Are Dentists Getting the Short End of the Stick?

Viewpoint:

If you believe that everything has been just peachy in dentistry, don’t read this. This article isn’t for you.

Of late, dentist owner/operators have been getting the short end of the stick. Poor public perception. Negative media attention. Threats of public health units shutting offices down and warning patients to get tested. Costly changes in tax and employment laws. Difficulty finding and keeping skilled labour. Increased scrutiny from insurance companies. Higher operating costs. More competition. And now, the COVID-19 pandemic.

Here are just a few ways the dental community is losing out.

Poor public perception
Once you enter the workforce as a dentist, you’re branded for life by some negative stereotypes. There’s a large segment of the population that’s either afraid to visit you because they think you inflict unnecessary pain, can’t trust you because “you’re getting rich off of digging for money in their mouths,” and/or they don’t think there’s much value in what you’re “selling”.

Those perceptions – in addition to low income levels, low dental IQ and lack of dental insurance – help explain why roughly a quarter of Canadians don’t regularly visit a dentist.¹

Unfortunately, these people miss the whole point about you being a professional health care provider whose job it is to get them out of long-term pain, make/keep them healthy, and gift them a big, bright, beautiful smile for everyday use.

And that perception of all dentists being rich is way off base: the typical dental office in Ontario reportedly made $654k in revenue in 2018 but only kept $209k as income.² If the job was easy, that would be easy money. But becoming and working as a dentist – especially an owner/operator – isn’t easy at all. And those are average numbers, so many offices made less than that (the lower quartile of dentists took home $119k and the bottom quartile only took home $46.7k).

Negative media attention
In 2017, public health units across Ontario targeted dental practices for IPAC issues. Mainstream media got wind of it and put out blistering stories that raised questions about dentists and the transmission of infectious diseases.³ The profession went on the defensive, but the damage had already been done. A tidal wave of online negative comments against dentists (citing the usual anti-dentite rhetoric) ensued. Then came one class action lawsuit by some patients against their dentist⁴ and one lawsuit by a dentist against a public health unit for going too far.⁵

Dentists everywhere ended up spending lots of extra time, money and effort trying to achieve even higher IPAC standards. All of this, despite there being only anecdotal stories of actual harm done (like that of a Florida dentist who, back in 1990, allegedly infecting 6 patients with HIV),⁶ and public health officials⁷ and reports stating the exact opposite – namely, that the risk of catching an infectious disease from a dental practice is extremely low.⁸

And let’s not forget those sensational headlines the media put out just when fragile practices were desperately trying to bring nervous patients and staff back in during the COVID-19 pandemic:

“Coronavirus: Ontario dental hygienists raise health concerns about safety standards”. This Global News article included this statement: “Many dental office employees who’ve contacted Global News said they’re terrified to go back to work and expressed caution for patients making bookings.”⁹
“Dental hygienists worry about COVID-19 safety guidelines as clinics get set to reopen”.¹⁰ This CBC News article included this statement: “As many shuttered dental clinics are preparing to reopen, a rift is growing in the industry over proper protocols to keep patients and staff safe – with one Ontario dental hygienist calling clinics a ‘ticking time bomb’ for creating new COVID-19 cases.”
“Routine dental visits should be delayed where there is still community transmission: WHO”.¹¹ This CTV News article included this statement: “The World Health Organization (WHO) is recommending that routine, non-essential dental visits should be delayed in areas where there is still community transmission of COVID-19.”

Actually, a few months after these stories were published, an ADA study concluded the opposite: dental practices were actually very safe. Maybe it has something to do with the fact that dentists have always had to deal with the transmission of deadly viruses.

Increased competition
There’s been no slowdown in the number of dentists entering the workforce. (One report showed there were over 1,100 people certified as dentists by the National Dental Examining Board of Canada in 2018.)¹³ But population growth hasn’t kept up,¹⁴ causing many dentists to compete for the same patient. In dense urban areas, you can find a dental practice on practically every corner of a busy intersection.

More and more GPs are placing implants, offering clear aligner solutions and performing complex surgeries – all at the expense of referring it out to specialists. GPs are also investing in in-house milling machines and digital dentistry to speed up delivery of certain treatments – at the expense of referring it out to a lab.

Meanwhile, the traditional model of going to see your dentist at their office has shifted in part due to big ortho companies offering DIY teeth straightening kits, coupled with tele-dentistry and big discounts. These businesses market aggressively online and offline, sometimes raising alarm bells among some established dentists.

Finally, traditional practices must now compete with ever-growing dental service organizations (DSOs), which own and operate multiple practices. DSOs are sophisticated and well-funded, and can achieve economies of scale. DSOs can also keep more treatments (and fees) in-house and command deep discounts with their buying power (e.g. on sundries, equipment, and marketing). And if a dentist grows tired of competing or dealing with the business headaches of running a practice, DSOs are happy to buy you out at a good price and have you associate for them.

Costly tax law changes
In January 2018, the federal Trudeau Liberal government changed tax laws to make it much more difficult, if not impossible, for dentists to use their professional corporations to income split with their families as they had been doing before.

And if that wasn’t enough, there were rumours in early 2020 that the minority Liberal government, in order to pass their budget and stay in power, would have to accept an NDP proposal to require small business (like dentists) to pay more taxes when they sell their business corporations.¹⁵ The COVID-19 pandemic put a stop to those rumours, but possibly only temporarily.

