Why Your Dentist Might Seem Pushy

In 1993, Dr. David Silber, a dentist now practicing in Plano, Texas, was fired from the first dental clinic he worked for. He'd been assigned to a patient another dentist had scheduled for a crown preparation – a metal or porcelain cap for a broken or decayed tooth. However, Silber found nothing wrong with the tooth, so he sent the patient home.

He was fired later the same day. "Never send a patient away who's willing to pay the clinic money," he was told.

Silber said what happened to him then still happens today, that some dentists who don't think they receive enough from insurance reimbursement – whether private insurance or Medicaid – have figured out ways to boost their bottom lines. They push products and procedures a patient doesn't need or recommend higher-cost treatment plans when less expensive options might accomplish the same thing.

The pressure is more intense now since the covid pandemic cut traffic into dentists' offices. But while most dentists are ethical, the practice of going with more profitable procedures, materials or appliances is not new. In 2013, a Washington dentist writing in an American Dental Association publication lamented a pattern of "creative diagnosis." A 2019 study of dental costs found wide differences in the price of certain services. It said teeth whitening at the dentist's office, for example, is no more effective than whitening strips one buys at the drugstore – and at least 10 times more expensive.

But sometimes dentists escalate to outright fraud. A recent article in the Journal of Insurance Fraud in America put it plainly: "Medicaid fraud is the most lucrative business model in U.S. dentistry today."

Indeed, the ADA sees a problem. Dr. Dave Preble, senior vice president of the American Dental Association's Practice Institute, said, "Hundreds of thousands of dental procedures are performed safely and effectively on a daily basis." But he cited a study from the National Health Care Anti-Fraud Association that says between 3% and 10% of the $3.6 trillion Americans spend annually on health care is lost to fraud each year. That's as much as $13 billion of the $136 billion Americans spend annually on dental care lost to dental fraud.

Silber said he saw the X-rays of one patient after she'd seen another dentist and was shocked to learn she'd had two crowns put in when she needed only one minor filling or mini dental implants. She was told the first crown was necessary to treat decay in one tooth, and the second crown was needed to make the first crown fit better. "She only needed one small filling. It should have cost her $100 or so," Silber said. "Instead, the dentist convinced her to replace two perfectly good teeth just so he could make $2,400 from her insurance company."

The absorption of small private practices by corporations, private-equity buyouts or group practices over the past two decades has increased the emphasis on higher profits. "The executive at the top tells the dentists working for them which procedures to push, like a chef tells their team of waiters to push the daily special," Silber said. "If a dentist refuses to comply, they're shown the door."

One treatment patients are commonly pressured to undergo in corporate dental chains is quadrant scaling: an invasive teeth-cleaning procedure along the gum line, usually done over three or four visits. While the procedure can be helpful if a patient suffers from severe gum disease, it can erode gum tissue that cannot grow back. Dentists can charge between $800 and $1,200 for each procedure, while a standard cleaning nets them only about $100.

Dr. Michael Davis, a dentist practicing in Santa Fe, New Mexico, said some dentists look for procedures for which Medicaid pays more. He explained that Medicaid pays three to six times more for nickel-chromium steel crowns than for standard fillings, so some dentists recommend those more profitable and invasive treatments to unsuspecting patients. "The fit of premanufactured steel crowns is unfavorable and can show gaps," Davis said, "so unethical dentists target little children who won't notice the misshapen fit until their permanent teeth come in."