In 1970, Nobel Prize winning economist George Akerlof published his landmark article “The Market for Lemons: Quality Uncertainty and the Market Mechanism"1. This monumental economics paper utilized an example of how used car salesmen held significantly more information about their vehicles’ condition than the buyers purchasing them, resulting in some buyers ending up purchasing a “lemon” (defective or malfunctioning vehicle).
The concept illustrated the idea of quality uncertainty, and defined how information asymmetry leads to unhealthy market economics, and unhappy market participants for both sellers and buyers. More on that later.
How does a 1970’s economics paper about used cars apply to dentistry? Dentists are taught to educate their patients as much as possible about their treatment options based on the patient’s diagnosis, all while considering the individual patient’s outcome expectations through an informed consent process. The patient then makes a choice to proceed with said treatment or not, understanding the consequences of their decision.
However, what information does the patient use to make their decision?
It’s largely based on the information the dentist just provided them. Sure, the patient can go home and perform research, seek second or third opinions, or ask the infamous “Dr. Google”. The conundrum is that there is simply no definitive way for a patient to verify what the dentist says is accurate or correct, short of the patient going to dental school themselves.
So how is a patient expected to make their decision? The answer is trust. A fellow Nobel Prize winning economist, and one of Akerlof’s contemporaries, Keneth Arrow, described how an element of trust exists in the patient-doctor relationship, as the patient “cannot test the product before consuming it”. Arrow discusses how it is socially expected for physicians to act in the best interest of the patient2. Keep in mind, this publication was from the 1960s, and today’s society may not be as trusting with doctors as they were half a century ago.
In the dentist-patient relationship, trust or mistrust is highly correlated to the patient's perception of pain and anxiety3. At least some level of trust is needed in order for the patient to make an informed decision about their treatment. Trust can be gained through reputation, bedside manner, and certainly “gut feel”. But at the end of the day, trust is a leap of faith. Although the majority of people appear to exhibit trust in dentists, mistrust is associated with unhappiness with the care received4.
If there is an inkling of mistrust, where does it come from in dentistry? I personally don’t believe it stems from personal interaction between a patient and dentist. I believe much of patient sentiment of uncertainty and lack of trust comes down to the current systems in place within the dental industry, and a sense of a lack of transparency overall. Let’s break It down.
Let’s take a look at some common complaints from patients.
A patient may visit one dentist who recommends four fillings, but a second dentist may recommend zero on the same patient. Why is that?
Part of this comes down to a restorative dentistry philosophy, and variation in operative dentistry education. Significant, large cavities are universally recommended similar treatments: fillings, crowns, and occasionally root canals if the decay extends to the pulp. However, very superficial or small cavities may not warrant a filling at all. Some dentists may opt to “seal” these deep fissures, some may recommend remineralization treatment, while others may recommend to simply watch and observe them. Without getting into the weeds of operative dentistry treatment philosophy, there certainly exists some variability within restorative dentistry which largely depends on individual treatment philosophy, and dental schooling background.
Today we have impressive AI technologies that exist now to help identify cavities on x-rays with the help of algorithms (Pearl, Overjet) which can correlate to a dentists’ clinical findings. Nevertheless, dental treatment is not always not cut and dry. Differing second opinions patients may receive from two different providers may certainly contribute to a sense of mistrust towards the profession.
When it comes to insurance coverage of dental procedures, dentists face challenges in obtaining this information. When treatment is planned for a patient, dental offices are tasked with finding out what portion (if any) of the treatment is covered by a patient’s particular insurance plan. This information can be disseminated electronically to the dentist, by means of an online portal hosted by the insurance company. However this treatment-specific insurance coverage information must occasionally be sought out manually, over the phone in some cases. It’s astounding to think that in 2023, some insurance companies will not offer online portals for their providers to seamlessly access coverage information for their patients. Is this on purpose? Who knows. But that’s a discussion for another time.
