Dentists are bad

A field full of scams, with incomes propped up by irrational regulation

In these polarized times, I think it’s important to try to find opportunities to bring people together and draw attention to public policy issues that are orthogonal to deeply entrenched culture wars.

For example: Dentists.

On one level, yes, oral health is important, and it is good that there is a profession dedicated to advancing it. On the other hand, the form of dental care that most people need is a regular cleaning, and perhaps some x-rays just to check for problems. And if you’ve ever been to a dentist’s office, you’ve probably noticed that the dentist does not actually do this work and that it is done instead by a dental hygienist. One might think that since the work of a routine dental appointment is done by a hygienist rather than a dentist, a standard oral health appointment would simply be with a hygienist who lets you know if you need more specialized dental care. In reality, however, “scope of practice” rules pretty strictly limit which services a hygienist can provide, and only in Colorado and Oregon can hygienists perform diagnostic work.

Some states have updated their scope of practice laws since this chart was published, but hygienists still face heavy restrictions in almost every state.

There is, notably, no real ideological or partisan pattern to this patchwork of regulations, which is usually a sign that you are dealing with shady interest group politics rather than any plausible theory of public interest. You’ll also note that it’s not like we all walk around with stereotypes in our minds about people from Colorado and Oregon having bad teeth — there’s no Portlandia sketch about that.

And while I, of course, condemn anti-dentitism in all its forms, dentistry’s bad regulatory state turns out to be just one part of a broader web of unsavory business practices in the oral health industry.

This is, admittedly, a kind of random topic.

But part of my (so far vain) hope that a full employment economy would generate a healthier politics is that this is precisely the kind of issue that policymakers who want to see stronger growth and higher wages need to focus on in a world where unemployment is low.

The troubled dental insurance landscape

The rational, politically unrealistic (though existing in many foreign countries!) way to organize health care policy would be for the government to decide on some amount of money that it’s willing to spend on providing health care services to people, and then to put together a list of covered services that prioritized cost-effective services over low-value ones. Anything else, people could pay for out of pocket. There would then be political debates like “maybe we should spend more so we can cover more stuff” and counterarguments like “no, we shouldn’t do that because we would have to raise taxes.”

Instead, America has a system that is largely “private” but massively subsidized through the tax code.

This means of providing public subsidy has a lot of odd and mostly bad consequences (it’s quite regressive, among other things), including the creation of a confusing corporate benefits landscape that includes lots of subsidiary products, like dental insurance.

The problem with dental insurance is that because it’s not regulated particularly stringently, you can’t typically buy a product that insures you against the risk of catastrophically high dental bills. Instead, you get plans with relatively low annual maximums, which defeats the purpose of having insurance. What you are essentially doing is pre-paying for routine dental care, which doesn’t make a lot of sense conceptually — you end up paying an average payment $47 per month, when an uninsured tooth cleaning runs about $80-$100 on average. For the record, $47 times 12 is $564. It doesn’t pencil out.

One of the best-polling proposals from Build Back Better was to have Medicare include dental coverage, which would make sense because it’s actually possible to deliver real insurance value in that context. What’s more, the government could take advantage of Medicare’s massive scale to push the per unit cost of treatments down. But of course dentists don’t like that idea, so the American Dental Association lobbied against providing seniors with dental coverage. But it’s not like dentists would be out in the street, impoverished, if they had to accept lower fees.

Dentists are rich and often shady

Dentists occupy a kind of blind spot in the popular understanding of the American class structure.

They’re not billionaires or corporate executives, obviously. The field is not in the consulting/banking/tech bucket of careers that whiz kids from the top colleges pursue. It is famously easier to get into dental school than medical school. And, of course, dentists are scattered all across the country, not clustered in superstar metro areas. Yet it’s still professional training for college graduates; it’s not in the bucket of low-education rich guy fields like owning a car dealership.

And dentists make a lot of money. As Jonathan Rothwell points out, “there are five times as many top 1 percent workers in dental services as in software services.” About fifteen percent of dentists earn enough to qualify for that lofty status. The median hourly wage in the United States is $22.26 versus $74.54 for dentists. That doesn’t make the Medicare concept a total no-brainer — there are plenty of competing potential uses for tax money — but it certainly underscores that driving down the profits earned by dental businesses would have a progressive and beneficial impact on the distribution of wealth and income in this country.

This is particularly true because, as best I can tell, the dental industry is significantly under-regulated and under-scrutinized in regard to it’s science and ethics.

