A Survey of Dental Fees in Lebanon.
Author: Lamia Abi Aad Khoury.
LDS, DU Oral Biology, DESS in Community Oral Health and Epidemiology.
Associate Clinical Instructor, Department of dental Public Health.
Lebanese University School of Dentistry, Beirut, Lebanon.
Objective: The aim of this study was to evaluate the average honorarium dental fees of Lebanese dentists and to analyze fees variation by location of practices, specialty, academic position, gender, years of experience, and origin of basic dental qualification.
Materials and Methods: Collected information was based on a questionnaire distributed to the participants of two dental conventions in Lebanon. Number of participants was 365 dentists and their age varied between 22 and 70 years. T-Test, One Way Anova, and Chi-Square tests were performed to analyze the data. The software used was SPSS virgin 20.
Results: This study showed that standard deviation for every procedure of dental fees is very large. Many dentists’ fees were less than the minimal fees recommended by the Lebanese Dental Association- LDA. Statistical analysis showed a positive relationship between dentists’ fees, and several variables such as gender, specialty, location of practice, academic position, and basic dental diploma. Years of experience of dentists were not in correlation with dental fees.
Conclusion: Dental honorarium fees should be based on expenses, level of professional expertise, and difficulty of dental procedures.
How do Lebanese dentists set their honorarium fees for services? Is it reasonable or not?
According to the American Dental Association- ADA, the “usual” honorarium fee is the fee usually charged for a given service by an individual dentist to all private patients; A fee is “customary” when it is within the range of usual fees charged by dentists of similar training and experience for the same service within the same geographic area. A fee is “reasonable” when it meets the first two above criteria, and it is justifiable, considering the special circumstances of the particular care involved (1).
Achieving dental practice objectives requires many resources, such as personal, equipment, money, materials, knowledge, time, and space. The personal financial situation is important to begin this profession. The global economic situation is also a very important factor to keep the practice evolving. The successful practice of marketing rests on three basic principles: differential advantage, customer value, selectivity and concentration. So it is imperative to view dental private practice as a profession and as a business (1). Dental students were found to lack confidence in their role as team leaders; this was due to their lack of knowledge of team roles, responsibilities and experience (2). This survey tries to find out if dentists respect the minimum fee mentioned by LDA, if they charge reasonably for different dental treatments, and if their fees cover their expenses. Fees were analyzed by different variables such as location of practice, specialty, academic position, gender, years of experience and origin of basic dental diploma.
MATERIALS and METHODS:
This survey was conducted in 2013 during two main dental conventions: the biannual meeting of the International Convention of the Lebanese University in June and during the Beirut International Dental Meeting of the Lebanese Dental Association in September.
The questionnaire was anonymous and included two parts: the first one contained socio- demographic data concerning age, gender, location of practice, status of practice (private practice, polyclinic, or dispensary), working with a dental assistant, years of experience, country of graduation, specialty, academic position, if any, and presence of computer or network.
In the second part of the questionnaire, dentists were asked to report their fees for selected dental procedures.
The purpose of the study was explained to the 400 participants and questionnaires were distributed to all of them. The method for answering the questionnaire was also explained. Only dentists in private practice were included in the study (dentists employed by different institutions were excluded).
Questionnaires were filled by the participants and collected the same day. 400 questionnaires were filled, 35 of which were not completely filled and therefore were excluded from the study. Only 365 questionnaires were included in the study and data.
Data were processed and analyzed using the SPSS program. The statistical tests used were Sample T-Test, One Way Anova, and Chi-Square with p value < 0.05.
The average dental Lebanese fees were compared to minimal fees recommended by the Lebanese Dental Association and compared with the average dental fees in the US and Switzerland, as well as to the average fees that dentists working with the social health insurance in Belgium charge.
58.6% responses were collected in June 2013 and 41.4% in September 2013.
The mean age of participants was 40.7 years and the average years of experience was 14.6. The percentage of participants male was 67.1% and of female was 29.9.
The mean values of dental fees (in US dollars) are a little above the minimum fees recommended by LDA and many dentists often charge less than the fees settled by LDA (table1).
The average of Lebanese dental fees is compared with the average dental fees in the US (2013), as well as the fees agreed upon between Social Security and dentists in Switzerland and Belgium ( table 2). This shows that the mean dental fees of Lebanese dentists with 14.6 years of experience were lower than those in other countries.
Statistical analysis showed a correlation between dentiststs’ honorarium fees and several variables such as:
By Gender (chart 1 a, b), on average, responding males charge more than females for some selected dental treatments.
By location of practice (chart 2 a, b), On average, dentists working in Beirut charge more than those working in Mount Lebanon for the same procedures. Fees for the placement of the implant and the crown over the implant with abutment tend to be higher in Mount Lebanon. The average fees for orthodontic treatment are considerably higher in Beirut than those in Mount Lebanon.
By origin of basic dental qualification (table 3), on average, responding dentists who graduated from Western Europe charged more for selected procedures than those who graduated from other countries. Dentists who gratuated from Eastern Europe charged more for surgical placement of implant than others. Dentists who graduated from Lebanon charged more for orthodontic treatment than others.
