When is dentistry not medicine? When insurance is involved

David Tuller removes his partial dentures. During a period of intense dental care, he often went out with missing front teeth.

Story highlights

  • Even under a decent plan, you'll have to dig deep in your pocket for crowns, bridges and implants
  • The mouth isn't covered by insurance the same way as the rest of the body

I'm 61 years old, a San Francisco homeowner with an academic position at the University of California-Berkeley, which provides me with comprehensive health insurance. Yet, to afford the more than $50,000 in out-of-pocket expenses required for the restorative dental work I've needed in the past 20 years, I've had to rely on handouts -- from my mom.

This was how I learned all about the Great Divide between medicine and dentistry -- especially in how treatment is paid for, or mostly not paid for, by insurers. Many Americans with serious dental illness find out the same way: sticker shock.
    David Tuller says that despite decent dental coverage, he has needed financial help to pay for restorative work on his teeth.
    For millions of Americans -- blessed in some measure with good genes and good luck -- dental insurance works pretty well, and they don't think much about it. But people like me learn the hard way that dental insurance isn't insurance at all -- not in the sense of providing significant protection against unexpected or unaffordable costs. My dental coverage from UC-Berkeley, where I have been on the public health and journalism faculties, tops out at $1,500 a year -- and that's considered a decent plan.
    Dental policies are more like prepayment plans for a basic level of care. They generally provide full coverage for routine preventive services and charge a small copay for fillings. But coverage is reduced as treatment intensifies. Major work like a crown or a bridge is often covered only at 50 percent; implants generally aren't covered at all.
    In many other countries, medical and dental care likewise are segregated systems. The difference is that prices for major procedures in the U.S. are so high they can be out of reach even for middle-class patients. Some people resort to so-called dental tourism, seeking care in countries like Mexico and Spain. Others obtain reduced-cost care in the U.S. from dental schools or line up for free care at occasional pop-up clinics.
    Underlying this "insurance" system in the U.S. is a broader, unstated premise that dental treatment is somehow optional, even a luxury. From a coverage standpoint, it's as though the mouth is walled off from the rest of the body.
    My humbling situation is not about failing to brush or floss, not about cosmetics. My two lower front teeth collapsed just before my 40th birthday. It turned out that, despite regular dental care, I had developed an advanced case of periodontitis -- a chronic inflammatory condition in which pockets of bacteria become infected and gradually destroy gum and bone tissue. Almost half of Americans 30 and older suffer from mild to severe forms of it.
    My diagnosis was followed by extractions, titanium implants in my jaw, installation of porcelain teeth on the implants, bone grafts, a series of gum surgeries -- and that was just the beginning. I've since had five more implants, more gum and bone grafts and many, many new crowns installed.
    At least I've been able to get care. The situation is much worse for people with lower incomes and no family support. Although Medicaid, the state-federal insurer for poor and disabled people, covers children's dental services, states decide themselves on whether to offer benefits for adults. And many dentists won't accept patients on Medicaid, child or adult, because they consider the reimbursement rates too low.
    The program typically pays as little as half of what they get from patients with private insurance. For example, as