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Journal of the
American College
of Dentists
The Evidence
for Ethics
Winter 2020
Volume 87
Number 1Journal of the
American College
of Dentists
A publication advancing Communication Policy
excellence, ethics, professionalism,
and leadership in dentistry
It is the communication policy of the American College of Dentists to identify and
The Journal of the American College of Dentists place before the fellows, the profession, and other parties of interest those issues
(ISSN 0002-7979) is published quarterly by that affect dentistry and oral health. The goal is to stimulate this community to
the American College of Dentists, Inc., 839J remain informed, inquire actively, and participate in the formation of public policy
Quince Orchard Boulevard, Gaithersburg, MD and personal leadership to advance the purpose and objectives of the college.
20878-1614. Periodicals postage paid at The college is not a political organization and does not intentionally promote
Gaithersburg, MD, and additional mailing
specific views at the expense of others. The positions and opinions expressed in
offices. Copyright 2020 by the American
college publications do not necessarily represent those of the American College
College of Dentists.
of Dentists or its fellows.
Postmaster—Send address changes to:
Managing Editor
Journal of the American College of Dentists
839J Quince Orchard Boulevard Objectives of the American College of Dentists
Gaithersburg, MD 20878-1614
T HE A MERICAN C OLLEGE OF D ENTISTS , in order to promote the highest ideals in
The 2020 subscription rate for members of
health care, advance the standards and efficiency of dentistry, develop good
the American College of Dentists is $30 and
is included in the annual membership dues.
human relations and understanding, and extend the benefits of dental health to
The 2020 subscription rate for nonmembers the greatest number, declares and adopts the following principles and ideals as
in the United States, Canada, and Mexico is ways and means for the attainment of these goals.
$40. All other countries are $60. Foreign
optional airmail service is an additional $10. A. To urge the extension and improvement of measures for the control and
Single-copy orders are $10. prevention of oral disorders;
B. To encourage qualified persons to consider a career in dentistry so that
All claims for undelivered/not received
issues must be made within 90 days.
dental health services will be available to all, and to urge broad preparation
If the claim is made after this time period, for such a career at all educational levels;
it will not be honored. C. To encourage graduate studies and continuing educational efforts by dentists
and auxiliaries;
While every effort is made by the publishers
and the Editorial Board to see that no inaccurate
D. To encourage, stimulate, and promote research;
or misleading opinions or statements appear E. To improve the public understanding and appreciation of oral health service
in the Journal, they wish to make it clear and its importance to the optimum health of the patient;
that the opinions expressed in the articles,
F. To encourage the free exchange of ideas and experiences in the interest
correspondence, etc., herein are the
responsibility of the contributor. Accordingly, of better service to the patient;
the publishers and the Editorial Board and G. To cooperate with other groups for the advancement of interprofessional
their respective employees and officers accept relationships in the interest of the public;
no liability whatsoever for the consequences
H. To make visible to professional persons the extent of their responsibilities
of any such inaccurate or misleading opinions
or statements. to the community as well as to the field of health service and to urge the
acceptance of them;
For bibliographic references, the Journal I. To encourage individuals to further these objectives, and to recognize
is abbreviated J Am Col Dent and should meritorious achievements and the potential for contributions to dental science,
be followed by the year, volume, number, art, education, literature, human relations, or other areas which contribute to
and page. The reference for this issue is:
human welfare—by conferring Fellowship in the College on those persons
J Am Col Dent 2020; 87 (1): 1-68.
properly selected for such honor.Editor
David W. Chambers, EdM, MBA, PhD
dchamber@pacific.edu
Managing Editor
Theresa S. Gonzales, DMD, MS, MSS
Editorial Board
Rick Asai, DMD
Phyllis Beemsterboer, EdM, MS
Greg Chadwick, DDS, MS
R. Bruce Donoff, MD, DMD
Nanette Elster, JD, MPH The Evidence for Ethics
Nancy Honeycutt, CAE
Robert Lamb, DDS
Philip Patterson, MA, PhD 4 Focus Group Results
Carlos Quiñonez, DMD, MSc, PhD David W. Chambers, EdM, MBA, PhD, FACD
Ken Randall, DMD
Lindsey A. Robinson, DDS
Harriet F. Seldin, DDS 18 The Dental Ethics Teaching Case
Robert Sherman, DDS David W. Chambers, EdM, MBA, PhD, FACD
Ronald Tankersley, DDS
Design and Production 26 Dentists’ Knowledge of ADA Code
Annette Krammer, Forty-two Pacific LLC David W. Chambers, EdM, MBA, PhD, FACD
Correspondence
Address correspondence relating to the Journal to: 35 Ethical Touchstones
Managing Editor
David W. Chambers, EdM, MBA, PhD, FACD
Journal of the American College of Dentists
839J Quince Orchard Boulevard
Gaithersburg, MD 20878-1614 41 Practice Goals: Opportunities and Obligations
Letters from Readers David W. Chambers, EdM, MBA, PhD, FACD
Comments concerning any material appearing in
this journal are welcome at dchamber@pacific.edu. 48 Survey of Dental Ethics Education: 2018
They should be no longer than 500 words and will David W. Chambers, EdM, MBA, PhD, FACD
not be considered after other letters have already
been published on the same topic. The editor
reserves the right to refer submitted letters 59 Ethical Attribution Effect Hypothesis
to the Editorial Board for review. David W. Chambers, EdM, MBA, PhD, FACD
Business Office
Journal of the American College of Dentists
Tel. (301) 977-3223; Fax. (301) 977-3330
Officers
Stephen A. Ralls, President
Leo E. Rouse, President-elect Departments
Richard E. Jones, Vice President
Robert M. Lamb, Treasurer
Thomas J. Connolly, Past President 2 From the Editor
Theresa S. Gonzales, Executive Director
David W. Chambers, Editor A Dead Letter?
