Mother With Dental Insurance Kissed by two children

Dental Coverage is one of the best values in the world of insurance.

I have read more than a few articles on how bad dental care and dental insurance is.  Some of the articles have focused on how tough it is to even find a dentist in rural America.  Then when you find one you have to be able to afford the fees.  As in a lot of industries there isn’t a great deal of information out there to help people understand if what they are getting charged is fair or not.

First, I want you to think about this, people with dental insurance take care of their teeth much more pro-actively than people without.  Those with dental insurance are 200% more likely to have their preventive work done than those without dental insurance.

On top of these issues some articles start talking about the skimpy coverage offered by dental insurance.  Which makes me think the author does not understand dental insurance.  Dental insurance is just about the only kind of insurance that pays out before something bad happens.  With medical insurance there are token “Wellness Programs” that the insurer (or most of the time) or employer pay for before disaster strikes, but nothing on the scale of dental.

Dental Insurance pays for preventive care.  It would be like a health insurance policy paying for a nutritionist and a gym membership with a physical trainer.  Why do they do this?  They do it because prevention matters!  When you take care of your oral hygiene you are less likely to have cavities.  You are less likely to need crowns.  Prevention matters so most dental policies cover preventive care at 100%!

What is Plaque? 

It is the build-up of bacterial residue that calcifies.  Left untreated it can start to move below the gum line and cause some super serious issues with tooth and even bone loss.  By the way…sugar from sweets when combined with plaques forms acids that eat at the enamel of your tooth.  Plaques can also be a contributing factor in heart disease and diabetes.

Dental Insurance Covers Preventive Dental Care

What is Preventive dental care you ask?  Preventive dental care typically includes two (2) cleaning a year as well as bitewing x-rays once a year and a “panoramic” x-ray every three (3) years.  For most dental insurance policies your out of pocket costs for those services is $0.00.  What would it cost you if you just paid for that out of pocket?  It’s going to vary across the nation.  It might be a low of $99 for each cleaning ($198 per year), $55 for the annual x-ray, and maybe $85 for the panoramic x-ray every 3rd year.

That would average out to $281 (on the low end) and many dentists nationwide are going to charge $150 a cleaning without dental insurance and charge more for x-rays as well.  The high end for preventive care could easily be $387 a year.  Let’s average that and say the preventive care costs $334 a year.  I want you to remember that number and we will come back to it later in the article.  For now, I want to discuss what else dental insurance covers.

What does Dental Insurance pay for Cavities and Root Canals

Then it typically pays for 80% of cavities and fillings.  That leaves you with 20% of the cost and that is very analogous to what a health insurance policy might pay on a medical claim.  Cavities are not terribly expensive to fix so again your out of pocket costs will generally be very manageable.

It is the big charges for things like root canals and crowns that leave many people questioning as to whether or not the dental insurance is worth it.   Major dental procedures are covered at 50% with most individual plans.  The chief complaint is that 50%.  I understand.  Those major services are expensive.  Let me restate that…Expensive with a capital “E”.  Root canals cost bank.  Those fees can be $1300-$1900 depending on the tooth and associated procedures being done in conjunction with the root canal.

Fifty Percent (50%) is half that cost.  That leaves the other half to you the consumer.  Let me ask this…what did you pay for your dental insurance to get that 50% coverage on major dental services?

Now let’s say you have an individual dental insurance plan.  Your employer isn’t paying a chunk of the monthly premium, you are paying it all yourself.  Your premium is likely to be $36 a month or $432 a year for one individual.  Now remember that $334 number?  That is what you would have spent anyway if you were taking care of your preventive care (and you NEED to take care of your preventive care).  So let’s subtract that $334 from the annual premium.  Why?  Insurance is to financially guard against when things go bad.  Things that are expected are not insured.

Preventive Care is Budgeted for While Problems are Insured Against

When you have to replace your tires your automotive insurance doesn’t pay for that does it?  When you need to replace your oil and oil filter it doesn’t pay for that either right?  My point is that expected expenses are not insured they are budgeted for.  Most of the premium (the monthly cost) of your dental insurance policy is really being budgeted for your preventive care.  $432 a year in annual premium minus $334 budgeted for preventive care equals $98 a year in “insurance premium” if you will.  That breaks down to $8.16 a month.

You can’t buy a dental insurance policy for $8.16 a month.  Why?  Because they WANT you to use the preventive care provisions of the policy.  Remember prevention counts.  With prevention comes fewer cavities, fewer crowns, fewer root canals.  That preventive care lowers their liability!  Now let’s take a look back at that 50% coverage.  How much did you actually pay for that?  Not much!  That $8.16 a month got you 80% coverage on simple extractions and fillings and 50% coverage on crowns and root canals.  That ladies and gentlemen is one of the best deals in the world of insurance!

