A lot of the problems are the result of misaligned incentives. While it's applicable to almost all of healthcare, it's especially prevalent in dental. Providing high-level what I've seen with the understanding that I am talking about the worst outcomes of our care model and certainly not hitting all of the problems. That said, I have met many more dentists who genuinely care about their patients than those who don't - and I truly believe that is the norm.
*Payers* Dental insurance is glorified discounting. Medical insurance provides annual out-of-pocket maximums (deductibles) where anything you pay beyond that is covered by the insurer. Dental insurance is the opposite. There is an annual maximum the insurer will cover (usually ~$1500) and anything beyond that is covered by the patient. In both cases there are some covered services (medical: checkups, some tests, etc. dental: X-rays, cleanings, etc.) but the second you have something even marginally serious your insurance SHOULD kick in. The problem with dental is that it doesn't. I've spoken with people that had to defer necessary procedures for a year because insurance could only cover half - so 1/2 this year and 1/2 next year.
The problem with this model is that while medical insurance is (theoretically) more incentivized to keep costs low since they will have to pay for major care, dental insurance has a natural ceiling. Yes, if you need $5k of dental work the insurer "suffers" - but it's maxed out for whatever your coverage limit is. There's not a severe financial downside to extensive care.
*Providers* Complimentary to the model of dental insurance is a fee-for-service (FFS) model for care. What this means is that providers are paid based on services. In other words, a provider makes more money doing a cavity filling than not having to do one because they kept you healthy.
The extreme opposite would be a model where a dentist was financially penalized every time you needed a filling - you can imagine how the relationship and role of the provider would change.
Something that gets overlooked, but is important to call out, is that the system for becoming a dentist doesn't help. There are 4 years of dental school. When you graduate, you're likely $XXX,XXX in debt. On top of that, private practice is still extremely prevalent in dental care - so add another $XXX,XXX in debt. Plus the cost of the equipment you need. This isn't an excuse, but its a reality for many dentists. When you combine massive debt and a care model that prioritizes paying for procedures the result is what we see today.
The other problem is that this misalignment means providers have to make personal/ethical choices around care. Sometimes those choices mean performing unnecessary procedures on patients. Sometimes it's the opposite, and the provider takes a personal hit on revenue. So you end up with 5 second-opinions, none of which line up to the others. A provider should not have to choose - or eve consider - ethical responsibility to patients vs. financial stability.
*Patients* We - patients - get shafted in dental care. Our system is incentivized to reactively treat disease over maintaining good health. On average we pay [40% of dental expenditures out of pocket](https://www.carequest.org/system/files/CareQuest-Institute-B...). That's ~4x more than the average for all other healthcare services.
We're left to navigate oral care on our own. Of course you're skeptical when a dentist says you need 10 fillings - they're incentivized to perform the procedures. Would you be as skeptical if you knew the dentist was getting charged $50 for every filling they had to do? Do you think the care model would change if dental insurers suddenly had to pay for your $10k dental procedure instead of you?
Cavities and gum disease - largely preventable conditions - are the most prevalent diseases on the planet. And we're not talking about some complex, mysterious disease. These are microbial infections. We have tools to detect them early and interventions that work (at least work well enough to make a major dent). Misaligned incentives don't motivate anyone to adopt these technologies or encourage preventive care.
Anyway, that's my rant. There are lots of things I didn't cover but I have to get back to work. Linking [my company here](https://www.bristlehealth.com/) to minimize self-promoting but provide some more info.