Retirement Dental Planning

This essay was the result of a conversation with a patient facing imminent retirement. His request was simple: to create a plan with long term prognosis of teeth and gums in mind and to do the needful to prepare him for a trouble free retirement.

Most people begin the process of planning for their retirement years sometime during employment and the essence of that planning goes towards financial planning. The diligent saver would have worked out a game plan early in their careers and stuck to it and not surprisingly would be well positioned to enter retirement with a healthy safety net. The late comers will never truly remain retired as the financial pressures of lifestyle needs will force them back into some form of employment. There is a difference between people who seek employment for the sake of the activity which keeps them on a motivated daily routine versus those that desperately need to remain employed for financial reasons. With so much of the emphasis falling on the financial side of retirement people tend to forget that there is another criteria to take into account which will affect the quality of retired life immensely.

Coincident with retirement is also the acceptance of the reality of aging. Medical planning is to a large extent already fulfilled through a mix of personal insurance and social safety net programs by the Government. It is the catastrophic care and the end of life care that individuals have to pay particular attention to and financially plan for. The often forgotten puzzle piece in this planning is the dental care planning. Dental care rarely rises up to the importance of health and wealth planning but can become insidious and financially taxing at the most inopportune of moments.

Most individuals who worked for employers that provided health and dental insurance will be shocked to know the actual cost of maintaining a dental/health insurance on their own without the benefit of group discounts their company had negotiated with insurance industry. Additional shock at retirement, is the realization of the actual cost of dental maintenance and treatment especially without the comfort of the umbrella of the “dental insurance” (Dental insurance is not really an insurance …to know why see my earlier blog on ‘Dental insurance- A Dentist Perspective’).

Most individuals who have gone through a medical screening are quite aware of the status of their health. They may choose to ignore the medical recommendation but it is never due to ignorance. Therefore if a patient has been diagnosed with high cholesterol or pre diabetic conditions they are aware that without treatment and maintenance they will eventually have undesirable and expensive health consequences. With dental, a lot of the information is, even in the best of times, too esoteric for most. Devoid of symptoms, concerning an area that they cannot see and given that most dental conditions rarely threaten lives, dental problems are easily ignored and pushed onto the backburner. This habit of procrastination eventually does catch up with the patient and results in the day of reckoning. All through their working lives such emergencies could be dealt, either with or without the help from Dental Insurance, on the confidence of being financially capable, due to the regular arrival of new monies via the paycheck. At retirement this guaranteed source of funding shrinks considerably and can no longer be depended on to pay for sudden catastrophic needs. Retirement is the stage where the individual has to become more disciplined and proactive in planning out the ways by which they spend so that they can make their financial nest egg last out as long as possible.

How does one then go about establishing a path forward at retirement for dental needs? If the patient at the time of retirement has had all necessary dental work completed and has been educated and trained to do their best in home care maintenance then this individual can be expected to maintain their teeth in the current condition for many years without needing any catastrophic care. This individual can manage with one or two visits annually to the dentist to verify their maintenance. Devoid of major changes in health such as Cancers, Cardiovascular incidents, loss of motor abilities or immune diseases, the patient should be able to live long and at least with regards to their mouths, be stable. This patient can even take the bold step of living without dental insurance, the saving in premium will more than offset the financial need for the odd emergency care.

However this hypothetical state of being restored to a stable optimal dental condition is within the reach of only a small percentage of individuals. Majority of the patients will enter retirement with significant amount of dental deficit. Considering the fact that all restorations have a mean life expectancy of between 5-20 years, most patients entering retirement might have some restorations that are old and needing of replacements. If these restorations are not evaluated for the replacement potential prior to retirement then these might be items responsible for some unpleasant unexpected dental expenses after retirement. Furthermore procedures that were delayed prior to retirement are less likely to be completed at retirement due to the negative financial pressures. Such an individual is likely to elect for less expensive ‘patch-up’ style repairs and thus postponing the more definitive treatments, which with delay becomes more expensive. In addition with increasing age, medical conditions might make the patients less amenable to extensive dental procedures.