Regents 66 Code of Conduct of the American College of Dentists
Paula K. Friedman, Regency 1
David A. Anderson, Regency 2
Carole M. Hanes, Regency 3
Terry L. Norris, Regency 4
Charles F. Squire, Regency 5
Robert M. Anderton, Regency 6
Gary S. Yonemoto, Regency 7
Lance M. Rucker, Regency 8
Teresa A. Dolan, At Large
Robert A. Faiella, At Large
Stephen M. Pachuta, At Large
Toni M. Roucka, ASDE Liaison
Michael C. Meru, SPEA Liaison
Erik C. Klintmalm, Regent Intern
Cover image Imagine you were on trial, accused of being ethical. Would there
be enough evidence to get a conviction?
© 2020 peshkov, istockphoto.com. All rights reserved.Editorial
From the Editor
A Dead Letter?
about topics that seem to be fuzzier ethics. First I learned that the lead
L et’s consider what to do with this
journal. For the first 13 years the
college had none. Then for about half
and faster moving than in simpler
times. But the essential concern is that
material, the few paragraphs of news
written by Dr. Bicuspid staff, were
a century it was the way the Board of the ways dentists find information and timely, informative, and balanced. The
Regents informed the fellowship what use it have evolved. responses were certainly not. Ethics is
they were doing. There were minutes Only a Rip van Winkle would be not a hot topic. Only a handful of
of meetings, announcements, letters, surprised to learn that the computer “regulars” seemed to have opinions,
policy positions, committee reports, has changed the way we communicate. but they had opinions about nearly
and some scientific articles. It was What I have in mind is cost, speed, everything. Most tellingly was the
what held a national organization number of folks who have something chaining of the comments. The first
together. This was followed by a shift they have to say, diversity of opinions, responder addressed “something” in
to publishing refereed papers as the shallowness of messages, absence of the lead post; that was followed by a
newsletter took over the task of expert vetting, and ability on reaction to “something” the first
sharing timely and personal “readers’” part to find anything they commenter had said. By the third or
information. Since 1990 the journal want and only that. Twenty-five years fourth comment, it was impossible to
has done theme issues, presenting ago a troll was a fairy tale creature who connect the comment to the original
multiple responsible perspectives on lived under bridges in Scandinavia, story. Remember the game of
emerging concerns in the profession. conflict of interest disclaimers were telephone? The only way to protect
It is the only publication in dentistry superfluous, and, as Tom Nichols said your message would be to participate
to be focused on discussions regarding in The Death of Expertise, knowing at multiple points in the channel.
policy issues. what you are talking about was The high-value coin in the
But it may be time to discontinue praiseworthy instead of inviting communication world today is timely
the journal. This is certainly not knowing sneers. pictures and very short messages. And
because hosting discussions of policy It is not so much a question of these should be easy to find, flattering,
matters has lost its significance. True, whether the college should continue and brief enough to present only the
it is getting more difficult each year to to speak usable truth to the profession correct perspective. Message selection
find the right people willing to write as whether we should recognize that matters more than message evaluation.
the game has moved to a new field. Several months ago I emailed the
Should we not think about moving young dentist I mentioned above and
too? Even if our mission has not asked whether she ever checked in
changed, it may be time to with blogs such as Dr. Bicuspid. The
communicate it differently. answer was that she “might have done
I wrote an editorial about blogs in so once long ago.” I have a habit of
2010 based on a conversation I circling back on those who tout
overheard between some senior reports or articles in meetings. Most
dentists and a junior member of the cannot remember even having seen
profession. The direct question of the
millennial was, “Where do you get
your information?” The answer was
Dr. Bicuspid. So I monitored the site
for a few months, focusing on dental
2 2020 Volume 87, Number 1Editorial
what was once “really great.” The first impressions, short, actionable
shadow of message awareness messages from multiple sources
increasingly stands in the place of work best.
content evaluation. There are only three problems It is not so much a question
The point is not to belittle those we with a serious quarterly journal:
of whether the college should
want to communicate with. It is to be (a) it covers only a small segment of
realistic about who is listening, what the communication market; (b) it is continue to speak usable
they are listening for, and where they expensive and may burn through the
truth to the profession as
are listening. If we do not know this or limited resources of the college, and
choose to ignore it, the shame is on us. perhaps most worrisome; (c) it whether we should recognize
Good communication involves nourishes the illusion that we have
that the game has moved
listening as well as talking. The college the most important aspects of
may well want to invest in systematic communication covered. to a new field.
and wide listening campaigns to Dare we remain the only or one of
decide who should be part of the a very few places dentists can go to
conversation and what should be on find a balanced discussion of emerging
the agenda. One definition of news is issues, knowing that this will be, of
what we get credit for knowing before necessity, heavy lifting and almost
others do since it will be of little certain to contain a few things some
importance tomorrow. The pace of will find indigestible? Do we have
considered change in dentistry is the gumption to listen as well as tell
beginning to creep up on the status of others what we think? And do
news. Certainly yearly or quarterly we have the skills and financial
cycles will be increasingly behind the resources to undertake this? Would
times. The professionally appropriate we be welcomed?
ways to practice dentistry are shifting I would love to hear what you think.
