This industry consists of offices and clinics of licensed practitioners of dentistry with the degree of D.M.D., D.D.S., or D.D.Sc. Included in this industry are the offices of dentists, dental surgeons, pediatric dentists, endodontists (root canal specialists), oral pathologists (specialists in mouth diseases), orthodontists (specialists in straightening the teeth), periodontists (gum specialists), and prosthodontists (artificial teeth and denture specialists).
621210 (Offices of Dentists)
During much of the 1990s, the number of professionally active dentists was on the decline. By 2000, there were 154,459 professionally active dentists in the United States. Approximately 4,000 new dentists graduate in a typical year, whereas 6,000 retire. Throughout much of the 1980s, there was a perceived oversupply of dentists, which gave insurers the upper hand—providing patients for dentists in exchange for discounts. Due to the perceived decline in the number of dentists in the early 2000s, insurers had to compete for doctors with services and information they could provide. Approximately half of U.S. citizens had some form of dental coverage in 2001, steadily rising over the last two decades. Self-pay and private prepayment each accounted for about 47 percent of payments for dental care, with government financed care making up 4 percent and other private funds accounting for 2 percent.
Total dental revenue in 2001 was approximately $65.5 billion, up 8. percent from an estimated $60 billion in 2000. Revenue also grew in 2000, up 7.7 percent from $56.3 billion in 1999. Growth has been slightly less than the growth rate of the Gross Domestic Product (GDP). Dental costs were on the rise, climbing an estimated 6 percent in 2001, which was about two or three times higher than the growth in the consumer price index.
Employer funding of dental benefits is an area that is expected to experience major changes in the coming years. Medical costs will continue to rise, and health benefits will continue to compete with dental benefits for employer dollars. More employers will be expected to play a bigger role in cost sharing, and contribution programs will become more defined. These factors will affect dental services and the types of services provided. A growing number of patients are frustrated with increasing restrictions from their insurance companies, service limitations, larger co-payments, and annual caps on benefits. Some dentists are similarly frustrated with dealing with the bureaucracy and complicated paperwork of dental benefits companies and have been moving toward "insurance free" services. If this trend continues, dental insurance could be negatively affected.
The dental profession is divided into eight types of practices carried out at dental offices and clinics: general dentistry, oral and maxillofacial surgery, endodontics, orthodontics, pediatric dentistry, periodontics, oral pathology, and dental public health.
Prior to the 1980s, establishments in this industry that were owned by self-employed dentists were operated by the dentist and a small staff. During the 1980s, dentists began running their offices like small businesses, employing the outside services of managerial consultants and dental office advisers. These organizational changes continued throughout the industry in the 1990s. With the health care industry moving toward managed care, dental maintenance organizations (DMOs) grew rapidly; at these organizations, participating dentists were paid fixed monthly rates. In 1989, only 10 percent of dentists worked with DMOs. By 1992, 15 percent of all dentists participated in these organizations, and analysts fore-casted that 40 percent would be participating in such plans by the year 2000. Another reason that DMOs were seen as necessary was because the dental inflation rate had started to exceed the medical inflation rate in the mid-1990s. In 1995, approximately 18 percent of Americans were enrolled in a DMO. In fact, a total of 100 million people (including 52 percent of adults) were in a dental plan that covered part or all of their dental expenses.
Modern dentistry began in the sixteenth century with the European revival of arts and sciences. According to dental historians, dentistry was being practiced independently from general medicine and surgery as early as 1544. Dentistry and medicine had been united for centuries because both sciences were practiced by barbers. The sixteenth century saw the important developments of dental instruments designed for cleaning and filling teeth.
In the seventeenth century, dentistry developed into an area of scientific inquiry in the way medicine had for many centuries. In Europe and America, academic and scientific articles began to appear on dentistry topics. During this time, the occupation of the barber-dentist evolved into that of tooth puller, while a separate practice of dental surgeons began to develop. The practices of periodontics and dental pathology began to develop during the eighteenth century.