By academic post (chart 3a- b) On average, responding dentists with an academic post charged more than those with no academic post for the same procedures. Except for surgical placement of implants, dentists with no academic position charged more than those with academic position.
By specialty (chart 4a -b). On average, responding specialists charged more than general practitioners for this selected dental treatment. Except for surgical placement of implant, general dentists charged more than specialists.
No statistically significant differences were found between honorarium dental fees and years of experience, working in private clinic or polyclinic, having computer and internet, and working with dental assistant.
Honorarium fees are always a questionable topic. Self- esteem of dentists plays a major role in fee’s setting process (3). Dentists are able to set fees for their services that they believe to be fair and equitable for both their patients and themselves (4). This is the reality in many countries. For example, Australian dentists in private practice charge for services on a fee-for-service basis and have their own level of fees for the services they usually perform. Their fees may vary depending on unexpected difficulty encountered, ease of execution, patient’s ability to pay, patient’s compliance, or when the service is carried out concurrently with other kinds of service. For some items, the final amount charged depends, partly, on dental laboratory charges and/or the cost of dental materials used (5). In the United States of America, survey data from a nationwide random sample of dentists who were asked to record the fees most often charged for different dental procedures were collected and published in the ADA’s Survey of Dental Fees report. The report provided information on what dentists who completed the survey typically charge, but these were neither the recommended fees from ADA, nor an ADA standard for fees (6).
How do Lebanese dentists set their fees?
A newsletter published by the Lebanese Dental Association is a source that mentions the minimum fees that dentists may charge (7). This collected fees survey showed how typically dentists charge for each dental procedure, and that there is a large standard deviation between dental fees. Many dentists charge less than the minimal fees settled by the LDA, leading to competition of fees among dentists. Whitney and co-workers showed that “when the price of dental services is low, then the quality of care provided by the dentist may be reduced” (8): in this study, for example, the minimum charge of a full ceramic is 200usd, and the maximum charge is 750usd, with 91.625 standard deviation. The usd standard deviation between dentists is not the problem, but rather it is how a good full ceramic crown could be made with a cost of 200usd. The wide range in clinical fees for a service that is so commonly needed and that constitutes a significant portion of the income of typical general dentists and prosthodontists is also found in the United States. According to the American Dental Association 2005 Survey of Dental Fees, the mean national fee for a porcelain-fused-to-high-noble-metal crown in the United States is 808usd, including the cost of laboratory service. The standard deviation reported for this service was152usd (7). This wide range is due to differences in quality of clinical and laboratory aspects of fixed prosthodontics. There are bad, good, and excellent crowns (8). This means that the 200usd charge for a full-ceramic crown is questionable.
There are geographical reasons for some differences in fees owing to the variable cost of living in different regions of Lebanon. Dentists in Beirut charge higher fees due to the higher cost of living in the capital; which does not necessarily mean a higher quality of service (9). A 2012 survey done by the Australian Dental Association showed a considerable variation in the levels of fees charged both within and between states (10). Around one fifth of general practitioners (21%) provided intraoral radiographs records as 0 usd fee (11). This survey showed that also in Lebanon, some dentists do not charge any fees for intraoral radiographs.
The Australian Dental Association survey showed that specialists charged higher fees than General Practitioners (10). The situation is similar in Lebanon. An exception is the surgical placement of implants. Non-specialists with no academic positions, who are graduates of Eastern Europe, charge the highest fees. This shows the competitive fee between dentists practicing in Lebanon.
This survey showed a gender gap in fees between dentists that cannot be explained by specialty choice, practice setting, work hours, or other characteristics (11). Dental profession is becoming more and more a female’s one. An international comparison of students in orthodontics education programs found that the number of female students is increasing (12).
Academic position and origin of diploma of the dentist plays a positive role too. People tend to trust academics.
Years of experience play no role. A dentist who is a recent graduate may charge the same dental fees as experienced dentist.
This overview showed that there is no logical basis for honorarium dentists’ fees. Many Lebanese dentists with 15-years of experience are charging a little higher than the minimum fee recommended by LDA. There is a competition between dentists. Many fees are questionable and can’t cover the expenses of the dental practice. Low fees may be due to a lack of management. It is imperative that dentists do not forget infection measures control that are an integral part of their profession and a part of expenses. Honorarium fees should be based on expenses, level of professional expertise, and the difficulty of dental procedures.
