In part 1 of this series, we distinguished between the concepts of morals, ethics, and law, examined the role of intention, and identified the growing tensions that arise when oral health care is governed by competing health and business logics. Now, we’ll look at the institutional, economic, and regulatory frameworks that can either support ethical care or erode it. 

As we discussed before, business ethics treat profit maximization as the central duty of enterprise. Health-care ethics begin with patient welfare and the maxim  primum non nocere—“first, do no harm”—grounding practice in nonmaleficence and justice, while treating financial viability as necessary but distinctly secondary.¹ This commitment is embedded in contemporary forms of the Hippocratic oath and its equivalents that dentists and dental hygienists recite as they enter their professions.²

The trickle‑down tremor 

These two moral systems are not naturally aligned, but American health policy spent much of the last half-century pretending that they were.^3,4 Beginning in the Nixon era, policymakers increasingly embraced market competition, private administration, and managed care as solutions to rising costs.⁵ In the Reagan era, that orientation deepened under a broader political faith in deregulation, privatization, and trickle-down economics—the belief that if government stepped back and private enterprise expanded, efficiency and prosperity would eventually diffuse outward to everyone else.⁶

In theory, such a model is not inherently unethical. A single‑payer public system can fail just as easily if it becomes indifferent, bureaucratic, or coercive, and a privately organized system can function ethically when strong norms and laws keep business conduct subordinate to patient welfare.⁷

The problem is that American health policy increasingly relies on the moral restraint of private actors without building legal safeguards strong enough to make health, rather than profit, the nonnegotiable endpoint.^7,8

If laws are weak, fragmented, or easily influenced, then profit-seeking does not naturally “trickle down” into ethical care. 6,8 It flows toward whatever is most financially rewarded. In health care, that means the enterprise tends to favor billable intensity, scale, consolidation, leverage, and price inflation unless law and professional accountability intervene.¹⁰ The burden of restraint, in other words, was placed on the conscience of organizations structurally designed to pursue financial return.⁶  

From mission drift to market quake 

The consequences of that mistake are now visible across the health sector, including dentistry. Private equity and other investor-driven models promise capital, efficiency, modernization, and managerial discipline. 11 Those benefits can be real in limited cases, but the growing body of evidence suggests that when financial ownership is driven by aggressive return expectations, the result is pressure on quality, rather than a stable alignment with patient welfare.¹²  

A 2023 systematic review found that private equity ownership in health care was most consistently associated with higher costs to patients or payers and mixed to harmful effects on quality, with no consistently beneficial impacts identified.¹⁰ Other studies of privatization in hospitals have found financial savings for operators or governments accompanied by evidence of worsened outcomes for some patient populations, underscoring the danger of assuming that market efficiency is ethically self-correcting.¹³

Dentistry has increasingly been pulled into that same logic. As DSOs expand, private equity-backed platforms multiply, consolidation spreads, and business decisions are made farther from the operatory and closer to the spreadsheet.

The issue is not merely that corporations are involved; it is that the organization's governing logic is misaligned. Scheduling templates, staffing ratios, purchasing systems, marketing priorities, and compensation incentives are designed first for growth, efficiency, and return on investment, while ethical care is expected to survive inside those parameters. Clinicians are told they retain professional independence, but independence inside a tightly engineered revenue system is often more formal than real.  

This is where system ethics becomes visible. Every health-care organization has an operational morality, whether it admits it or not. That morality is revealed by what gets measured, what gets rewarded, and what gets tolerated. If the dominant metrics are production, collections, case acceptance, and margin, then those become the practical definition of success.

If patient education, prevention, thoughtful restraint, and extra time for complex needs are not protected, they gradually become luxuries rather than obligations. The mission statement may still invoke service, trust, and health, but the daily structure tells clinicians what actually matters. 