Dentistry saw tremendous growth in the twentieth century. Preventive dentistry and public education on the importance of dental health and hygiene paid off for this industry. The number of patient visits rose significantly, especially for preventive measures. Moreover, elderly patients, unlike previous generations, did not lose their teeth and therefore went to dentists regularly.
Advances in fluoride treatments and dental technology have decreased the number of cavities Americans have. In 1990 Americans had 151 million fillings, only half the number of fillings in 1959, even though the population had doubled during that time. The number of root canals, however, tripled.
Income levels play a significant role in the number of times a person visits the dentist. In 1997, approximately 59 percent of people with household incomes between $10,000 and $19,999 indicated they had visited a dentist within the past 12 months, whereas 84.9 percent of people with annual household incomes of $55,000 or more said they had been to a dentist.
Technological Advances. The expansion of this industry during the twentieth century was also due to numerous technological advances. During the 1940s and 1950s, new methods of anesthetics greatly reduced pain during clinical procedures. The 1960s saw the development of bonding, whereby a liquid resin is applied to a tooth, then shaped as it hardens, providing a better fitting and more attractive cap, or crown.
In the late 1980s, orthodontists' offices increased as new types of braces and appliances were developed that were suitable for adults. Clear plastic braces and more cosmetically appealing appliances that fit inside the mouth were marketed toward adults undergoing orthodontic treatment. Similarly, dental surgeons provided services for an increasing number of adults wanting to have their jaws realigned for both medical and cosmetic reasons.
Perhaps the most significant technological development for modern dentistry has been the surgical laser, which came into common use at the end of the 1980s. In 1997 the International Academy of Laser Dentistry estimated that across the world 5,000 lasers were in use, often shared by several dentists.
The Nd:YAG laser has been the laser most commonly used by dentists. This laser is used for soft-tissue procedures to heal inflammation and reduce bleeding. Since 1987, Nd:YAG has been studied for its use in hard-tissue cutting procedures, such as working with enamel and metal for orthodontic dentistry. The CO2 laser was the first to be approved by the Food and Drug Administration (FDA) and is the second most widely used laser in dentistry. It is employed for soft-tissue surgery, such as removing lesions and, like Nd:YAG, has been experimented with for hard-tissue applications. The third major type of laser is the argon laser, which has been used for soft-tissue procedures, such as curing tissue. All three lasers also have uses for sterilizing dental instruments and are expected to undergo further developments.
Other significant technological innovations for this industry have been in intra-oral television and T-Scan devices; both have been utilized to educate patients on the condition of their teeth and the work involved in various procedures. Intra-oral television, as its name indicates, shows patients an enlarged view of their teeth and gums on a television screen. T-Scan uses a computer screen to show patients the static and dynamic contacts on their teeth. Both of these types of visual aids have helped dentists explain procedures to their patients and make them feel more comfortable.
Dental Office Hazards. Working with nitrous oxide (commonly known as "laughing gas") has long been a concern of dental office workers. In 1993 this gas was used by nearly 50 percent of all dentists in the United States, primarily by general dentists. Although the government recommends that dentists take in under 25 parts per million of this gas, most dentists get 250 times this amount, according to Elise Tanouye in the Wall Street Journal. Realizing possible health hazards, this industry has tried to lower the amounts that escape by using special types of masks, known as "scavenging systems," that are worn by the patient.
Although the risks of nitrous-oxide exposure are not fully known, the increase in the number of female dentists, dental assistants, and hygienists has drawn attention to reduced fertility among women working in dentists' offices and clinics. A 1992 study showed that women exposed to high levels of nitrous oxide were 60 percent less fertile than women who had not been exposed to the gas, according to Tanouye in the Wall Street Journal. The Dental Assistants Association suggested that nitrous oxide exposure could be linked to miscarriages, liver disease, and neurological problems. As the twentieth century drew to a close, the topic was still being hotly debated.
