Why is dentistry so expensive?
The very simple off-the-cuff answer is because the provision of private, quality, healthcare, be it dental or medical, is “expensive”. Everybody knows this. But what is expensive?
What is “Expensive”?
If I said that a chersonese costs £10,000 is this expensive? If a chersonese was a cup of coffee, then yes. Nobody (apart from possibly an exceptionally ardent coffee aficionado) would pay that for a cup of coffee. But if it is a land peninsula of several square miles that may allow multiple housing developments by the sea, perhaps it is a bargain.
One person’s expense is another person’s value.
Nevertheless, this is the question we get asked most.
• “How much will this cost?”
Worryingly this is asked far more often than other question. Even more than “Will this hurt?” (the answer is no). But nobody asks, “What do I get for that?” Nobody, in 30 years, has ever asked me this question. I find that fascinating. What exactly do patients think they are getting for the fees they pay that makes them feel that dentistry is “expensive”?
Is this question based on absolute costs or perceived value? Is a patient able to make a judgement on value unless they know what their fees include?
This article is to provide some information and food for thought as to why dental surgeons charge what they do. I speak from a position of owning a fully private referral practice in London’s West End, the roots of which were planted 23 years ago in central London. But the principles are the same for any practice anywhere. (Before you mention NHS practices, there is not a single NHS-owned dental practice in the UK. Every single one is a privately-owned business that receives most of its income from NHS government contracts. The laws of capitalism and market forces are still applicable to every “NHS” practice for their outgoings, only their scope of practice and income is regulated and capped by the government).
The reasons for the fees we charge may not be immediately evident to our patients. This blog article explains these reasons. Our hope is that when our patients see what these costs include, they will understand what cannot be left out if they are serious about their dental and general health. There will always be some dentists or huge multichair practices providing cheap dentistry around the world, for a while. But most will be unsustainable because either their low quality will lose them patients (or their careers) or their businesses will not be able to thrive long term.
What a patient pays for dental treatment covers the following:
• Business overheads,
• Level of experience, scope of work and quality of care,
• Service and peace of mind.
Let us look at each of these:
Business Overheads
Fixed overheads
It is a boring but inescapable fact that every business has overheads that must be met, from the local sandwich booth to Google HQ. Where a dental practice is situated will obviously affect this. A practice in a rural town or village will not have the same overheads as a central city practice so their fees can be lower.
Fixed or static overheads include rental or mortgage on a property, business rates, key staff salaries who not only work chairside but also in the background to prepare before you arrive and tidy up after you have gone, utility bills, loan repayments for setup and upgrade costs (presuming you would like a modern, safe and fully equipped state of the art environment for your care), technical and computer equipment and software subscriptions that must be kept up to date, insurance, uniforms, cleaning and laundry, compulsory professional subscriptions, accounting and bank charges, clinical waste collection, – everything that costs money to have a dental practice, or indeed any business, and keep it running day to day regardless of whether patients attend or not. Between 2010 and 2020 this made up around 60% of our practice costs as an average. We would obviously like to keep these overheads lower, but we rarely have a choice in making significant changes to them.
Variable overheads
Variable overheads are those associated with business activity, in our case, seeing patients for dental care.
These include consumable materials costs, laboratory fees, additional staff salaries as business activity grows and more patients are treated, up to a maximum capacity allowed by chair time in the practice.
Let us put one myth to bed. Dental fees have very little to do with the cost of materials. Dental materials including dental implants are around 9% of our costs on average over the last 10 years. So, the old excuse of “using better materials” to inflate costs carries little value. This is only a small part of your fees and the difference between the cheapest and best materials is a small fraction of costs.
Laboratories, however, vary greatly in quality and with good reason. An experienced laboratory and technician team has a unique skillset that is developed over may years. To be able to design and manufacture good laboratory work that looks natural and stands the test of time is a separate art and science about which a separate article can be written. We do not cut corners with laboratories. Cheaper laboratories cost far more in the long run than the savings they may initially provide.
These variable overheads make up around 20-25% of our overhead costs reflected in what we charge for phases of treatment.
What is left?
These overheads constitute 80-85% for running costs on average over the last 10 years. This has increased in real terms for us from about 66% ten years ago.
