During the height of the COVID-19 pandemic, many dental offices across the nation were closed. Even after they re-opened, there were many Americans delaying dental care. In some cases, job loss from the pandemic's effect on the economy resulted in the discontinuation of employer-provided dental benefits. Regardless of the reason, putting off necessary dental care presents a risk of deteriorated oral health since conditions may worsen or contribute to additional problems with the teeth or gums.
In the interests of exploring the matter more fully, DentalInsurance.com commissioned a nationwide survey investigating multiple factors that may lurk behind postponed dental care. Specifically, the survey asked over 1,200 people across the U.S., "What issues have made you put off dental work?" Respondents could choose one or more of the following answers:
If none of the answers applied, respondents could select "none of the above."
Over half of respondents (59.5 percent) indicated that none of the survey's options had resulted in a delay of dental care. Of the remaining 40.5 percent, postponement reasons ranked as follows:
High out-of-pocket costs was the number one reason for delaying dental care and was selected by one-in-five survey respondents. Expensive out-of-pocket costs for someone with dental insurance may occur from causes such as:
High out-of-pocket costs are best avoided during the shopping period for a dental insurance plan. Once consumers are enrolled in a plan, they are subject to coverage conditions of that dental policy. Reviewing a dental plan's summary of benefits prior to enrollment is essential because it will:
A consumer cannot assume all dental care will be covered by a dental insurance plan because dental insurance does not have standardized benefits. Consequently, the review of benefits is a necessary task when a consumer is investigating what coverage represents the best match for his or her oral health circumstances and budget. The nationwide survey results reflected these realities. For example, about one-in-ten respondents indicated postponed dental care because their dental plan did not cover the treatment and 4 percent reported care was delayed because their dentists were out-of-network. For those without dental coverage, 13 percent delayed care because of an absence of insurance.
Another consideration related to out-of-pocket costs concerns the issue of "maximum benefit." A maximum benefit is a term used by insurance companies to indicate a limit on the amount of annual spending the company will make on behalf of an enrollee for covered dental services. Most dental plans have a maximum benefit, though coverage options such as dental HMOs and dental discount programs typically lack this limit. Preferred Provider Organizations (also known as dental PPOs, constitute 80 percent of dental coverage in the U.S. and these plans normally have maximum benefits. There are many plans with maximum benefits in the range of $1,500 to $2,000 per year, though some plans may be as low as $500. Recently, some PPO dental plans have advertised maximum benefits as high as $5,000 annually.
A 2014 National Health Interview found 7.2 percent of seniors age 65 and older did not get dental care services due to cost barriers. In DentalInsurance.com's 2022 survey, 20.8 percent of seniors had delayed care on account of high out-of-pocket costs. The reason for this increase observed between the two surveys is not clear because of differences in population sampling as well as differences in economic conditions between 2014 and 2022. One contributing factor to dental access problems for seniors is that Original Medicare does not include routine dental coverage. However, Medicare Advantage enrollment continues to rise among seniors and most of these insurance plans delivering Medicare benefits include some supplemental level of dental coverage. According to the Kaiser Family Foundation, 94 percent of individual Medicare Advantage plans in 2022 had dental benefits.
The second most common reason given for delaying care was fear that dental care will be painful. Approximately 13 percent of adults surveyed delayed dental care on account of this fear. Interestingly, fear of dental pain was twice as common an answer than people delaying care because it was so major that it required time-off for recovery (5.5 percent). Dental research performed by British scholars estimate 36 percent of the U.K.’s population suffer from a fear of dentists, with an additional 12 percent of the population being characterized as experiencing an extreme dentistry fear. A separate 2018 survey by market research firm DentaVox claimed one third of the U.S. population avoids dental visits due to fear or anxiety.
With respect to DentalInsurance.com's nationwide survey, there were significant differences regarding fear of dental treatment pain among demographic segments. Among respondents in the 18-24 year-old age segment, fear of treatment pain was the number one reason for delaying dental care. 23.6 percent of this age group reported delaying dental care for this reason. In comparison, less than 9 percent of seniors age 65 and older delayed care because care was assumed to be painful. Of all age groups, seniors were least likely (8.65 percent) to report fear as a reason to postpone dental care.
Men were also slightly more likely than women to avoid dental care because of a fear of pain. 14.1 percent of men delayed dental care due to a fear of pain. 12.63 percent of women, in contrast, selected "fear of pain" in answer to the question "What issues have made you put off dental work?"
