Image: Dental insurance © Creatas, SuperStock

Four years ago, 12-year old Deamonte Driver died of a toothache. Extreme neglect had led to an abscess that spread to his brain and killed him. The Drivers were a desperately poor family in Maryland that had trouble locating an oral surgeon who would work for Medicaid rates.

But whether rich, poor or in between, regular dental care has declined as out-of-pocket costs have risen during the Great Recession. Few people know that good dental care can be the key to good overall health. According to the Mayo Clinic, a full menu of diseases can result from poor dental care, including endocarditis (an infection of the inner lining of the heart), cardiovascular disease (clogged arteries and stroke may be linked to oral bacteria) and premature birth and low birth weight babies, to name a few.

In the months after the Wall Street crash of 2008, Dr. Aziza Askari faced her own financial crisis. Patients in her Farmington Hills, Mich., dental practice began asking for refunds on prepayments for planned dental work. Askari honored their requests but wondered what was going to happen to her practice. "It was hitting us from everywhere," she said.

To save the practice, she focused on holistic treatments and expanded into sedation dentistry, in which anxious patients are relaxed before the drill begins to whir. Along with a hefty investment in laser technology and digital X-rays, this appealing change broadened her client base. She advertised her new services, which grew to 10% of her practice's costs. Despite the expense, offering this mix of services without raising prices for customers was necessary to survive, she said. "It kept us afloat. If not, we could be down 50% or close to it."

In a recent poll of 1,000 Americans conducted by Empirica Research for, a dental discounter, 74% of respondents said they go to the dentist only when there is a problem; nearly one-third who did not have dental coverage said they'd been to the dentist "only once" or "not at all" in the previous 10 years; 73% without coverage said they had delayed care because they feared the costs.

For those who skip regular dental visits, like Deamonte, the long-term costs can be alarming. In his case, after two operations and six weeks in the hospital, the bill was more than $250,000. But even less dramatic dental neglect can cost a bundle: A $125 cavity filling can prevent the need for a root canal or crown down the road, or even a dental implant, which can costs thousands.

Americans spent a total of $102.2 billion on dental care in 2009, down slightly from 2008 as patients pulled back. For those who do visit the dentist, costs are continuing to rise. Annual spending for dental care is expected to increase 58% in the next seven years, according to a 2010 Pew Center on the States report. While dental care is only 4.3% of total health costs, consumers are paying more dental bills themselves.

A 2009 report in the New York State Dental Journal showed that while 10.3% of physician costs, 3.3% of hospital care and 26.8% of nursing care expenses were paid out of pocket in 2007, 44.2% of dental bills were paid out of pocket.

In addition, the cost of dental insurance has risen over the past decade at an annual rate of 4% to 7%, depending on the level of coverage, according to consultancy Aon Hewitt. Yet the average annual dental benefit has remained capped at around $1,000 to $1,500 for the past four decades. This is also causing fewer Americans to buy dental insurance. The most recent report by the National Association of Dental Plans reveals that 166 million Americans were covered by some sort of dental plan at the end of 2009, down 10 million from the year before.

Even for Americans who are covered, many dentists have stopped taking state-provided insurance like Medicaid, and some have stopped accepting insurance altogether. Dr. Robert Minch, a dentist in Lutherville, Md., said he does not take dental insurance to avoid dealing with low reimbursements. Instead, he said, he's offering elective procedures such as Invisalign braces and veneers because they are not covered by insurance and are therefore more profitable.

An American Dental Association survey released in August reveals a struggling industry: Nearly 39% of dentists saw their patient billings decrease in the first quarter of 2011. In addition, only 16% of dentists added to their patient base, while the rest stayed the same or had a decline.

There is also a huge variation in dental costs and access in the country. People in rural areas, the poor and minority communities are suffering from a severe lack of dentists, said Cathy Dunham, the executive director of the Children's Dental Health Project, an advocacy organization. Also, costs for many procedures vary greatly. The cost of a dental crown can be anywhere from $600 to $1,800, depending on the type of material, where it's made and the dentist's experience.

"We're talking apples and oranges," says Dan King, the marketing director of the Atlanta Center for Cosmetic Dentistry. "A lot of people think 'a crown is a crown is a crown,' but they're not. . . . It's like comparing the Ritz-Carlton or the Hilton to the Motel 6."

To cope with the changing industry, many dentists are offering cosmetic procedures, but in the past few years, cosmetic dentists have been some of the hardest hit. "A few years ago, you had people taking second mortgages or using their credit cards to pay for procedures. That easy credit has dried up," said Dr. John Sullivan, the president of the American Academy of Cosmetic Dentistry. King said the flow of customers to his Atlanta practice had gone from a "fire hose" to a "garden hose," but the practice held up its bottom line by halving its staff.

Askari faced the choice that confronts dentists around the country: either invest in expensive new equipment to expand the procedures offered or risk a "race to the bottom" on prices for basic services such as teeth cleaning and cavity filling, which could lower the quality of service.

"It really is a tale of two cities," said Bassim Michael, a CPA who works with more than 30 dental practices across the country. "The practices that are doing well are the ones that are very growth-oriented," Michael said. "They've put more money in marketing, and they're investing in new technology."

The low end of the dental market is served by discounters such as, a website that includes 25,000 dentists who offer reduced-price services, such as crown work that would normally cost $1,340 for $595. Askari, the dentist from Michigan, said such "rock bottom" prices make it extremely hard to remain profitable and require a practice to have very little overhead.

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Minch, the dentist in Maryland, said that while discounter services fill a niche, it's important to keep in mind that dentists are running businesses and have fixed costs they need to meet. The cheaper the care, the more likely some corners will be cut.

"Dentistry is a labor-intensive operation," he said. "It's hard to do it on a heavily discounted basis. You'll likely get heavily discounted work."