Balancing Intuition and Technology: Ethical Considerations for AI in Dental Practice

By Robert D. Stevenson Sr., DDS, FAGD, FACD, FICD, FPFA, FAAHD

This column is a collaboration between AGD and the American College of Dentists.

As artificial intelligence (AI) technology becomes increasingly integrated into dental practices, dentists like Amanda Jones, DMD, find themselves navigating new ethical and professional challenges. Jones sits at her office computer, her brow furrowed in concentration. An emergency patient waits in the next room, and the diagnostic software on her screen recommends extraction of a grossly carious, painful tooth. Despite the software’s recommendation, Jones, a recent graduate, believes the tooth is restorable. She faces a dilemma: Should she trust her intuition or the judgment of the computer program?

Our society has become captivated with the possibilities of AI. Generative AI has shown its value in creating documents, images and video. The technology is also making inroads into the practice of dentistry, with the promise of improved diagnostic accuracy, streamlined operations and enhanced administrative management. Studies show that AI’s accuracy in identifying caries, periapical radiolucencies and bone loss may equal or exceed that of the average dentist.(1,2)

Generative AI can be valuable administratively as a tool for claims submission, marketing and treatment planning. It can also aid in evaluating contracts. Generative AI will also provide an executive summary of articles in dental journals that busy dentists can’t seem to get to otherwise. Predictive AI is a new application of AI to healthcare. Predictive AI can evaluate patterns and predict possible outcomes based on the patterns it discerns. Besides obvious business and investment applications, it has the potential to predict possible outcomes, particularly in disease progression such as precancerous lesions. It may also help in establishing prognoses for treatment of intraoral diseases, implant placement and other processes.

While AI offers many benefits, it also raises important ethical questions that must be addressed. Data privacy and security are high on the list for dentists. The current models of AI are trained to recognize patterns in words or images. As a platform is exposed to more samples, its accuracy increases. Bear in mind that the dentist has the ultimate responsibility for securing protected health information when using AI; this responsibility must not be entrusted to the software alone.

An AI system is no better than the data it has reviewed. Methods must be developed to ensure AI is exposed to diverse patient groups to minimize biases that could lead to inaccurate diagnoses. A prudent dentist should be prepared to critically evaluate output from the tools he or she uses; there is no substitute for critical thinking in dental care. As dentists use these tools, they must be aware of the limitations of computer learning and be prepared to evaluate the responses they receive from their software.

Eric S. Swirksy, in the Journal of the American College of Dentists, notes that “the words ‘bias,’ ‘disparities’ and ‘algorithm’ do not appear in American Dental Association (ADA) Principles of Ethics & Code of Conduct, but they do not need to.”(3) The American College of Dentists’ (ACD) “Ethics Handbook for Dentistry” also applies but does not specifically address AI. Each of the five principles in the ADA Code has application to AI. Even if one is not an ADA member, the legal system expects that each dentist should abide by these principles. The principle of stewardship, as described by the ACD, describes the responsibility as a member of the dental profession to safeguard the standards and reputation of the dental profession, including one’s colleagues.(4)

The principle of autonomy applies to the choices the dentist makes as well as to empowering the patient to participate in treatment decisions. Data privacy is an essential element of autonomy, and respect for the patient’s preferences about diagnostic processes and treatment are crucial. For instance, if an AI system recommends a treatment that conflicts with a patient’s preferences, how should a dentist navigate this situation while respecting the patient’s autonomy?

Nonmaleficence is honored as the practitioner critically assesses the options provided by his or her electronic consultant. If critical thinking and professional clinical judgment are discarded, the inherent risk of unwanted outcomes leading to harm increases. Protocols should be developed to ensure that the dentist’s professional judgment is respected and takes precedence over artificial opinions.

Beneficence is at the heart of all dental treatment. Competence is a key part of providing appropriate care; it develops through experience, focused continuing education and training in new methods of technology. The dental team, under guidance of the dentist, should be well informed.

The principle of justice focuses on minimizing biases and promoting fairness in clinical decisions. Bailey states that “AI-driven interventions should improve equity and not worsen existing disparities.”(5) Justice, in tandem with veracity, suggests that the provider be transparent and honest about the tools used in diagnosis and treatment-planning if the patient expresses an interest. Justice also demands the use of critical thinking in clinical decisions.