Goal:

One of the ultimate goals of attempting to achieve optimal stable oral conditions in preparation for retirement is the desire for preventing compromised health condition due to poor nutrition in the later decades of life. As individuals we have great abilities to compensate for our deficiencies through most of lives. This resiliency is expectedly decreased drastically towards the final decades of our life. Poor oral condition leads to poor choice of foods, leading to compromised nutrition which in turn plays havoc with the general health. The other goals are obviously to prevent unnecessary pain and discomfort, to avoid situations of chronic infections and last but not the least maintain one’s dignity by having the ability to face the world without any esthetic embarrassments. The process of achieving these goals is what retirement dental planning is all about.

Pre-retirement Evaluation:

Retirement planning therefore has to start with taking stock of the current status of the mouth with the intent of anticipating treatment for projected damage from wear and tear and the potential for damage based on past history of patient’s food habits and hygiene habits. This step should probably done at least 4-5 years prior to retirement so that adequate time is allotted for planned dental work to maximize the help from dental insurance that the patient may have.

In this stage the easiest treatment to plan for are those that are connected with a definite damage processes, such as, active gum disease, cavities, infections caused by dead or dying root canal tissue or surgical requirements to remove offensive teeth or tissue. What is more difficult to prognosticate is the damage from habitual clenching and grinding of teeth or secondary changes from age related health changes such as, diabetes, heart ailment medications, thyroid issues, cancers etc.

Obviously patients who have managed to retain most of their teeth, have lead a disciplined life and are reasonably healthy will enter this pre-retirement evaluation requiring little to minimal corrective work and therefore can be expected to attain and maintain a stable mouth environment for years to come. The difficult patient to adequately prepare for is one of unstable oral health, possessing poor dental IQ and requiring considerable treatment. The financial burden itself will make the task of preparing for retirement with a cleaned up mouth very daunting. This is where the issue of financial planning and insurance coverages becomes critical.

Financial stock taking and Insurance Decisions:

Individual Dental insurances can be expected to have premiums of $200.00 to 2000.00 per year. In addition to this, patient will still responsible for the copayments for various procedures. Dental insurance play a bigger role in the dental treatment commitments before retirement as most who have it, get it as an employment benefit where the cost is to a large extent ameliorated by both negotiated group discounts and the employer paying a portion of the cost. After retirement, it is the patient’s personal finances that become the major factor in paying for and hence determining the dental care. It rarely makes sense to maintain a dental insurance after retirement as the terms and premiums are rarely favorable to the individual. The example to illustrate the futility of Dental Insurance is:

Annual premium

Insurance benefit Max.

Dental treatment

Net Out of pocket

1.500.00

1000.00

0.00

500.00 (Loss)

2.500.00

1000.00

1500.00

1000.00

3.1000.00

1000.00

1500.00

1500.00

4.1000.00

1000.00

2000.00

2000.00

5. 750.00

1000.00

3000.00

2750.00

6.2000.00

2000.00

10,000.00

10,000.00

In the examples above I took some liberties with realities to make the case as simply as possible. Firstly I am assuming that the dental insurance pays for all claims with no question at or close to 100% which is never the case. Secondly I am also assuming that the premiums being paid allows for coverage with no limitations on procedures, again which is rarely the case. In the example above the only people who came out slightly ahead were No. 2 and 5. In the real world where the first two assumptions I made do not pan out, even patients No. 2 and 5 will come out with a net negative. The same insurances offered under the aegis of employment will probably cost the patient about $20.00- 50.00 in annual premiums, which makes them a decent investments to have. There is however one other benefit to having dental insurances and that is the ability to get to access to pre-negotiated discounted fees. For instances without insurance a crown procedure might cost upwards of $ 1000.00 but with a PPO the same procedure might be done for a contracted fee of $ 750.00.

