Letter from America

Dentistry today - putting profit before patients

Health care in the United States, and I am úsure in Europe and other developed úareas, is becoming an increasingly competitive business. The once taboo practice of physicians or dentists seeking publicity has become commonplace. The pursuit of profit, rather than patient and professional needs, is driving the creation of new publications, and of new products. Thus is created, I believe, a potential conflict between serving the patient's best interests, and promotion of a product, procedure, or individual for personal monetary gain.

Each month I receive many journals and they tend to be grouped into four categories. The first is the traditional peer-reviewed, rather eso-teric scientific journals that I would guess few practising dentists read with any regularity. The second category is the organizational journals that many colleagues probably read frequently for clinical information, such as the Journal of the American Dental Association, or, in Norway, Tidende. The third and fourth categories are both essentially publications whose primary goal is the selling of advertisements and they are generally sent to all dentists, and others in the industry who are interested, for no charge. The fourth category that I call the tabloids, is clearly a growth industry aimed at selling techniques and materials to dentists, by selling advertisements for these products and techniques to manufacturers.

The problem category, in my opinion, is the third group that I call the magazines - the group that falls in between the association journals, clearly scientific in most cases, and the tabloids, which are entirely market driven. The magazines blur the line between scientific articles and advertisements by mixing peer-reviewed material, with articles paid for, written for or by, and submitted by companies, without disclosure that what the reader is seeing, is, in actuality, nothing more than an advertisement disguised as an article. Dentists need to develop a sceptical, questioning attitude towards these new publications and learn how to separate useful information from marketing hype. The combination of advertisements and articles is dangerous and clearly challenges the ethical guidelines and restraints that are a part of the dental industry, as well as of our society.

There is nothing wrong with advertising, nothing wrong even with the dental tabloids per se. Similarly, there is nothing wrong with publishing for profit. But since we are dealing with a branch of health care, as professionals imbued with public trust, we are obligated to adhere to a higher level of trust and truthfulness than normally expected from a tabloid. When profit and truth collide, the scientific journals, many of which serve a small esoteric group and for which profit is subordinate to truth, have no reason to choose anything but the truth. On the other hand, the raison d'ˆtre of the tabloids is first and foremost profit. The tabloids will promote an unproven material or technique if they are paid, in advertising or other ways, whether or not it is in the best interest of the profession or the patient. Again, there is nothing wrong with a promotional article, let's just make sure it is disclosed as a manufacturer-supported advertisement and not disguised by mixing it in with peer-reviewed articles. Dentists would be wise to once again pick up the scientific journals where evidence rules, and treat the clinical information in the tabloids for what it is, anecdote and opinions not supported by evidence.

Recently in the United States, there has been a huge increase in usage of testimonials by dentists appearing in dental advertising for new materials - why is this? Could it be there are no articles to quote, no data to refer to, no reason to purchase the product other than the word of one or more hired guns? It is disappointing that some manufacturers feel that insulting the intelligence of dentists with testimonials, rather than providing data, is the way to higher profits.

Some manufacturers apparently see their only way to profit, as to constantly put out new editions of materials, or to create new categories of materials (ie compomers, flowables, ®condensables¯, ceromers - all simply variants of composites). Instead of waiting until they have the product right, they rush to market to beat the competition and then have to come out with version 2.0, and then 2.1, then 2.1 Super etc. A quick new version is a not-so-subtle way of saying the original product failed to live up to expectations. In this way, not only can the unscrupulous marketers fool the gullibel customer (we, the dentists) and disguise that the manufacturer is having trouble getting the product right, they can also appear to be at the cutting edge of technology with perpetually-new products. Incredible! One company will soon launch its ninth adhesive in nine years! These ®new generation¯ products should not be confused with true improvements based on a successful product of many years' duration. I am willing to bet that many of the compomers, flowables and ®condensables¯ presently on the market will not be around in their present form by the turn of the century - an extraordinarily short market life.

The ethical limits of our profession are presently under siege. It is a sad reflection on dentistry, when monetary gain appears to be the all-encompassing goal of some in the profession.

It's time once again to put the patient before profit.