Holden A C L, Quiñonez C R. Is there a social justice to dentistry's social contract? Bioethics 2021; DOI: 10.1111/bioe.12915. Online ahead of print.

The lines are blurred but professional responsibility is clear

Dentistry operates within a social contract - the provision of oral care by an altruistic profession which places the interests of the public above the interests of the profession, engendering trust and allowing self-regulation. Traditionally, the profession's role was seen as the alleviation of pain and the restoration of the consequences of disease, in line with other healthcare professions. However, consideration of the role of aesthetics in oral care blurs the margins of the social contract. Aesthetics (there is no such thing as a non-cosmetic dentist) form an integral part of oral health, which includes being able to smile and convey 'a range of emotions through facial expressions with confidence'. There is now a public expectation that the profession will meet their aesthetic needs as a part of the social contract.

The authors make two caveats to this accommodation of aesthetics within the social contract. Firstly, they draw a distinction between needs fulfilment (as a part of improving health) and needs creation, where advertising exploits the links between oral health, appearance and social status. Commercial practices may undermine the profession's altruistic commitment. Secondly, there is a concern for social justice. Can the profession still be called such if, diverted by cosmetics for the few, it can no longer provide the core service of pain control and disease management to the many, the very basis of its social contract with society?

However, lack of definition of what is and what is not essential for oral healthcare compounds the difficulties of achieving social justice in the provision of dentistry, in particular for those who are worst off in society. The nebulous nature of dental aesthetics and its relationship to the treatment of dental disease make it difficult to establish equitable boundaries for social justice to be achieved.

Incursions into the professional monopoly of dentists have recently become more common, as in the introduction of dental therapists, as mid-level providers, in an attempt to reduce the costs of treatment provision. The introduction of direct-to-consumer whitening services and orthodontic treatment threaten the monopoly. However, rather than try to improve access to care, to negate the need for these incursions, the profession's reaction has been to try to reassert its monopoly by legal means.

If the profession fails to acknowledge its commitment to the social contract and social justice, then it should not be surprised that society seeks alternative means to ensure its needs are met. Equity of access to oral care for both those with a compromised dental appearance and those with existential threats to health from oral disease are core requirements of the profession under the social contract.