The business world has a penchant for taking hold of a perfectly sound idea and debasing it, first into a cliché, then a joke and finally an expletive. The term "customer focus"—certainly a worthy principle, and one that characterizes the best and most successful organizations—has, in some cases, been twisted out of all recognition. For a decade or so, an army of consultants has insisted that "meeting and exceeding customer expectations" is the one true path to success. The dictum has been applied to virtually every field of endeavor: to selling soap, to running the national parks and (ad nauseam) to delivering health care. Has it worked? Have quality and customer service improved? Here and there, yes, though, as usual, the credit belongs more to dedicated people than to grand schemes. But as a rule, if my expectations are exceeded these days, it’s only because they were so low in the first place.

One reason for the divergence between good intentions and bad results is that "customer expectations" are not the whole story. Important, yes. But not sufficient. Sometimes the most critical aspects of a product or service are unrecognized, or unarticulated, by the consumer. While this holds true for toys and helicopters and bituminous coal, I’ll leave those sectors to their own practitioners. I want to talk about dentistry.

Just what do our patients expect when they come to the dental office? Do we meet those expectations? What should the patient expect of the dentist? And how can we bring perceptions into harmony with reality?

My own highly unscientific survey reveals that patients come to the dentist for relief of pain, a nice smile and a good start for their children. These are reasonable expectations touching on important aspects of oral health. Beyond any doubt, dentistry has made great strides in all three areas. Most kinds of pain can be accurately diagnosed and quickly eliminated without sacrificing the dentition. Spectacular advances in periodontal therapy, restoration materials and implant-based prostheses have made attractive dentition the norm for patients of all ages. New procedures, products and scientific knowledge have given oral and maxillofacial surgeons the ability to achieve dramatic esthetic results. Fluoridation, fissure sealants, scientific orthodontia and pervasive educational efforts have made each successive generation healthier than the last, as far as their teeth are concerned.

Overall, then, we have succeeded spectacularly in meeting patients’ most pressing expectations. Not that we should rest on our laurels, of course. Patients still would like dentistry to be painless, quick and free. Many of our practices would benefit from improvements at the front desk. On balance, though, there is some cause for satisfaction.

So expectations, as far as they go, are fine. Yet a great deal of the care that dentists provide is more or less invisible to the patient. All those new materials and procedures are not only more esthetic, they’re more durable and atraumatic than their forerunners. Periodontal surgery not only relieves pain, it saves teeth. Orthodontics and prosthetics not only improve appearance, they preserve function and contribute to nutrition. Things we do "in the background"—a thorough examination and an intelligent treatment plan—can spell the difference between health and disease. But while the patient may recognize these things, they’re not usually uppermost in his or her mind when the chief complaint is a broken incisor.

Never forget that patients are just as smart as anyone else. They have no difficulty understanding that we’re more than simply "mouth carpenters," poking around for holes to fill. But somebody (read: you and I) has to tell them. Offer to explain what you are doing, and why. Mention the fact that you are looking not only at the teeth and gums but also screening for oral cancer. Select patient literature that is both current and accurate and keep it accessible. When you have the opportunity, tell the Kiwanians or the Girl Scouts something they don’t know about dentistry.

What price complacency? Imagine for a moment that you are a state legislator presented with a bill authorizing "dental salons," where licensed non-dentists would provide cosmetic care: bleaching, polishing and maybe a fluoride treatment on the side. Why not? No needles, burs or knives are involved; there are no irreversible procedures; and think of the cost savings! After all, we license barbers and manicurists and inspect them occasionally to make sure they wash their tools. There still will be dentists to take care of toothaches. Behold, expectations met and exceeded! Sounds like a fantastic idea.

No, it’s a rotten idea. Regardless of public perceptions, the dentist’s core responsibilities are diagnosis and treatment. These cannot be safely delegated to people, even very skillful people, whose education has not prepared them for the task. In the real world, the serious work of diagnosis is closely linked with the periodic recall and cleaning visit, during which the dentist and hygienist work as a team. How many patients (or rather, customers) will leave the "salon," teeth all shiny and fresh, and make an appointment for diagnosis by a dentist?

The issue is not loss of business—simple prophylaxes are certainly not a lucrative way to spend your time—but one of public trust. Of course we want our patients to be pleased with every aspect of their treatment. We strive for the best possible esthetic result. But as more people come to understand what dentists really do, there will be less risk that America’s dental care will fall victim to the misguided view that patients are mere consumers and nothing more.