Report data is based on 1,214 respondents to a nationwide multiple choice survey conducted from May 5, 2022 to May 7, 2022. The single-question survey asked adults in the United States, "What issues have made you put off dental work?" Respondents had the option of selecting one or more of the seven following options:
Below the aforementioned six options, there was an additional option for "None of the above." The survey prevented the user from simultaneously selecting a reason for dental delay AND "None of the above" at the same time.
Answer options for the survey question were displayed in randomized order across respondents. 1,513 options were selected by 1,214 adults who responded to the survey. Survey respondents were drawn from Google's AdMob network. Advertisements are displayed within mobile apps and consumers can voluntarily participate if they choose. For more information, see What Is Admob?
In order to achieve representative targeting, Google (who performed the survey on behalf of DentalInsurance.com) dynamically targeted respondents to match the demographics of the internet population using their inferred demographics (age, gender, and geography). Google used estimates for the national internet population from the U.S. Census Bureau's 2017 Current Population Survey (CPS) Computer and Internet Use Supplement. Their dynamic targeting approach approximate the target distribution after running, and the amount of weighting needed is minimal. Google states "Weighting is designed to remove bias from a survey sample and make the results more closely represent the target population. For example, if the percentage of female respondents in a survey is less than that of the target population, we increase the contribution of the female responses by a factor (a weight) so that females are representatively proportionate to the target population in the weighted results."
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The COVID-19 pandemic had profound effects for the dental industry during 2020. Temporary office closures were widespread and, even after re-opening, a February 2021 poll reported overall patient volume was down by nearly 20 percent. At the same time, personal protective equipment (PPE) costs have risen while consumer spending on dental care has been projected to decline 38 percent in 2020 and 20 percent in 2021. Together these circumstances have produced substantial financial pressures on dental practices and made the issue of patient retention all the more urgent.
To explore the factors eroding dental patient retention, a survey of over 2,000 adults across the United States asked, "Which of the following issues would make you change your dentist?" Six concerns were offered as potential answers. The issues included economic considerations ("Cheaper prices from a different dentist," "Dentist not in-network for your insurance"), general patient experience ("Dental appointments start late," "Dentist criticizes your teeth or oral health," "Inconvenient location") and the absence of a service specifically accommodating patients with dental anxieties ("Sedation dentistry not offered"). Poor dental work was not provided as an option within the survey since it was assumed that an egregious quality issue was an obvious justification to change dentists.
Each survey respondent had the option of selecting one or more of the six concerns, or rejecting them all as a basis for leaving a dentist. The options were in randomized sequence across survey respondents to minimize an answer bias based on the option order.
More than half of respondents (53.8 percent) identified one or more conditions that would make them switch dentists. The selection rate for the individual reasons to switch dentists ranged from 30.5 percent to 7.5 percent and, as mentioned above, a single respondent could choose more than one reason to change dentists.
Survey results and supporting commentary for each of the conditions for dentist switching is provided below.
According to the American Dental Association’s Health Policy Institute, 59 percent of adults between the ages of 19 and 64 have private dental benefits. An additional 7.4 percent have dental benefits through the government’s Medicaid program. However, having insurance coverage does not guarantee insurance acceptance. For example, government-supplied dental coverage from Medicaid and the Children’s Health Insurance Program (CHIP) is accepted by less than half of dentists (43 percent) according to the American Dental Association.
With respect to insurance coverage, three-in-ten (30.5 percent) survey respondents selected "Dentist not in-network for your insurance" as a reason to change dentists. Higher costs is the assumed rationale for avoiding out-of-network care. Out-of-network care risks the patient paying full price for dental services (in the case of HMO dental plans and discount dental card programs) or higher out-of-pocket costs.
Out-of-network status was the single most common survey response for changing dentists. Women were more likely than men to indicate out-of-network status as a reason to change dentists. 34.1 percent of women responding to the survey selected this answer as compared to 26.5 percent of men.
Three of the potential answers to the question "Which of the following issues would make you change your dentist?" concerned problems with general patient experience: inconvenient location, dental appointments beginning late, and the dentist criticizes the survey respondent’s teeth or oral health. One or more of the above patient experience problems was a basis for dentist switching among 27.7 percent of all adults surveyed. When examined separately, the rate at which Americans viewed each issue as a condition for changing dentists was:
As illustrated in the below table, the study found men were slightly more likely to cite an inconvenient dental office location as a reason to change dentists while women were slightly more likely to cite late starts for appointments. However, the big divide between women and men on patient experience centered around criticism from a dentist about the patient’s teeth or oral health. Women were twice as likely as men to cite a dentist’s criticism of their teeth and oral health as a reason for seeking a new dentist. 14.3 percent of surveyed women gave this answer compared to 7.1 percent of men.
