Teledentistry Rules: Still Unclear After a Year

A year-plus into the teledentistry rule debate, the honest answer is that there are no national rules, there won't be any soon, and the ADA is actively working to keep it that way. If you were waiting for the dust to settle before you built a virtual visit workflow, stop waiting. The dust is the permanent condition. What you can do is build a program that survives a rule change, because the rules in your state are going to change again.

Here's the state of play as of this quarter, and what it means for the three decisions you actually control: whether to offer virtual visits, how to bill them, and how to price the doctor time they consume.

What Actually Changed in the Last Year (Not Much)

The clearest evidence that teledentistry rules are unsettled isn't a survey. It's a rulemaking calendar. The Colorado State Dental Board held a rulemaking hearing on July 8, 2026 for a brand new Rule 1.36, Practice of Teledentistry, implementing SB 25-194, with a public comment deadline of June 30, 2026. That's a state writing its foundational teledentistry rule from scratch this year, well after the pandemic-era emergency waivers expired and well after everyone declared the question settled.

Colorado isn't an outlier. It's just the state that put its process in a public bulletin. If your state board has a teledentistry rule on the books, check the adoption date before you rely on it. If it doesn't, you're operating under general practice-act language written before anyone imagined a hygienist collecting records in a nursing home and a dentist reviewing them from forty miles away.

Adoption data is thinner than the noise suggests. The ADA Clinical Evaluators Panel found that 30% of dentists surveyed (n=244) use teledentistry, with most adopters having picked it up within the prior three years. That's roughly one in three, and half of those came to it because COVID forced them. Note the date on that panel report: 2023. The fact that it's still the most-cited adoption figure in the profession tells you something about how little rigorous measurement has happened since.

The Licensure Wall Is Deliberate

A lot of practice owners assume the state-by-state patchwork is an accident of slow government. It isn't. The ADA's policy on teledentistry requires that a dentist be licensed in the state where the patient receives the service, and the ADA explicitly "opposes a single national federalized system of dental licensure for the purposes of teledentistry". That's not a placeholder position pending further study. That's the organized profession taking a side, and the side it took locks in the patchwork.

Practical translation for your operation:

• The patient's physical location at the moment of the visit determines which license you need. Not where your office is. Not where your server is.
• A patient of record who drives across a state line for work and calls you from their office on a Tuesday is, under a strict reading, receiving service in a state where you may not be licensed.
• Any DSO or teledentistry platform pitching you on "expanding your patient radius" is selling you a licensure problem unless they can name the specific state licenses that cover it.
• Waiting for federal preemption to fix this is a bad plan. The largest professional association in the field is lobbying against it.

If you practice near a border, this is your single biggest compliance exposure, and it costs you nothing to fix. Add one field to your virtual visit intake: where is the patient physically located right now. Document the answer. That one question is the difference between a defensible record and a board complaint you can't win.

Reimbursement Is the Blocker, and Dentists Already Know It

Ask dentists who don't use teledentistry why not, and the answer isn't technophobia. In that same ACE panel, 39% of non-users cited reimbursement concerns as a barrier. Nearly two in five. That's a rational business objection, not resistance to change.

The broader telehealth data explains why the objection persists. The Center for Connected Health Policy's Fall 2025 report found that only 32 state Medicaid programs reimburse across all four telehealth modalities, and just 24 states plus Puerto Rico require explicit payment parity. Fewer than half the states in the country guarantee that a virtual encounter gets paid the same as the in-person equivalent. In the other half, a payer can acknowledge the service, accept the claim, and pay you a fraction of your usual fee, legally.

So your billing plan depends entirely on which half you're in. Two questions to answer this week, in writing, before you promise a patient anything:

• Does your state require payment parity for telehealth services, and does that statute cover dental or only medical? Many parity laws were written with physicians in mind and are silent on dentistry.
• Do your three largest PPO contracts specifically address D9995 (synchronous) and D9996 (asynchronous) teledentistry codes, or are they silent? Silence in a contract is not permission. Call the provider relations line and get the answer in an email.

Practices that skip these two questions end up doing the work, submitting the claim, getting denied, and then eating the cost or balance-billing a confused patient. That sequence is how a teledentistry program gets killed internally after four months.

Patients Are Further Ahead Than Payers

The demand side is not the problem. A peer-reviewed literature review published February 10, 2026 found teledentistry acceptance rates of 70% to 87% and patient satisfaction of 72% to 94% across studies in Saudi Arabia, the UK, and Malaysia. Those are strong numbers for any care delivery channel.

But read the qualifier, because it's the whole operating instruction: the same review found acceptance drops sharply for complex treatments requiring physical intervention. Patients will happily take a virtual visit for a question, a check-in, a post-op concern, or a "is this an emergency" triage call. They do not want a virtual visit when they think they need hands in their mouth, and they're right.

That gives you a clean scope. Teledentistry is a triage, consultation, and follow-up channel. It is not a treatment channel. Any program that tries to push it past that line will run into patient resistance before it runs into a regulator. Build for the narrow use case and it works.

