The role of the dental professional association in the 21^st Century

INTRODUCTION

The formation of a professional association has traditionally been viewed as an essential step in the development of a profession and the acquisition of professional status¹. Following the nascent professional identities that Pierre Fauchard (in France), Philipp Pfaff (in Germany), John Hunter and Joseph Fox (in England) brought to dentistry, the birth of organised dentistry is arguably found in the USA. Dental professional associations (DPAs) began to take their current form in the USA from the end of the Civil War to the end of the 19^th Century, where dental societies joined with state governing bodies to ensure public protection. This was assured through the setting of ethical and technical standards that members were obliged to meet². The aims of the first DPA formed in USA, the Society of Surgeon Dentists of the City and State of New York, were set out as follows.

The objects of the society are to promote union and harmony among all respectable and well-informed Dental Surgeons; to advance the science by free communication and interchange of sentiments, either written or verbal, between members of the Society, both in this and other countries; in fine, to give character and respectability to the profession, by establishing a line of distinction between the truly meritorious and skilful, and such as riot in the ill-gotten fruit of unblushing impudence and empiricism.³

The society’s membership eventually fell into decline with the organisation folding in 1856, following a requirement for members to sign a pledge that they would not use amalgam, which at the time was the favoured material of the unqualified practitioner2, 3. Nevertheless, the spirit of the society’s mission is congruent with the theory of professionalisation put forward by Abbott; the pursuit of jurisdiction and the besting of rival professions¹, in this case, the unqualified practitioner of dentistry.

While it might be tempting to suggest that, over 160 years on, organised dentistry has evolved away from merely being concerned about jurisdiction and addressing outside competition, it is still very much a primary consideration for DPAs at the national but also subnational level. Here, we define DPAs as all collectives of dental professionals (both national and international) that historically seek to promote the success of the dental profession. Thus, regardless of the organisational level, one can question whether preoccupation with such things as jurisdiction and outside competition is helpful, and whether DPAs might be more efficacious at promoting the profession of dentistry through the conceptual framework of the social contract4, 5. The social contract between the dental profession and society exists as a fluid and unwritten exchange of promises and obligations between, and to, each party. Of primary importance to this relationship is the ability of the dental profession to provide alleviation from the pain and suffering of dental disease, and to do this in an altruistic, trustworthy and accountable way. In exchange, society grants the profession benefits, including status and rewards, a monopoly, and self-regulation. In this commentary, the framework of the social contract will be used to explore the function and purpose of the DPA in the 21^st Century, and how it might contribute to dentistry’s professional status and relationship with the society it and its members serve.

A BETTER TRAJECTORY?

Altruism and the effacement of self-interest are key tenets of dentistry’s social contract. Logically, when dentists group together in forming an association, it follows that these same principles of service are demonstrated by such a collective. Therefore, DPAs must not act in a way that would conflict with their own individual members’ professional obligations. However, there is a risk that political, commercial and economic agendas can take priority over the ethical obligations of individual members and the profession’s duty to promote them⁵. Dental professionals who join their professional association may do so as a means to amplify their own commitment to societal service, and so as to be represented in higher-level advocacy efforts. Yet, professional associations can often behave as businesses that are oriented to view their members as customers. Where associations treat their membership in this way, this risks the association’s focus becoming fixated upon the retention of members, through value-added services and products, rather than a focus upon collective obligations and empowerment to act cohesively in the public’s interest.