more quickly than big reports can
manage. What matters to some does
not necessarily matter to all. Or at least
not in the same way. The number of
channels dentists are listening to is
multiple and each often only lasts
for a few months. Professors and
practitioners of marketing have long
known that deep, logical arguments
are attractive to those involved in
serious matters, but they seldom
change opinions. On the other hand,
for awareness and forming favorable
Journal of the American College of Dentists 3The Evidence for Ethics
Focus Group Results
David W. Chambers, EdM, MBA,
PhD, FACD T here is value in listening to what
patients and dentists say about
ethics in dentistry. If anyone knows
themselves as American Dental
Association (ADA) members. These
sessions were conducted by Dr.
how ethics “feels” rather than what it Chambers. He also conducted four
Abstract “should” be, they would be the first focus groups with leaders in the
One hundred eighty-two dentists and ones to say. A reasonably large sample profession. These included nine
patients participated in 18 focus groups should give a true picture, one richer officers of the California Dental
across the United States in approximately than theory or statistics. Association (CDA), 13 members of
one-hour discussions of the perception of the CDA Judicial Council, 20 “young
ethical issues facing the dental profession. The Sample dental leaders” identified by the Ohio
Additionally, 237 dentists completed an Small groups of dentists, leaders in the Dental Association, and 17 officers in
open-ended survey on dental ethics. profession, patients, and those involved the Oklahoma Dental Association.
All data gathering was unguided. Written in healthcare policy contributed their All of these participants were assumed
and oral comments were recorded. opinions. Eight focus groups were to be members of the ADA.
Results of this “listening” are reported conducted among 86 patients in the The CAC conducted a session for
here, grouped by type of respondent. The states of California, North Carolina, healthcare policy experts in
findings are reported as frequency of Ohio, and Oklahoma. Six of the focus Washington, DC. Those participating
common responses and verbatim remarks. groups were organized and conducted on this panel included former staffers
No attempt has been made to interpret by the Citizen Advocacy Center (CAC), of AARP, a representative of a state
these comments or to connect them to a Washington, DC, nonprofit that dental board, and policy analysts and
positions or opinions regarding approaches represents members who serve on lobbyists. There were nine participants
to addressing ethical concerns. state health boards. Two groups were as well as three representatives from
conducted by Dr. David W. Chambers. the CAC and Dr. Chambers present.
Patient groups were recruited by The final such viva voce source was
professional polling agencies or from an anonymous survey completed by
church groups in an effort to sample 237 graduates of one dental school as
the range of the public. All sessions part of the school’s annual survey of
were recorded, and written summaries graduates. Written comments
were made immediately following regarding ethical issues in dentistry
the sessions. Dr. Chambers reviewed were provided in response to open-
Dr. Chambers is editor of all tapes and was present at four of ended questions.
the college. This report is part
of the empirical study of
the panels.
ethics in the profession Thirty-seven dentists in the The Stimulus
requested by the regents of practitioner cohort participated in For all cases, respondents were invited
the college and known as the
ACD Gies Ethics Project. four groups, two each in Maryland to address questions regarding ethics
Photo by Dr. Herb Borsuk and North Carolina. By show of based on their personal experience.
hands, approximately two-thirds of Most groups answered three
those participating identified questions: “What is the greatest
current ethical issue regarding the
relationship among dentists?” “What
is the greatest ethical issue regarding
4 2020 Volume 87, Number 1The Evidence for Ethics
the relationship between dentists and analysis, data was aggregated (but not
patients?” and “What is the greatest modified) for each of the types of
ethical issue regarding the relationship panels: practitioners, leaders, patients, For all cases, respondents
between dentists and organizations?” policy experts, and alumni. The final
Respondents usually answered these level of analysis involved highlighting, were invited to address
questions by writing short phrases on but not further synthesizing, trends questions regarding ethics
personal but anonymous response for each of the five respondent groups.
forms, followed by public discussion. This final level was called the “story based on their personal
Both written remarks and group according to…” experience.
contributions were recorded verbatim This article reports the summary
and counted in common categories. data at the third level: combined
The discussion sessions were mature summaries for each of the five
and candid, with no steering by the data sources. “When I see something that should
facilitators. Usually no comment was not have happened in a patient’s
made by the facilitators other than to Results mouth I am angry with my colleague.
ask the major questions. Participants Practitioner Focus Groups But I don’t know what to say to him or
did not make frivolous remarks since what to say to the patient.”
Fifteen practitioners in two sessions in
they were commenting in public in “Dentists just don’t talk much with
North Carolina; 22 in two sessions in
front of their peers. each other about what they have in
Maryland. Approximately 66% ADA
common, except for common
members. Written notes were
Summarizing the Data ‘enemies’ such as insurance, under-
completed by participants prior to
Conventional standards were followed stood in the sense of common excuses.”
open discussion.
in analyzing such qualitative data “ADA Code requirement to
(Charmaz, 2006; Corbin & Strauss, report improper behavior is generally
Dentist-to-Dentist Ethical Issues
2008; Denzin & Lincoln, 2003). ignored.”
[N = 18] Differences of opinion “Everybody knows we have
Recordings and written records were
among dentists is an ethical issue. problems and challenges, but we are
preserved. These were summarized
“There’s a dentist in our area who afraid to talk about it. There is no
separately for each panel or set of
pays people a ‘finder’s fee’ to get forum for communication and there
related panels. Naturally occurring
referrals. I don’t know what to do seems to be a tacit understanding that
clusters of comments were identified
about that. There’s no point in going even talking about differences is an
in each group independently of what
to the board.” insult to professional integrity.”
other focus groups reported. The
“Afraid of conflict; must go on “Most differences of opinion
number of mentions of each topic was
tip-toes when discussing values in among dentists are about very small
recorded, and illustrative verbatim
dentistry.” differences; often just preferred habits.”
comments were recorded [shown
“Mostly when there is bad dentistry “The best way to manage patients’
below in square brackets]. These
that comes to my attention I try to problems caused by other dentists is to
numbers may be interpreted as
smooth it over. But if it is serious I
reflecting the extent of concern over
suggest that the patient contact the
various themes. At the third level of
state board—it is ultimately the
patient’s problem.”
