Dentistry Has a Margin Problem—and Underneath It, a Progress Problem
Field Note 001: What if some of the margin we are trying to recover is being lost when patients stop moving forward?
FIELD NOTE 001
Question: What if some of the margin we are trying to recover is being lost when patients stop moving forward?
Health Path: Patient + Practice
Status: Working theory with emerging evidence
From the field
Since 2019, we have lived through one of the sharpest inflationary periods of my practicing career.
Our teams need to earn more to support their families. Supplies, equipment, laboratories, technology, and nearly every other cost required to operate a dental practice have become more expensive.
That is how inflation works in almost every other industry: costs increase, and prices eventually follow.
Dentistry does not always work that way.
For many common procedures in our markets, Delta Dental reimburses us roughly what I remember receiving decades ago. The American Dental Association’s Health Policy Institute recently described the result as a significant “fiscal squeeze,” with reimbursement failing to keep pace with inflation—and falling even further behind practice expenses.
This is not simply dentists complaining. The economics are real.
For years, I have carried a great deal of frustration about it. We want to keep care accessible, compensate our teams fairly, invest in better technology, and operate healthy practices. How can we do all of that when our industry seems determined to ignore basic economic laws?
It is not difficult to understand why consolidation has become attractive. Scale promises leverage, centralized resources, negotiating power, and a potential escape from some of the pressure.
But spending an entire career lamenting forces we cannot control is both depressing and paralyzing.
We should continue advocating for fair reimbursement. We should renegotiate or leave contracts that no longer make sense. We should control unnecessary expenses and use scale intelligently.
But reimbursement is not the only place margin is disappearing.
The Health Progress question
Despite the need for dental care, most Americans do not visit a dentist in a given year.
The latest available data show that only 46% of the population had a dental visit in 2023. Among working-age adults, it was approximately 41%. Among uninsured working-age adults, only 15.8%—about one in six—visited a dentist.
Meanwhile, people continue showing up in hospital emergency departments with dental pain. The ADA estimates that an emergency-department visit for dental pain can cost between $400 and $1,500, compared with approximately $90 to $200 for a dental visit.
The need clearly exists.
At the same time, one-third of dentists reported in early 2026 that they were not busy enough and could have treated more patients.
How can all of those things be true at once?
Perhaps the problem is not simply a shortage of patients or a shortage of need.
Perhaps it is a progress problem.
Consider how much has to happen before a person actually becomes healthier:
Someone recognizes a need and decides to call a dentist.
The call is answered.
The person understands the insurance, network, scheduling, and financial information well enough to continue.
An appointment is scheduled.
The patient arrives.
The patient receives a comprehensive understanding of their current health.
A clear plan is developed.
The patient understands the plan and decides to move forward.
The first treatment appointment is scheduled.
The patient maintains momentum through every necessary step.
Health is rebuilt and then protected over time.
At every transition, people become stuck.
A patient calls but never schedules. Another visits for an emergency but does not return for the offered comprehensive evaluation. A patient receives a treatment plan but leaves without a clear next step. Someone begins a multi-appointment plan but never schedules the second visit, allowing disease to continue progressing.
Sometimes we contribute to the problem clinically. We are afraid of overwhelming the patient, so we present only the immediate repair without helping them understand what it would take to rebuild the health that has been lost.
In our own practices, we have experienced periods when only 30–40% of recommended care moved into scheduled treatment. Across a multi-location group, that can represent millions of dollars in recommended care that patients never complete.
That number is troubling economically.
It is even more troubling when we remember what the number represents: people who were diagnosed but never became healthier.
What we’re trying—and learning
Traditional dental reporting tells us how much we produced, collected, diagnosed, or scheduled.
Those numbers matter, but they tell us what happened after progress was created or lost.
We are trying to look earlier.
Where is each patient on the Path to Health? What is the next appropriate step? Is that step clearly documented? Has it been scheduled? If not, where did progress stop—and why?
The stages are not all the same:
A patient who came in with an emergency needs help returning for a comprehensive understanding of their health.
A patient who completed an examination needs a plan they understand.
A patient with a plan needs help taking the first step.
A patient in active treatment needs to maintain momentum until disease is controlled.
A patient who has controlled disease may need help rebuilding function, confidence, and long-term health.
A healthy patient needs an appropriate plan for prevention and protection.
Each transition requires a different conversation and a different kind of support.
The goal is not to push more treatment or manipulate patients into saying yes. The goal is to make it easier for each person to understand their situation, make an informed decision, and take the next right step.
When more patients make appropriate progress, more care is completed. Chairs are filled with people who already know and trust the practice. The team sees greater meaning in its work. Practice economics improve as a consequence of creating more health.
That is the idea I keep returning to:
Margin is not only a financial metric. It can also be the economic shadow of patient progress—or the lack of it.
We may not be able to control inflation, reimbursement, or every force reshaping dentistry.
But we can become much better at recognizing where patients are getting stuck and helping them move forward.
Try this in your practice
Look at the last 20 patients who came to your practice with an emergency and the last 20 who received a comprehensive examination.
For each patient, ask:
What was the next appropriate step?
Was that step clearly documented?
Was it scheduled?
If not, do we know why?
Does anyone have clear responsibility for helping the patient continue?
Do not begin by calculating the value of all their unscheduled treatment.
Begin by identifying the transition where progress stopped.
That is where the opportunity lives.
Compare notes
Where do patients most commonly become stuck in your practice: before the first appointment, after an emergency, after diagnosis, before beginning treatment, or somewhere in the middle of a multi-step plan?
And what have you found that genuinely helps them move forward?
—Josh