In 1993, Dr. David Silber, a dentist now practicing in Plano, Texas, was fired from the first dental clinic he worked for. He'd been assigned to a patient another dentist had scheduled for a crown preparation — a metal or porcelain cap for a broken or decayed tooth. However, Silber found nothing wrong with the tooth, so he sent the patient home.

He was fired later the same day. "Never send a patient away who's willing to pay the clinic money," he was told.

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Silber said what happened to him then still happens today, that some dentists who don't think they receive enough from insurance reimbursement — whether private insurance or Medicaid — have figured out ways to boost their bottom lines. They push products and procedures a patient doesn't need or recommend higher-cost treatment plans when less expensive options might accomplish the same thing.

The pressure is more intense now since the COVID-19 pandemic cut traffic into dentists' offices. But while most dentists are ethical, the practice of going with more profitable procedures, materials or appliances is not new. 

In 2013, a Washington dentist writing in an American Dental Association publication lamented a pattern of "creative diagnosis." A 2019 study of dental costs found wide differences in the price of certain services. It said teeth whitening at the dentist's office, for example, is no more effective than whitening strips one buys at the drugstore — and at least 10 times more expensive.

But sometimes dentists escalate to outright fraud. A recent article in the Journal of Insurance Fraud in America put it plainly: "Medicaid fraud is the most lucrative business model in U.S. dentistry today."

Indeed, the ADA sees a problem. Dr. Dave Preble, senior vice president of the American Dental Association’s Practice Institute, said, "Hundreds of thousands of dental procedures are performed safely and effectively on a daily basis." But he cited a study from the National Health Care Anti-Fraud Association that says between 3% and 10% of the $3.6 trillion Americans spend annually on health care is lost to fraud each year. That's as much as $13 billion of the $136 billion Americans spend annually on dental care lost to dental fraud.

Silber said he saw the X-rays of one patient after she'd seen another dentist and was shocked to learn she'd had two crowns put in when she needed only one minor filling. She was told the first crown was necessary to treat decay in one tooth, and the second crown was needed to make the first crown fit better. 

"She only needed one small filling. It should have cost her $100 or so," Silber said. "Instead, the dentist convinced her to replace two perfectly good teeth just so he could make $2,400 from her insurance company."

The absorption of small private practices by corporations, private-equity buyouts or group practices over the past two decades has increased the emphasis on higher profits. "The executive at the top tells the dentists working for them which procedures to push, like a chef tells their team of waiters to push the daily special," Silber said. "If a dentist refuses to comply, they're shown the door."

One treatment patients are commonly pressured to undergo in corporate dental chains is quadrant scaling: an invasive teeth-cleaning procedure along the gum line, usually done over three or four visits. While the procedure can be helpful if a patient suffers from severe gum disease, it can erode gum tissue that cannot grow back. Dentists can charge between $800 and $1,200 for each procedure, while a standard cleaning nets them only about $100.

Dr. Michael Davis, a dentist practicing in Santa Fe, New Mexico, said some dentists look for procedures for which Medicaid pays more. He explained that Medicaid pays three to six times more for nickel-chromium steel crowns than for standard fillings, so some dentists recommend those more profitable and invasive treatments to unsuspecting patients. 

"The fit of premanufactured steel crowns is unfavorable and can show gaps," Davis said, "so unethical dentists target little children who won't notice the misshapen fit until their permanent teeth come in."

Children who still have their baby teeth are prime targets for pulpotomies — the removal of the pulp of a tooth — whether they need them or not.

Unethical dentists also perform shortcut versions of otherwise covered procedures for a patient, while billing the insurer for the full amount — a practice known as upcoding.

Mini-implants, for example, can be easily upcoded. A standard dental implant is an artificial tooth root that dentists install to anchor a dental crown or bridge. A mini-implant, by contrast, is like "a thumbtack compared to a bolt," said Dr. David Weinman, a dentist practicing in Buffalo, New York. In the past, mini-implants were used only to hold dentures in place, but because they are so much quicker to install and cost the dentist as much as 60% less than a regular implant, more dentists have been recommending them as a long-term solution.

"We in the dental community see a high failure rate when mini-implants are used where a regular implant is needed," Weinman said, "but that hasn't stopped some dentists from pushing them on patients who don't know better."

Then there are horror stories of dentists gone bad. In March, Dr. Mouhab Rizkallah, a Massachusetts orthodontist, was sued by the state's attorney general for deliberately keeping his patients in braces longer than medically necessary and for deceptive billing for mouth guards. The complaint against him alleges he instructed his staff to buy plastic mouth guards at a discount store even though he knew they wouldn't fit the patients' teeth properly. Rizkallah then billed Medicaid $75 to $85 more than the retail price for each one and was reimbursed more than $1 million for the mouth guards alone, according to the lawsuit.

Other dental practitioners have done far worse. After a video of Dr. Seth Lookhart, an Alaska dentist, riding a hoverboard during a dental procedure went viral, intrigued authorities found he'd been sedating nearly all his patients to cash in on the reimbursements Medicaid pays for general anesthesia. He was sentenced last year to 12 years in prison.

The Texas Dental Board revoked the license of Bethaniel Jefferson, a dentist who was practicing in Houston, after she was found to be endangering her patients by needlessly administering general anesthesia to take advantage of the same insurance payments. She left one patient in an oxygen-deprived state for so long the child suffered severe brain damage.

Dr. Scott Charmoli, a Wisconsin dentist, was charged with fraud after he was found to be using his drill to intentionally break patients' teeth so he could bill the insurance company for crowns instead of fillings. The indictment alleges that he performed more than $2 million worth of crown procedures between Jan. 1, 2018, and Aug. 7, 2019 — amounting to more than 80 fraudulent crown procedures a month.

Weinman said patients can always seek a second opinion — especially for expensive treatments — and that a dentist who seems hesitant when you say you want a second opinion is worrisome. "A dentist who is confident in his or her abilities won't have a problem with you checking a diagnosis or treatment plan elsewhere," he said.

Other red flags: Weinman said to be wary of any dentist who seems to be reading from a script, or who pushes a treatment plan too hard or refuses to explain treatment options. "There may be several scientifically sound, evidence-based treatment plans available to a patient," Weinman said, "and a good dentist is willing to explain your options — even the ones that may not be as profitable."

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.