Journal of the American College of Dentists 5The Evidence for Ethics
keep the discussion at the descriptive [N = 9] General practitioners (GPs) [N = 2] Quota dentistry displacing
and technical level. Stick to the facts.” and specialists competing for patients quality dentistry in schools and in
“Most problems about the poor “Fewer referrals. More GPs trying corporate model
work colleagues have done is really to do all the work to avoid losing the “If parts of the profession are
about money—who is going to pay patient.” moving to judging success as
to make it right. And the insurance “Specialists are now doing general production, the rest of the profession
companies keep out of these things, dentistry.” has an excuse to follow.”
saying they have ‘already paid for the “Sometimes specialists cherry pick
treatment.’” care provided.” Dentist-to-Patient Ethical Issues
“I just do not know what to say to “Turf or scope of practice conflicts [N = 20] Overtreatment: Profit-driven
my colleagues, especially those who in dentistry: specialists want treatment planning
have a different idea about dentistry.” regulations that favor them; generalists “In the competition between ethics
“Problem patients are passed from want to do traditional specialty and business, business usually wins.”
one dentist to another.” treatment.” “Treatment options given or
“The whole business of the preferred may be ones with highest
[N = 13] Each has his or her own relationship between GPs and profit margin.”
standard; dentists mistrust each other; specialists is murky; it goes differently “Patient selection by ability to pay.”
cannot communicate in different situations.” “Here patients are written up for
“There is diversity of opinion the most expensive treatment options
regarding standards in the profession.” [N = 4] Misleading advertising plausible on the grounds that it is
“‘Standard of care’ is a term with “Marketing has gotten out of hand. easier to forgive planned treatment
unclear and often private or expedient The claims dentists are making to than to break the news that more is
meaning.” patients have nothing to do with needed.”
“We are a profession of self- dentistry. They are about price and
appointed experts.” convenience and smiles.” [N = 17] Inadequate informed
“Differences in professional “Some make promises about consent, “steering” patients; breaches
opinions are about ego and money.” treatment outcomes that are of confidentiality
“Dentists do not always share impossible without seeing the patient.” “Who should decide when there
information about their patients.” “Internet marketing is not about are alternative treatment options?”
quality of dental care.” “Dentists just tell patients enough
[N = 10] Competition among dentists “Voluntary restraint on advertising to get them to go along with what the
“Criticize others’ work in effort to only penalizes the good dentist.” dentist wants to do.”
steal patients.”
“Not commenting on the consistent [N = 4] Questionable business [N = 7] Piecemeal treatment, not
bad work of colleagues creates an practices, kickbacks, pay for referrals comprehensive care
environment where standards other “Unethical business practices are
than quality of treatment are becoming the norm: ‘everybody is [N = 5] Eroded trust; conflicting
acceptable or even come to define the doing it’ becomes the justification.” opinions
profession.” “I know a dentist who has for years “Dentistry is no longer about the
“Sense of professionalism seems to kept two sets of books.” dentist and the patient and oral health
be declining. Dentists are withdrawing needs; it is about money and outside
into their own offices.” [N = 2] Fear of having own work interests. The patient is the one who is
“Dentists competing for insurance evaluated [not mentioned in the being used.”
contracts drives down the general discussion] “Patients hear different stories from
reimbursement rates for everyone.” different dentists and so they lose faith
“There are too many dentists.” [N = 2] Pseudo credentials and in the profession as a whole.”
“Dentistry is becoming a job rather specialties “The Readers’ Digest story was fully
than a profession.” to be expected: each of the alternative
treatments could be justified.”
6 2020 Volume 87, Number 1The Evidence for Ethics
“Patients just go from one dentist [N = 8] Organized dentistry no longer “The ADA is too far away and
to another until they find one they represents the profession, controlled seems to want to relate in terms of
can trust.” by the few, lost trust money and advertising. Real
“The ADA gives too much participation is at the local level.”
[N = 4] Misleading advertising attention to specialties.” “The ADA’s primary objective is to
“Advertising is creating unrealistic stay in business.”
expectations.” [N = 6] Insurance
“PPOs [preferred provider [N = 4] Corporate entities are taking
[N = 4] Use of unproven technology, organizations] and managed care are advantage of student debt to intrude
bad science taking control away from the commercial values in place of
“New technologies seem to be practitioner.” professional ones
profit driven and are often untested.” “Insurance is intruding on
“EBD [evidence-based dentistry] diagnosis, treatment planning, and [N = 4] Dentists cheat on insurance
does not help in this area because tech- dentist-patient relationship.” “Waiving copays is common
niques are evaluated in isolation and “Insurance limits treatment because patients ask for it.”
because there is so little actual data.” options. Patients perceive that
insurance undermines patient [N = 4] Live patients on initial
[N = 2] Faulty or improper care confidence in the dentist.” licensure exams
“It is impossible to standardize the “Such tests are out of context and
[N = 2] Patient self-determination correct reimbursement for any invalid because they do not measure
“Don’t try to stand in the way of procedures because of differences in comprehensive care.”
patient who wants a second opinion.” clinicians’ skills, lab costs, front desk “Would like to see nationally
“Patients want to be heard; to know and other practice characteristics.” standardized licensure.”
that the dentist has their best interests “Insurance industry has failed in
in mind.” the role of standardizing and raising [N = 3] Intrusions into treatment and
level of care: only concerned with its dentist-patient relationship from
[N = 2] Not current on CE own bottom line.” various sources
“Dentistry needs to involve the “Beginning practitioners cannot
Dentist-to-Organization employer and government and those start their own practices so they have
Ethical Issues who ultimately pay for dental health, to start as associates or employees and
[N = 8] Organized dentistry less not just the insurance companies.” pick up the business habits of their
valuable, declining membership and “Insurance companies are profiling profit-oriented bosses.”
participation dentists’ claims, ostensibly to detect “Younger members aren’t joining
“Does anybody know why the abusers, but perhaps to lower benefits organized dentistry.” [Fact: They are
membership in the ADA is declining?” generally.” overrepresented compared to general
“The ADA is ‘toothless.’” “Capitation doesn’t work for dentists in their mature years.]
