Why your dentist costs so much

Back in April I wrote about a person near and dear to me -- yes, my husband -- who needed two new crowns for $3,442. I published his experience in a post, Is Your Dentist Ripping You Off? Dentists howled in protest at the provocative headline, though most agreed with the content of the story.

Patients howled too, about the high cost of dental work, and the feeling that they’ve encountered dentists who don’t have their best interests at heart. Here’s a typical letter: “My wife saw a dentist who quoted her $750. Then halfway through the job, when she was numb and had a big hole in her mouth, he told her he misquoted the price and it was going to be $1,500. She could not exactly argue.” Another reader wrote of going to two different dentists and getting two completely different opinions about what his mouth needs and when it needs it. Who do you trust?

I heard from people who work in dental labs that charge the dentists $125 for a high-end crown, so why the tenfold markup? One dentist in Grand Rapids, Michigan, offered to do my husband’s work for him for $1,395, or 40% of what he was quoted by his guy. All we would have to do was get him from Pennsylvania to Grand Rapids. (We passed.) Another dentist criticized my “gummy smile.” Others wrote of the hours of pro bono work they do and how that’s never noticed.

Two dentists, Dr. M. in upstate New York and Dr. W. near Indianapolis, agreed to be interviewed. They spoke to me at length about why fees are what they are. Here’s what I learned about why dental work is so expensive.

Dental care is not a commodity. It’s not laundry detergent or breakfast cereal or wireless minutes. Dentistry is a professional service that’s both art and a science. Yes, there are excellent dentists and not-so-great dentists. Often, you get what you pay for. Yet even great dentists have bad days. “I consider myself an awesome dentist,” Dr. W. told me. “And I’ve had failures.”

Overhead costs are huge. Anywhere from 60% to 80% of what a patient pays goes toward the expense of running a modern dental practice. Dentists pay for rent or mortgage payments on their office space, payroll for hygienists, office managers and receptionists, health insurance, taxes, supplies, business insurance and technology -- just to name a few. “A lot of people would be surprised to know how tight the profit margins are,” Dr. W. says. And many dentists are still paying student loans from dental school.

Labs differ in the quality of the products they produce. We all want our dentists to be using high-quality labs for things like crowns and dentures. Should we have to ask about the labs? No. We should trust our dentists to select a good one. “In my view, you always want to use a good lab,” Dr. M. said, “because if the crown breaks, I’m the one stuck redoing the thing for another hour and a half for free. It’s important to make sure I’m putting good stuff in people’s mouths, because the last thing anyone wants to deal with is a redo. It doesn’t make me look good, the patients get angry, insurance doesn’t cover it, and it’s a waste of time. You want to do a good job.” Dr. M. has invested in a $100,000 machine that lets him make the crowns himself and cement them in one visit. He says patients love it and it allows him to control the process and do a better job. His fee, however, is higher than many in the area.

Insurance isn’t really insurance. Dental insurance, the dentists told me, is nothing like health insurance or auto insurance. It’s a maintenance plan that will cover cleanings and x-rays, maybe half the cost of a crown. It will not protect you if you need a lot of work done. The maximum annual benefits, $1,000 to $1,500, haven’t changed in the 50 years since dental insurance became available. “It’s a minor cost assistance, and there’s a widening divide between patients’ expectations of their dental insurance coverage and the actual coverage that’s provided,” says Dr. W.

Dental insurance drives docs nuts and they wish they didn’t have to use it. “The number one most complicated aspect of running a dental office, bar none, is dealing with dental insurance. You wouldn’t believe how long it takes to get through to a rep, make sure the patient does have benefits, calculate a copay,” says Dr. M. And the largest insurance plans in the country discount most dentists’ fees by 10% to 20%. If you’re paying out of pocket, ask for a discount. (You might discover the dentist is giving you one already.)

Dentists wish patients would value their teeth more. Teeth are a crucial part of health and appearance. Untreated gum disease, for instance, is linked to heart disease. (Would you choose a cardiologist based on price?) “With time, you will come to realize that shopping price is a minor concern when it comes to your health,” says Dr. W. “Any minor cost differences amortized out over a lifetime will become insignificant. You will get the best results and have the most long-term satisfaction getting care from someone you trust.”

So if you’re convinced dentists are worth their fees, how do you find a good one? The dentists had some suggestions:

• Ask if he or she uses specialists. Who does your root canals? If the person on the phone says, “We do everything here, that would scare me,” Dr. M. says. Especially orthodontia.

• Ask your primary care physician which dentist she uses. Ask your lawyer. Ask your boss. In other words, ask professional people whom they trust with their mouths.

• Ask a dental specialist, like an endodontist. One specialist wrote to tell me, “The best way to find a good dentist is to find a specialist who sees everyone’s patients on a referral basis. He or she will know who is good and who isn’t. Trust me, as a specialist, I know who is doing what, because I see their work every day.”

• If a dentist doesn’t take insurance, because he or she doesn’t need to, that will be a pretty good dentist. Those pros can book you for longer, and they don’t have to work under the constraints of insurance companies. Be prepared to pay higher fees.

• Look and look some more. Interview dentists, if they’ll let you. Take the view that your teeth are a lifetime investment.