Dental professional associations also demonstrate the orientation of their focus through the way they conduct their operations. Some can appear as corporate entities, partly focussed on profit-driven strategies, creating diverse and robust investment portfolios, all with a focus of growing and retaining their customer base. This might be achieved through offering exclusive deals on financial products or professional services only available to members, or through offering practice management assistance and advice. In themselves, these are all ethically neutral activities – in some cases, the reduction of business costs may help to enhance access to professional services – and the authors do not assert that these activities are inappropriate in the context of the role of a DPA. However, when such activities are placed above the ethical duties of the profession, they become distinctly unethical activities for DPAs to place as their core business. DPAs might benefit from reviewing their own strategic plans and priorities, and asking whether they are primarily focused on the advocacy and delivery of better oral health for all, or on the maintenance and sustention of dentistry’s professional monopoly. The authors present this as a point of reflection for the leadership of DPAs to consider in regards to their greater purpose. Indeed, at the beginning of dentistry’s professional history, DPAs were positioned as monuments to the credibility, responsibility and rigour of the fledgling profession. In an era before regulation, they overtly excluded those who might practice dentistry in an unsafe or reckless manner. In contemporary DPAs, the protection of dentistry’s monopoly is still a zealously fought cause. The proliferation of businesses offering teeth whitening and the more recent establishment of direct-to-consumer orthodontics have prompted reactions from DPAs in many jurisdictions. DPAs have also been antagonistic towards the development of allied dental practitioners. Examples include the negative reaction to dental therapists in the USA, which had an historical precursor in Canada to the same effect, and which followed the same trajectory as antagonism towards denturism, the expanding role of dental hygiene, and even physician involvement in preventive oral health care. One of the problems with dentists reacting protectively to perceived incursions into their professional monopoly is the lack of support for the profession’s perspective from society. In an increasingly commercialised world, the public are intolerant of powerful professions inhibiting their choices of where to access and purchase services. This is compounded further when there may be a cost disparity between dentist- and non-dentist-provided services. DPAs are right to challenge practices that are perceived by the profession as unsafe, but they must be measured in their reaction to perceived competition, avoiding arguments of public safety where evidence is only anecdotal in nature or absent. Professional reaction to what is perceived as healthy competition by the public may damage faith in the profession’s ability to practice the effacement of self-interest, as well as attenuate efforts of genuine advocacy to the point where they are at risk of being dismissed entirely. Similarly, DPAs should ensure that they contribute in a constructive manner to the political discussion of how dentistry might be incorporated within public healthcare. Where dentistry is highlighted to be an area in need of public investment, the role of the DPA should be to positively engage in this discourse to secure greater access for the public to essential services. An example of this can be seen where the Australian Dental Association New South Wales Branch (ADA NSW) publicly supported an independent report produced by the Grattan Institute⁶ that called for government investment in a Universal Dental Scheme.⁷ In the USA, the American Dental Association discusses Medicaid-funded dentistry as a challenge. The association acknowledges that publicly funded dentistry is important, but also claims that provision of publicly funded care under the scheme does not meet the costs of providing dental treatment⁸. Where DPAs operate in jurisdictions where the public health system does not support equitable access to dentistry, it becomes an important point of advocacy to promote policy change and investment in oral health as an integral part of health and wellbeing. Another area of important advocacy is in the integration of dentistry within the rest of healthcare. DPAs have an important role in the promotion of interprofessional collaboration that will both enhance attention to oral health, as well as increase access to oral health care.

Due to the fractured nature of the profession, working in very small and unconnected units, collective action on such issues as social justice and access to care can be challenging. Research examining logics within practice have found that practitioners focus far more on matters pertaining to their own local communities and practices, than broader societal issues. Harris et al.⁹ state, “professionalism is a shifting not concrete phenomenon, and we find this to be the case, notably with the expansion of commercialism in dentistry – the social contract has become one between the dentist, dental staff, patients and the local community”. The lack of individual capacity to effect action on unjust oral health-related outcomes can be mitigated through action by DPAs. Therefore, one of the key strengths of the organised profession is its ability to act against social injustices that impact oral health at a higher level than individual practitioners are able to. The common origin of most DPAs is arguably linked to such activities, making this part and parcel of the process of professionalisation. While DPAs do play a crucial role in promoting and protecting the interests of dental professionals, a role that is valued by many professional members, we argue that this role still needs to be undertaken within the bounds of the social contract. DPAs might reflect upon their unique positions within both the profession and wider society, and how this may enable them to assert an effective function in addressing broader societal issues while balancing the needs and preferences of individual members. There is little doubt that a broader agenda focussing on the public interest is likely to gain credibility with policymakers and the public.

Nevertheless, when opportunity is presented for DPAs to undertake oral health promotion activities, much of the advocacy is directed towards promoting dentally focused messages, aimed at individual-level behaviours and personal responsibility. Also, there is often a lack of integration within the wider health professional community, with oral health being siloed away from collective health action projects. There has been a reluctance from some DPAs to engage in wider health dialogues that would act against the greater social determinants of ill health and associated inequities. DPAs might consider their role as partly being at a population-level, with an ability to effect meaningful change in population-level health and social issues.

COLLECTIVE ACTION WHILE MITIGATING CONFLICTS OF INTEREST?