“The way it is now, a smaller and dentists because each office is like a
smaller number of dentists is carrying private hospital and we do surgery, not [N = 3] Tech companies, suppliers
the water for a larger and larger comprehensive and long-range care.” influencing treatment decisions
number of those who are getting a free “Massive advertising in
ride. Not sustainable.” [N = 6] Lack of transparency professional journals, at trade shows,
“Organized dentistry’s voice is “Corporate hides what is really and in ‘throw-aways’ distort true
getting weaker while Kellogg and going on behind nondisclosure.” professional values.”
Macy and others is getting stronger.” “There is no forum for discussing “Gurus hype major productivity;
“The ADA does not even seem to our concerns.” what’s in it for them?”
be aware of what EBD is or whether it
matters.” [N = 5] Organized dentistry is too
focused on political action committees
and lobbyists, own structure, and
survival
Journal of the American College of Dentists 7The Evidence for Ethics
“Boards are not taking on the Dental Leader Focus Groups
known offenders; afraid of counter-
Seventeen leaders in the Oklahoma
suits, underfunded.”
Dental Association; 9 officers of the
“Boards are overdoing the idea of
California Dental Association (only
recovery or reclaiming previous
addressed issues relating to dentists
offenders and letting bad actors back
and organizations); 13 CDA Judicial
into the profession when they have
Council members; 20 Ohio “Young
“The ethics of the emerging not changed.”
dental leaders”
graduates is the ethics of the [N = 2] Government: regulations and
Dentist-to-Dentist Ethical Issues
future of the profession.” low reimbursement rates
“FTC’s [Federal Trade [N = 40] Practicing in isolation
Commission’s] preoccupation with “We can still afford to live in our
driving down cost is destroying quality own worlds; no need to collaborate.”
of care is an issue that is having “Little real opportunity to
“Product endorsements are communicate or cooperate on
unintended consequences.”
becoming more common.” treatment standards.”
“Legislators always respond to
appeals for ‘free trade’ and ‘patient “Practice is in silos.”
[N = 3] Organizations are “fronts” “Patients are confused, and
safety.’”
for self-interest of members. consequently trust in the profession is
“Factionalism.” eroded.”
[N = 2] Dental school environment
“Multiple professional “Neither patients nor colleagues
fosters competition.
organizations are competing for have a voice in quality or type of care
“Dental schools are falling behind in
membership, causing a narrowing of provided.”
what they are teaching about ethics.”
focus and appeal to self-interests.” “Dentists can collaborate as much
“The ethics of the emerging
“Some organizations exist to or as little as they want to.”
graduates is the ethics of the future of
promote a business model, e.g., sleep “Lack of clear and consistent
the profession.”
dentistry.” standards for what constitutes good
“Schools may not be able to do
“ASDA [American Society for dental care.”
anything about the ethics of young
Dental Ethics] and the ADA need to “Every dentist can do whatever he
people (already formed in youth), but
grow up on this issue of patients on wants as long as he can talk enough
they should be more selective in
licensure exams.” patients into it.”
admissions.”
“Different organizations are “Egos.”
“Young people today are going into
representing particular interests in an
dentistry for the money.”
effort to draw membership from those [N = 18] Lack of collegiality: view
seeking personal advantage at the other dentists as competitors
[N = 2] Mid-level providers are a
expense of colleagues generally.” “Some make unjustifiable negative
question mark.
“The effects of mid-level providers remarks about others’ work.”
[N = 2] Weak leadership, tolerate “Overtreatment comes from feeling
may be positive for patients and
unethical members, commercial of competitive need.”
negative for dentists.”
interests
“State boards have lost control of [N = 8] The profession does a poor job
[General comment: “There are so
the profession.” of policing itself.
many definitions of ethics and so
“Ethics has become ‘enforceable up “Justifiable criticism is mistaken for
many applications of principles. We
to the cost of legal defense.’” unprofessional poaching, so avoided.”
need to work on what to do when
there are differences.” There appeared
to be more concern over dentist-to- [N = 5] Unclear relations with
dentist ethical issues than over those specialties and medicine unclear
involving patients.] “Currently care for the patient is
divided and allocated to individuals
8 2020 Volume 87, Number 1The Evidence for Ethics
with specialized training or public disguises what oral health is really “Dentistry is defining itself in
perception of best care, including on about.” terms of services delivered, especially
the basis of patients’ perceptions of “Patients treat dentists as providers at very high levels of excellence. But
cost/benefit calculations.” of commercial services rather than this is not the way patients define
“Fragmentation causes appearance professionals.” dentistry. They seem to define good
of competition is for market share.” “Loss of trust, bad-mouthing, oral health as not needing to see the
“Generally, evidence is lacking to skipping payment, shopping (both dentist.”
support often voiced claims of dentists and patients are doing this).”
superiority of outcomes for many “Patients demanding specific care [N = 7] Failing to present all treatment
kinds providers.” based on advertising or recommen- alternatives, lack of informed consent
“Better interprofessional dations from other dentists.” “Treatment options are often
communication and outcomes-based “Conflicts between treatment tailored to maximize profit or the
decision making are needed.” priorities and patients’ financial dentist’s view of optimal oral health.”
resources.” “Dentists are trying to take treat-
[N = 3] Different practice models “In the corporate model we are ment decisions away from patients.”
and reimbursement systems seeing ‘diagnosis’ at front desk.”
