Dental Tourism: An Opportunity for Public Health

Lois Cohen (LC): What is dental tourism and describe its scope and market penetration?

Irving Stackpole (IS): Most people think of dental tourism in the context of crossing an international border—for example, traveling from the United States to Costa Rica, or from the UK to Hungary—in order to consume dental services, but I believe it's anyone who travels from their area of residence to another location in order to consume dental services. While it is significantly under-reported, it is considered to be the largest segment of the medical tourism sector.

David Vequist (DV): A 2010 Center for Medical Tourism Research¹ study reported that 1,800 potential medical tourists from the United States found that dental procedures are the most frequent type of healthcare procedure that potential travelers were interested in—at 18.1%.

LC: What are the main drivers for dental tourism?

IS: The primary driver appears to be economics—and the evidence of this is both intuitive and logical. There's a very large Mexican-American and Hispanic diaspora in the southwestern US who travel to Mexico to consume services, and part of the reason for that is the cost differential. However, a secondary driver can be cultural affinity and familiarity when there are no obstacles associated with the language or culture of the destination.

DV: There is also the issue of increasing the value for consumers, as discussed in Redefining Health Care.² If the perception of value is greater by traveling to receive procedures that are not available or more expensive in your home location, the patient may be willing to travel. In our 2010 study,1 65.9% of potential patients said they would travel because of higher prices, 32.9% because treatment wasn't available, and 31.7% because of more advanced technologies. A study of dental tourism in Hungary noted that air travel to Budapest tended to be used for more expensive procedures, whereas less expensive treatments attracted tourists to the smaller cities. This suggests a value proposition in which the patient determines where and how far to travel depending on the type of procedure, the perception of quality, and the possible savings.³

LC: How do patients receive information about the quality and location of treatments and dentists?

DV: For good or bad, our research shows that the majority of medical travelers are using the Internet, social media, and family and friends to make these decisions. Frost & Sullivan (www.frost.com), the global thought leadership firm, recently forecasted that the medical tourism industry would be a $100 billion market by 2012, and that this huge global industry has grown primarily through the Internet and word-of-mouth, with little traditional advertising.

IS: While the Internet has been enormously important in accessing information about foreign or destination providers, the information available and the quality of the websites varies widely. The standards portrayed by destination providers seem to correlate to those in the US and in Europe. The challenge for consumers, of course, is to validate that the provider actually has those certifications and benchmark qualifications.

LC: What are the strengths and weaknesses currently associated with dental tourism?

IS: The greatest strength is clearly economic. Even going to the highest-priced oral surgeon in Costa Rica, and using a top-shelf lab, the patient spends 25% to 35% less than in the US for excellent work by any standard. Many of the destination providers recognize that they are competing against the factor of convenience, so they have collaborated to make the entire experience seamless and pleasant. However, a weakness is that if something goes wrong, the patient is removed from his/her regular support network. In addition, the medical malpractice systems might not be as robust and as easily accessed; therefore, the adjudication of claims and systems in place for addressing complaints may not be in place.

DV: I consider the strength of dental and medical tourism to be the introduction of new competition to an industry that had been restrained in the past. The issues of concern, however, are: 1) the lack of studies that support similarity in clinical outcomes between providers in different locations and countries; 2) the possible economic impact of patients' leaving their home geography for other locations to receive care; and 3) the ethical and legal implications of this fascinating trend.

LC: What are the opportunities to build upon dental tourism for public health purposes?

DV: Dental tourism provides the possibility of both helping and hindering public health causes. On one hand, procedures may become more accessible for those who can't afford them or who live in an area where they aren't available. On the other hand, dental tourism may be limiting the availability of providers, as they perform procedures more profitably for out-of-town visitors, whom they can charge more. Because of the current lack of empirical research, we don't know if this is a positive or negative contribution to society.