Table 1: Mean values of dental Fees in Lebanon (in comparison to LDA minimal fees) (expressed in US dollars)
|Peri-Apical radiographic (N=120)||0||25||8.6583||4.8758||6.6|
|Root canal filling 3 canals (N=232)||30||300||69||35.734||50|
|Retreatment 3 canals or more (N=214)||40||300||87,579||44.875||83|
|Amalgam filling – 2 or more surface (N=203)||15||70||29.91||10.297||26|
|Composite filling- 2 or more surface (N=254)||25||120||40.471||14.444||33|
|Oral prophylaxis (N=244)||15||120||30.471||11.916||30|
|Gingival curetage /per semi-arch(N=133)||30||350||71.011||64.594||33|
|Ceramo- metallic crown (N=239)||70||550||152.73||68.306||133|
|Full- ceramic crown (N=207)||200||750||314.46||91.629|
|Simple extraction (N=247)||10||120||23.861||12.641||20|
|Surgical extraction (N=189)||20||300||84.92||51.379||66|
|Fissure sealant (N=1640||10||120||24.854||15.341||13|
|Implant placement (surgical) (N=98)||450||1800||798.48||253.48||250|
|Crown over Implant with Abutment ( N=99)||150||1300||392.27||195.52||250|
|Orthodontic Device Bi-Maxillary (N=36)||1000||3500||1900||566.82||1500|
|Bleaching (In office) (N=202)||80||800||289.41||99.525|
This table shows that mean dental fees are a little above the minimum fees settled by LDA. Many dentists charge less than the fees settled by LDA.
The following table shows the average Lebanese dental fees compared with the average dental fees in the US (2009), as well as the fees agreed upon between Social Security and dentists in Switzerland and Belgium.
International Comparison of dental fees ( mean currency in 12/2013: USD/EUR 0.684; EUR/USD 1.461; USD/CHF 1.028; CHF/USD 0.972; USD/LBP 1509; LBP/USD 0.000663).
|Root canal filling 3 canals||1147||69||896||210|
|Retreatment (3 canals or more)||87|
|Amalgam filling – 2 or more surface||203||30||259||81|
|Composite filling- 2 or more surface||342||40||434||97|
|Gingival curetage /per semi-arch||383||71||56|
|Ceramo- metallic crown||1074||153|
|Full- ceramic crown||1051||314|
|Extraction (non surgical)||162||24||56||49|
|Implant placement (surgical)||2962||798||1200|
|Crown over Implant with Abutment||2644||392||1124|
|Orthodontic Device Bi-Maxillary||7978||1900|
|Bleaching (In office)||289|
This table shows that the mean dental fees of Lebanese dentists with 14.6 years of experience are lower than those in other countries.
Chart 1-a: Fees by Gender
On average, responding males charged more than females for there selected dental procedures.
Chart 1-b: Fees by Gender
On average, males who responded to the questionnaire charged more than females for there selected dental procedures.
Chart 2: Fees by Region:
The following chart compares, by region, the mean fees charged by dentists.
On average, dentists working in Beirut charged more than those working in Mount Lebanon for the same procedures.
This chart showed that only the fees for surgical placement of implant and the crown over the implant with abutment tend to be higher in Mount Lebanon. Average fees for orthodontic treatment were considerably higher in Beirut than those in Mount Lebanon.
Table 3: Fees of dental procedures by country of basic dental diploma
|Origin of diploma
|Lebanon||Western Europe|| Eastern
|Orthodontic Device Bi-Maxillary
(N = 34)
|Implant placement ( (N =94)||774.3
|Crown over Implant with Abutment (N = 89)||419.4
|Full- ceramic crown (N = 172)||316.9
|Bleaching (In office) (N = 195)||301.2
| 293.5 (147.8)
|Ceramo- metallic crown (N = 228)||156.6 (61.5)
| 134.3 (82.4)
|Retreatment ( 3 canals or more)
(N = 197)
| 92.3 (53.6)
|Surgical extraction(N = 182)||91.1 (49.4)
|Scaling gingival curettage /per semi-arch
(N = 90)
| 107.6 (92.7)
|Root canal filling ( 3 canals) (N = 222)||67.2 (29)
| 68.4 (44.3)
|Composite filling-( 2 or more surfaces)
(N = 237)
| 42.5 (21.5)
|Oral prophylaxis (N = 233)||29.4 (9.6)
| 28.3 (13.7)
|Amalgam filling ( 2 or more surfaces)
(N = 195)
| 27.9 (12.7)
|Fissure sealant (N = 159)||23.5 (13.9)
| 27.6 (20.3)
|Extraction non surgical (N = 238)||24.7 (12.6)
| 21 (11.7)
|Peri-Apical radiograph (N = 117)||9.2 (5.6)
| 7.1 (3.7)
On average, responding dentists who graduated from Western Europe charge more for selected procedures than those who graduated from other countries. Dentists graduating from Eastern Europe charge more for placement of implant than the others. Dentists graduating from Lebanon charge more for orthodontic treatment than the others.
Chart3: by Academic Position ( teaching post).
The following chart compares the average fees charged by dentists, academics and non- academics, for identical procedures.
On average, responding dentists with an academic position charged more than those with no academic position for identically procedures.
Chart 3-b: By Academic Position ( teaching post)
On average, responding dentists with an academic position charged more than those with no academic position for identically procedures. Except for the placement of implant, dentists with no academic position charge more than those with academic position.
Chart 4: by specialty.
The following chart compares average fees charged by dentists for identically procedures, grouped by specialty.
On average, responding specialists charge more than general practitioners for this selected dental treatment.
On average, responding specialists charge more than general practitioners for this selected dental treatment. Except for the placement of implant general dentists charge more than specialists.
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