Costly employment law changes
If you were a practice owner in 2018 and 2019, you probably experienced terrible anxiety when you heard about the new employment laws that were being made by the Ontario Wynne Liberal government. Just to remind you of how bad it was going to get for dentist employers, here were some of the changes:

Increasing minimum wages across the board, which gave existing dental staff an excuse to ask for and receive pay raises.
New ten days of Personal Emergency Leave (2 of which were to be paid by the dentist employer).
Employers having to pay team members equally for equal work (what ever happened to experience and seniority?) or face a Labour Relations Board complaint.
Employers having to pay team members at least 3 hours if they didn’t give them enough notice of a change or cancellation in their schedule that amounts to less than 3 hours of work on a particular day.
Employers having to give 3 weeks and 6% vacation pay to anyone with 5+ years of experience.

All of this added more stress and labour costs to practice owners. Thankfully, the Ontario Ford Conservative government did away with some of those changes and modified others.

The very recent Ontario Court of Appeal decision in Waksdale,¹⁶ which Ontario Superior Court followed in the Sewell¹⁷ Decision, have been absolutely devastating for dentist employers. These two cases, if not reversed or undone by provincial legislation, have the potential to render the majority of written employment agreements invalid.

Conclusion
Is it any wonder why, once the COVID-19 pandemic hit, fed up dentists headed for the exits? Dentists need to come together now and stop being the punching bag of poor public perception, negative media attention, power-tripping public health units, and anti-business and pro-employee government bodies.

Oral Health welcomes this original article.

References

The State of Oral Health in Canada, March 2017. https://www.cda-adc.ca/stateoforalhealth/_files/thestateoforalhealthincanada.pdf; date site accessed: 26 December 2020).
2018 Report for: NAICS 6212 – Offices of dentists – Financial Performance Data” (URL: www.ic.gc.ca; date site accessed: 26 December 2020).
“Burlington dental patients may have been exposed to improperly cleaned tools, HIV”, 21 June 2017 (URL: https://www.cbc.ca/news/canada/hamilton/dental-1.4170706; date site accessed: 26 December 2020) .
“What’s New” (URL: http://handadentalclassaction.com/whats-new/; date site accessed:26 December 2020).
“Dr. Joe Philip files $10 million lawsuit against health unit”, 30 April 2018 (URL: https://www.orilliamatters.com/local-news/dr-joe-philip-files-10-million-lawsuit-against-health-unit-908929; date site accessed: 26 December 2020).
“AIDS and a Dentist’s Secret”, The New York Times, 6 June 1993 (URL: https://www.nytimes.com/1993/06/06/weekinreview/aids-and-a-dentist-s-secrets.html; date site accessed:
26 December 2020).
“Burlington dental patients told to get tested for hepatitis and HIV”, 21 June 2017 (URL: https://globalnews.ca/news/3544446/burlington-dental-patients-told-to-get-tested-for-hepatitis-and-hiv/; date site accessed: 26 December 2020).
H. Cody Meissner. “What is risk of infection transmission in dental offices?”, AAP News, 30 January 2018, (URL: https://www.aappublications.org/news/2018/01/30/IDSnapshot013018; date site accessed: 26 December 2020).
“Coronavirus: Ontario Dental Hygienists Raise Health Concerns About Safety Standards”, 5 June 2020 (URL:https://globalnews.ca/news/7031217/coronavirus-ontario-dental-hygienists-covid-19-safety/; date site accessed:26 December 2020).
“Dental Hygienists Worry About COVID-19 Safety Guidelines as Clinics Set to Reopen”, 5 June 2020 (URL: https://www.cbc.ca/news/canada/toronto/dental-hygienists-worry-about-covid-19-safety-guidelines-as-clinics-get-set-to-reopen-1.5599034; date site accessed: 26 December 2020).
“Routine Dental Visists Should be Delayed Where there is Still Community Transmission: WHO”, 12 August 2020 (URL: https://www.ctvnews.ca/health/routine-dental-visits-should-be-delayed-where-there-is-still-community-transmission-who-1.5061568; date site accessed: 26 December 2020).
“ADA Study Finds COVID-19 Rate Among Dentists Less Than 1 Percent”, 15 October 2020 (URL: https://www.ada.org/en/publications/ada-news/2020-archive/october/ada-study-finds-covid-19-rate-among-dentists-less-than-1-percent; site accessed: 26 December 2020).
“Number of individuals certified as dental practitioners in Canada in 2018, by type*”
(URL: https://www.statista.com/statistics/756126/number-of-new-certified-dental-practitioners-in-canada-by-type/; date site accessed: 26 December 2020).
“Canada’s population estimates: Age and sex, July 1, 2020” (URL: https://www.150.statcan.gc.ca/n1/daily-quotidien/200929/dq200929b-eng.htm; date site accessed: 26 December 2020).
“Expanding capital gains tax would be very short-sighted approach to fighting federal deficit”, National Post, 28 February 2020 (URL: https://nationalpost.com/opinion/john-ivison-
expanding-capital-gains-tax-would-be-very-short-sighted-approach-to-fighting-federal-deficit; date site accessed: 26 December 2020).
Waksdale v. Swegon North America Inc., 2020 ONCA 391 (Ontario Court of Appeal)
(decision released June 17, 2020). The Employer’s leave to appeal to the Supreme Court of Canada was refused.
Sewell v. Provincial Fruit Co. Limited, 2020 ONSC 4406 (Ontario Superior Court) (decision released July 17, 2020).

About the Author

Michael Carabash is a founding partner of DMC LLP, Canada’s largest dental-only law firm that helps dentists prepare, market and sell practices in Ontario. Michael leads DMC’s annual Caribbean dental mission trips (Grenada, Jamaica and Turks & Caicos). michael@dentistlawyers.ca or 647.680.9530.