Another cause of concern in dental offices has arisen with the frequent use of lasers. Lasers can be harmful to both patient and staff if misdirected to the wrong tissue, especially toward the eyes. Given the risks, dentists have taken precautions, such as the use of eye protection and surgical masks specially developed for laser surgery.
Costs of Infection Control. In 1990 a Florida dentist who had AIDS had allegedly transmitted the HIV virus that leads to AIDS to at least three of his patients. Although it is not certain that the patients contracted the virus from their dentist, these cases received much public attention and national publicity. As a result of this, dentists' offices and associations received thousands of inquiries from concerned patients. Throughout the industry, dentists responded to these new concerns by investing in more infection-control measures. Moreover, the Occupational Safety and Health Administration has enforced additional regulations for the safety of dental office workers, who are believed to be at greater risk of getting AIDS from their patients than vice versa.
Infection control includes the use of more disposable items, disinfectants, sterilizers, and ultrasonic cleaners. According to a 1993 study by Clinical Research Associates, infection control cost an average of nine dollars per patient visit, adding more than $30,000 annually to a dentist's overhead costs, according to Gordon J. and Rella P. Christensen in the Journal of the American Dental Association. These costs have been handed down to patients, with some dentists adding an extra fee to their bills and labeling it "infection control."
Dental Fraud. With an overall increase in dental benefits insurance plans starting in the 1980s, this industry was noted for significant amounts of billing fraud. Though exact numbers are not available, according to Nancy Coe Bailey in Business and Health, one large insurer reported 88 dental fraud cases in 1989, whereas another insurer was investigating claims of $300,000 in billing fraud from one dental group alone.
There are basically three types of dental fraud: double-billing, where dentists charge both a patient's insurer and the insurer of the patient's spouse for the same procedure; billing for services not rendered; and manipulating billing codes by "unbundling" a procedure and billing it under several codes. Partially in response to the growing amount of billing fraud in the health care field in general, the Department of Health and Human Services enacted the Health Insurance Portability and Accountability Act of 1996. This act established a national bank to take reports of fraud and abuse and issue regular reports on the issue.
A related problem for this industry has been the concern that insurance companies have been "downcoding" dentists' bills. In downcoding, insurance companies price a procedure based on less complex and lower-cost procedures than that reported by the dentist. This is part of a larger problem facing dentists' offices and clinics, where insurance companies have started to play an important role.
Marketing. According to the American Dental Association (ADA), less than 1 percent of income from dentists' offices and clinics was spent on advertising in 1993. Traditionally, this industry has taken a nonaggressive approach to advertising because most patients go to a dentist who has been referred to them by other patients or to the dentist their parents sent them to as children. This industry has benefited, however, from indirect advertising. The ADA recognizes that public health programs, as well as toothpaste and mouthwash advertisements, promote preventive dentistry and indirectly advertise for dentists' offices and clinics.
In 1997 Americans spent almost $51 billion on dental services from the nation's 150,090 professionally active dentists, more than 138,000 of whom worked in private practice in an independent office or through a group practice or clinic. Nearly 20 percent of all active dentists in the United States were specialists, with the two largest groups made up of orthodontists and oral surgeons. The total number of board-certified dentists in 1997 exceeded 150,090, but many of those not actively practicing were involved in dental education or research projects.
According to the 1997 Survey of Consumer Attitudes and Behaviors Regarding Dental Issues, conducted by the American Dental Association (ADA), most American adults reported that they had visited a dentist within the past year. Nearly 60 percent of adult Americans reported that they had visited a dentist in the previous 6 months, while another 16 percent said they had seen a dentist between 6 and 11 months ago. For most Americans, the factor most influential in making a decision to visit a dentist was the elimination of pain, according to the ADA survey.
The industry has expanded to meet the needs of two growing sectors of the population: the aged and babies. Pediatric dentistry is one of the fastest-growing sectors of the industry. Additional growth has occurred as an increasing number of Americans have acquired dental insurance.
