Open wide

In the age of fluoride, how did dentistry get to be so lucrative?

Open wide

The chic, downtown dental clinic in Vancouver’s Yaletown neighbourhood tempts new patients with a sexy, sidewalk ad: a close-up of a woman’s mouth, glossy red lips parted as she sucks on a black cherry. Inside, in the elegant, steel-and-glass reception area, a giant, flat-screen TV broadcasts a gruesome loop: an endless barrage of mangled, rotting, yellow teeth. Fear not. Nearby are advertisements for procedures to cure your train-wreck smile, including Lumineers, Zoom! Whitening, and Botox—whose virtues the stunning, 24-year-old dental hygienist rattles off as the exam begins. She’s used it to treat her wrinkles and frown lines, she says. She loves it.

In the past 20 years, even as fluoridated water, toothpastes, sealants and protective resins have greatly cut down on cavities and decay, dentists have somehow flourished. In Canada, dentists now earn an average of $140,000 a year, roughly the same as doctors—up from $125,000 a decade ago. In the U.S., they’re quickly outpacing doctors. In 2004, U.S. dentists earned an average of $185,000, compared with primary care physicians, who earn between $140,000 and $160,000. Factor in the number of hours worked, and the disparity grows even wider. After a bit of creativity, marketing, and a few aesthetic touches, some of today’s clinics look more like spas, offering paraffin-wax hand treatments, massage chairs and Zen lighting—dentistry has reinvented itself.

It’s a far cry from two decades ago, when the profession seemed destined for trouble. The rate of fillings—once a dentist’s bread and butter, with children in the ’50s and ’60s perennially turning up for checkups with five, six or seven cavities—had dropped by 60 per cent by the late ’80s. The parents of these kids, meanwhile, now required fewer expensive procedures like bridges, root canals and dentures. In 1984, Forbes magazine forecast the end of the profession. Among dentists, the mood was grim. “It seemed as though in one day, half my practice decided to go elsewhere,” a New Jersey dentist told the New York Times; reduced to a three-day workweek, he could barely cover expenses. Another practised just one day a week; his mainstay was making promotional appearances dressed as Darth Vader.

In Canada, the culture shifted in 1990, when the Supreme Court struck down the ban on dental advertising. Dentists, who previously hadn’t even been allowed to print their names in bold in the Yellow Pages, became entrepreneurial in competing for patient dollars. But it was the explosion in bleaching and wafer-thin porcelain veneers that may have been key to dentistry’s resurgence. To keep patients coming back, some clinics have even started offering free “lifetime whitening,” to every new patient. “Every six months, as long as they keep their regular appointments, they get a free bleach,” explains one dentist, who recently began the campaign. Others use before-and-after images to show patients what their smiles might look like with bleaching, $15,000 veneers or even $30,000 “full smile makeovers.” Today, dentists perform twice as many cosmetic procedures as they did just three years ago; last year, the Canadian dental industry generated $11 billion, up from $6 billion a decade ago.

Nowadays, rather than lecturing patients on the need to floss, dentists are more likely to call to thank you for your business, a technique described in books like Helping Patients To Say Yes, a guide to increasing dental profits by a British “selling coach,” Ashley Latter, who has no training in dentistry. It’s full of tips on flogging cosmetic treatments at a cost of thousands of dollars—right, that should be “investment,” not “cost”—and suggested “closers” to rebuff common push-backs, like “I want to think about it.” (“Impose a cut-off time,” Latter suggests. “For example, you could say that you can guarantee the price for a period of time.”) This spring, Vancouver’s Pacific Dental Conference, one of North America’s largest, will offer seminars in the “Yes System,” and “How to Apply Show Business Principles to Your Dental Practice.”

Ethically speaking, dentists are in the clear, says the Canadian Dental Association. “Ultimately the patient is the one making the choice,” says president Deborah Stymiest, who is based in Fredericton.

But the line is blurrier when dentists channel fear to lucrative ends. For years, some dentists have claimed, without scientific evidence, that silver fillings are dangerous, urging patients to replace them with plastic substitutes, at a high cost. One woman says her dentist used the intra-oral camera, a pen-shaped digital wand used to broadcast “gross,” magnified, colour images of hairline cracks and blackened fillings, to talk her into replacing her amalgam fillings. More recent controversy has developed around ViziLite, a cancer-screening tool used by roughly five to 10 per cent of Canadian dentists, in an effort to screen for abnormalities that could lead to oral cancer. But the Journal of the American Dental Association and the journal Oral Oncology have each concluded that the value of the $80 oral cancer test is unproven; the American Dental Association, meanwhile, has denied ViziLite its “seal of approval.” There’s no data showing these devices can identify pre-malignant lesions, says Mark Lingen, of the University of Chicago Medical Centre, who headed a recent study of the tool. He suggests the $80 is its real advantage.

Aggressive sales tactics, according to a recent article in the Journal of the California Dental Association, have the potential to “erode public confidence in dentistry.” This fall, when Denise Perna was told by a new dentist that she needed $13,000 of dental work (implants, mainly), the dentist asked for her signed consent while she was still reclined in the chair. “When I said that I needed to discuss the matter with my husband, a dental assistant gave me her cellphone number, telling me to call as soon as I made a decision,” Perna recalls. “She stressed that the dentist had one opening, but I’d have to hurry, because he normally didn’t see patients on that particular day,” something Perna knew was untrue. When she didn’t call back, the assistant phoned repeatedly over a series of days.

Dentistry, however, isn’t recession-proof: in the U.S., some dentists are already reporting a 30 per cent drop in business. As discretionary spending slows, practices that focus heavily on elective services, like cosmetic or aesthetic dentistry, may be hard hit, says Sally McKenzie, a dental-practice consultant in La Jolla, Calif., who, three years ago, called this the “golden era for dentistry.” She’s downgraded her prognosis. Three years ago, the most common call she received, McKenzie says, was to help dentists manage “uncontrolled growth.” This month, she’s taking panic-stricken calls from dentists every single day.

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