“Dentists working for dentists “Treating to insurance.” [N = 4] Others than dentists or other
introduces new layers of ethical dentists are influencing patient
complexity and responsibility.” [N = 11] True market demand does expectations; extra-professional values
not reach what dentists hope for.
Dentist-to-Patient Ethical Issues “Dentists blame government and [N = 4] Increasing specialization
[N = 21] Overtreatment insurers for not putting enough and defining practice in terms of
“Overtreatment is driven by money into the system.” techniques rather than comprehensive
competition among dentists.” “Dental care trends toward services health outcomes causes fragmenta-
“Advertising serves greed rather beyond true oral health needs because tion of both the profession and care.
than trying to reach those most in that is where the money is. This makes
need of dental care.” dental care appear ‘elective.’” [N = 4] Patients no longer trust
“The new standards are money, dentists, weak relationship, shift to
technology, and egotism.” [N = 10] Advertising, misrepresen- financial basis of relationship
“Patients and insurance companies tation, media advertising “Old model of dentist and patient
are putting downward pressure on “Patients do not hear same story (with dentist having recognized
dentists’ ability to maximize treatment from all dentists.” authority) being replaced by multiple
offered.” “Patients are being told that forces competing to represent dentists’
dentistry is a series of one-off and patients’ interests.”
[N = 21] Bad dental practices transactions rather than a “Patients can no longer afford to stay
Over-diagnosis, Botox, not being relationship.” with a dentist long enough to build
honest about own bad work, fraud, “Claims of superior or exclusive relationship because of cost factors.”
cherry-picking treatment, treatment skills or services.”
beyond competence, insurance “Appeal to uneducated public [N = 2] Conflict between ideal care
manipulations rather than colleagues to decide who is and what patients can afford
good dentist.”
[N = 16] Commercialism: business is “Getting too close to commercial [N = 2] Undertreatment of those
the new standard. organizations, advertisers, web without funds
“Patients as ‘customer’ rather than designers, group-ons.”
individual needing professional care. Dentist-to-Organization
Dentistry is now something to ‘sell’; [N = 8] Patients and dentists have Ethical Issues
treating teeth instead of patients.” different views of good dentistry. [N = 21] Organized dentistry cannot
“Rebranding (anti-aging dentistry), influence the way dentistry is
smiles, brand named technologies practiced.
Journal of the American College of Dentists 9The Evidence for Ethics
“We are aware of the problem “The ADA has become a “Money and technical excellence
(confusion and miscommunication bureaucracy that does not represent on big cases (“show-off dentistry”) is
leading to reduced trust), and we talk individual practitioners.” becoming an independent standard.”
about it. But organized dentistry really “Organized dentistry is prevented “HMO [health maintenance
cannot do anything about the by law from interfering in individual organization] practice model is
problems.” dentist’s commercial activities.” inserting new values.”
“There is no common place to “The [ADA] code of ethics is “Practice is increasingly being
discuss ethics or the alternatives to the aspirational and not enforceable.” steered by marketing values.”
way dentistry is trending.” “Is it wise to have one organization
“Even in the face of strong attempting to speak for all dentists?” [N = 13] Benefits companies will
messaging from organized dentistry “Oral health no longer a standard.” not pay for all work dentists want
and mandatory continuing education, “Using political position to advance to provide
the fact that dentists do not depend on private practitioner income.”
each other collectively for achieving [N = 6] Turf battles (in court), who
best outcomes, or even financial [N = 20] Benefit of organized dentistry gets to provide care, competition
success, means that public relations not clear, too many organizations, among groups, organized dentistry no
campaigns will be superficial and the fragmented participation longer single clear voice
potential impact of professional “Organized dentistry could “Many organizations besides
communication is diluted by messages overcome the isolation of individual organized dentistry are now
from other, often commercial, sources. dentists, but it does not seem to be influencing practice.”
Organized dentistry may not be using effective at doing so.”
its communication platform effectively, “It is hard for individual dentists to [N = 6] Student debt
or it may be too focused on legal and resist the pressures of commercialism, “Dental schools cannot change
financial aspects of dentistry.” advertising, politics and regulation by ethical orientation in the face of what
“Enforcement is spotty. State themselves.” is happening in practice.”
boards no longer involved except in “Young practitioners learn how to “The young want to live the life
most outrageous cases or cases where practice from senior dentists.” style of their parents.”
dentist does not put up a fight.” “We want more from organized “As a younger dentist, I resent the
“There are silos; folks are now dentistry.” claims that I must be unethical just
using private definitions of what is because I have a high debt load when
right. There is a growing sense in [N =18] Fragmentation in under- no one has shown me any evidence
American culture that ‘everyone standing what it means to be a that this is true of me or of my peers in
has a right to be right by his or her professional general.”
private standards.’” “We are not sure how to reach the
“It is inappropriate to comment on cost/value point of practitioners.” [N = 4] “Good old boys’ club”: no
a colleague’s work. It is even becoming “One can be ‘professional’ without longer representing all dentists.”
inappropriate to discuss this. We lack sharing values or activities with one’s
the language and opportunities to colleagues. Traditional dental [N = 4] Corporate is a viable
have discussions (other than attacking professionalism competes with many alternative
others self-righteously).” other value sets.” “Corporate and ‘institutes’ are a
“Organized dentistry focuses on “Non-membership is a growing viable alternative home for dentists
legal and regulatory action rather than issue.” drifting toward a business definition of
dealing directly with influential others.” “Educational debt must be dentistry rather than a professional one.”