The insurance companies are simply not incentivized to make accessing treatment-specific coverage information easy. After all, if they make it difficult for dentists to obtain the coverage information (several hours on hold via phone in some cases), the dentist’s accuracy of pricing estimate information provided to the patient decreases, which ultimately increases the chance of patients receiving a “surprise” bill after the treatment is performed and the insurance claim is submitted. There are some amazing technology companies working to address this manual process on the revenue cycle management of dental practices (Zuub, Zentist) which may help reduce surprise charges. However, without true transparent access of coverage data from payors, and the feeling of uncertainty with treatment costs with potential “surprise” bills, through no fault of the dentist, the patient-dentist relationship may certainly carry a sense of inadequate transparency.
We all know someone who has a friend or acquaintance who had a bad experience with dental implants. As an oral and maxillofacial surgeon myself, I hear this quite often during consultations. It usually goes like this:
“My friend needed some dental implants, they had to do 5 surgeries and it cost him 20K for one tooth! It was a nightmare!“
The reality is we don’t know what the true clinical situation was with that particular patient story, nor the context without speaking to the treating provider. Dental implants do involve several phases, require several parts, and may involve different providers performing different parts of the treatment.
In actuality, dental implant procedures can be variable and complex. Replacing a single missing tooth with an implant and a crown is a significantly different process than replacing a full mouth of teeth on a patient who has been wearing a denture for 20 years.
Many patients may not know this. Some patients have the attitude that “it’s just teeth”. They may not know if what they are signing up for is more similar to a mole removal versus an orthopedic joint replacement in the context of risk stratification and expected recovery time.
Although dental implants are highly successful, and are an excellent option for replacing teeth, dental implants and their outcomes depend on patient physiology, anatomical variation, surgical technique, and are at risk for complications like other surgical procedures in healthcare.
Given that patients show up to the dental office and may receive variations in recommended treatment, unclear pricing with potential surprise bills, and not understanding nuances of complex implant procedures, all of these attitudes contribute to a sentiment of uncertainty or mistrust.
In my experience, most dentists are up front and quite open about their processes. I don’t believe the aforementioned patient complaints are indeed a form of inadequate transparency by the dentist themselves, but rather, the systems, infrastructure, and the nature of patient education are not built in a way to allow a clear and seamless patient experience. Rather than a true lack of provider transparency, I believe any sentiment of patient uncertainty stems from one of Akerlof’s concepts, information asymmetry.
From an economic standpoint, information asymmetry exists when one party of a transaction (either the buyer or the seller) knows significantly more than the other. In the used car example from earlier, only the car salesman actually knows the true condition of the used car, and if they are selling the buyer a “lemon”. However, information asymmetry can lean towards the buyer as opposed to the seller, as well. For example, a buyer of a life insurance policy could potentially withhold information about certain medical conditions or lifestyle behaviors, to which the insurance company may not have access to.
In the dental industry, the cohort who has all of the information is the provider. As discussed earlier, attempting to explain exactly how and why particular treatment options are recommended is not something that can be done in a 30 minute consultation. At the least, dentists can empower and educate the patient on the best options.
Information asymmetry exists far beyond simple fillings and crowns in dentistry. It exists in more complex treatments like orthodontics, cosmetic dentistry, and the most involved, dental implant procedures. In order to further examine information asymmetry in dental implants, it’s important to understand the current state of the implant market.
Technology improvement, pervasive marketing, higher patient demand, increased awareness, and more dentists wishing to learn how to place implants have shaped the dental implant market over the past 10-15 years5. Today, we have billboards and TV ads marketing dental implants which have somewhat commoditized the treatment into a consumer product as opposed to an oral healthcare treatment.
"There are more dental implants placed every year than hip replacements in the US"6,7
With such an influx of dental implants being placed, dental implant related complications have also increased significantly8. Fortunately, thousands of dental implants are performed every day in the US by highly qualified and exceptionally trained dentists with an astounding 95% success rate9. There are amazing organizations that help dentists get the training they need, such as the ADA, AAID, ICOI, ABOI, AAP, ACP, and AAOMS, to name a few. However, the successful and routine implant treatments don’t end up making the evening news. It’s the cases that encounter complications which make the headlines.
