EDITORIAL

 

Who is defining the future of Dentistry? Patient needs, or market demands?

 

 

Prof NH Wood

Managing Editor, SADJ

 

 

There was a time when a visit to the dentist followed a familiar pattern: patients arrived seeking relief from pain, treatment for decay or guidance on maintaining oral health. The role of the general dentist was clear. Dentists prevent, restore and preserve. Dentistry was a profession grounded in necessity, where a well-placed restoration, a thorough periodontal cleaning or a carefully executed extraction was valued as much as any cutting-edge innovation.

But times have changed.

Today, dentistry exists in a world where profit margins, branding and competitive marketing strategies increasingly shape the profession's identity. Some procedures such as implants, veneers and aligners are actively promoted, their promise of transformation broadcast across social media feeds and waiting room screens. Others such as extractions, denture provision and even deep periodontal therapy seem to fade into the background, less talked about, less marketed and, perhaps, even less prioritised.

The shift is subtle but undeniable. Where once a dentist's skills defined their practice, now commercial influences increasingly dictate what is perceived as "worthwhile", both in terms of financial return and professional prestige.

But at what cost?

Are we as practitioners allowing financial incentives to shape not just our treatment recommendations, but the very scope of our profession? Are we practicing the full breadth of dentistry, or only the aspects that fit the economic realities of modern private practice? And, more importantly: what does this mean for the patients who rely on us for care?

It is time for a critical conversation. Not to point fingers, not to assign blame, but to pause, reflect and recalibrate before dentistry loses its balance. Because if we, as a profession, do not decide what dentistry should be, the market will decide for us.

The commercialisation of dental services

Dentistry has always been both a healthcare service and a business but, in recent decades, the scales have begun tipping, sometimes uncomfortably, toward the commercialisation of dental care. The modern general dentist no longer operates solely within the framework of clinical necessity but must also navigate an environment where financial viability and competitive market forces shape daily practice decisions. The rise of high-margin procedures, aggressive marketing strategies and corporate dental models has shifted the profession's focus, leading to a growing disparity between what is profitable and what is essential in patient care.

The rise of high-profit procedures

The modern dental landscape reflects a clear economic hierarchy of services. Certain treatments, such as cosmetic procedures, implants and short-term orthodontics, have become focal points in many general dental practices, not only because they are clinically valuable but because they offer significantly higher profit margins. These services require fewer appointments, command premium pricing and, crucially, are often less dependent on third-party reimbursement policies.

In contrast, preventive care, extractions and periodontal therapy (cornerstones of long-term oral health) are far less lucrative. Despite their critical role in maintaining dental and systemic health, they generate lower revenue, leading to a reduced emphasis on these essential treatments in some practices. The result? A profession that increasingly markets elective, high-end procedures over foundational, health-driven treatments.

The influence of corporate dentistry and private investment

The corporatisation of dentistry has further fuelled this shift. Private equity Arms and dental service organisations (DSOs) have introduced a new financial model to dentistry, prioritising efficiency, revenue maximisation and scalability. While these business models increase accessibility in some cases, they also introduce performance targets and revenue benchmarks that may influence treatment planning. In corporate-owned practices, dentists may experience subtle or overt pressure to prioritise services that yield the highest return on investment rather than those that align with traditional preventive and restorative care models.

Even in independently owned practices, the financial realities of high operational costs, equipment investments and patient demand push many practitioners toward a more commercially driven approach. In urban, competitive markets, practices are increasingly engaging in marketing tactics once reserved for retail businesses, using social media influencers, financing incentives and limited-time promotions to attract patients seeking elective procedures.

Where does this leave essential care?

While there is nothing inherently unethical about offering high-margin procedures, the growing preference for profit-driven treatments raises concerns about accessibility, patient health outcomes and professional integrity. When the focus shifts away from disease prevention and routine care, it risks creating a two-tiered dental system, one where those who can afford elective, cosmetic and hi-tech solutions receive ample attention, while those requiring basic but necessary services face dwindling availability.