Increasingly, more is understood about the commercial determinants of health, and how larger, transnational corporations may damage health and wellbeing through the pursuit of profit. In 2003, the American Academy of Paediatric Dentistry (AAPD) announced that they had received a donation of $1 million to the AAPD Foundation from the Coca-Cola Foundation. In criticising the Academy’s decision to accept this funding, the director of the Center for Science in the Public Interest (CSPI), Michael F. Jacobson, stated, “It’s hard to imagine a professional association of dentists choosing a more inappropriate partner to fund educational programs”¹⁰. Reading the AAPD’s statements surrounding the grant, it is hard to disagree with the CSPI’s assessment that accepting the money would make the association unable to make critical statements about Coca-Cola. The then President of the AAPD, David K. Curtis, is quoted as saying, “Scientific evidence is certainly not clear on the exact role that soft drinks play in terms of children’s oral disease”¹¹, with the then President-Elect, Paul A. Reggiardo, quoting research suggestive that regular cola is not acidic enough to cause enamel demineralisation and dissolution¹¹.

Also consider that, both nationally and internationally, DPAs endorse the protective effects of chewing sugar-free gum by permitting Wrigley to display their logos on the reverse of its chewing gum packets. Wrigley was purchased by Mars in 2008 for $23 billion¹². Before the sale, Wrigley produced both sugar-free and sugared gum, as well as other confectionaries. Now purchased by Mars, they are part of a vast empire of popular, high-sugar confectionary brands that dominate the marketplace. At the same time, the Wrigley Company Foundation has funded dental care and oral health promotion projects, stating that, since 1987, the foundation has donated over $70 million to non-profit partners¹³. The authors recognise the potentially protective effects of sugar-free gum against caries; however, the wider commercial ties to other products that are damaging to oral and general health cannot be dismissed.

What’s more, the conflicts of interest involved in the sugar industry funding research into the effects of sugar on health has shown that the involvement of these sources of funding for professional and research activities is fraught¹⁴. The endorsement by DPAs of products that are manufactured and distributed by companies whose activities could be ultimately damaging to oral health, however well intended, is conflicted. One might also argue further that to take no or little action on both the commercial and social determinants of health (e.g. sugar-sweetened beverages, vaping, food security, income security) is similarly fraught. The social contract stipulates that the dental profession must manage its interactions with society in a way that fosters and preserves trust. When conflicts of interest arise at an individual level, professional associations typically espouse in their codes of ethics that they must be managed. This should arguably apply to dentistry at a collective level as well, despite the fact that the effects of such conflicts might be harder to identify and manage. As a start, DPAs might consider greater public involvement in their processes of product endorsement in order to examine the issue of perceived conflicts of interest and any possible impacts this may have on the trusted nature of the dental profession.

It is important to state that many DPAs do organise and coordinate charitable programs that arrange for member clinicians to provide pro bono treatment to vulnerable population groups. This occurs both at national and subnational levels, such as in the USA, through the ‘Give Kids a Smile’ and ‘Remote Area Medical’ programs, respectively. These activities are important and laudable; they have provided dental care for thousands of underserved members of the public. However, the impact of such initiatives is attenuated if not complemented by population-level activities such as effective advocacy against the social and commercial determinants of oral health.

THE ALIGNMENT OF DPAS AND DENTAL REGULATORS?

Associations and regulators increasingly exist as a dichotomy. In some jurisdictions, there has always been a clear distinction between the regulator of dentistry and DPA, in others there may be no clear political demarcation between the two, and they may even be one and the same. A discussion of the merits or disadvantages of a closely associated DPA and regulator is out of scope for this article. However, consideration of how the professional purposes of these two categories of organisation might align is important to how DPAs might operate within the social contract.

In March 2019, the federal body of the Australian Dental Association published a press release announcing that it had awarded the main regulator of dentistry in Australia, The Dental Board of Australia, a failing grade for effective regulation¹⁵. The report card listed five areas where the DPA and its members believed the board was failing. These all related broadly to the professional monopoly of dentistry, either regarding its protection or, in the case of neurotoxins and dermal fillers, its expansion. The concluding statement, “93% of ADA member dentists have lost faith in the Dental Board’s ability to protect the public”¹⁵ seemed to be somewhat remote from the areas where the association believed the board to have failed, with none being supported by evidence to confirm a demonstrated issue of public safety.

The above example is important because it demonstrates a lack of alignment of greater purpose between the DPA and regulator. Negative sentiments between the two institutions are present in other jurisdictions as well16, 17. Broadly put, the aim of regulators is to act in the public interest and protect the public, with the aim of DPAs to support the interests of professionals. For the reasons explained above, these two interests can align; the primary professional principle is to place the interests of the public (and thus patients) before their own. Whilst framed in terms that appear to support the public interest, the example of the report card from Australia is arguably an overt statement of self-interest. Actions such as these by DPAs can potentially be viewed as a breach of the social contract.