Look…I’m not saying there isn’t room for improvement.  There always is.  A more expensive policy would pay for more benefits.  The problem is it would be even more expensive.  As coverage gets more expensive fewer people have it.  As fewer people have it it gets more expensive.  The current type of dental insurance in the marketplace is GREAT!  Could it be better?  Probably not for the current premium.

Retired? How are you taking care of your dental hygiene?  Use Dental Insurance

The whole time you were working your company’s benefit package included dental insurance coverage, but now you are retired.  Now instead of a group plan supported by your employer you are in the Medicare system supported by Uncle Sam and you.  Medicare is different than anything you have encountered so far, but let me make sure you understand this.  Medicare is actually a very efficient system.  It’s different to be sure and it isn’t perfect, but it really is quite good.  For most things that is.

There are a couple of things Medicare lacks.  The first of which you may or may not have experienced with your prior medical coverage and that it has (or had) an out of pocket maximum (OopMax).  With your old coverage you spent so much out of pocket in a given year and once you hit that limit the insurance company covered 100% of your medical expenses.

In traditional Medicare there is no OopMax.  Traditional Medicare is designed to cover approximately 80% of your healthcare expenses.  It does that through Parts A & B while you pay certain deductibles or dollar amounts for services.

What does all of this have to do with covering your dental care?  In a word…nothing.  There is no regular dental insurance coverage built into Medicare.  There is no dental coverage in Medicare supplemental (Medigap) plans.  Some Medicare Advantage plans have some dental coverage.  Most of the time the coverage in Advantage plans is quite deceiving.

Advantage plans will sometimes pay for the annual preventive care (or a portion of it), but cover nothing for filling cavities or root canals.  It’s deceiving to a lot of people because they are going to the dentist regularly and they aren’t paying anything or just something minimal.  They think they have a “real” dental insurance plan.  Then a cavity pops up or even worse a root canal.  What do they ask at the front desk of the dentist’s office?  “How much of this will my dental insurance cover?”  The reply, more often than not, is, “We’ll just have to file and see what they say.”

When the bill finally makes it way through the morass of your advantage plan and gets back to the dentist’s office it very well might turn out you owe the whole bill!  Beware of Advantage plan dental benefits.  I want to mention an exception.  If someone is very low income and is getting extra help with their Medicare (specifically if they are Medicare AND Medicaid eligible) there are Advantage plans that are made specifically for this group and they often have full dental benefits.

In general, for those in the Medicare system a separate dental insurance policy is what is needed to cover your dental health.  This will be an individual policy as compared with the group policy you had previously at work.  Most individual dental insurance plans have annual maximum benefits of $1000 though with some you can pay extra get a $2000 benefit.  There are others still that have an increasing benefit the longer you keep the policy.

Waiting Periods or Phase in of Benefits with Dental Insurance Plans

Benefits of an individual dental insurance plan are typically similar to most group plans with some exceptions.  Generally, preventive care is covered at 100% with no waiting period.  The waiting periods are a key area where many dental plans are different.  For basic services like filling a cavity many individual dental plans have a six (6) month wait for benefits.  Major services like root canals generally have a twelve (12) month wait.  Instead of waiting periods many policies now phase in benefits over the first several years so that something will be paid even if it is not the full 80% or 50%.

The reason for these waiting periods or phasing in of benefits is simply that it is individual coverage instead of group coverage.  Think about it.  There are many people who would get a policy have a root canal done and then drop the policy.  Whereas with a group plan if that same person has a root canal the employer is going to keep on making those premium payments every month.  Individual dental doesn’t make financial sense for the carrier without the waiting periods.

There are exceptions (aren’t there always exceptions?).  There are some dental insurance plans that provide first day coverage.  That is the first day you have the policy you can go get a tooth filled or have that fun, fun root canal.  What these policies do is pay at a much lower percentage.  The second year they pay a bit higher, and by the third year they tend to be near parity with the policies that have waiting periods.

Why is Dental Insurance Coverage and Care so Important?

Finally, let’s take a look at the why.  Why should you bother with dental hygiene? The answer is that dental hygiene can affect the rest of your body’s health.  Think about it.  Your gums are vascular.  They have a lot of blood vessels…if you cut them they bleed.  If you have tartar below the gum line you may have issues.  Tartar is the build up of hardened plaque.  It’s full of bacteria.

