)

CamCare Health Corporation — Clementon

856-627-7701

(Medicaid accepted)

UMDNJ — Somerdale

856-566-6969

(Medicaid accepted)

Virtua Dental Health Center

856-246-3545

(Medicaid accepted)

SOURCES: Pennsylvania and New Jersey dental associations

Contact staff writer Brooke Minters at 215-854-2244 or bminters@phillynews.com.

Credit: The Philadelphia Inquirer

As much as we might hope to buy coverage in a pinch, insurance companies are smarter than that. They might cover exams and X-rays immediately, but fillings and oral surgery usually require a one- to two-year wait.

Instead, the reader bought into a discount network and saved about $800 after purchasing an individual membership for $100 a year. The waiting period before her benefits kicked in? Three days.

It’s called a discount dental plan and it’s similar to buying a membership at Costco or Sam’s Club. For the price of your annual membership, you get the benefit of paying lower prices on the products or services offered.

The dentists who participate in the program agree to accept a discounted fee from the plan as payment in full for their services. For example, a white filling is typically $173, but discount plan members pay $51 to $116, depending on the plan. A crown is typically $1,200, but members pay $473 to $1,000.

Annual membership fees range from $80 to $160 for an individual and $130 to $200 for a family.

One of the best ways to shop for a plan is at www.dentalplans.com. It has aggregated plans from more than 30 companies, including Aetna and Cigna. After putting in a ZIP code, you can find dentists in your area who accept the plans and what the discounted rates are for fillings, crowns, root canals and dentures.

Most people have never heard of the discount plans, probably because nearly 70 percent of Minnesotans have dental insurance, said Loren Hanson, director of marketplace activities at the Minnesota Dental Association in Minneapolis.

But even those with insurance might want to consider a dental plan if they have some unexpected big bills. Dental insurance typically has a maximum benefit per year of $1,000 to $1,200. Anyone who has already met the annual maximum and develops a new toothache is unlikely to wait until January to get it fixed.

Hanson said the MDA has had few complaints about the discount dental plans but says many patients will find that their dentist doesn’t offer the discounts. About 10 percent of dentists in the Twin Cities offer them, he said.

Dental plans have a 30-day cancellation policy and no waiting periods, deductibles or maximums. Orthodontia and cosmetic procedures are included in some plans. DentalPlans.com is offering a 10 percent discount with the code “July10,” but when I called several months ago I was offered a 20 percent discount after I balked about joining. Call 1-888-632-5353 or visit the website.

Dental implants already hold a substantial 18% share of the global dental device market, and are also expected to have one of the highest growth rates amongst all dental device submarkets. This is primarily because dental implants offer an effective treatment for edentulism and because of the rising demand for cosmetic dentistry worldwide across all age groups.

The global dental implants market is expected to grow from $3.2 billion in 2010 to $4.2 billion in 2015 at a CAGR of 6% from 2010 to 2015. Europe currently forms the world’s largest market for dental implants with a 42% market share, and is also expected to have the highest CAGR, 7.0%, from 2010 to 2015.

While the lack of consumer awareness in developing economies may hinder market growth, industry players still have immense growth opportunities as merely 2% to 3% of the global edentulous population has already received dental implant treatment so far. The aging baby-boomer population in developed nations offers an especially high-growth opportunity, as this consumer segment is characterized by high disposable income, and also by an increased need for dental care due to longer life expectancy.

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Comprehensive market analysis for the following sectors:

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Key Questions Answered:

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Cosmetic dentistry has been a staple of dental practices since the ’90s, when the widespread availability of teeth whitening products revolutionized the market.

Even the recession couldn’t vanquish vanity; steady consumer demand for teeth bleaching, tooth-colored fillings, implants and other cosmetic procedures has kept dentists smiling through today’s tough economic times. It’s also helped keep dental benefits popular and prompted some leading dental insurers to broaden plan coverage to include cosmetic services.

“More and more dentists see cosmetic procedures as a way to increase their revenue,” says Dr. Roma Virani, second vice president, Dental Cost & Utilization at Assurant Employee Benefits. For example, “most practices are doing tooth-colored fillings. It used to be that only a third of the fillings on back teeth were composites. Now that is reversed.

“While some people are concerned about the safety of amalgams,” she continues, “the switch is primarily driven by aesthetics. You get equally good results, so one type is not better than the other. However, people want their fillings to be tooth-colored so they are not as visible.”

Whitening leads the way

By far the most popular cosmetic procedure is teeth whitening. Dental magazines report that the most common conversation dentists have with their patients is about bleaching. Bradley Dykstra, DDS, wrote about the trend in Dental Economics magazine in April.

“The quest of baby boomers to stay forever young and society’s expectations to look our best drives this demand,” he says. “It is important to understand that patients, both male and female, want whiter teeth – period.”

Until a few years ago, bleaching was not covered by dental benefit plans. This changed when a handful of dental plan providers heeded requests from brokers and employers for voluntary insurance products that would offset the cost of cosmetic dental procedures for employees.

“All insurers in this industry are always looking for something new and different for brokers to sell,” says Kevin Martin, dental product development leader at Sun Life Financial. “Cosmetic was something the industry shied away from because it was not necessary care. Sun Life came up with the thought that since people want nice, shiny teeth, wouldn’t it be nice to offer a benefit that covers some, but not all, of the cost. I guess covering cosmetic was our iPod.”