More concerningly, this shift may also redefine the perceived value of essential services. If routine extractions, comprehensive periodontal therapy or even simple restorations become less prioritised in undergraduate training or in continuing professional development, future dentists may not see these services as the foundation of their profession. Instead, they may be drawn toward expanding their skill set primarily in areas that yield greater financial rewards, further skewing the balance between business and healthcare.

Clinical decision-making: How much is influenced by profitability?

The dental chair is more than just a space for treatment. It is where science, ethics and economics intersect in ways that few other healthcare professions experience. Every diagnosis, every recommendation and every treatment plan is crafted within a delicate balance of patient need, clinical judgment and financial viability. But the question that looms, sometimes unspoken, is this: To what extent are these decisions influenced by profitability?

The subtle influence of profit in treatment planning

Few dentists would openly admit to prioritising financial gain over patient wellbeing, yet the economic realities of modern dental practice are impossible to ignore. Consider a general dentist faced with multiple viable treatment options:

• A patient presents with a moderately compromised tooth that could be saved with root canal therapy and a crown or, alternatively, extracted and replaced with a dental implant.

• Another patient requires mild to moderate orthodontic correction. Should they be offered a traditional approach, or a highly marketed clear aligner system with significant cost differences?

• A patient with incipient caries could benefit from preventive remineralisation therapies, but will they instead be guided toward early restorative intervention?

The decisions made in these scenarios are not always black and white. While clinical outcomes should drive choices, the profitability of one option over another inevitably plays a role. Restorative and surgical treatments often generate higher returns than preventive or conservative approaches. Similarly, cash-pay elective procedures such as implants, veneers and clear aligners are significantly more financially rewarding than routine periodontics or Allings reimbursed at lower rates by medical aids and insurance companies.

Does the economic model of dentistry shape clinical priorities?

Unlike many other healthcare professions, dentistry operates in a predominantly fee-for-service model, one in which dentists earn directly from the treatments they provide. While this model supports independent practice and professional autonomy, it also creates inherent financial incentives that can subtly shape treatment priorities.

• In private practice, hi-tech, high-margin services often take centre stage in marketing and promotional efforts.

• In corporate dentistry, production quotas and financial targets may steer dentists toward performing more expensive procedures per patient encounter.

• Even in training and continuing education, the popularity of courses on aesthetic and implant dentistry far outweighs those on preventive, periodontal or geriatric care, not necessarily due to clinical necessity, but because they align with what is financially lucrative.

The danger lies not in offering these treatments, many of which genuinely enhance patient outcomes, but in allowing financial factors to disproportionately influence treatment choices at the expense of comprehensive, patient-centred care.

A fine line between business and ethics

Some argue that economic sustainability is a necessity, not a compromise. After all, without financial stability, a practice cannot invest in quality materials, staff training or cutting-edge technology, all of which benefit patient care. However, the ethical boundary is crossed when profit-driven treatment planning leads to unnecessary procedures, overtreatment or the neglect of cost-effective alternatives.

For instance:

• A clinically restorable tooth being extracted in favour of an implant due to higher profitability.

• Unwarranted full-mouth veneer cases being promoted to young patients with minimal dental issues.

• Cosmetic aligner treatments being pushed where traditional, more affordable orthodontic solutions may be equally effective.

Each of these scenarios represents a deviation from patient-centred care, reinforcing the idea that scope of practice is increasingly shaped not just by clinical guidelines, but by economic considerations.

Undergraduate training: Are future dentists being primed for profit-driven decision-making?

This raises another critical question: How does undergraduate training prepare dentists for these economic realities? I have personally faced the statement: "I did not decide to become a dentist just to be poor."

Dental education traditionally focuses on clinical competence, diagnosis and evidence-based practice, but in the real world, financial considerations play a role that is often overlooked in formal training. Graduates enter private practice ill-prepared for the financial realities of running a business, yet they quickly learn that certain procedures are more "worthwhile" than others, financially speaking.

• Are new dentists subconsciously nudged toward high-value procedures by what they see their mentors prioritising?

• Is there sufficient emphasis in training on the importance of foundational, preventive and public health dentistry, or is the focus shifting toward aesthetic and elective treatments?

• Do young practitioners, burdened with debt, feel pressured to pursue financially rewarding treatments over more conservative approaches?

