CDA Journal - September 2020: Dental Ethics for the 21st Century

Journa

Law and Ethics Business Ethics and Dentistry Ethical Treatment Planning Avoiding Bad Choices

S C I H T E C A L I F O R N I A

D E N TA L

A S S O C I AT I O N

e c n e r e ff i d e h t g e n v i a w h o n u k o y is t a h t w a n h e e w w d t n e a b o d o t t h g i r a . o d o t t h is rig —

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S E P T E M B E R 2020

Robert D. Stevenson, DDS

Vol 48 Nº 9

DENTAL ETHICS for the 21st Century

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Sept. 2020

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d e pa r t m e n t s

419 The Associate Editor/A Man, a Plan, a Cabal 423 Impressions 459 RM Matters/COVID-19 and Informed Consent: What You Need To Know

463 Regulatory Compliance/Who Determines Dental Infection Control Standards?

465 Ethics/Everything You Wanted To Know About Ethics in Dental Marketing but Were Afraid To Ask

466 Tech Trends

423

f e at u r e s

427 Dental Ethics for the 21st Century An introduction to the issue.

Robert D. Stevenson, DDS

431 Ethics and Law: ‘Truth’ and ‘Trust’ in a 21st Century Practice Nick F. Forooghi, JD, Esq.

437 Business Ethics and Dental Professionalism: Commentary Kenneth Jacobs, DDS

447 Treatment Planning: Making a Case for Its Ethical Importance: Commentary Gary Herman, DDS

451 How Dentists Can Avoid Bad Choices: Commentary Robert D. Stevenson, DDS

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Journa C A L I F O R N I A

D E N TA L

published by the California Dental Association 1201 K St., 14th Floor Sacramento, CA 95814 800.232.7645 cda.org

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Ruchi K. Sahota, DDS, CDE Associate Editor

John L. Blake, DDS Secretary secretary@cda.org Steven J. Kend, DDS Treasurer treasurer@cda.org Debra S. Finney, MS, DDS Speaker of the House speaker@cda.org R. Del Brunner, DDS Immediate Past President pastpresident@cda.org

Volume 48 Number 9 September 2020

Brian K. Shue, DDS, CDE Associate Editor Gayle Mathe, RDH Senior Editor Robert D. Stevenson, DDS Guest Editor Andrea LaMattina, CDE Publications Manager Kristi Parker Johnson Senior Communications Specialist

Blake Ellington Tech Trends Editor

Manuscript Submissions

Journal of the California Dental Association Editorial Board

Jack F. Conley, DDS Editor Emeritus

www.editorialmanager. com/jcaldentassoc

Charles N. Bertolami, DDS, DMedSc, Herman Robert Fox dean, NYU College of Dentistry, New York

Robert E. Horseman, DDS Humorist Emeritus

Letters to the Editor

Steven W. Friedrichsen, DDS, professor and dean, Western University of Health Sciences College of Dental Medicine, Pomona, Calif.

Production Randi Taylor Senior Visual Designer

Upcoming Topics October/COVID-19 November/Sugar December/Dental Student Research

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Subscriptions Annual subscriptions are available to association members at a rate of $36.

Advertising Sue Gardner Advertising Sales Sue.Gardner@cda.org 916.554.4952

Mina Habibian, DMD, MSc, PhD, associate professor of clinical dentistry, Herman Ostrow School of Dentistry of USC, Los Angeles Robert Handysides, DDS, dean and associate professor, department of endodontics, Loma Linda University School of Dentistry, Loma Linda, Calif.

Bradley Henson, DDS, PhD , associate dean for research and biomedical sciences and associate professor, Western University of Health Sciences College of Dental Medicine, Pomona, Calif.

Paul Krebsbach, DDS, PhD, dean and professor, section of periodontics, University of California, Los Angeles, School of Dentistry

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Lucinda J. Lyon, BSDH, DDS, EdD, associate dean, oral health education, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco

The Journal of the California Dental Association (ISSN 1043–2256) is published monthly by the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. The California Dental Association holds the copyright for all articles and artwork published herein.

