The American Way of DentistryHow dentists think.

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Jerome Groopman wrote a book titled How Doctors Think, and it became a best-seller. A book titled How Dentists Think would likely beat a quick path to the remainder bin. But to understand the crisis in dentistry, it's necessary to consider how the world looks to a dentist.

Dentists earn their living in a way that's markedly different from the way doctors do. Somewhere between 80 percent and 85 percent of American dentists practice as owner-operators, as compared with only about 20 percent of physicians. Group practices, which are common for doctors, are rare for dentists—about 63 percent work solo, 20 percent practice with one other dentist, and 17 percent are in business with two or more dentists. A dentist's "income" is therefore typically the difference between the fees she receives and the expenditures she lays out, which are considerable. This is usually true even for dental specialists.

In contrast to the surgical specialties of medicine, which are delivered in ambulatory care centers and hospital operating rooms, where the operating expenses and the cost of equipment and support staff are borne by hospitals rather than individual doctors, dental surgeons must pay for equipment, supplies, the electricity that powers drills and X-ray machines, malpractice insurance, rent on office space big enough to house the reception, a waiting room, clinical areas, and—often the biggest expense of all—staff to make appointments, submit insurance claims, and provide support services as dental assistants and dental hygienists. Unlike hospitals, which buy in bulk, dentists have very little leverage to negotiate discounts for fixtures and supplies.

The economic inefficiency of dentists' working solo is mitigated by other factors. Expensive drugs, frequent technological advancements, and endless tests of dubious diagnostic value—all significant drivers of medical inflation—are largely absent from the dental world. Because every procedure typically incurs only a single charge, billing is much more straightforward and transparent than it is in most areas of medicine. Although dentists prefer to leave the money talk to their billing manager, they usually know the cost of every procedure, which isn't necessarily true of physicians. The solitary nature of most dental practices also steers most dentists away from the excessive and costly specialization that bedevils the rest of medicine. Only 21 percent of dentists are specialists, compared with 60 percent of physicians.

Overall, dentists are doing very well, thank you. According to the American Dental Association, in 2006 the median income for a dental general practitioner was $180,000. That's a whisker below the median annual wage for primary care physicians ($182,000), and on an hourly basis it's probably higher. The median for a dental specialist was $296,640. (To see how much dentists' income increased between 1982 and 2000, see Table 2 in this paper from the March 2005 issue of JADA.)

Hospitals never close, but dentists' offices are often open only four days a week or less. That's mainly because staffing is a dentist's biggest operational cost; the fewer days the office stays open, the less a dentist has to shell out to office personnel. (Of course, dentists do respond to emergency calls. On more than one occasion, my Seattle dentist opened up her office to treat a problem that had cropped up on a day her shop was closed. Needless to say, on those occasions she worked without an assistant.)

Like many small-business operators, dentists often work toward a predefined goal. As Burton Edelstein, the chairman of Columbia University's Department of Social and Behavioral Sciences and the founder of the Children's Dental Health Project, explains, "Everybody—not just dentists—who has control over their income will design their time to reach their target. So long as dentists can reach their target income with ease, there's little incentive for putting in more hours. It's hard work." With a limited number of appointments available and—for many dentists—enough full-fee patients to fill the slots, there's little incentive to serve the low-income people who need them most.

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June Thomas is Slate's foreign editor. You can e-mail her at or follow her on Twitter.

Illustrations by Dave Franzese.

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