Table: Patient Experience response rates to the question "Which of the following issues would make you change your dentist?"
| Patient Experience Issue | Women | Men |
|---|---|---|
| Inconvenient location | 16.8% | 17.2% |
| Dentist criticizes your teeth or oral health | 14.3% | 7.1% |
| Dental appointments start late | 10.3% | 9.1% |
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Two of the survey answers pertained to financial issues associated with dental care: a dentist’s network status (addressed earlier) and the scenario of a different dentist offering lower prices. 10.5 percent of adults surveyed indicated that cheaper prices from another dentist would motivate them to switch practices. Women were 52 percent more likely than men (12.6 percent vs 8.3 percent) to indicate lower costs were grounds for switching.
From a geographic perspective, price sensitivity (as captured by this response) was most prevalent in the western United states. This answer was selected by 13.8 percent of respondents living in that region, which was a response rate 31 percent higher than the national average. The region least interested in price was the midwest where 7.8 of respondents selected the answer.
The uninsured are most exposed to the prices dentists charge. The American Dental Association’s Health Policy Institute estimates 33.6 percent of U.S. adults lack dental benefits. However, even the insured face considerable costs even with an in-force dental plan. Approximately eight-in-ten dental plans are Preferred Provider Organizations (PPOs) and these plans commonly have a cap (e.g. $1,500) on how much the plan will pay for dental care within a year. These plans may also charge a percentage of the cost for major dental work (as opposed to a flat-fee copayment). This percentage is known as a coinsurance fee. For example, if the price for a crown is $1,500 and the coinsurance fee is 50 percent, the patient will be responsible for paying $900. Consequently, dentists offering lower prices in this scenario will benefit a person even though they already have insurance.
Researchers estimate 36 percent of the population suffer from a fear of dentists, with an additional 12 percent of the population being characterized as experiencing an extreme dentistry fear. Sedation dentistry, otherwise known as "painless dentistry" or "mild sedation dentistry," is the use of medication to relax a patient who suffers from considerable anxiety regarding dental procedures. The level of sedation varies according to need, and deep sedation using general anesthesia requires a dentist’s completion of the Commission on Dental Accreditation (CODA) program in this practice.
Despite the prevalence of dental fear (nearly half the population), a lack of sedation dentistry was the least common basis for which a survey respondent would change dentists. Only 7.5 percent of adults surveyed said the absence of sedation dentistry would motivate a dentist switch. While there was some difference in response rates, this issue was the least frequent rationale for dentist switching among women and men alike.
There are multiple questions raised by this result. For example, are Americans with dental fears aware of sedation dentistry as an option to alleviate their anxiety? Additionally, are Americans with extreme dental fears avoiding dentists altogether, thus making the question of switching dentists irrelevant?
Given new patient acquisition is accompanied by considerable marketing expenses (e.g. direct mail, social media placements, online reputation management, etc.), the retention of existing patients is of paramount importance to the financial health of dental practices. Many of these practices still suffer from the financial stresses brought by the COVID-19 pandemic and may face further revenue challenges if another COVID-19 spike occurs and reduces patient volume.
The results of this survey identify a variety of issues that can contribute to patient attrition and lost revenue. With less than half of surveyed adults not giving a reason for changing dentists, dentists should give considerable attention to the extent to which these six issues may apply to the majority of their patients. Making adjustments, when necessary, can be an inexpensive means to preserve their existing base of clients and increase word-of-mouth referrals.
Report data is based on 2,110 respondents to a nationwide multiple choice survey conducted from July 20, 2021 to August 17, 2021. The single-question survey asked adults in the United States, "Which of the following issues would make you change your dentist?" Respondents had the option of selecting one or more of the seven following options:
Below the aforementioned six options, there was an additional option for "None of the above."
Answer options for the survey question were displayed in randomized order across respondents. 2,788 options were selected by 2,110 adults responding to the survey.
The survey was displayed to adults located in the United States who visited websites within the Google Surveys Publisher Network. Respondent demographics were collected to approximate the age, gender, and geography of adult internet users in the United States based on the US Census Bureau’s 2015 Current Population Survey (CPS) Computer and Internet Use Supplement. For more information on the survey’s audience and data collection, see the linked white paper. Race, education, income, and other demographic factors were not examined. The margin of error across this survey’s responses is estimated at +1.7%/-1.7%.
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