Strategies for dental treatment planning:

  1. Target the expensive procedures first: There are dental procedures that can cost a great deal more than the annual maximum of Insurances and then there are dental treatments consisting of multiple procedures that can exceed the annual maximum benefit payout. It is important to understand that in Retirement planning the procedures that are the most expensive need to be targeted for completion prior to collecting that last pay check. These are usually procedures such as teeth needing Root canal treatment followed by crown restorations, multiple crown restorations, Implant restorations or even extraction followed by dentures. These procedures can cost $ 1500.00 to 6000.00 and upwards. Insurance help, even if small, will be available to use through the employed period. This will also minimize the financial load on the financial nest egg. The remainder of treatment can be done piecemeal within the budget limitations of the retired life. Postponing any of the more expensive procedures after retirement is a sure way of either running into a lot of financial stress or worse never getting it done.
  2. Increase the employment period by a few years: The other way to improve the possibility of attaining a stable and optimal oral health is to delay the onset of retirement if possible by a few more years to maximize the advantage of having both a steady income and employer sponsored dental insurance coverage. Even a 2-3 year increase in working time will allow for completion of planned treatment in a timely manner and at the same time allowing for the retirement financial plan to end with a more positive balance.
  3. ‘Interest Free ‘Credit line use: For all patients the main challenge is to budget for a large unexpected dental expenditure. Since some of the treatment required might be complex and expensive the only way most patient can bear the brunt of this unexpected cost is to apply for a healthcare credit line. Dental offices help in the utilization of these credit lines by absorbing the interest for short periods and thus they are presented as “interest- free” credit lines to the patient. Depending on the office they might get interest paid credit available from 3 months to 12 months or more. While this provides some assistance the patient still needs to be financially capable of paying it all back in the time period allotted.

Travel/ Dental Tourism: US is very expensive for healthcare. There are other nations that provide similar care at a fraction of the cost. The trouble is in find qualified and trained dentist who will provide similar or higher standard of care as can be expected in US. There is the fear that healthcare and dental care outside the US is universally substandard and to be avoided. The continuing education circuit in US, for providing ongoing training to US dentists, every year invites dentists from abroad to provide lectures and are considered to be experts in their fields of expertise. If these professionals are being held in high esteem within the international and national dental communities then it reflects on the availability of high standard of care outside US too. Patient will have to do some personal research and due diligence before committing to a trip abroad for treatment and not be gullibly swayed by marketing promotions.

Financially strapped patients: These are individuals who have been either forced into retirement before adequate planning could be done or those who ran into life situations resulting unexpected financial duress or those who did not budget for a retirement plan or those whose lifestyle exceeded the revenue stream and are in need of considerable dental work. Unfortunately for these individuals the options are quite limited. They could try and get most of their dental work done through free clinics, subsidized Governmental programs like Denti-Cal in California, or sign up for the cheapest Managed care insurance. The goal here is to minimize the eventuality of active infection and pain and some restoration of the repairable teeth.

Finally, one has to be cognizant of the fact that even with the best of efforts by both the dentist and the patient there are certain eventual breakdowns that will happen in the later years of a person’s life. There is no way to adequately compensate for these completely. These are usually the extreme wear that accrue from lifelong habits of clenching an grinding teeth- stress release mechanism or gum disease as a result of inabilities to maintain perfect hygiene either due to loss of motor control from diseases like Parkinson’s disease or as a result of stroke, or loss of muscle tone with advancing age along with the onset of sleep disorders, compromised tissue immunity with conditions like diabetes, kidney disease or even as side effect of medications. These patients might therefore all benefit from being provided mouth guards and oral medication delivery trays which can be used to apply antibacterial gels or hydrogen peroxide gels (Perio-Protect system: www.periprotect.com) and working in concert with medical personal trained to handle sleep disorders. These additional steps might reduce the need for expensive and dramatic intervention in the later years and prolong a relatively pain free living.

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