Throughout the 1990s, dentists' offices and clinics were faced with new challenges related to industry reforms and the rise of managed care. Dentists sought changes in managerial practices and human resources to bring down high overhead costs. With inflation rates for dental care exceeding those for medical care, DMOs were becoming more popular. Growth in DMOs, however, has been slow, with only about 25 percent of people enrolled in one by the end of the 1990s.
Health in America is continually improving, with more people aware of the positive effects of hygiene, exercise, and a generally healthy lifestyle. Oral health has also been on the rise in recent times, with an increasing number of children and adolescents from 5 to 17 who have never experienced dental caries in their permanent teeth. Adults from 18 to 34 years also have fewer fillings and less decay than ever. There has been a dramatic decline in people who lose all their teeth. Oral cancer rates are also down. Due to these reasons, dental services continue to shift based on demand for services. Basic services, such as fillings, have slowed, whereas cosmetic dentistry has become an increasingly important trend, albeit one that is not covered by insurance companies. Americans spent about $1.3 billion in 2000 on professional teeth-whitening procedures, with analysts predicting a 24 percent growth annually. Cosmetic procedures more than tripled between 1996 and 2000. This gave rise to BriteSmile Professional Teeth Whitening Centers in the early 2000s, a Walnut Creek, California-based company that offers one-hour professional tooth whitening via laser. The "dental spa" came about in the early 2000s, offering clients a retreat with traditional spa services, including facials, foot massage, and limo service, along with dental treatments. Traditional dentists even began to add spa treatments to their services to attract clients.
Another trend in the field was the significant rise in dental visits by uninsured people, although still far less than the percentage of people seeing a dentist with private insurance, according to an ADA news release. The percentage of people with private dental insurance who visited a dentist in 1999 was 75.2 percent, up 5 percent from 71.4 percent in 1989. Among those without dental insurance, the percentage rose to 58.1 percent in 1999, up 22 percent from 47.6 percent in 1987. In total, the percentage of Americans who reported a dental visit jumped to 64.1 percent in 1999, from 57.2 percent in 1989. The percentage of people with private dental insurance dropped, however, to 35.2 percent in 1999, from 40.5 percent in 1989.
In 2003, the ADA and two member dentists filed a class-action suit against some of the largest insurance companies in the United States. The ADA claimed those insurers—which included CIGNA Corporation; CIGNA Dental Health, Inc.; MetLife, Inc.; Mutual of Omaha Insurance Company; Metropolitan Life Insurance Company; and Connecticut General Life Insurance Company—violated the federal Racketeer Influenced and Corrupt Organization Act (RICO) and supported state law for insurance abuses against dentists contracted under the insurers' managed-care plans. Among the charges were that the insurers illegally paid their in-network dental providers less than their charges for provided dental services and with late payments in states with prompt-pay status; downcoding, or changing the procedure code to a less expensive code; and bundling, or combining codes of two or more performed procedures into one billed procedure.
By the close of the 1990s, the industry boasted more than 109,000 dental offices and clinics. A 1996 report by Inc. magazine listed dental offices as the third-highest category of start-up businesses that were likely to survive. The industry leaders were companies that owned several dental clinics and/or group offices. In the late 1990s, the industry leader was SafeGuard Health Enterprises, Inc., a publicly held company headquartered in Anaheim, California. In 1999 the company provided dental services to well over 1 million employees in both the private and public sectors, as well as multiple-employer trusts. SafeGuard offered dental care through a force of about 16,000 dentists practicing in some 14,000 independent offices. The states in which SafeGuard did the most business included California, Florida, Texas, Missouri, and Colorado. In 1998 the company posted revenues of $97.4 million, a 2 percent increase over its sales in 1997.
In 2000, there were approximately 154,459 professionally active dentists. The average annual salary for dentists in 2000 was $129,000. Almost all dentists work in private practice, with about 80 percent of dentists in private practice sole proprietorships and 13 percent belonging to partnerships. Additionally, the industry in the 2000s employed about 247,000 dental assistants. Companies operating large dental offices and clinics employ additional office personnel, including insurance claims specialists and managers.
