Occupational Hazard is a series about how different jobs affect workers' mental health.
"I'm happy and satisfied in my work," Franklin Niver, a dentist practicing in Encino, California, tells me with enthusiasm. "It's very rewarding professionally and emotionally to help nervous patients and solve their disease. I've been practicing dentistry very happily for 50 years. It almost doesn't seem like work. It's a wonderful career."
I then ask him if he'd ever known anyone in his profession who died by suicide.
"Three," he responds.
The "In Memoriam" section of Volume 10 of the 1911 American Dental Journal lists ten dentists who passed away that year. Three of them died by suicide, one from "nervous collapse due to overwork," and one reportedly "accidentally shot himself while cleaning a revolver." While one century-old obituary page certainly can't offer a definitive view on the topic, it's curious. Also curious? Of the ten dentists I interviewed for this article, eight of them knew someone from their profession who had died by suicide.
So began my descent into the mystery of whether the long-running perception of dentists as significantly more prone to suicide than the rest of the population was true—or as false as an ill-fitting porcelain veneer. Every dentist I spoke to was familiar with the notion, whether they believed it or not.
"The first thing people say when I tell them I'm a dentist is 'Oh! Dentists have the highest suicide rate!'" says a dentist who asked to be referred to only as Dr. O.
"You've done the research," he says, turning the interview back on me. "Is it true?"
After weeks of poring over statistics, hundred-year old dental journals, and dentist obituaries, all I can say is: "Ummmm…maybe."
The most recent report from the CDC on professions with the highest suicide rates came out in 2012 and stated that it's actually farmers, fishermen, and forestry workers who are at the highest risk of taking their own lives. Dentists were way down on the list at number 12, lumped in with physicians and other health professionals. A query of the CDC's National Occupational Mortality Surveillance for the years 1999-2010, however, showed that dentists were 2.5 times as likely to die by suicide as members of the general population, while farmers, fishers, and forest workers were only .9 times more likely. The discrepancy could be related to a reduction in suicide rates by dentists or it could be a matter of the research methods and analyses being used.
The elevated suicide rates in both queries were most significant for white men, which makes sense because middle aged white men now have the highest suicide rate in America. And guess what demographic the majority of dentists in America fall into? Middle aged white men. Steven Stack, a criminal justice professor at Wayne State University, is one of the few researchers to study the specific correlation between dentistry and suicide. His 1996 study cited decades of previous research on suicide rates among dentists and showed that being a dentist increased one's risk of suicide by a whopping 564 percent. The 2012 CDC study swung all the way in the opposite direction, stating that dentists and health professionals were 80 percent less likely to die by suicide than members of other occupations.
There are inherent problems with determining suicide risk by occupation. Unless the deceased leaves behind a note specifically stating that their suicide is a result of occupational stress, it's impossible to point to it as a direct cause. There is clear evidence, though, that occupational stress can lead to depression and anxiety, substance abuse, and marital problems, all of which increase a person's chance of suicide. Another factor to consider is that suicides across the board are underreported. Suicides may be recorded as accidental deaths because of stigma, especially among families with strong religious ties.
Even the dentists I spoke to who were happy in their profession agreed that they were practicing under significant stress. Money trouble, physical and emotional stress, isolation, and the unfavorable public perception of dentists in general were all cited as negative aspects of their jobs.
The American Dental Association states that 80 percent of dental students graduating in 2016 were at least $100,000 in debt, and the average debt for dental school students in 2016 was $261,149. That's just for the degree. When it comes to starting your own practice, hiring staff, buying the latest high-tech equipment, renting or buying office space, and insurance to cover it all, costs can reach well over a million dollars. One dentist I spoke to stated that he was, at one point in his career, $2 million in the hole. That kind of debt leads to extended work hours, working through lunch breaks, and very few vacations.
"When I was in dental school, tuition was $70,000 to $80,000 a year, and that was almost ten years ago," says Jeffrey Rappaport, a dentist practicing in Manhattan. "Then you go into a residency which pays very little money and then you have to start working. That's why you see so many group practices right now. To start your own business is hundreds of thousands to millions of dollars. It's difficult."
And then there's the physical stress. Dentistry might be a white collar profession, but it's also physically grueling. Dentists are at increased risk for back, neck and shoulder injuries because their work requires them to be bent over in unnatural positions for extended periods of time. A 2016 study showed that more than 90 percent of practicing dentists reported experiencing musculoskeletal pain. "It's a physically laboring job," Rappaport says. "It's easy to think in the moment: 'I'm just going to turn my head and get in this weird position for five minutes,' but if it's five minutes three times a day for 30 years, it adds up."
On top of that, some patients can be difficult to work on because they're physically tense due to anxiety. "It can be very physically taxing, holding a drill all day—drilling on people's teeth," Dr. O says. "They can be on edge and when they're on edge, you're on edge. Even though you're not lifting heavy weights all day it does take a toll on your body."
And speaking of stressed patients, a 2014 study by the National Association of Dental Plans showed that 114 million Americans have no dental insurance, which means that dentists are often confronted with patients who wait until a dental emergency to get help, and then can't afford the treatments they really need. Dentists are regularly faced with tough decisions about helping patients who need much more treatment than they can actually afford.
A 2015 study by the American Dental Association showed showed that 11 percent of dentists responding were diagnosed with depression, while the rate for the general population was 6.7 percent. Six percent of dentists surveyed had an anxiety disorder while only 3.1 percent of the general population did. Four percent of dentists reported panic disorder, while only 2.7 percent of the general population reported the same.
"Burnout is a very real thing that I have observed many times, but outright depression isn't something that's widely discussed," Jennifer Dean, a dentist from Rancho Santa Fe, California, tells me. "There's a mixture of general societal taboo relating to depression along with a low tolerance for what is considered complaining from dentists. The prevailing perception is that dentists are successful and wealthy, so sympathy is, somewhat understandably, harder to come by."
A 2004 survey of 3500 dentists showed that 38 percent reported they were "frequently or always" worried or anxious and 34 percent stated they were "frequently or always" physically or emotionally exhausted. While the statistics on dentists and suicide may be debated, there's no question that stress in the dental profession is a valid concern.
Additional emotional stress can come from isolation, which the CDC lists as one of the main risk factors for suicide. While it's true that dentists are in close contact with other people all day long, they're also often perceived to be people who cause pain or have the potential to cause pain, which can make it difficult for them to develop close personal relationships with their patients.
"I don't know the last time there's been something in the media that's positive about dentists," says Dr. O. "The movies are all horror. Or the guy who killed that lion in Africa—there was a heavy association that he was specifically a dentist. There's a lot of negatives."
The mystery surrounding the validity of the perception of dentists as disproportionately suicidal remains unsolved, but the volume of anecdotal evidence paired with hard statistics about the real ongoing stress dentists face is eyebrow-raising at the very least.
"Honestly I don't know if the statistic is true, but it's still something you hear and it makes sense," Rappaport says. "Generally people just don't like going to the dentist. You're in a career where nobody wants to see you and you're the last place they want to come back to and it's depressing."