The reimbursement rift 

Inflation, student debt, and stagnant reimbursement have intensified the structural imbalance in oral health finances. Operational costs for practices—supplies, equipment, rent, wages, and education—have steadily increased, while many dental and medical reimbursement schedules have remained flat or grown far more slowly.¹⁴ That divergence is not accidental; it reflects a business-first design in which large insurers and financial intermediaries can protect margins and shareholder value even as the clinical cost of delivering care rises.^10,12  

Because reimbursement is only weakly linked to documented improvements in oral health outcomes, the system can reward cost containment and revenue growth without necessarily rewarding better health.¹⁵ For practices, the resulting gap manifests as a chronic “profit squeeze,” and for new graduates with substantial educational debt, it narrows the range of sustainable practice settings, especially given the lower reimbursements they receive as newly credentialed providers.¹⁴  

When organizations respond to this squeeze by raising production expectations, compressing appointment times, and shifting more work to the lowest‑cost personnel, they are not simply adapting to the market; they are doubling down on a business ethic that treats efficiency and quantity as primary goods, with patient health outcomes left to fit around the edges.^11,13 

For dental hygienists, this tension is even more revealing because it exposes not just market pressure but hierarchy.¹⁶ The structural subordination of dental hygiene to dentistry was not an accident.¹⁷

It was built into law and practice through supervision requirements, ownership limits, and scope constraints, positioning hygienists as indentured laborers rather than fully empowered professionals.¹⁷ These arrangements were presumptuously justified in the language of safety, but they primarily control workforce structure, revenue flow, and competition. In that sense, they function not as professional regulation but as a system of power.¹⁶  

This matters ethically because autonomy is not a luxury; it is the condition that allows licensed professionals to act on their judgment in the interest of patients.¹⁸ When hygienists are restricted from practicing to the full extent of their education, when community-based or independent models are blocked, and when preventive capacity is kept subordinate to dentist-controlled business arrangements, the public loses access while the profession preserves hierarchy.^19,20 The benefits of this arrangement accrue to those at the top, not to patients most in need of care.  

Scaling the wrong fault line 

This concern is especially visible in the current controversy surrounding oral preventive assistants (OPAs) and the introduction of “supragingival scaling” by unlicensed staff. Proponents have framed this model as an access solution, but critics justifiably argue that it is a barefaced attempt to normalize a legally and ethically contested form of incomplete, substandard care.²¹  

The central concern is not simply who removes visible calculus; it is whether a stripped-down service with medically contested health outcomes is being advanced to reduce labor costs and preserve profit margins while presenting itself as innovation.  

That concern is intensified by a substantial and longstanding body of research showing that expanded dental hygienist autonomy, direct access, and broader scope of practice improve access to care, increase preventive utilization, and reduce costs without compromising quality or safety.¹⁸

Yet despite this evidence, organized dentistry has incessantly defended its model of concentrated regulatory control and governance that does not track with stronger access to care, raising legitimate questions about whether its governing priority is public protection or the preservation of institutional and economic control.^16,22 

Of even greater concern is that independent empirical work has documented the economic cost of constraining hygienists’ practice. Occupational regulations requiring dentists’ control have been associated with roughly a 12% increase in prices for basic dental services, while policies that allow direct reimbursement or higher levels of hygienist autonomy are linked to greater utilization of preventive care, lower use of restorative treatment, and improved oral health outcomes, particularly in shortage areas^19,20

In contrast, independent dental hygiene practices and other high‑autonomy models consistently demonstrate that when hygienists are allowed to practice to the full extent of their education, care becomes more accessible, more preventive, and more cost-effective.²³ 

Recentering the moral epicenter 

The deepest policy mistake was assuming that privatization and business deregulation could be trusted to serve health without robust ethical and legal guardrails. 7 A publicly financed system and a privately financed system can both function in theory; either can also fail. What determines their moral legitimacy is whether their design reliably compels power, money, and decision-making to remain answerable to patient welfare rather than to investor return. 7  

That is the structural load now bearing down on dentistry. The problem is not whether individual clinicians mean well; it is whether the system surrounding them has been engineered to reward the wrong motives. When business success is not legally and structurally tied to health improvements, the enterprise drifts. And once that drift becomes normal, ethical professionals are left trying to resist a machine that was never designed to protect their judgment in the first place. 

Part 3 will move from structure to rupture: what happens when these business pressures begin to distort diagnosis, documentation, veracity, and the integrity of clinical judgment itself.  

