Oral Health Group

Is Dentistry a Business or a Profession?*

September 1, 2005
by Bruce S. Graham, DDS, FACD

Today I have chosen to talk to you about our profession’s image in the public’s eyes and to explain to you why I am truly fearful about the significant erosion of our profession’s stature in North American society. In the title for this address, I have posed the question. “Is Dentistry a Business or a Profession?’ Of course, the answer to my rhetorical question is: “It is both.” In the way that our profession is traditionally practiced in North America, it is both a health profession and a small business. Now you are asking yourself, “So what? We all know that dentistry is both a profession and a business!” I believe that the profession’s core duality, that is its simultaneous existence as both a health care profession and a small business, creates a dangerous tension between dentists and the public.

“Dangerous?” you ask, “Why dangerous?” Dangerous because dentists are challenged to maintain a precarious balance between the roles of doctor and businessperson. Precarious because there is always the very real danger that our need to make a living as a dentist will compromise the decisions we make about providing oral health care for our patients.


Now let me tell you how I believe that the business side of North American dentistry is, in fact, endangering the integrity of our profession and demeaning dentistry in the eyes of the public.

The most obvious sign of the commercialization of our profession today is the unfortunate evolution of esthetic restorative dentistry into the cosmetic dentistry business. It seems that “Bright Smiles” and White Teeth” are the predominant public face of dentistry today. Everywhere that the public looks on the streets of the United States and Canada, they see commercial signs in dental office windows, and dental industry sponsored billboards, trumpeting the white tooth business. Every magazine and newspaper seems to deliver the same message too, in not so subtle ways. The ubiquitous message is: “If you want to look young and sexy. you need to whiten your teeth.” Please notice that the message is “whiten” your teeth, not “bleach your teeth.” Apparently, the thought of bleach in your mouth is not a particularly palatable advertising message–please excuse the pun. But the marketing message for those of us who want to look good used to be that we couldn’t be too thin. Now it seems to be that our teeth cannot be too white!

The latest fad in the cosmetic dentistry business capitalizes on the baby-boomer’s obsession with appearance and luxury in offering the dental spa experience. In dental spas you can not only have your teeth whitened, but you can also simultaneously experience a massage, aromatherapy, a manicure and even a pedicure. And some dental offices are now offering the ultimate cosmetic makeover service of permanent makeup tattooing. There are even dentists who offer botox injections, justified as dental treatment, because, and here I am quoting from the advertisement, “They reduce the muscle tension that contributes to oral pain and damage with the main side effect that you can lose some of your wrinkles and refresh your aging smile.” Now isn’t that clever commercial marketing?

And, I can hear you thinking again, “So what? Who cares if whiter, brighter teeth is dentistry’s ubiquitous public message today? At least it brings patients into our offices. How is this message demeaning to the profession of dentistry?”

Because it is a solely commercial message. It is not a health care service message. It is a cosmetic business service message. And again you answer: “So what? So is plastic surgery.” Well, tooth whitening isn’t surgical unless it involves veneers. When it is tooth bleaching and the spa experience, it is directly analogous to hair bleaching and cosmetics. It is not surgery; it is cosmetology-plain and simple.

Parenthetically, we are not even sure of the long-term effects that tooth whitening might have on the oral health of our cosmetology clients. Do we know what effect the bleach and heat used to whiten teeth will have on pulpal tissues? No. But many of us seem only too eager to offer tooth bleaching as a commercial dental service.

And what of the public’s attitude toward dentists? How do they see a profession that offers them cosmetology as its most visible public service? Does the general public embrace the notion that oral health is part of their overall health, and that you cannot be healthy without a healthy mouth? Sadly, I think not.

Ever since the profession of dentistry stood by while dental care for seniors was omitted from Medicare, we have fought an uphill battle to convince government, health insurers, and the public that oral health is an essential component of overall systemic health. I think that we have been making significant progress in this uphill battle, most notably with the Surgeon General’s Report on Oral Health and the resultant National Oral Health Plan. But today the loudest message being received by North American society is that dentistry is an elective cosmetics service which can help you look younger and sexier. There is no message about oral health as a vital component of overall health in the “bright smile and white teeth” advertising campaign.

And again you are asking yourself. “So what? This is the platinum age of dentistry. Dentists’ incomes have never been higher. Things have never been so good for the dental profession! Why is Graham complaining about cosmetic dentistry? So what if the public sees us as cosmetologists?”

Let me try to explain what is bothering me. Put simply, our existence as a profession of dentistry is dependent, in the final analysis, on what the public thinks of us. The public – that is, society, affords us the privilege of being a profession on the basis of its trust that dentists put the oral health care needs of our patients ahead of our own desires to make money. Because of society’s trust in us we have the privilege of educating dentists, licensing dentists and disciplining dentists, all with virtually no societal-that is, no governmental, oversight. We are, perhaps, the last real true profession in North America.