“The most questionable dentists are managed.”
probably not members of organized “We now expect organized [N = 3] Online discussions, social
dentistry, so we have no influence dentistry to promote profession only, media, unproductive
over them.” not profession and patients.” “I do not trust or participate in
“Dentists are getting their values online discussions because they are
from places other than their colleagues.”
10 2020 Volume 87, Number 1The Evidence for Ethics
dominated by commercial interests Appearance of office, Finding a Dentist
and people with axes to grind.” current equipment......................... 7
References from friends...............11
Care about pain, taking time.........4
Looking for location,
Patient Focus Groups Reputation in community .............3
convenience ....................................5
Eight-six patients in eight focus Online references ...........................3
Consult lists, shop for price,
groups in San Francisco, California; insurance .........................................4
rural and urban North Carolina; Public Emblems of Quality
Avoid appearance of oversell.........3
Cleveland, Ohio; and Oklahoma City, of Little Value
“I actually do an internet search
Oklahoma. License on the wall is a given ........7 and look on the website where they
Report card of little value ..............5 got their degree, when, what they
First Thought That Comes to Too much technology ....................2 studied. I read all of that.”
Mind Regarding Dentistry “I think when you are a professional “One of the things I look at is do
Cost................................................17 you will show that, when you are they work in the community for
Issues of competence......................7 examining a patient, or whatever; it’ll people who are in need. That ranks
Overcharge, overtreat.....................6 show. You will know whether they are high. A lot of times they say if they
Pain, scary ...................................... 6 dedicated to their craft or are just volunteer. When you go online, you
Hassle, inconvenience, going through the motions. The way find all kinds of stuff.”
unavoidable necessity................... 4 they interact with you. You’ll know “I want to steer away from the
Cleaning, health, whether they know what they are people with the new technology and
professionalism, quality ................ 5 doing, or not.” stuff because, I mean, like, you’re
Communication issues ..................4 “I went to a dentist before and he going to be doing fillings and root
caused the start of my problem. He canals and things like that just like
Quality first said I needed a root canal, so he everybody else and you’re going to
No specific question was asked about shaved it all the way down to a point. have to charge three times as much for
how patients define quality of oral The next day it broke off at the gum all your new machinery and it doesn’t
health care. Generally, quality seemed line, so I had no tooth left. When I necessarily make you a better dentist.”
to mean technical outcomes and first started going to him, I just didn’t “I refused to get involved in the
treatment in the process as expected. think he was the right one for me. I huge medical school, dental school
“Durable,” “no mistakes,” shouldn’t have gone back to him. He system. It is so impersonal. I won’t see
“preventive,” “effective,” “explained didn’t even say hello to you. I stopped any healthcare provider in that setting.
so I understand,” “not being going to him after that.” I want them to remember me from
pressured,” “nothing unnecessary.” “I don’t think you know it until time to time.”
Overall, about half have been you actually go to them and see what
satisfied with their dentist; those he’s like.” Communication
dissatisfied have moved on. “I take ratings kind of with a grain
Could be better .............................11
“Good is not having to go back or of salt.”
Generally good when talking
to hassle the encounter.” “It [dental license] doesn’t
about procedures ............................8
“I think most of the dentists have differentiate any of them from each
other because they all have it.” “The hygienist will come in and
competence. It really boils down to explain what she’s doing and what she
their personality. Do they make you “A professional testing organization
would be fine for the technical aspects found. The dentist comes in and
feel at ease?” agrees with her assessment. Then I go
of what type of equipment they have,
what their training is, how good their to the front desk.”
Judging Competence [Criteria “Don’t like the way he comes
valued by patients]
training was. This is a given. But, once
you get into various mouths, everyone across as knowing everything but not
Interpersonal relationship ...........18 in here has different sensitivity.” really telling me anything.”
Clear explanations........................15
Friendly, efficient staff .................. 8
Journal of the American College of Dentists 11The Evidence for Ethics
Paying for Care “(Even with insurance), it’s still too They jack up the price for any one
much. From my experience, I feel like desperate enough to pay it, and then
Selling, overselling........................21
a lot of dental offices charge extra offer discounts.”
Generally, dentistry is too
because they know it’s covered.” “Now I’ve found a good dentist.
expensive.......................................19
“They have these vouchers where if Previously I had one I felt was in it for
Cost affects when and whether
I hand them out and get referrals, I get the money. He had a high priced office
care is sought ................................11
$100 for every person I get. So, I could and needed to make money. He was
Postponed work because of cost ...7
get 4 people to go, I could get the $400 probably 50% higher than the rest of
Medicaid coverage is
(for a mouth guard).” the dentists in the area.”
inadequate for costs....................... 6
“The only other option was to do a “I have doubts about my dentist. He
Combine dental and medical
credit-type thing where you get a let some stuff go…. I didn’t trust him
insurance .........................................6
credit card and put money there and and went to see someone else.”
Treatment offered as “Take
there is 37% interest, so you are paying “I think he wants to do things just
it or leave it”....................................5
on it beyond the year you die.” because he can do them.”
Private insurance is good...............4
“A good dental visit is when I don’t
Credit, other option
see the dentist or he doesn’t have Behaviors That Are Not
“bad deals”......................................4
much to say.” Appreciated
Like that insurance covers
“I have insurance, but I’m paying Excessive cost................................16
prevention .......................................4
more and more out-of-pocket; it’s like Overtreating..................................11
Fail to distinguish optional from
the dentist is trying to get paid twice.” Poor communication ....................4
necessary .........................................4
“Dentistry has become preventive; Assess for the well-off ....................3
“This ‘full amount up front and I don’t expect to need treatment for
then we’ll see what we can squeeze out Self-promotion................................3
things I am unaware of.”
of the insurance company’ attitude “Cost of procedures.”