IS: Why shouldn't individuals be able to travel to a destination to consume services that they couldn't afford or access in their primary marketplace area? The question is whether the developed-country consumers who visit a developing country are making an economic contribution that benefits the local population in that destination. While there is evidence that the money is used only to the benefit of the well-to-do locals, I believe that there are cases where the migration of dental consumers is of huge benefit to the local well-being. I suspect that the public health benefits of dental tourism vary widely in different areas.

LC: How would you envision dental tourism as a mechanism for building entrepreneurial skills in countries needing to develop their health workforce?

IS: The entrepreneurial drive needed to develop a robust and sustainable dental tourism practice is the same as that needed to build a sustainable practice in any marketplace. There must be systems in place for consumers, who, in this case are international patients. Entrepreneurs must also be sensitive to the market. The primary marketing piece for virtually every destination dental practice is the website—the messages, images, and the language need to conform to the culture of the intended marketplace.

DV: Interestingly, it can be argued that the entrepreneurship shown by providers and facilities in developing nations has been a significant factor in growing this trend. From a cursory evaluation, it seems their efforts, in total, have been greater than the providers and facilities in more developed countries. The positive aspect is that there are more incentives for becoming healthcare providers in these countries. However, the negative side is that many of these providers are focused on providing private, fee-for-service care, which may hinder local public health efforts.

LC: Clearly medical tourism offers many opportunities for those seeking to maximize their healthcare dollars, but there are also legal, ethical, and safety issues to consider. As noted by Matthias Helble in a recent article for the Bulletin of the World Health Organization,⁴ "Medical travel is challenging our traditional ways of thinking about public health, and we are confronted with a wide array of questions that still need to be answered." Noting a series of papers commissioned by the World Health Organization that explore questions such as legal and regulatory issues, ethical concerns, and infection control, he concludes, "The ultimate challenge in all these efforts will certainly be to find a strategy that allows harvesting of the benefits for public health of medical travel while limiting the risks."

Clearly there is so much to be learned and a large research agenda for a potential investigator community, particularly focused on comparative effectiveness studies of health outcomes. The data on dental tourism is sparse and, hopefully, given the growing dental tourism market, the incentive to engage in such research will also grow.

Dental Tourism by the Numbers

Medical/Dental Tourism in the News

PepsiCo employees incentivized to travel to Johns Hopkins in Baltimore for surgery—According to a December PepsiCo press release, the company, which sponsors its own self-funded medical plans, will offer its employees the option of traveling to Johns Hopkins Medicine in Baltimore for cardiac and complex joint replacement surgeries. Employees and covered family members who elect to have their surgery at Johns Hopkins will receive an all-inclusive rate for hospital and physician charges and certain preoperative testing, with deductibles and coinsurance waived. The company will also cover the travel and lodging expenses to Baltimore for the patient and a companion.

Johns Hopkins Medicine to Offer PepsiCo Employees New Travel Surgery Benefit. Available at: https://www.pepsico.com/PressRelease/Johns-Hopkins-Medicine-to-Offer-PepsiCo-Employees-New-Travel-Surgery-Benefit12082011.html. Accessed January 4, 2012.

Businessweek notes dental tourism trend—This article highlights what it terms a "dental crisis" —lack of or inadequate insurance coverage—that is driving an increasing number of US citizens to take their dental dollars abroad. Reporter Catherine Arnst writes, "For years dental tourism has been a thriving subset of medical tourism, as American and European patients seek affordable care for decaying teeth. Some surveys estimate that as many as 30% of the population along the Texas side of the Rio Grande cross the border into Mexico for cheaper dental services. British dental patients have long traveled to Eastern Europe for care. And in a 2008 survey, the nonprofit Healthcare Tourism International found that dental services were the most common procedures sought out by medical travelers."

Arnst C. Lack of Insurance Drives Dental Tourism. Available at: https://www.businessweek.com/globalbiz/content/nov2008/gb2008119_541944.htm. Accessed January 5, 2012.