Veracity calls for the clinician to be honest with patients and honest with themself. The limitations of artificial decision-making must be honestly accounted for when considering what and how to treat any condition within the scope of the dentist’s practice. The dentist should also consider the principle of reflection, as addressed by the ACD. Being reflective assists the dentist in developing clinical judgment and is a valuable tool in improving the delivery of dental care.

Finally, the ACD discusses accountability. Each dentist is accountable for his or her own actions and decisions. The dentist must be willing to bear responsibility for their own treatment decisions and for treatments rendered. The increasing integration of AI in dental practices complicates the attribution of responsibility for errors or incorrect diagnoses. When an AI-recommended treatment leads to poor patient outcomes, it’s unclear who bears liability — the dentist relying on the AI, the AI’s developers or the AI system itself. To ensure responsible AI use in clinical settings, it is crucial to develop explicit guidelines and legal frameworks. Both AGD and the ADA are already taking steps to address these issues.

Understanding these ethical principles is crucial as dentists navigate the practical implications of AI in their daily practices. AI is likely to become more consistent and objective than any single human clinician. Human practitioners rely on their limited personal experience and gut feelings, while AI relies on patterns drawn from the broad experiences of many. It may offer a second opinion based on its compilation of numerous successful outcomes. AI can augment what we see, influence how we see it, and enhance the management of our treatments and our decisions.

In conclusion, while AI has the potential to revolutionize dental practice, it is crucial for dentists to critically evaluate AI recommendations and uphold ethical standards. Jones’ dilemma at the beginning of this column highlights the importance of balancing technological advancements with professional judgment and patient-centered care. Dentists can ensure that AI serves as a valuable tool rather than a replacement for human judgment. What should Jones do? What would you do if you were in her position?

My late colleague, Ronald Antimarino, DMD, often said, “You’re the doctor. Make the right decision.” Take responsibility and choose a course of action.

Disclosure: The author was assisted by Microsoft Copilot AI in creating the clinical scenario and editing this paper.

Robert D. Stevenson Sr., DDS, FAGD, FACD, FICD, FPFA, FAAHD, is associate professor and preclinical curriculum coordinator at Western University College of Dental Medicine. To comment on this article, email impact@agd.org.

References

1. Perhani, F. “Promises and Perils of Artificial Intelligence in Dentistry.” Australian Dental Journal, vol. 66, no. 2, June 2021, pp. 124-135.

2. Alowais, S., et al “Revolutionizing Healthcare: The Role of Artificial Intelligence in Clinical Practice.” BMC Medical Education, September 2023, vol. 23, no. 689.

3. Swirsky, E. “Plausible Deniability and Algorithmic Bias in Automated Decision-Making.” Journal of the American College of Dentists, vol. 90, no. 3, Fall/Winter 2023, pp. 25-31.

4. Ethics Handbook for Dentistry. American College of Dentists, 2024, acd.org/communications/ethics-handbook/.

5. Bailey, Meredith A. “Ethical Considerations for the Integration of Artificial and Augmented Intelligence in Dentistry.” The Journal of the American Dental Association, vol. 155, no. 8, 2024, pp. 721-722.

Recommended Reading

“Principles of Ethics and Code of Professional Conduct: With Official Advisory Opinions Revised to March 2023.” American Dental Association, ada.org/-/media/project/ada-organization/ada/ada-org/files/about/ada_code_of_ethics.pdf.

Kluck-Nygren, Cindy. “Dental Practice Advocacy Survey Results: AGD Members’ Use of Artificial Intelligence (AI)/Augmented Intelligence (AuI) in the Dental Practice.” Academy of General Dentistry, 2024, agd.org/docs/default-source/default-document-library/ agd-member-survey-re-ai-aui_2024-june30_cd.pdf.

“Dentistry—Overview of Artificial and Augmented Intelligence Uses in Dentistry.” American Dental Association, 2022, ada.org/-/media/project/ada-organization/ada/ada-org/ files/resources/practice/dental-standards/ada_1106_2022.pdf.