Editor's note: This article appeared in the August/September 2026 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.

References: 

1. Ozar DT, Sokol DJ, Patthoff DE. Dental Ethics at Chairside: Professional Obligations and Practical Applications. 3rd ed. Georgetown University Press; 2018. 

2. ADHA. Code of Ethics for Dental Hygienists. ADHA; 2023. 

3. Hai S, Daft RL. When missions collide: lessons from hybrid organizations for sustaining a strong social mission. Organ Dyn. 2016;45(4):283-290. doi:10.1016/j.orgdyn.2016.10.003 

4. Stevens RA. History and health policy in the United States: the making of a health care industry, 1948-2008. Soc Hist Med. 2008;21(3):461-483. 

5. Seervai S, Blumenthal D. Lessons on universal coverage from an unexpected advocate: Richard Nixon. To the Point. 2017. 

6. Enright SM. Effect of Reaganomics on the US health-care system. Am J Hosp Pharm. 1982;39(7):1169-1175. 

7. Gostin LO, Hodge JG. Global health law, ethics, and policy. J Law Med Ethics. 2007;35(4):519-525. doi:10.1111/j.1748-720X.2007.00176.x 

8. Kassler WJ. Turning barriers into benefits to facilitate public health and business partnership. Am J Public Health. 2020;110(4):443-445. 

9. Vorster N. An ethical critique of Milton Friedman’s doctrine on economics and freedom. J Study Relig Ideol. 2010;9(26):163. 

10. Borsa A, Bejarano G, Ellen M, Bruch JD. Evaluating trends in private equity ownership and impacts on health outcomes, costs, and quality: systematic review. BMJ. 2023;382. 

11. Kannan S, Bruch JD, Song Z. Changes in hospital adverse events and patient outcomes associated with private equity acquisition. JAMA. 2023;330(24):2365-2375. 

12. Goodair B, Reeves A. The effect of health-care privatization on the quality of care. Lancet Public Health. 2024;9(3):e199-e206. 

13. Rickert J. On patient safety: the danger of private equity involvement in healthcare. Clin Orthop Relat Res. 2024;482(6):936-939. 

14. American Dental Association Health Policy Institute. The State of the US Dental Economy Q2 2025 Report. American Dental Association; 2025. 

15. Chalmers NI, Compton RD. Children’s access to dental care affected by reimbursement rates, dentist density, and dentist participation in Medicaid. Am J Public Health. 2017;107(10):1612-1614. 

16. Kleiner MM, Park KW. Battles Among Licensed Occupations: Analyzing Government Regulations on Labor Market Outcomes for Dentists and Hygienists. 2010. 

17. Sven DJ. Breaking chains: the case for dental hygienists’ autonomy. RDH. Endeavor February 27, 2025. https://www.rdhmag.com/career-profession/alternative-practice/article/55265894/breaking-chains-the-case-for-dental-hygienists-autonomy 

18. Chen J, Meyerhoefer CD, Timmons EJ. The effects of dental hygienist autonomy on dental care utilization. Health Econ. 2024;33(8):1726-1747. doi:10.1002/hec.4832 

19. Wing C, Marier A. Effects of occupational regulations on the cost of dental services: evidence from dental insurance claims. J Health Econ. 2014;34:131-143. doi:10.1016/j.jhealeco.2013.12.001 

20. Akinlotan MA, Ferdinand AO, Maxey HL, Bolin JN, Morrisey MA. Dental hygienists’ scope of practice regulations and preventable non-traumatic dental emergency department visits: a cross-sectional study of 10 US states. Community Dent Oral Epidemiol. 2023;51(2):274-282. doi:10.1111/cdoe.12737 

21. Sven DJ. Unleashing the truth: dogs get better laws than you. Hygienists’ Hub. American Dental Hygienists’ Association; 2025. 

22. National Institutes of Health. Oral Health in America: Advances and Challenges. National Institute of Dental and Craniofacial Research; 2021.  

23. National Governors Association. The Role of Dental Hygienists in Providing Access to Oral Health Care. National Governors Association; 2014.