Operator Math

Let's price a modest program at a general practice doing 30 virtual visits a month. All of these inputs are yours to replace with real numbers from your own P&L; the structure is what matters.

Start with the cost side. A synchronous visit takes about 12 minutes of doctor time, so 30 visits consume 6 hours of doctor time a month.

Front office intake, scheduling, and documentation add roughly 15 minutes per visit at a loaded wage of $28 an hour, which is $7 per visit and $210 a month.

Add a platform subscription at $199 a month, and your hard monthly cost before doctor time is $409.

Now the doctor time, and this is where most practices fool themselves. If those 6 hours come out of a schedule that produces $450 an hour chairside, the true cost of the program is $2,700 a month in displaced production plus the $409, or $3,109.

If those 6 hours happen in blocks you weren't producing anyway (early morning, lunch, the Friday you're in the office on admin), displaced production is zero and your cost stays at $409.

That single scheduling decision swings the program's cost by a factor of about 7.6, which is why virtual visit blocks belong in dead time, not in the middle of a producing day.

Now the revenue. Say you're in a parity state and a payer pays $45 for a covered synchronous visit. Thirty visits at $45 is $1,350 a month in direct billing.

Against the off-peak cost of $409, that's $941 a month of contribution, or about $157 for each hour of doctor time you put in.

That's a thin hourly return for a dentist. Direct billing alone does not justify the program.

Here's where it actually pays. Assume 40% of those 30 virtual visits convert to an in-office appointment, which is 12 conversions a month.

At an average accepted treatment value of $1,100 per converted visit, that's $13,200 in production, and at a 96% collection rate you bank $12,672.

Subtract the off-peak program cost and the incremental clinical cost of delivering that production, and call variable clinical cost 30% of production, or $3,960.

Net contribution becomes $12,672 minus $3,960 minus $409, or $8,303 a month, which is $99,636 a year.

Now run the version where you're in one of the states that doesn't require parity. Strip out all $1,350 of direct billing and the program still nets $8,303 minus $941, or $7,362 a month.

The lesson is blunt: the reimbursement fight everyone is watching is worth about 11% of the program's value, while conversion to in-office care is worth the other 89%.

Stop building your teledentistry decision around whether a payer will pay $45. Build it around whether a virtual triage visit converts a hesitant patient into a scheduled patient, and measure that conversion rate every month. If your conversion rate lands at 15% instead of 40%, the program produces 4.5 conversions a month and roughly $3,114 in net contribution, still positive but no longer a priority.

Build It So a Rule Change Can't Break It

Given that your state board may rewrite the rules the way Colorado just did, design for reversibility. Four things that hold regardless of which way your state goes:

• Document patient location every single time. One intake field. It's the answer to the licensure question that the ADA policy makes unavoidable.
• Keep the clinical standard identical to in-person. Same records requirements, same informed consent, same documentation depth. Boards that tighten rules almost always tighten toward the in-person standard. If you're already there, a new rule costs you nothing.
• Never make the economics depend on a single payer's virtual visit policy. The math above shows why. Conversion carries the program; billing is a bonus.
• Put someone on board-notice duty. Colorado's comment deadline was June 30 and the hearing was July 8. If nobody in your office reads the board's bulletins, you'll learn about your new rules from a colleague's rumor. Assign it to one person and give them 15 minutes a month.

What to Watch Over the Next 12 Months

Three signals worth tracking, in order of how much they'll move your P&L:

First, whether your state's parity statute gets amended to name dentistry explicitly. With only 24 states plus Puerto Rico requiring parity today, dental-specific language is the cheapest legislative win available and the one most likely to actually change your collections.

Second, whether the states now writing rules follow Colorado's structural approach or invent their own. Early rules become templates. Read the Colorado rule text even if you practice nowhere near Colorado, because a version of it may show up in your state.

Third, whether any credible adoption survey replaces a 2023 panel of 244 dentists as the profession's reference number. When that lands, it will reset how payers and boards talk about how mainstream this is.

The Takeaway

Don't wait for teledentistry rules to stabilize, because the ADA's opposition to federalized licensure means they won't. Do three things this month: add a patient-location field to your virtual visit intake, get written answers from your three largest PPOs on whether they pay D9995 and D9996, and schedule any virtual visit blocks in dead time rather than during producing hours. Then track one number, the percentage of virtual visits that convert to a scheduled in-office appointment, because that single metric decides whether the program is worth your time. If conversion sits above 30%, expand it; if it sits below 15%, keep it as a patient-service courtesy and stop investing in it.

Most of the teledentistry decision comes down to what an hour of your clinical time actually costs, and most owners are working off a gut estimate rather than a real number. Before you decide whether to hand 6 hours a month to virtual visits, pin down your true cost per chair hour and where your overhead is actually going. Use The Dental Signal's free overhead calculator to run your own numbers, then bring the displaced-production line from the Operator Math above into your next schedule review.