As the great Kenneth Arrow wrote in his famous 1963 paper on the welfare economics of medical care, the market for health services is significantly influenced by asymmetrical information. In other words, when you pay a health care provider, you aren’t just taking advantage of the division of labor by outsourcing a task you could, in principle, handle yourself. You also aren’t buying something — like a movie ticket or a restaurant meal— where your own subjective evaluation of whether you enjoyed it is the relevant criteria. If someone tells you that you need a certain treatment, you don’t get the treatment because it’s fun, you get it because you trust their technical expertise… expertise that you don’t have. Arrow’s paper most frequently comes up in the context of doctors, but the point applies equally well to dentists, who in practice have less training and face less scrutiny.

Ferris Jabr noted in The Atlantic in 2019 that there is almost no systematic scientific evidence undergirding the practice of dentistry, such that even a maximally ethical dentist is, to an extent, just making informed guesses when she tells people what they should be doing:

The Cochrane organization, a highly respected arbiter of evidence-based medicine, has conducted systematic reviews of oral-health studies since 1999. In these reviews, researchers analyze the scientific literature on a particular dental intervention, focusing on the most rigorous and well-designed studies. In some cases, the findings clearly justify a given procedure. For example, dental sealants—liquid plastics painted onto the pits and grooves of teeth like nail polish—reduce tooth decay in children and have no known risks. (Despite this, they are not widely used, possibly because they are too simple and inexpensive to earn dentists much money.) But most of the Cochrane reviews reach one of two disheartening conclusions: Either the available evidence fails to confirm the purported benefits of a given dental intervention, or there is simply not enough research to say anything substantive one way or another.

Some people, of course, are not that ethical. And even those who are ethical are naturally going to find themselves inclined in the direction of self-interest when dealing with an evidentiary void. William Ecenbarger did a great investigative report for Readers’ Digest years ago where he visited dentists in different cities and asked for their recommendations and got prescribed courses of treatment ranging from $500 to $25,000. One outfit in Philadelphia diagnosed him this way: “Tell me what your insurance limits are, and we'll proceed from there.”

Back at Vox, I used to work with Joey Stromberg (whose dad is a dentist), who wrote a piece about how “while seeing other dentists, my brother has been told he needed six fillings that turned out to be totally unnecessary (based on my dad's look at his X-rays) and I've been pressured to buy prescription toothpaste and other products I didn't need.” Aspen Dental appears to have built a whole corporate dental chain around the observation that you can attract patients with low prices and then make it up in volume by prescribing unnecessary treatments.

The social science of dentistry

To return to the scope of practice issue that we began with, while the scientific underpinnings of dental medicine are awfully vague, we do have pretty clear social science about the economic and public health consequences of different paradigms of dental regulation.

Where hygienists are allowed to be self-employed, their incomes rise by about 10 percent, while the incomes of dentists fall. The median hourly wage for dental hygienists is about $39 per hour — higher than the national average, but much lower than for dentists, so this is a progressive economic change.

But what happens to patients? Does dental health get better or worse with a stricter regulatory regime?

The Air Force assesses the dental health of its incoming recruits, which researchers used to gauge state-by-state variation. They find that stricter rules are associated with higher prices for consumers of dental services and worse oral health outcomes. A different team looked at state-by-state variation in the need to have teeth removed due to decay, and found that “more autonomous dental hygienist scope of practice had a positive and significant association with population oral health in both 2001 and 2014.”

Dental trade publications are full of advice about how to help your practice weather a recession, indicating that dentists themselves are well-aware that patients’ willingness to undergo routine tooth cleanings is responsive to their ability to pay. Of course, I think a person experiencing acute dental distress that requires high level treatment is likely to seek that treatment out even if it’s financially difficult. But the kind of basic cleanings and x-ray screenings that are the cornerstone of preventative dental health are things that people skip when they are squeezed financially. Letting hygienists do it more autonomously means it can be done more cheaply, which means not only savings for patients but better health outcomes. What’s more, in the very near future it should be possible to have x-rays evaluated by AI models that could be centrally regulated and would give standardized prescriptions for treatments rather than the current patchwork of humans making stuff up.

I acknowledge that this kind of thing can feel a little picayune relative to policy disputes that speak more to our core values and our identity as a nation. But to restate a theme I’ve been trying to hit more and more over the past year, having an economy with low unemployment means you need to try to find more ways to improve efficiency. Dentistry is also just a good example of how it’s not true that we face a routine tradeoff between efficiency and equality — the more efficient approach here is also more egalitarian. And the very fact that this topic, while important to families’ finances and health outcomes, does not touch at core questions of values and national identity means that talking about it can be non-polarizing and, hopefully, help diminish the tendencies through which this country is currently tearing itself apart.