“It’s like going to get your oil
makes me think they are in it for the “Overcharging.”
changed, then the sales guy comes in
money.” “If they can turn it around and have
with a list of things that ‘really’ need
“Way too expensive.” a good practice for years, they become
to be taken care of even though I
“I’m missing two teeth because I a millionaire they charge such high
didn’t know they were a problem.”
couldn’t pay for what I needed…. I’d prices.”
“Is it really true that I need a cone
still have these teeth if they’d given me “Dentists go into a lot of debt for
beam every year without the dentist
a payment arrangement.” schooling. I don’t know if that is tied
even looking to see if things have
“Under Medicaid we’re usually not to what they charge.”
changed in my mouth?”
covered for crowns or major work or “At least cover part of the cost
“They do a lot of stuff that is
cosmetic work.” rather than saying you’re out of
unnecessary.”
“Cleanings and screenings—I luck, man.”
“Several charge you interest as high
think they should be made available to “I think there are a lot of goof-balls
as 18%.”
everybody as often as necessary. out there who are dentists.”
“I think dentists just charge as
Anything that has to be done after that “Somehow he changed after he
much as they think they can get. They
will have to be negotiated.” built that beautiful new office.”
get paid by both the insurance
“It is a put-off when they start “Make sure everyone has access
company and the patient. They are
talking about a ‘perfect mouth.’” to care.”
willing to give me a discount, so I know
“Dentists charge extra if they know “Make sure they don’t gouge
they are overcharging somewhere.”
you have insurance.” anybody.”
“I asked for a payment plan and got
“Our dentist says, if you want to “When you go to the dentist, even
no sympathy.”
pay cash, I’ll take some off.” if you are going for your six months,
“Dentists want it both ways. They
“Dental insurance makes a lot more every time I go in I get nervous in the
sell as much as they can, so insurance
sense than medical insurance.” chair because first I’m looking to see
picks up some and the patient gets
if they find something and then if
stuck with the rest. Those without
they don’t, it always feels like a little
insurance, are just out of luck.”
bit of a hustle to get more money from
“Just like business at the malls.
12 2020 Volume 87, Number 1The Evidence for Ethics
you. ‘Why don’t you think about “I’d go back and if I don’t get
whitening?’ or, ‘What about that tooth resolution to my satisfaction, I leave
that’s missing?’ There’s always and find somebody else.”
something extra.” “I am beginning not to trust [some]
“They have to take continuing dentists. But I trust lawyers and the
education, right? Unfortunately, I can government even less. I hope dentists
tell you my beautician takes more don’t become like lawyers or big
continuing education than my dentist. business retailing.”
Licensure only establishes
How do you know they actually went “I’m more concerned about fixing
to those classes?” the problem without putting more minimal competency, and is
“Reduce the amount the dentist money into it.”
often unevenly enforced.
takes.” “Part of the question for me is the
“Consistency in pricing.” trustworthiness of any agency that There was little interest in a
“Universal healthcare should be a monitors the healthcare professions.”
“report card” or other
percentage of your gross income.” “Is it about teeth or is it about
“If there were some way to keep the money?” external monitoring of
dentist honest. They are in private “I would show up and ask
continuing competence.
practice so they charge whatever they questions.”
want, do whatever they want.” “I wouldn’t pay.”
“Address it; fix it; change the
Response to Bad Encounters practice; not charge you.”
Unaware of reporting options.......8 “If they screw something up, they “The dentist is playing a smaller
Online and word of mouth............5 better damned well pay for it.” and smaller part in the system, just the
Go somewhere else ........................5 “Ethical issues are likely technical stuff.”
Confront the dentist.......................5 underreported.” “Keep it simple—go to the
Fix the problem, complaints “We should reduce cost by having hygienist unless you need something
are useless........................................4 dentists take home less money.” more serious.”
Profession and state boards “Is there a dentist’s association that “For basic cleaning it would be
cover it up........................................4 a patient could go to?” better to make an appointment
Report to insurance company directly with the hygienist and have it
or somebody ...................................3 Second Opinions be cheaper and easier. All the dentist
Avoid multidentist offices .............3 Yes, if did not like options does is go over and look at it for 30
Preserve dentist’s reputation offered..............................................8 seconds and you have to spend
if possible.........................................3 Expensive and questionable however much money just for that.”
value.................................................5 “I go to the hygienist; they have a
“The oral hygienist put me in so
Second opinion if suspicious.........3 dentist there too.”
much pain. I told her and she started
crying. The next thing I know, the Second opinion if large and
irreversible case ............................. 3 Policy Experts Focus Group
dentist comes in and I can’t tell you
how rude she was. My friends told me “The first guy seemed drunk. My Nine individuals representing various
that’s how she is.” sister went to him anyway and they healthcare and patient advocacy
“I’d talk about it at work because double-charged her, so I decided to groups, such as AARP, who interact
everyone has the same insurance. It get a second opinion.” with dentistry; one state board
gets around that a certain dentist sucks representative.
and people won’t go to him.” Impression of Hygienists
“I wish there were some sort of Positive volunteered comments...13
peer review. Four or five years ago I Favor independent hygiene...........5
had a really bad crown put in and I
“To me, the hygienists—they are
had 4 dentists in 3 different states tell
the face of the practice. They are the
me it was a horrible crown.”
ones you’re going to work with.”
Journal of the American College of Dentists 13You can also read
