If you haven't visited a dentist in the past few years, first of all, that's gross. (Checkups are every six months, and don't pretend you forgot.) Second, be grateful that you have avoided the "intra-oral camera." As the dentist (or assistant) navigates this horrifying little gadget through the graveyard of your mouth, a color television magnifies the florid pustulance of your gums and the puke-yellow dinge of your smile. A harmless crevice in your silver-mercury amalgam filling looks like Hell's Canyon. The microcracks in your enamel look like a broken window. All this can be fixed, of course, with 10 grand of straightening, filling, sealing, and whitening. "You will agree to anything the second they put that thing in your mouth," says one recent victim of the camera. "You can't believe you are walking around with that, that, that ick in your mouth."
The transformation of American dentistry from drill-and-fill to shoot-and-loot is an unlikely business success story of the '90s, a case study in how a profession can work itself out of a job and still prosper. Dentists, after all, are supposed to be extinct by now. While they happily (and profitably) scraped teeth and filled cavities during the '60s and '70s, fluoride was quietly choking off their revenue stream. The percentage of children with cavities fell by half and kept falling. People stopped going to the dentist, because they didn't need to. At the same time, the government funded dental-school construction, spilling new dentists into a saturated market. Many found themselves cleaning teeth for $10 an hour in mall clinics. In 1984, Forbes magazine forecast the end of the profession. Only a few lonely dentists would survive to fill the few remaining cavities, the last vestiges of a once-great civilization on Long Island.
Instead, the number of dentists has jumped 20 percent, and the average salary soared from $76,000 in 1987 to $124,000 in 1996. What happened? In part, the oversupply of dentists and the declining demand for fillings forced the profession to change. Dentists had to become nicer and visits less unpleasant. The Marathon Man has been replaced by Dr. Soothe. "People figured out pretty darn quickly that if you were an ass, patients would not come to you," says Dr. William Hartel, a St. Louis dentist. Many dentists' offices let you don virtual reality glasses and watch movies on them. Others offer massage therapy and hot tubs. Does your dentist have a certificate of pain management on her wall? I bet she does.
The most important discovery dentists made was the endless vanity of aging baby boomers. "We are dealing now with the boomers who are the runners and the joggers and the dieters, and they are very concerned with how they look," says American Dental Association President Dr. Timothy Rose. Since going to the dentist was no longer a necessary evil, dentists made it an unnecessary pleasure. They allied themselves with the self-improvement movement. "You still go for the needs, for the cavity that has to get filled, but more and more people ... come here to feel better about themselves," says Dr. Stephen Friedman, a Maryland dentist.
People used to be happy if they made it to old age with enough choppers to chew. But boomers, lured by media images of the Great American Smile, expect more. According to an ADA poll, the percentage of people who are "very satisfied" with their teeth has dropped from 57 percent to 46 percent in the past decade. Dentists have learned to play on this vanity and anxiety, encouraging dental care that is medically unnecessary but attractive to patients. "It's as if you went to a physician for a treatment for a disease and he said you needed a nose job," says Dr. John Dodes, author of Healthy Teeth: A User's Manual.
To flog $500 teeth whitenings and multi-thousand dollar adult orthodontic treatments, dentists run computer simulations of your whitened, straightened teeth. Tooth color is measured on a scale that starts at A1. "My dentist showed me these disgusting color charts and told me, 'You're an A2 now, but by the time you want to get married you are going to be an A4. And no one wants to marry an A4,' " says one woman who got her teeth bleached. Dentists also prod patients to replace perfectly functional gray-metal fillings with tooth-colored plastic ones and to dump their solid gold crowns for white porcelain. Other dentists sell the psychology of tooth appearance. One dentist specializing in porcelain caps advises that male bosses with small teeth seem "weak."
Some dentists dress up these cosmetic measures in medical scare talk. A friend of mine just quit a dentist who was pressuring him to whiten his teeth as a "preventive measure." (To prevent what? Yellow teeth?) Many dentists claim, without scientific evidence, that the mercury in amalgam fillings is dangerous. They urge patients to replace the excellent amalgam with plastic fillings at four times the price.
Dentists make a killing on bad breath--or "halitosis," as they prefer to call it. Breath clinics have sprouted up all over the country and are heavily advertised on the Web. They terrify patients with a "halimeter," a new gadget that measures a nasty smelling chemical called methyl mercaptan. Armed with the halimeter proof, the dentist then dangles expensive mouthwashes and tongue scrapers in front of the patient. Never mind that you can get the same results for free with careful brushing and basic tongue-scraping. The machine makes the sale. "Now that there is this machine that can document your complaint and can put a number on it, it motivates a patient to actually do something about it. But the treatments available now are the same ones that have been available for 15 years," says Hartel.
E ntrepreneurial dentists market this elective care with trained aggression. Dental management organizations often require their employees to recite a quasisales script guiding patients toward profitable cosmetics. Ads in the Journal of the American Dental Association and on the Web promote tapes and classes on marketing techniques. One person I know quit his dentist when he spied a pamphlet in the office instructing the dentist in how to get his patients to "trade up" to more expensive treatment. The ADA's annual conference is overflowing with seminars on topics such as "how to move your patients to 'yes.' "
The industry calls this technique "treatment acceptance," a marvelous euphemism for parting you from your money. According to the ADA's journal, this year's ADA conference will include an all-day "Treatment Acceptance" seminar "for the dental team that is fed up with patients accepting only what insurance covers or asking for alternative cheaper treatment plans. Involve the entire team in creating the strategies for patients to accept optimum care."
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