Although dental assistants may begin their career without a college degree, dentists increasingly are looking for assistants with at least some college education. Most dental assistants are employed by dentists in general practice, although dental specialists, including endodontists and periodontists, employ assistants as well. The average hourly wage for dental assistants was $12.49 in 2000. The employment outlook for dental assistants was bright in the early 2000s and beyond. Employment was expected grow significantly faster that the average for all occupations through 2010.
Even though the need for dental health was expected to grow substantially in the twenty-first century, most of the increase in the workforce is expected to come from dental hygienists and assistants. The number of dentists in the field was expected to grow more slowly than the average of all occupations through 2010.
According to the American Dental Association, this industry is not characterized by its international market. Although foreign dentists come to the United States to study procedures related to the latest technology, American dentists tend to practice and perform research in the United States.
As information technology grew in the late 1990s and early 2000s, however, health care and dental health became an increasingly global concern. New scientific findings could be researched over the Internet while microbes could be transported worldwide in a short amount of time.
In the realm of dental health, periodontal (gum) disease remained the biggest concern among dentists in 1998, according to the American Dental Association (ADA)/Colgate Oral Health Trend Survey. More than half of the dentists surveyed reported that periodontal disease was the one area of dental health about which their patients seemed inadequately concerned. Nearly three-quarters of the dentists surveyed reported they planned to step up educational efforts about the dangers of periodontal disease, particularly in view of the recently discovered links between gum disease and heart problems. According to Dr. Timothy Rose, president of the ADA, "it's possible to have periodontal disease and not recognize the warning signs. That is why regular dental check-ups and periodontal examinations are important."
According to Howard Glazer, president of the Academy of General Dentistry and associate clinical professor at the Albert Einstein College of Dentistry, new techniques being considered in the dental industry included "digitized x-rays, laser techniques for painless drilling, osseo-integrated implants to replace bridges and other nonpermanent artificial teeth, and synthetic tooth enamel."
Other advances in research were predicted in the development of new procedures and materials, such as techniques used to perform tooth implants and substances used for bonding and repairing teeth.
Scientific and technological advances were growing rapidly in the early 2000s, a trend expected to continue in the coming decade and beyond. As social, biological, and physical sciences begin to merge and evolve, a greater understanding of human health is emerging. The map-ping of the human genome was a large step toward understanding the organisms associated with dental conditions, including oral candidiasis, dental caries, and periodontal disease. Genetic engineering has produced new and altered animals and foods with applications that could make new tissues, organs, and drugs. Of course, new ethical, legal, and social issues have arisen due to these advancements. Dental tools continue to advance via miniaturization and nanotechnology. Optical laser systems and computer-assisted informatics are in the fore-front of new technological applications. In addition, information technology has also revolutionized this industry, via information dissemination through the Internet to both medical professionals and consumers alike.
American Dental Association. "American Dental Association, Member Dentists Sue Health Insurers Under Racketeering Act, Citing Insurance Abuse Against Dentists." ADA News Release, May 2003. Available from http://www.ada.org .
——. "Dental Assisting." 1999. Available from http://www.ada.org .
——. The Future of Dentistry Executive Summary. 2002. Available from http://www.ada.org .
——. "Uninsured Persons Record Big Increase in Dental Visits, Remain Far Behind Those With Dental Insurance, Study Says." ADA News Release, May 2003. Available from http://www.ada.org .
Chaker, Anne Marie. "Massaging More Than Your Gums—Dentists Brush Up Practices With Spa-Like Amenities; A Root Canal, Then A Facial." Wall Street Journal, 10 September 2002.
Dolbow, Sandra. "BriteSmile Sinks its Teeth into $20M Push." Brandweek, 17 December 2001.
Panko, Ron. "Taking a Bite Out of Profits." Best's Review, March 2002.
U.S. Department of Labor. Bureau of Labor Statistics. Occupational Outlook Handbook, 2002-03 ed. Washington, DC: GPO, 2003. Available from http://stats.bls.gov .
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