The answers to these questions are complex, but they underscore an uncomfortable reality: the very way dentistry is practiced, taught and valued is shaped by financial structures that may not always align with optimal patient care.

The ethical responsibility of the profession

Ultimately, the responsibility of maintaining integrity in treatment planning lies not only with individual practitioners but with the profession as a whole. Regulatory bodies, universities and thought leaders must actively work to:

Ensure that financial incentives do not undermine patient care.

Promote a balanced approach to treatment planning that prioritises both ethical care and economic sustainability. Recognise that not every treatment should be dictated by market value, but by clinical necessity and long-term patient benefit.

Scope of practice: Expanding, shifting or being distorted?

Take a moment and think about your daily clinical routine. Which procedures do you perform most frequently? Which treatments do you actively market to patients? More importantly, which services have you slowly moved away from, not because they are outdated, but because they no longer seem "worth it"? This is the unspoken reality practitioners face today. While dental education prepares general dentists to be comprehensive, primary oral healthcare providers, the way dentistry is practiced is evolving - sometimes out of necessity, sometimes by choice and sometimes due to forces outside of our control.

How economics is reshaping the general dentist's scope

Historically, the general dentist was the backbone of oral healthcare, handling everything from diagnostic care and restorations to periodontal therapy and simple extractions. However, as financial dynamics and commercial pressures have reshaped the profession, certain areas of general dentistry are being minimised or replaced in favour of procedures that are more lucrative and require fewer patient visits.

Consider these trends:

i. The rise of high-value, specialist-driven procedures in general practice

• More general dentists are investing in implantology, orthodontics and aesthetic dentistry, often through short courses that promise high return on investment.

• While upskilling is critical for professional growth, it raises questions about whether core, bread-and-butter procedures are being deprioritised in everyday practice.

• Are extractions, denture provision and full periodontal treatment plans becoming "less desirable" because they are less profitable?

ii. The decline of preventive and restorative services

• When was the last time you actively promoted preventive services such as fluoride treatments, dietary counselling or early-stage caries intervention?

• The reality is that these services, while clinically essential, generate significantly lower revenue than surgical and cosmetic procedures.

• Do financial constraints subtly discourage the provision of cost-effective, long-term solutions in favour of high-fee treatments?

iii. Are "routine" procedures still routine?

• Once considered standard for every general practitioner, procedures such as full denture fabrication, complex endodontics and non-surgical periodontal therapy are now frequently referred out.

• The argument for referral is often based on the complexity of care but, in some cases, it is because these services are time-consuming, labour-intensive and less financially rewarding.

• Has scope of practice shifted organically based on clinical evolution, or have we allowed economic incentives to dictate what general dentists should or shouldn't be offering?

Where does undergraduate training fit into this?

New graduates step into the profession equipped with clinical skills but are often unprepared for the financial realities of private practice. They are trained to diagnose and treat comprehensively but, in the real world, they quickly learn that:

• Some procedures are heavily promoted in professional circles because they are high-value and patient-demand driven.

• Others, such as periodontal maintenance and removable prosthodontics, can fade into the background, not because they are unnecessary, but because they are perceived as financially and logistically inconvenient.

• Certain areas of dentistry receive far more postgraduate course offerings and private mentorship opportunities than others, shaping the subconscious idea that some treatments are more "worthwhile" than others.

This raises an uncomfortable question: Are we preparing the next generation of dentists to be comprehensive primary care providers, or are we grooming them to be selective, high-value service providers?

Self-reflection: Is scope of practice being distorted?

As you read this, take a moment to reflect:

• Are there procedures you once did confidently but have now stopped offering - not because of lack of skill, but because they no longer fit your business model?

• Do you find yourself marketing certain treatments more aggressively than others, even when multiple viable treatment options exist?

• Are patients being given all available options, or is treatment planning subtly guided by what makes the most financial sense for your practice?

• Are you practicing the full scope of general dentistry, or has economic reality shaped a new version of your scope?

This is not about blame, but about awareness. The pressures of running a financially viable practice are real, and they cannot be ignored. However, as we evolve in our approach to dentistry, we must remain conscious of how these pressures affect not just our professional choices, but also the health and access of the patients.