New York Times covers the vacation aspect of dental tourism—This news story about an extended California family that turned a dentally necessary visit to Mexico into a regular family vacation highlights the trend both in terms of such patients' willingness to travel to secure affordable healthcare as well as how they arrange their trips and spend their time and money at the dental vacation destination.

The article cites a recent report by HealthCare Tourism International that dental bridges and bonding are ranked Nos. 1 and 2 on a list of most sought-after procedures for Americans traveling abroad for medical care, and that a growing number of medical travel agents in the US can facilitate both the dental and vacation aspects of the arrangements.

Sweeney C. More Fun Than Root Canals? It's the Dental Vacation. Available at: https://www.nytimes.com/2008/02/07/fashion/07SKIN.html. Accessed January 6, 2012.

American travels to Sweden for procedure not yet available in the US—This article in the online publication Medical Tourism Magazine recounts the struggle of a Baltimore man with tracheal cancer who goes to Sweden for a lifesaving transplant neither covered by his insurance nor yet available in the US. The operation performed in Sweden involved the transplantation of a synthetic, tissue-engineered trachea created by a device—called the "InBreath" bioreactor—manufactured in the United States by Harvard Bioscience of Massachusetts.

America has the best medical technology in the world—but sometimes a procedure is so new that it is not available in the US, even if the technology is American.

Medical Tourism Magazine. Available at: https://www.medicaltourismmag.com/newsletter/64/best_technology.html. Accessed January 4, 2012.

US residents return to native India for dental care—In a Washington Post news story on medical tourism, reporter Manoj Jain describes his parents' decision to have dental treatment in India. "When my father had a toothache, he saw a dentist in Boston who recommended a root canal and dental crown costing about $2,000. He decided to wait until he was in India, his native land, for holidays and had the procedure done there for $200. Extremely satisfied with the service and the price, my mother decided to have her two front teeth replaced, eliminating a wide gap that tarnished her smile, and estimated she had saved $3,000."

According to the article, the 90% savings reflected in the cost of these dental procedures extends to medical procedures as well. Jain noted that Devon Herrick of the National Center for Policy Analysis in Dallas, specified the following factors that make foreign hospitals less expensive: lower labor costs, fewer third-party payments, price transparency, limited malpractice liability, and fewer regulations.

Jain P. Medical tourism draws growing numbers of Americans to seek health care abroad. Washington Post. April 4, 2011. Available at: https://www.washingtonpost.com/national/health/medical-tourism-draws-growing-numbers-of-americans-to-seek-health-care-abroad/2011/02/09/AFkbobeC_story.html. Accessed January 5, 2012.

Australian man has dental surgery in Bangkok—The Sydney resident depicted in this Medical Tourism Magazine article headed to Thailand, which is considered one of the world's most popular destinations for dental work, after receiving a $6,000 quote from a local dentist for two root-canal treatments. He received treatment at a clinic in Bangkok, where he was quoted $2,400 for that work plus whitening, cleaning, and changing old fillings.

According to a report by the Singapore-based travel supplier Abacus International, Asia's medical-tourism industry is expected to generate more than $4.4 billion by 2012.

Smile, you're in Bangkok. Medical Tourism Magazine. Available at: https://www.medicaltourismmag.com/newsletter/64/smile-you-re-in-bangkok.html. Accessed January 5, 2012.

Maryland woman saves 75% on dental treatment in Hungary—A USA Today news story describes the experience of a Silver Springs, Maryland, woman, who, even with dental insurance coverage would have paid $11,150 for dental work that cost $2,900 in Mosonmagyarovar, Hungary. Adding an additional $1,400 for hotel and travel, she is able to save money and explore the town, which caters to long-distance dental patients with special travel and lodging arrangements, including "dental week" packages. The article explains how the woman located the dentist through a Reno-based travel agency that has been offering dental tours since 2001.

Marklein MB, The inciDENTAL tourist. Available at: https://www.usatoday.com/travel/news/2005-07-28-dental-tourism_x.htm. Accessed January 5, 2012.