Sun Life offers two cosmetic dental riders to its insurance plan. One covers teeth whitening done in the dental office or at home with products provided by the dentist. The other includes veneers as well as whitening.

The cost of the riders is based on the annual maximum selected and adds 3% to 6% to the standard dental insurance premium.

“It’s all about the smile,” maintains Paul Sherman, vice president and national sales director for American General Benefits Solutions, which began covering cosmetic procedures under its voluntary “Smile Maker” benefit plan two years ago.

Smile Maker currently covers teeth whitening and implants and will soon be expanded to include implants and composite fillings, according to dental product manager Sadia Zoppi. “It works like a lifetime orthodontia benefit for each family member,” she says. “About 2% of our business has this feature, but we anticipate that it will increase as more plan sponsors ask employees to contribute to the cost of their dental plan.”

The Smile Maker add-on is $8 per month for an individual and $32 per month for a family. “That can be a substantial increase in cost on a lower-priced dental plan that’s, say, $50,” notes Zoppi.

These products are expensive in nature, says so you’d expect this, says Zoppi. “But they are still very attractive, and they are meeting a need. There is a growing demand for these services.”

According to AACD, the mean amount spent by the average patient in 2006, the last year for which data is available, was $5,640 and the median was $3,860. At the high end, 3% of practices indicated an average amount spent per patient of $20,000 or more.

At the other extreme, 2% of practices reported average patient costs of less than $500. The most often indicated categories were $5,000-$9,999 (23%) and $2,500-$4,999 (22%).

Assurant Employee Benefits also was one of the first to cover teeth bleaching. Some of its plans also include posterior composites and porcelain crowns on posterior teeth, which it considers restorative rather than cosmetic.

“Going along with these trends, Assurant has come out with products that will take employees’ benefits farther,” says Virani. “We have Family Share Max and Preventive Max Waiver products that give more benefit dollars to plan members for these services. With the Preventive Max Waiver, preventive work does not count toward the annual maximum, so more dollars are available for non-preventive services.

“This supports our belief that if patients are getting preventive work done, they’ll need less restorative work in the future.”

Guardian broke new ground in 2004 when it extended coverage to implants. The company also offers coverage for whitening, posterior composites, porcelain inlays and onlays, and porcelain crowns and veneers.

“We take a lot of pride in customizing our plan designs to meet brokers’ and plan holders’ price points,” says Dr. Richard Goren, second vice president of Guardian’s group dental unit.

“There are hundreds of options. No one offers everything that we do.”

Brighter smiles, better health

Dentists view cosmetic dentistry not only as a means to increase revenue, but also as an important way to improve Americans’ oral health.

“If I want to whiten my smile, the dentist is going to talk about restorative needs before doing cosmetic work,” says Goren. “The motivation for a bright smile and white teeth is coming from the individual patients, and the drive for overall care is coming from the dentists.”

Like bleaching and tooth-colored fillings, implants improve patients’ appearance and promote self-esteem. But they also can help prevent problems down the road, Goren notes. “Bridge work involves shaving the tooth and cementing the bridge on top of it. When that happens, the tooth is never as good as when it was healthy. With an implant, no one is contributing to a tooth’s demise.”

Dermal filler next?

Dermal filler therapy may be a natural progression of where the cosmetic dental industry is heading, according to Goren. “With proper training, these procedures are easy for dentists to accomplish. Patients are motivated to accept these therapies and excited about having them done under local dental anesthesia, making dentists the health care professionals of choice to deliver these procedures.”

Whether dental plan providers will push the cosmetic coverage envelope to cover dermal filler therapy remains to be seen. Meanwhile, however, a new national movement is underway among dentists that could spark discussions about including cosmetic procedures as part of basic dental plans.

The dental industry has been lobbying across the country for states to prohibit insurers from negotiating discounts on services that are not covered.

Because there is a great deal of discounting on cosmetic procedures, this trend is significant, according to Evelyn Ireland, executive director of the National Association of Dental Plans in Dallas.

“The dentists feel that they are in an unequal, negative position,” she says. “Their position is if a carrier won’t pay toward a service, they shouldn’t be required to discount it.”

“The no-discounts on non-covered services legislation is not very consumer friendly,” says Virani. “If a service that is cosmetic in nature is not covered, the dentist will have better luck convincing the patient to have it done if it can be provided at a discount. Discounts are the cornerstone of PPO products, so this is changing things quite a bit.”

“Carriers aren’t happy [with these regulations] because employees are losing out on discounts,” agrees Martin. “It is possible that we’ll see a resurgence of requests for coverage for cosmetic services because then we could offer a discounted fee if that’s requested.”

Discounted or not, there’s no doubt that patients will continue to request cosmetic procedures and dentists will continue to expand the scope of these services.

“It’s a nice time to be a dentist when you have patients who are smiling, looking good and you know they have a healthy mouth,” says Guardian’s Goren. “It’s a stark contrast to getting feedback that it hurts and they don’t like anything you can do for them.”

By the numbers

In 2007, the American Academy of Cosmetic Dentistry put the market for cosmetic dental procedures at $2.75 billion, based on a 2006 survey of its members. Of that, $138.8 million was for bleaching and whitening, $383 million was for posterior composites, or rear fillings, and $144.3 million was for implants. The total number of patients seeking cosmetic services was estimated at 2.69 million, which represented a 12.8% increase over 2005. Furthermore, the survey respondents expected another 11% increase in patients and revenue in 2007.

Credit: By Lynn Gresham