What many patients may not realize, is that dental implant surgery varies in complexity, and certain cases require advanced techniques and expertise. Specifically full arch implants, or “all on four” or “all on six”, which involves dental implants to replace a whole jaw (“arch”) of teeth. Some of these full arch implant cases require more invasive and specialized techniques, such as zygomatic implants, or pterygoid implants. In my opinion, such advanced techniques require advanced training, far beyond what is taught in dental school. However, no specific advanced training or certifications are required by state licensing boards to allow a dentist to perform these advanced techniques, and patients have no way of knowing the expertise, training level, or experience of their dentist if such advanced implant techniques are needed.
Patients cannot assume that any dentist is proficient in dental implant surgery, let alone advanced dental implant techniques. A vast variability in training and experience amongst implant surgeons exists in the marketplace. Patient’s may not know the difference between a novice dentist compared to an experienced periodontist or oral surgeon. Or on the contrary, a fellowship trained oral and maxillofacial surgeon with very little dental implant experience compared to a general dentist who has successfully placed thousands of implants. Vast variability exists in dental implant training and experience.
Unless the patient specifically asks, a dentist has no obligation to inform the patient what type of advanced training beyond dental school, if any, was completed. Such variability in implant training and experience, if present, contribute to the significant information asymmetry in the dental implant marketplace.
Let’s go back to our friend and Nobel Prize Winner, Akolov. Him, along with his colleagues Spence and Stigilitz, proposed solutions on how to overcome information asymmetry from an economic perspective; Signaling and Screening.
Signaling is a seller electively transferring information to the lesser informed party, the buyer. This is done by “signals” that indicate they are indeed appropriate sellers for their prospective buyers. For example, in a job market scenario, employers may be looking for applicants who possess certain skills. Only the applicant truly knows if he or she actually possesses the skills the employer is looking for. An example of signaling in this case would be the applicant displaying their college degree or particular certifications relative to the particular skills the employer is looking for.
In a dental implant market context, implant providers can volunteer their training and advanced implant credentials up front to signal that they are indeed experienced and highly qualified for the dental implant treatment a patient may be seeking.
Screening is the practice of the uninformed party (a used car buyer) to push the informed seller (a used car salesman) to reveal private information about the vehicle. For example, screening in this example could be that the buyer requests an auto mechanic to inspect the car prior to the sale. This act of screening helps to level the information asymmetry.
Enacting the concept of screening in the dental implant world can entail a prospective patient having access to reviews written by former patients who experienced dental implant treatment with the provider of interest.
These economic concepts have been applied in the modern day. Continuing with the used car shopping theme, third party business-to-consumer online marketplaces such as CarFax, AutoTrader, Car-Gurus, and Co-Pilot were created to give customers a sense of verification that the seller is not selling “a lemon”. By displaying and compiling photos, reports and certifications, and customer reviews, all in one convenient place, the problem of information asymmetry is solved. By employing Akolov and Co’s suggested solutions to the problem, buyers and sellers can interact on a level playing field.
How can we address information asymmetry with dental implants?
A strong need for a tech-enabled platform for patients seeking dental implant care in a convenient, and highly accessible manner is greatly needed in the market. A dental implant services marketplace such as Toothsome provides this solution. The Toothsome platform utilizes principles such as signaling (compiling implant provider credentials and training) as well as screening (patients able to read reviews, and view treatment photos) to address the information asymmetry problem in the dental implant market.
Toothsome Implant Concierge serves as a bridge between patients and dental professionals. It not only offers patients a comprehensive view of implant providers in their area, but also celebrates and showcases the dedication, skills, and expertise of dentists, from those just starting in the field to seasoned specialists. By reading patient reviews, examining credentials, viewing before and after photos, and accessing transparent pricing, patients can make more informed decisions. Simultaneously, dentists have an opportunity to highlight their commitment to excellence and continuous growth. The platform champions collaboration and shared growth in the dental community.
The future is bright for the dental implant market, with new tools, innovations, and techniques constantly coming out, and Toothsome is ready to empower patients to pursue dental implants with confidence.
Learn more at toothsome.io. Sign up for early access for practice listings here.
Shouvik Ponnusamy “Dr. Samy” is the Founder of Toothsome, a tech enabled dental implant concierge platform, connecting patients with expert dental implant providers. He is also a practicing oral and maxillofacial surgeon, and full arch implant rehabilitation expert and educator.
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