The consequences for patients and public oral health

For every shift in dental practice, there is an equal and opposite effect on patient care. The increasing prioritisation of high-margin treatments over essential, routine care is not just shaping the financial landscape of dentistry, it is fundamentally altering who gets treated, how they get treated and the long-term impact on public oral health.

Who loses when basic care is deprioritised?

i. Patients who cannot afford high-end procedures

• The shift toward cosmetic, elective and high-fee treatments has created a growing divide between those who can afford private dental care and those who cannot. Routine procedures such as simple extractions, denture provision and caries control, once standard offerings in private practice, are at risk of being seen as lower-value services, pushing patients toward overburdened public dental systems or forcing them to forego care entirely. The result? More untreated disease, worsening oral health disparities and an increasing reliance on emergency dentistry rather than preventive and routine care.

ii. The neglect of preventive and conservative dentistry

• When was the last time a patient in your practice requested a fluoride treatment or a diet consultation over a whitening or veneer consultation? Preventive strategies, early-stage caries interventions and minimally invasive dentistry are being overshadowed by restorative, surgical and aesthetic solutions that generate greater revenue but often come at the cost of unnecessary tooth modification or overtreatment. The danger here is a reactive approach to oral health, where prevention is neglected in favour of procedures that "fix" problems rather than prevent them from developing in the first place.

iii. A two-tiered system in dentistry

• We are witnessing the fragmentation of dental care into two distinct models: One for those who can afford premium care, filled with smile transformations, digital dentistry and high-end restorative solutions. Another for those without financial flexibility, relying on public clinics, extractions as first-line treatment and limited access to modern dentistry. This is no longer a problem of public vs private care - it is happening within the private sector itself as the economic divide forces patients into different tiers of service based on affordability.

Long-term impact: The future of oral health

If these trends continue unchecked, what does the future hold for patient care?

The burden of oral disease will increase, as those who cannot afford private care will experience more untreated decay, infections and early tooth loss. General dentistry may become increasingly selective, with fewer practitioners offering routine, lower-fee services, pushing patients toward underfunded public health systems. New graduates may enter a profession that steers them toward a narrow scope of profitable procedures, leaving essential skills underdeveloped and reducing the availability of full-scope general practitioners. Dentistry risks losing its reputation as a core component of healthcare if it becomes too commercially driven, eroding public trust and potentially inviting increased government regulation to correct accessibility issues.

The need for self-reflection and systemic Change

If these issues sound concerning, it is because they should be. The commercialisation of dentistry is not inherently wrong. Practices must be financially viable, and advancements in technology and aesthetics have brought tremendous benefits to patients. However, when financial incentives begin to dictate who receives care and what kind of care they receive, the profession must pause and reflect.

This is not a call for dentists to abandon profitable treatments, nor is it an argument against technological advancement. Instead, it is a challenge to acknowledge how financial priorities are shaping patient access and oral health outcomes and to take action to restore balance.

Finding the balance: Ethical and sustainable practice models

Dentistry is more than a profession. It is a commitment to care, a responsibility to uphold health and a privilege to restore not just teeth, but confidence and wellbeing. The commercialisation of dentistry has created challenges, yes, but it has also provided opportunities for reflection, adaptation and, most importantly, a renewed commitment to patient-centred care.

The question is not whether financial success and ethical responsibility can coexist, they must. The real challenge is how we, as a profession, strike this balance so that dentistry remains both a viable career for practitioners and an accessible, trusted service for patients.

Rethinking profitability: A shift in perspective

Sustainability in dentistry is not just earning more but about practicing smarter. Instead of chasing profit at the cost of essential care, forward-thinking dentists are finding ways to incorporate financial sustainability into an ethical, patient-first approach.

• Prevention as a profitable model: Rather than seeing preventive dentistry as a low-value service, innovative practitioners are repositioning it as a core offering, demonstrating its long-term value to both patients and practices. Membership plans, comprehensive wellness visits and minimally invasive interventions can be structured to generate income while maintaining ethical care. - Integrating high-value services without compromising core care: Dentists can embrace advanced, hi-tech and aesthetic procedures while still maintaining a commitment to foundational treatments such as caries control, periodontal therapy and extractions. Balance is key.