Nader A. Nadershahi, DDS, MBA, EdD, dean, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Francisco Ramos-Gomez, DDS, MS, MPH, professor, section of pediatric dentistry and director, UCLA Center for Children’s Oral Health, University of California, Los Angeles, School of Dentistry Michael Reddy, DMD, DMSc, dean, University of California, San Francisco, School of Dentistry

The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff. Neither the editorial staff, the editor, nor the association are responsible for any expression of opinion or statement of fact, all of which are published solely on the authority of the author whose name is indicated. The association reserves the right to illustrate, reduce, revise or reject any manuscript submitted. Articles are considered for publication on condition that they are contributed solely to the Journal of the California Dental Association. The association does not assume liability for the content of advertisements, nor do advertisements constitute endorsement or approval of advertised products or services.

Avishai Sadan, DMD, dean, Herman Ostrow School of Dentistry of USC, Los Angeles

Copyright 2020 by the California Dental Association. All rights reserved.

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Harold Slavkin, DDS, dean and professor emeritus, division of biomedical sciences, Center for Craniofacial Molecular Biology, Herman Ostrow School of Dentistry of USC, Los Angeles

Richard W. Valachovic, DMD, MPH, president emeritus, American Dental Education Association, Washington, D.C.

Assoc. Editor

C D A J O U R N A L , V O L 4 8 , Nº 9

A Man, a Plan, a Cabal Brian K. Shue, DDS, CDE

C

alifornia dentists made history in 1870 by creating their first state organization.

It was the California State Dental Association, of course, which became today’s CDA. But don’t take us for granted. State organizations didn’t always thrive in the Old West (I’m looking at you California State Odontological Society and Pacific Coast Dental Association).

Twenty-three of California’s best and brightest dentists — actually, Northern California’s best and brightest — from as far south as San Jose and Santa Clara, as far north as Healdsburg and Woodland and as far east as Placerville assembled in San Francisco, which was home to 32% of the entire population of California in 1870. At 179,473 residents, it was also the West’s most populous city, the second being Sacramento with 16,283.

In comparison, Los Angeles only had 5,728 and San Diego 2,300. No woman attended this first CSDA meeting. It would be nine years later before the first woman dentist practiced in California and 24 years before the first woman joined CSDA. And here we are 150 years later, 27,000 CDA members strong.

None of this would be possible without the leadership of the San Francisco Dental Association (Society), which was established the year before in 1869.

And certainly not without its progressive first president, Dr. C.C. Knowles, who was the “chief mover” and architect of CSDA. “Progress, gentlemen, is the living password by which to gain admission to higher degrees of professional excellence,” he stated in the opening speech on the day CSDA came into existence.

He was truly a visionary and the right man with the right plan. We can learn

“Progress … is the living password by which to gain admission to higher degrees of professional excellence.” — Dr. C.C. Knowles

much about leadership from him. It’s important to look at the three motions Dr. Knowles made at CSDA’s inaugural meeting, all in rapid succession, with far-reaching significance to protect the public and elevate the profession.

He wanted to create the first dental college on the West Coast, establish a periodical and enact state legislation to regulate the practice of dentistry.

First, Dr. Knowles hit the 19th century ground running with this: “Resolved, that a ‘dental college’ on this coast is essential to the interests of the profession.” In 1870, the majority of dentists still learned the profession through preceptorships instead of attending dental colleges.

There was no school of dentistry west of the Mississippi. “The future will demand men educated in all that constitutes the scholar and professional man and refined in all that makes the gentleman,” he said in his opening address.

What did CSDA do with his motion?

It referred it to a subcommittee, which referred it to the newly created CSDA Committee on Dental Literature and Education. The committee had no results to report the following year. In fact, it never met. Unfortunately, because of inaction and infighting among our wellintentioned pioneers, this was modus operandi, even with the most pressing issues of the day. For instance, CSDA leadership rejected and permanently

destroyed all records of its 1875 annual meeting as if it never existed.

The University of California (UC) established a dental college in San Francisco (which would become the UCSF School of Dentistry) in the next decade and appointed CSDA’s second president, Dr. Samuel W. Dennis, as dean. Many CSDA leaders balked at this new school. They wanted complete control of the operation and believed UC betrayed them. Sadly, this cleaved CSDA leadership evenly right down the middle, leading to the creation of the California State Odontological Society (CSOS), a separate state dental organization that barred CSDA members and required its members to be dental college graduates.

