While over $142 billion is spent annually on dental care in the U.S., many only really think of dentistry when in the exam chair and yet there are many exciting developments to chew on. The last 20 years witnessed a coordinated effort to implement more impactful public policies (expanded Medicaid, Affordable Care Act, more Federally Qualified Health Centers), improve educational programs, develop more effective therapies and powerful diagnostics, and to activate more robust professional societies to better integrate dental care with overall healthcare. Meaningful advances have been made to improve access, and while prevalence of oral diseases remains a persistent challenge, innovative new products and services, coupled with more informative diagnostics, have created more effective treatments.
An adult with relatively good dental health will spend about $1,000 on dental care each year. Over 40% of all dental care costs are covered by private health insurance, while just over 35% is out of pocket. With the onset of the Covid pandemic, there was a marked increase in one-time, non-recurring government support programs covering dental care costs. Notwithstanding that, there remain concerns that lower income and the elderly are not receiving adequate preventative care; in 2019, just 43% of Medicare beneficiaries had a dental exam.
Payment reform and appropriate insurance coverage continues to be a significant issue in dentistry. As of 2020, only 18 states offered extensive dental benefits under Medicaid, with another 10 states only covering dental emergencies and three states not providing any coverage. Despite the overall trend in dentistry to focus more resources on prevention, avoidance, and promoting good dental health, there are significant concerns that the economic burdens many states are confronting now will jeopardize the advances in extending coverage.
Globally, it is believed that there are 1.6 million dentists according to the World Health Organization. While there are 201k active dentists in the U.S. according to the American Dental Association, Health Resources and Services Administration data conclude that there is a shortage of nearly 11k dentists, which arguably undermines care for as many as 60 million Americans (dental coverage shortage areas). In response, a number of new dental schools have opened, which ironically has raised longer term concerns that there may be an oversupply of dentists in 20 years. It takes four years to earn either a Doctor of Dental Surgery (DDS) degree or a Doctor of Medicine in Dentistry or Doctor of Dental Medicine (DMD) degree, so addressing this gap will take some time.
Today there are nearly 61 dentists for every 100k Americans (Alabama has the lowest coverage with 41 dentists/100k, while Massachusetts has 83dentists/100k – D.C., with all of its big mouths, has 104 dentists/100k).
The Bureau of Labor Statistics tallied the national average salary for dentists who practice general dentistry to be $178.3k as of May 2019, which compares poorly to family practice physicians who earn $213.3k. Of the 201k dentists in the U.S., 159k were general dentists while the balance were specialists (orthodontics, dentofacial orthopedics, maxillofacial surgery, etc) that presumably pay substantially higher.
The comparison to PCPs is relevant as dental care becomes better integrated into overall care. The Institute for Health Metrics and Evaluation ranked oral disorders as tenth in terms of “years lived with disability” (“YLD”) disease burden to underscore the extent of the prevalence. It is estimated that globally that over 3.5 billion people live with some type of oral disease and that approximately 300 years of life are lost per 100k people due to issues of oral health. While the National Center for Advancing Translational Sciences track several thousand different diseases, it is estimated that more than 100 of these diseases are systemic and that more than 500 medications have oral manifestations. An emerging area of clinical focus is at the intersection of oral health and behavioral health, and the impact on salivation.
According to the 2016 Global Burden of Disease Study, four of the top 30 most prevalent diseases involved oral health – untreated dental caries (decay of tooth or bone) in adult teeth (#1), severe periodontitis (#11), untreated dental caries in baby teeth (#17), and severe or complete tooth loss (#29). This does not even account for craniofacial birth defects which have an incidence of 1 in 700 births. While the origin of dental medicine was thought to have started around 300 B.C., one of the most famous Greek doctors, Hippocrates, thought the cure to many diseases involved the removal of infected teeth.
While the prevalence of disease has been relatively consistent over many decades at around 20 – 25%, the improvement in access to oral care has had a profound reduction on the amount untreated disease. The chart below only looks at the prevalence of untreated caries among children, which augurs well for future health conditions for many who otherwise would have struggled with diseases related to poor oral health. While more needs to be done, the trend is encouraging.
Payment reform continues to be critical to ensuring better access and adherence to care. Interestingly, utilization of orthodontic procedures pre and post the Great Recession of 2007 – 2009 shows only a modest reduction in necessary services for children, but a significant decline among adults, suggesting that adults are likely to forgo care when economic conditions are more challenging. Analysts today are worried that as the economy heads into another possible recession, many adults will defer necessary oral care, perhaps reversing the improvement in treatment trends highlighted above.
The ”business of dentistry” is being transformed. There is a debate now playing out among dentists, orthodontists, oral care companies, and regulators as innovative new teeth straightening technologies come to market. Many of these “consumer” treatments from companies such as Invisalign and SmileDirectClub circumvent the traditional dental service providers, which is causing great consternation among certain professional societies. The American Association of Orthodontics is aggressively advocating that orthodontists must provide such teeth straightening services as these procedures “involves the movement of biological material.”
There are a handful of forces at work that promise to reshape dentistry. Patients are pressing for much greater convenience and comfort, which will push practices to be more consumer-centric much like what is happening in primary care. Tele-dentistry and “emotional dentistry” (utilizing virtual and simulation models) are being rapidly adopted. 3-D dentistry and laser printing are two technologies being incorporated into in-office settings. All of these advances are leading to practice consolidation and adoption of more subscription-based models. As with many health-related practices, the movement to true risk-based care models will be challenged by the need to link, with data and attribution, (reasonably) near-term economic value creation to effective oral health.
The amount of innovation in dentistry is exciting and tracks much of what is playing out in the broader healthcare and life sciences sectors, and yet Crunchbase only tracks 208 dental start-ups which have raised approximately $3.0 billion across 483 financing rounds. The amount invested in dental innovation in total is only 0.9% of what venture capitalists invested just in 2021 alone. The significant new market opportunities being created by digitization, consolidation of delivery services, and changing demographics strongly suggests that the amount of capital will increase dramatically. Advances in biomaterials, cellular analysis, regenerative therapies are pointing to an age of more robust personalized treatments in oral care. As professional societies more actively embrace novel risk-based models, innovative new care delivery companies will be started.
Innovation’s crowning achievement will be to take a bite out of poor oral care.
On the Flying Bridge 
Well can’t brush this one off. Will have to chew on it a bit.
Nice!! Let me know as you continue to probe…
You might consider adding the impact of the Oral Microbiome and the evolving science around its connection to systemic diseases including, CV, autoimmune diseases and maybe Alzheimer’s.