When insurance undervalues prevention: How third-party payers are pushing dental hygiene to the brink

For several years now, dentistry has complained of a “hygienist shortage.” This framing is convenient, but inaccurate. What we are witnessing is not a shortage of hygienists. It is the slow suffocation of a profession by a dental third‑party payer system that has failed to evolve for more than 30 years.

As a practicing registered dental hygienist (RDH) of 14 years, I have watched highly trained clinicians leave the operatory not because they no longer value patient care, but because the system makes it financially, physically, and emotionally impossible to continue. If this trajectory continues, dental hygiene as we know it faces potential extinction.

A broken economic model built on 1990s fees

In most in‑network practices, the hygiene department is expected to be self‑sustaining or profitable while operating under reimbursement schedules that have barely changed since the 1990s.¹ According to the ADA Health Policy Institute, dental benefit annual maximums have remained largely stagnant at $1,000–$1,500 for decades, despite inflation, rising overhead, and increased clinical complexity.²

Preventive procedure fees tell a similar story. Reimbursement for prophylaxis, periodontal maintenance, and even scaling and root planing often fails to reflect today’s labor market or the cost of delivering evidence‑based care. Meanwhile, hygienist wages (rightly) have increased to keep pace with inflation and the cost of living.

Practices caught between static reimbursement and rising expenses are left with only a few levers:

• Shortened appointment times
• Double‑ or triple‑booking hygiene schedules
• Increasing physical production demands
• Suppressing wages or benefits

The result is predictable: burnout, injury, disengagement, and exit from the profession. Musculoskeletal disorders among dental hygienists are well documented in the literature, with a high prevalence of chronic pain linked to time pressure and repetitive strain. A system that requires clinicians to sacrifice their bodies to remain financially viable is not broken—it is exploitative.

If it isn’t billable, it doesn’t count

Dental hygienists are educated and licensed to deliver comprehensive preventive and therapeutic care, not simply “cleanings.” CODA‑accredited programs require extensive training in:

• Comprehensive periodontal assessment and routine probing
• Oral cancer screening and risk assessment
• Oral hygiene instruction and behavior‑change counseling
• Nutritional counseling related to caries and periodontal disease
• Tobacco cessation counseling
• Caries risk assessment and disease management
• Salivary diagnostics and systemic health screening

Yet most dental benefit plans fail to reimburse for these services at all. They are bundled into a single low‑value procedure code or excluded entirely from coverage.

The message from third‑party payers is unmistakable: prevention only matters if it fits neatly into a decades‑old billing code. Everything else (assessment, education, and early intervention) is treated as optional, despite overwhelming evidence that these services improve outcomes and reduce long‑term costs.

The American Academy of Periodontology has repeatedly emphasized the importance of routine periodontal assessment and maintenance in preventing disease progression.³ The CDC continues to highlight links between oral health and systemic conditions such as diabetes, cardiovascular disease, adverse pregnancy outcomes, and respiratory illness.⁴ And yet, the very professionals trained to intercept disease early are financially penalized for doing so.

The insurance “access” myth

Dental insurance is often defended as a mechanism for access to care. In practice, it frequently does the opposite. Patients in in‑network practices routinely encounter:

• Annual maximums that cap care long before disease is controlled
• Frequency limitations that ignore individual risk
• Denials for diagnostics and preventive counseling deemed “nonessential”

This is not insurance in the traditional sense; it is a limited coupon system that prioritizes predictability for payers over health outcomes for patients.

Patients may have coverage, yet still be unable to afford comprehensive periodontal therapy, ongoing maintenance, or preventive interventions that would reduce long‑term disease burden. Meanwhile, practices are forced into high‑volume models that leave little time for individualized care. Quantity replaces quality, and prevention becomes performative.

Deskilling dentistry: A dangerous detour

Rather than addressing reimbursement failures, organized dentistry has increasingly explored workforce substitution models, including the proposed “oral preventive assistant.”⁵ These roles are framed as pragmatic solutions to workforce shortages, but in reality they represent a dangerous lowering of the standard of care.

Dental hygienists complete years of formal education, rigorous clinical training, and national and state licensure examinations. Replacing this expertise with minimally trained personnel risks:

• Missed periodontal and oral cancer diagnoses
• Inadequate assessment of medically complex patients
• Reduced infection control vigilance
• Further commodification of prevention

This is regression, not innovation. When a payment system cannot support licensed clinicians, the response should be reform, not replacement. Lowering the bar to accommodate broken reimbursement structures puts patients at risk and undermines dentistry’s credibility as a health profession.

Why dentists cannot afford to ignore this

High hygienist turnover disrupts continuity of care, damages patient trust, and increases recruitment and training costs. Burned‑out teams are less engaged, less productive, and more likely to leave.

Many dentists who have transitioned away from heavy third‑party payer dependence report longer appointments, greater clinical autonomy, and improved team retention. While moving out of network is not feasible for every practice, it exposes an uncomfortable truth: high‑quality preventive care and insurance‑driven volume dentistry are increasingly incompatible.

The choice is not between ethical care and patient affordability. The current system already fails patients by restricting benefits, delaying care, and exhausting providers.

A call to action for the profession

The erosion of dental hygiene is not inevitable, but reversing it requires collective action.

For dentists and hygienists:

• Stop normalizing burnout as the cost of doing business.
• Measure and communicate the true clinical value of hygiene services.
• Support hygienists practicing fully within their scope and training.

For professional organizations:

• Demand payer accountability and reimbursement modernization.
• Publicly oppose workforce models that dilute clinical standards.
• Invest in data demonstrating the return on investment of prevention.

For policymakers and regulators:

• Align benefit structures with evidence‑based preventive care.
• Recognize and reimburse diagnostic, educational, and risk‑based services.

And for the profession as a whole: We must stop allowing third‑party payers to define our worth.

Dental hygiene is not an auxiliary service; it is foundational to oral and systemic health. If reimbursement continues to reward speed over substance and procedures over prevention, the profession will continue to shrink. If we want dental hygiene to survive, we must be willing to confront the uncomfortable truth: insurance did not save dentistry—and it may ultimately dismantle it.

Editor’s note: This article first appeared in Clinical Insights newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles and subscribe.

References

1. Dental benefit trends. American Dental Association. https://www.ada.org/resources/practice/dental-insurance/dental-benefit-trends
2. The state of the U.S. dental economy. ADA Health Policy Institute. Revised February 3, 2026. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/state_us_dental_economy_q42025.pdf
3. American Academy of Periodontology. Comprehensive periodontal therapy: a statement by the American Academy of Periodontology *. J Periodontol. 2011;82(7):943-949. doi:10.1902/jop.2011.117001
4. Oral health surveillance report: dental caries, tooth retention, and edentulism, United States 2017–March 2020. Centers for Disease Control and Prevention. https://www.cdc.gov/oral-health/media/pdfs/2024/10/CS351478-D_OralHealthSurvReprt-28Pgs-91824_Print_FINAL.pdf
5. Emerging and current models to address dental team workforce. Activities by state. 2025. Updated May 15, 2025. American Dental Association. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/practice/practice-management/emerging_workforce_models.pdf