Moreover, regulators are also required to maintain public trust. The case of the General Dental Council in the UK actively advertising for complaints against registrants serves to illustrate how regulators may serve to damage the relationship between the profession and the public¹⁷. There is no doubt that regulators and DPAs have a broader aligned interest in serving the public good, yet it can be perceived that associations do not fulfil this role. Such misconceptions are, in part, present because it is perceived that only regulators are placed to serve the public good, with DPAs only serving professional interests. This, as is being argued, is not a zero-sum game and the two are not mutually exclusive. Nevertheless, an example of what might strengthen such misconceptions, and undermine the overall status of the profession, is seen in jurisdictions where the regulator and DPA are perceived to be too closely linked, attracting criticism and speculation of fitness for purpose¹⁶. Again, the authors suggest that the purposes of both DPAs and regulators are broadly aligned. The regulator acts in the public interest and protects the public, and in doing so ensures that dentistry maintains its professional status, while DPAs protect the interests of their members, but in doing so can help to promote and maintain professional standards, much less also advocate on behalf of the public interest (e.g. expanding access to care, mitigating the ill effects of the social and commercial determinants of health). Finally, where the activities of either organisation become antagonistic towards the other, it is likely that the public will not be benefitted and, in the longer term, neither will the profession.

BEST PRACTICES?

There are examples of best practices with regards to the arguments being made in this commentary. The authors suggest that the FDI World Dental Federation itself is an example, particularly in terms of its progressive suite of policy directions, statements and activities. These include its: Advocacy Strategy Vision 2020; Istanbul Declaration and Oral Health and the UN Political Declaration on NCDs; and associated Statements (e.g. Primary healthcare towards universal health coverage, Maternal, infant and young child nutrition, and Multisectoral action for a life course approach to healthy ageing). It is this type of focus that grounds dentistry and its DPAs within the social contract, maintaining the status of dentistry as a regulated and caring health profession, whose aim is to contribute to the societies it serves.

A very strong example of this recently materialised in Canada, where a task force commissioned by the Canadian Dental Association undertook an exercise to envision and shape the future of the profession, partly as a response to the perceived loss of public trust and increased competition and commercialisation of the profession¹⁸. The DPA’s task force arrived at four vision statements, with the second being: “By 2032, dentistry will fulfil its social contract through universal access to oral health care”. Under this vision, eight recommendations were made, which touched upon a broad range of issues, such as a basic ‘basket’ of oral health care services that could be made available to the entire population; delivering care to vulnerable groups through methods most appropriate for these groups; taking all possible steps to meet the oral health needs of all populations; and forming coalitions to promote the social and living conditions of all people living in Canada.

Ultimately, DPAs who embody such principles of empowerment and advocacy at a population-level will undoubtedly contribute to creating a more engaged and politically relevant dental profession.

CONCLUSION

In closing, the social contract is neither set in stone, nor is it a permanent obligation upon society to maintain the professional status of dentistry. Dentists and their associations worldwide should reflect upon their priorities and activities in relation to the social contract and related issues such as social justice and altruism. Dentistry should place the management of these issues at the highest priority within DPA strategic plans, replacing strategies of protectionism and self-interest, which only serve to alienate the public.

DECLARATIONS

ACLH is a Federal Councillor and Director of the Australian Dental Association Inc. and is a member of the New South Wales Registration Committee of the Dental Board of Australia. He is also an external consultant to the College of Dental Surgeons of British Columbia, and has received research funding from the Australian Dental Council and the Dental Council of New South Wales. ACLH is also a Councillor and Director of the Australasian College of Legal Medicine.

CQ is incoming President of the Canadian Dental Specialties Association, former President of the Canadian Association of Public Health Dentistry, and past-Chair of the Canadian Dental Association’s Committee on Clinical and Scientific Affairs. He is Editor of the Ontario Dental Association’s professional journal, an external consultant to the College of Dental Surgeons of British Columbia, and has received research funding from the Canadian Dental Association, Ontario Dental Association, and Royal College of Dental Surgeons of Ontario.

Author statements

This work has been solely submitted to the International Dental Journal for consideration.

Conflicts of interest

Both Dr Alexander CL Holden and Professor Carlos Quiñonez have declared their respective roles within dental professional associations and dental regulation at the end of the manuscript.

Funding

No funding was received relating to this work.

Contributions

Both Dr Alexander CL Holden and Professor Carlos Quiñonez contributed to the drafting, editing and preparation of this academic work.