If you have tartar below the gum line, it is full of bacteria, and it’s nice and warm and dark down there…what happens?  The bacteria kind of explode.  Those bacteria are right up against those vascular gums, it is absorbed into the blood stream, and transferred through the body.  It’s in this way that your dental hygiene can affect your overall health.  It can be a complicating factor in all sorts of chronic health conditions.  Heart disease, diabetes, it can even put you at higher risk of stroke.

The Perils of Gum Disease

According to the Centers for Disease Control and Prevention, researchers have uncovered potential links between gum disease, called periodontitis, and other serious health conditions.  These conditions include:

  • Diabetes — 95% of people with diabetes also have periodontal disease. Because diabetes lowers resistance and delays healing, people with poorly controlled diabetes have more dental problems and are prone to lose more teeth. Untreated, gum disease can make it difficult for a diabetic to stabilize blood sugar levels
  • Heart disease — Researchers have found that people with gum disease are more likely to suffer from cardiovascular disease than those without. Gum disease can also make existing heart conditions worse.
  • Respiratory conditions — The bacteria in gum disease can be inhaled into the lungs, aggravating respiratory conditions
  • Pregnancy complications — Pregnant women who have gum disease may be more likely to suffer pregnancy complications. Doctors recommend that women considering pregnancy have a periodontal evaluation.
  • Rheumatoid arthritis — Research shows that patients with rheumatoid arthritis are more than eight times as likely to have gum disease as others. Treating gum disease may alleviate some of the symptoms of rheumatoid arthritis.

Health Problems Your Dentist Can Spot

  • Risk of stroke — Dental X-rays can reveal blockages in the head and neck arteries, which can lead to strokes.
  • Oral cancer — Dental exams normally include a screening for oral cancer, which can be identified by tumors or sores in the mouth.
  • Eating disorders — Dentists can spot anorexia and bulimia by redness in the mouth and thin tooth enamel.
  • Oral thrush — Oral thrush is a yeast infection that leaves a white coating on the tongue and throat.
  • Anemia — Signs of anemia include pale gums; a red, burning tongue; and irritation at the corners of the mouth.
  • HIV — Symptoms include mouth sores, patches on the sides of the tongue and whiteness of the tongue caused by oral thrush.

Keep Your Mouth Healthy During Pregnancy 

Your mouth needs extra care when you’re pregnant.  Being pregnant can be hard on your teeth and gums. If you have morning sickness, it can be difficult to brush and floss, and if you’re vomiting, the acid can harm your enamel. Eating more often can increase your risk of tooth decay, especially if you choose sugary snacks. And hormone changes can lead to an increased risk of gingivitis, a gum disease caused by plaque.

During pregnancy, it’s important to work hard to keep your mouth healthy. Gum disease can increase your risk for complications including diabetes and preeclampsia, a condition where toxins build up in the blood and cause high blood pressure and other symptoms.  Even after you give birth, the health of your mouth affects the health of your baby. If you have gum disease or tooth decay, germs from your mouth can be passed to your baby by kissing or sharing a spoon. Those germs can later cause decay in your baby’s teeth.

Dental care tips during pregnancy

  • Brush your teeth at least twice daily using a
    fluoride toothpaste
  • Floss at least once a day
  • Rinse daily with a fluoride mouthwash
  • Choose healthy foods like fruits and vegetables, and
    avoid sugary or starchy snacks and soda
  • Visit your dentist at least once during your pregnancy. He or she can clean your teeth and help you control any tooth decay or gum disease. A dental visit is safe any time during your pregnancy.  By taking good care of your mouth while you’re pregnant, you’re giving your baby a great start on a lifetime of excellent oral health.

In brief:

  • Hormone changes during pregnancy can increase your risk for gum disease
  • If you have gum disease, you can pass decay-causing bacteria on to your baby
  • Brush twice a day using a fluoride toothpaste, and floss at least once daily
  • Dental work is safe any time during pregnancy

The information in this article has been provided is for educational purposes only. Please refer to your dental insurance certificate of coverage for a full description of benefits.

Sources of information:
National Institute of Dental and Craniofacial Research, “Periodontal (Gum) Disease: Causes, Symptoms, and Treatments,” nidcr.nih.gov/OralHealth/Topics/GumDiseases/PeriodontalGumDisease.htm, NIH Publication No. 11-1142, July 2011, no copyright

Mayo Clinic, “Preeclampsia,” mayoclinic.com/health/preeclampsia/DS00583/DSECTION=risk-factors, April 21, 2011

American Dental Association, “Baby Bottle Tooth Decay,” ada.org/3034.aspx