Dental Insurance Misconceptions

There are many misconceptions within the public perception of dentistry surrounding dental insurance. The first and most important is the idea that “dental insurance” is “insurance” at all. When individuals purchase “insurance”, the purpose is primarily to protect themselves from an unlikely event or situation that would cost a significant amount of money—for example, the loss of a house in a fire, or being diagnosed with cancer requiring hundreds of thousands of dollars in medical procedures. This is true for most types of insurance as the insurance company collects small monthly premiums from a large number of participants and pays out loss-connected benefits according to their policies on statistically rare events or situations. This is the true definition of insurance. Fire insurance, life insurance, homeowner’s insurance, and even medical insurance all come under this definition.

A better definition of dental insurance is that it is more of a “dental benefit.” Dentistry is not a rare event, and according to the CDC, more than 85% of adults and 45% of all U.S. children experience dental cavities. Dental caries (cavities) are the most common chronic disease of childhood in the United States. The cost of this care, while it is not inexpensive, does not accumulate to the levels of unexpected surgery and a long-term medical stay or replacing a home. Consequently, the classic model of insurance doesn’t work well in dentistry. For that reason, in the 1960s, dental insurance was invented as an employer-sponsored benefit to assist employees in offsetting the costs of regular dental maintenance. But because so many individuals have dental needs, in order to offer dental insurance, caps were put in place to limit the benefit to $1,000–$2,000 per year in most cases.

Due to this cap, most policies that are purchased by individuals, employers, and employees primarily include coverage for regular cleaning visits and restorative work like fillings and crowns. Although policies do exist with coverage for preventive therapies and other necessary dental procedures, often, dental customers choose insurance policies with a focus on restorative and regular checkup benefits based on a treatment model of care, not a wellness model.

The next most prominent misconception regarding dental insurance occurs when patients believe that their dental benefit covers all of their necessary oral health care needs, and anything that is not covered by their benefit is not necessary to maintain their oral health. This is often a real frustration for both dental practitioners and patients. For example, a patient presents with 4 new cavities and periodontal (gum) disease and has caries risk factors and a high biofilm challenge (caries infection). In order to adequately treat the patient and make strides toward health, all areas of decay need to be removed and filled, periodontal therapy performed, and antibacterial caries therapy started. But the patient only has enough dental benefits to cover 2 of the 4 necessary fillings and does not want to move forward with any treatment that is not covered by their benefit.

While “out of pocket” financial implications of dental and medical treatment are always a consideration, and for some, the costs are an insurmountable obstacle, untreated dental disease and untreated oral infections like periodontal disease and caries are extremely unlikely to “heal” on their own. Patients who do not take immediate action to repair and treat the disease, or allow their dental benefits to guide their treatment plan, will face amplified progression of the disease and increased costs. For some patients, this is a frustrating downward spiral, and eventually, they reach a “point of no return” and opt to have their teeth removed.

The truth is that dental insurance is a product, and what type of procedures are covered and the limitations of coverage are bundled into different “policies” or packages, which are then sold to employers or individuals.

The dental insurance policies are designed to do three important things:

  • The insurance plan must fit the insurance company’s financial needs for profitability
  • The plan must meet the annual policy price points expected by employers, employees, and individuals
  • The plan must provide adequate procedure compensation for the provider (dental practice)

  • CAMBRA coverages: Currently, multiple insurance companies sell policies with coverage for dental procedure codes associated with CAMBRA, including D0425 for caries susceptibility testing, D1206 for therapeutic applications of fluoride varnish for moderate- or high-caries-risk patients, D1310 for nutritional counseling for the control of dental disease, and D9630 for other drugs, medicaments, or fluoride dispensed by the office for at-home use (see chart of all codes). While this list is not all-inclusive and many other CAMBRA procedure codes exist, many patients believe that if their insurance policy doesn’t cover the therapies recommended by the doctor for the control of dental disease then they are not necessary. This is simply not true. It boils down to who you think cares more about your child’s personal dental health, your insurance company or your dentist.

    *Cavities are the most common chronic disease of childhood in the United States. Untreated cavities can cause pain and infections that may lead to problems with eating, speaking, playing, and learning. Children who have poor oral health often miss more school and receive lower grades than children who don’t.

  • More than half of children aged 6 to 8 have had a cavity in at least one of their baby (primary) teeth.
  • More than half of adolescents aged 12 to 19 have had a cavity in at least one of their permanent teeth.
  • Children aged 5 to 19 years from low-income families are twice as likely (25%) to have cavities, compared with children from higher-income households (11%).