This is before tax. If we remove tax, this means that around 10% is left. This pays for the final aspect, which we think you might feel is quite important:
Level of experience, scope of work and quality of care, service and peace of mind
So about 10% of your fees goes towards the commodity that is the most hugely undervalued: The dental surgeon’s time and knowledge and skill. Time is the only irreplaceable resource and usually the least valued. Patients tend to think of only paying dentists for the dentistry they physically do at the chairside, as if we sold dental items like a trader. They ask, “How much is a crown?” or “How much is an implant”. But this not how we work in reality. We don’t sell items. This is the remnant of a national tickbox healthcare system where items are arbitrarily costed against a budget for bureaucratic or insurance purposes and listed like a commodity but have little relationship to actual costs. Our time is the most costly asset, not items of treatment.
Patients, overall, do not pay for our time away from the chair planning their care. Every hour of dentistry requires an hour of administrative time. This is expected for free. How much would a patient expect to pay a barrister for the same amount of time we spend planning? To get an idea of this, please see our video from our website on what happens after your consultation. Yet dentists are not remunerated for this most priceless of commodities. Would you pay a builder before paying an architect first? Yet that is how most patients see the dental surgeon. The builder and not the architect. The architect side is expected for free. Often this means the building side costs more, both financially and biologically, due to errors. This is why we charge additional fees for full dental reports for patients with more complex issues that require much thought, planning and collaboration with multiple parties involved with your treatment.
What is the value to you of the following?
- knowledge accumulated over 5 years at dental school and years of clinical practice including specialist training,
- extensive experience,
- diagnostic skills,
- dedication,
- service,
- manual skill,
- stamina,
- patience and ability to listen and empathise,
- responsibility for our decisions and advice,
- organisation,
- accountability,
- diligence,
- sound advice,
- looking after your general health and safety,
- time for clear thought,
- time for reflection and self-evaluation,
- continuing personal training and development via a multitude of resources including travelling to conferences and seeing and discussing advances in our profession with our colleagues,
- compliance with a multitude of ever increasing and costlier regulations,
- time spent thinking and planning on your behalf to organise your care in a way that benefits you for the rest of your life, usually at weekends and evenings when we should be with family,
- everything else that goes into your long-term genuine care.
What is the value that gives you, our patients, the feeling that enough time is allocated to really listen to you, address your concerns and give you real peace of mind for the long term that your dental care is in the hands of professionals with your best interest at heart and who proudly put their name to your dental care and results achieved?
As we plan and carry out your work, we make literally hundreds of observations and decisions based on our knowledge that most patients do not appreciate. How does one put a price on this level of personal dedication, one of the most labour- and skillset-intensive professions in the world and certainly one of those with the highest problems with mental health and suicide rates, to call it expensive?
What happens when you ask for a fee reduction or discount?
THIS is what is most often cut out when patients complain that fees are too “expensive”. The automatic tendency of a professional to give a discount not to “lose” a patient comes from their own slice of the pie. Their own time and remuneration. Nobody else invoicing a dental surgery will reduce their fees for the patient to be able to pay less or the dental surgeon to earn more. The reward for being someone that carries the full ethical, moral and legal responsibility of your welfare and maintaining a compliant practice that caters to your dental problems is around 10% of your fees and this is normally what is discounted when a patient complains that their treatment is too “expensive”.
When you pay £1,000 to a dental practice, your dental surgeon would normally receive around £100 net. Outside city centres where running costs are lower, this may be £200 or even occasionally as much as £300. But statistics from practice accountants and practice sales teams up and down the country suggest that there are very few that achieve this figure, or better, consistently.
Most dentists have seen a real terms cut in their income of around 30% over the last 10 years whilst overheads and time spend in administration have doubled.
Dental surgeons are not expensive. They are often the least costly aspect of your dental care but carry the greatest burden of responsibility. One error can spell the end of their careers due to the current litigious nature of healthcare in this country which is the most litigious in the world, even more than the US.
Dental care is costly. Running a modern, compliant business that enables us to provide the immense skillset that we train for and love to do, with adequate allocated time to do a correct job in an environment that makes you feel cared for, is expensive, not just for you, but also for us. This is the same as any quality business that has trading facilities and face to face contact with their clients.
But for those that can benefit from what modern dental care can provide, only a tiny percentage claim that we are “expensive” at the end of treatment. They then understand the value and realise that as with all things in life, quality has a hidden cost and cutting corners by trying to do things cheaply often has a much higher cost. One of our patients once said “There is nothing more expensive than cheap dentistry” after having had work done cheaply but poorly abroad that required extensive revision. Not just financially, but biologically and time-wise.
Prevention is always better than cure. Paying a hygienist to look after your teeth every 3-6 months is infinitely better value than neglecting everything until thousands of pounds of dental work is required. Yet over 50% of the population still do not see a hygienist.
Dentistry is not expensive. Dental neglect is expensive.
Quality dental care may just be the best value for money you ever receive.