• Patient education as a business strategy: A well-informed patient is an empowered patient. By shifting focus from aggressive marketing to education-based engagement, dentists can build long-term trust and practice loyalty, ensuring both repeat visits and ethical treatment planning.

The role of professional leadership and education

The responsibility for finding balance does not rest solely on individual practitioners. The profession itself, through education, leadership and regulation, must help shape the future of ethical, sustainable dentistry.

Dental schools must reinforce comprehensive training. It is crucial that future dentists are equally trained in disease prevention, restorative care and ethical business models, rather than graduating with a mindset that equates success only with high-end treatments.

Professional associations and societies must advocate for ethical standards. Dental organisations must take an active role in ensuring that financial success does not come at the cost of patient wellbeing. This includes providing guidelines, mentorship programmes and financial training that empower dentists to balance care with sustainability.

Policy and industry support are key to change: Government health agencies, insurers and industry partners should be engaged in discussions about how to make necessary treatments more accessible while still supporting private practices.

A hopeful future for dentistry

The beauty of dentistry is that it is inherently a patient-centred profession. The connection between dentist and patient, the trust that is built in the chair, and the life-changing impact of even the simplest treatment are what make this profession unique. Yes, financial realities will always be a factor. But we have the power to decide what kind of profession we want to shape. Do we allow the pursuit of high-profit services to dictate how we practice, or do we build a model where financial success is the result of ethical, comprehensive and patient-focused care?

The answer does not lie in extremes. It lies in thoughtful reflection, a commitment to balance and a willingness to adapt. If dentistry is to remain a respected, trusted and accessible profession, then each practitioner, each educator and each leader in the field must commit to ensuring that success is measured not just in revenue, but in the health and satisfaction of the patients we serve.

I therefore believe that we are not at a crossroads, but at an opportunity. An opportunity to reshape the way we define success, to reclaim our profession from external financial pressures and to ensure that every decision we make, whether clinical, financial or educational, serves both the patient and the practitioner.

Reclaiming the integrity of dental practice

Dentistry stands at a pivotal moment. One where the forces of commercialisation, economic pressures and shifting patient expectations are reshaping the profession in ways that demand reflection, awareness and action.

There is no denying the reality: financial sustainability is essential. Dentists, like all professionals, must earn a living, invest in their practices and secure their futures. Advancements in dental technology and treatment modalities should be celebrated and high-value procedures, when clinically justified, offer undeniable benefits to both patients and practitioners.

But at what point does the pursuit of profitability begin to distort the very essence of dentistry?

If routine extractions, periodontal therapy and preventive care are sidelined because they are not as lucrative as cosmetic treatments, then we are no longer shaping our profession; external financial forces are shaping it for us. If young graduates enter the field believing that success is measured by aesthetic cases rather than comprehensive care, then the core identity of dentistry is at risk of being rewritten. If patients can no longer access affordable, essential treatments because the business model of dentistry increasingly prioritises elective services, then we cease to be a healthcare profession in the truest sense.

And so, we return to the question that has quietly lingered throughout this editorial:

Can dentistry reclaim its balance?

The answer is yes, but only if we make a conscious effort to redefine success in a way that integrates both financial sustainability and ethical responsibility.

We must recognise that preventive and basic restorative care are not "low-value" services: they are the foundation of long-term oral health and should be upheld, not marginalised.

We must equip new graduates with both the clinical and business acumen to navigate private practice ethically, ensuring that financial pressures do not dictate treatment choices.

We must advocate for a profession where profitability is the result of patient-centred care, not the primary motivator behind it.

The future of dentistry is not set in stone. It is written by the choices we make in our treatment rooms, in our professional organisations, in our training institutions and in the way we define the values that guide our practice. Dentistry will always evolve, but it must evolve on our terms, led by the principles of integrity, accessibility and excellence that have always defined the best in our profession.

We can ensure that every patient, regardless of their financial standing, receives the care they deserve, and that every practitioner finds success not just in profit, but in the fulfilment of knowing they are upholding the true purpose of dentistry. Because at the end of the day, the measure of a successful practice is not just the revenue it generates, but the lives it changes, the trust it builds and the legacy it leaves behind.