But I believe that this privileged status is in dire jeopardy. I believe that we are in danger of convincing society that we no longer deserve professional status, because we have crossed over the line between oral health professional and dental businessperson. crossed over that line to become full-fledged businessmen and women, as dental cosmetologists.

As an example of the way the commercialization of dentistry could cause its ‘de-professionalization’ we need only reflect on the precipitous fall of the pharmacist from professional status. Until the 1960s, the pharmacist was our society’s respected corner druggist, trusted to give the public sage advice about prescription and over-the-counter medicines. Then, with the corporatization of the corner drug store into chain mega-stores filled with more groceries and household goods than medications the pharmacist/druggist was downgraded in society’s regard to a slightly gentrified convenience store owner. It is only during the past decade, with the dual strategies of the pharmacy doctorate degree and the strong marketing by the drugstore chains of the pharmacist as a newly minted “medication counselor” that we have begun to see even a modicum of professional status returning to the pharmacist.

Could this happen to dentistry? Could we miss our chance to apply molecular medicine, tissue engineering and computer-assisted decision-making to the care of our future patients. Sinking instead under the weight of commercial cosmetic dentistry marketing to the level of mere dental spa operators? Yes, it could happen. It could happen far too easily, without our even noticing it.

But we cannot let this happen to our chosen profession. We must not let it happen, because society will ultimately suffer if the dental profession is degraded.

So, what must we do to save our professionalism? First, let me start with what dental educators are doing, because I know that
you are already blaming dental education in your minds for recruiting and graduating such deplorably business-oriented dentists. (After all, it must be dental education’s fault because this unprofessional commercially focused behavior wasn’t a hallmark of the profession when you graduated, was it?)

Well, in this instance, dental educators are not guilty. In fact, we are recruiting dental students who have already demonstrated their volunteerism and commitment to serving the public and who want to continue this service as dentists, ministering to the oral health needs of their patients and their community. In the dental education curriculum, we are already providing case-based, faculty-mentored small group discussions of the ethical issues, such as commercialism versus professionalism, that challenge their chosen profession. We are counseling dental students against falling into the commercial model of practice in order to pay off their sizable educational debt at the expense of their professional reputation. We are doing all this and more, and we will continue to help our students confront the profession’s tension between commerce and care. We will help our students to resolve this tension in their minds and in their hearts before they enter the profession after graduation.

But now, what do I want you to do? As Fellows of the American College of Dentists, you represent the 2.5 percent of American and Canadian dentists who have received the honor of fellowship as recognition of your professionalism and leadership. But this great honor of fellowship brings with it the weighty responsibility of leadership. So, I expect you to do a lot about this danger to the profession.

First, I expect you to drown out the noise of cosmetic dentistry advertising with a powerful counter-message. I want you to influence your dental organizations to spend money (yes, I said spend money) to market the message that dentists are healthcare professionals who are essential to the general health of the public. I want you to lead your dental organizations-whether it is your county dental society, your town dental study club, the provincial or state dental association, or the American or Canadian Dental Association-to mount marketing campaigns like the ADA’s successful oral cancer campaign. These marketing campaigns must emphasize that dentists do serve the public’s health by addressing the connection between oral health and diabetes, early term low birth weight infants, cardiovascular disease, tobacco abuse, and obesity. We do relieve pain and we do detect oral cancer and we are a vital healthcare profession.

Then I want you to widely publicize all of the voluntary care that dentists provide to disadvantaged children and adults every day in every town and city in North America. Oh, I know that goes against the grain of your personal and professional modesty. I know that you don’t voluntarily serve the underserved in order to be recognized for it. But you need to take your light out from under the bushel basket now, because we have to obliterate this dangerous message of commercial dentistry that is poisoning the public’s opinion about our profession and demeaning us in their eyes. We must tell the story of our profession’s service to the disadvantaged members of our society.

I also want you to screw up your courage and personally confront the dental cosmetologists, face-to-face and tell them what you think about the way they are degrading our profession. I know that also goes against your personality grain. Dentists are, by and large, not confrontational in their interactions. But you know that you can do this in a polite. respectful. and professional way, if you only push yourself to do it. You can influence your colleague to at least think about what they are doing to their profession.

You all have a position of respect and influence in your professional community. I implore you to use it to save our profession. If we don’t assertively confront the dental cosmetologists, we run the risk of losing this great profession to them.

I know that I am asking much of you today. But if the Fellows of the American College of Dentists don’t take on this responsibility, who will? Who will act to save our profession, if not you?

Dr. Graham is Dean, University of Illinois at Chicago College of Dentistry.

* Convocation Address to the American College of Dentists, September 30, 2004 Orlando, FL.

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