Second, Dr. Knowles made this next motion in 1870: “Resolved, that it is expedient that a periodical be published under the direction of the association.” He stated: “We need a periodical publication, partly as a means of communication among ourselves and the professional world, but mostly as a vehicle of special information and instruction to the people.”

What did our CSDA leaders do? They tabled it. Later, it was referred to the new CSDA Committee on Publication, which motioned: “Resolved, that we recommend that a periodical be published quarterly, under the supervision of the Committee on Publication, and distributed pro rata SEP TEMBER 2 0 2 0 419

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according to the amount subscribed by each member of the association.”

No dice. CSDA said, “Bring it up next year.” So they did. And it was laid over.

Then Dr. Knowles stepped in and reintroduced basically his same original resolution from the previous year that called for a periodical. It was referred.

In 1872, the publication committee put a fork in it, calling a journal “inexpedient” and recommending that further consideration of the subject be indefinitely postponed.

The motion was approved.

CSDA and the future Southern California State Dental Association eventually created two separate journals, which would later merge into today’s Journal of the California Dental Association in 1973 with the unification of the two associations.

Dr. Knowles delivered his third sweeping motion in 1870: “Resolved, that to elevate the profession and to protect the community against charlatanism, state legislation is necessary.” As the eastern states began to regulate the practice of dentistry, quacks and mountebanks moved west and thrived. Of all three resolutions, Dr. Knowles said there were “perhaps none more important than an inquiry into the propriety of obtaining state legislation regulating the practice of dentistry.”

CSDA adopted the resolution.

Success! Well, not quite. Remember, it was the 19th century CSDA. A bill to regulate the profession of dentistry eventually came to Sacramento, but it was written entirely by the rogue CSOS (them again!), led

by Dr. Samuel W. Dennis (him again!). CSDA leaders would have none of this. They corresponded with politicians, attacked the bill and the CSOS and printed nasty 420 SEP TEMBER

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newspaper articles. They even sent a delegation to squash this legislation.

The day of the important vote came to Sacramento. CSDA was nowhere to be found. The state’s legislative committee passed the bill. Minutes later, the CSDA delegation arrived.

They were too late. CSDA pleaded to be heard and made a scene and began to read a prepared diatribe against the bill and CSOS. No one paid attention.

The governor of California signed the Dental Act of 1885 into law, and licensure came to California.

What’s the take-home message?

Whether it’s the 19th or 21st century, a successful leader needs to know the mission and purpose and use that to chart the direction.

Aimless direction leads to nowhere and accomplishes nothing.

After creating CSDA, Dr. Knowles didn’t rest on his laurels; he identified three major issues and pursued them at great length. As he discovered, things don’t always turn out as planned; he adapted, even though his association stumbled. Leadership takes persistence.

Given his grand plan, he knew the course and did his best to guide CSDA. Where would we be as an association without leaders like him? He didn’t shy away in addressing the important issues of the day. We shouldn’t either.

One-hundred-fifty years ago, Dr. Knowles stated in his opening remarks: “Our future usefulness as an association will greatly depend on the manner in which we commence. Let no subordinate questions sway us from the stern duties we owe to ourselves and the age in which we live.” Before he died in 1888, he saw the establishment of a dental college and dental licensure in California, but alas, no journal.

Learning from our sometimestumultuous past can prepare us for

a brighter future. We need to step up and continue to make the hard decisions to advance our profession. We need to be leaders like Dr. Knowles. In 1973, the late CDA Editor Stephen S. Yuen stated it best in the first editorial of the first issue of the reestablished CDA Journal: “The real responsibility to your profession rests with you. We look forward to the future … with you.” n SOURCES Transactions. California State Dental Association. First, second, third and fourth annual sessions. Sacramento: Record Book and Job Printing House; 1873.

California State Odontological Society. Transactions, 1884– 1885. San Francisco: William S. Duncombe & Co.; 1885.

Brian K. Shue, DDS, CDE, is the dental director of a federally qualified health center.

He is a certified dental editor, president-elect of the American Association of Dental Editors and Journalists and editor of the San Diego County Dental Society.

The Journal welcomes letters

We reserve the right to edit all communications. Letters should discuss an item published in the Journal within the last two months or matters of general interest to our readership. Letters must be no more than 500 words and cite no more than five references. No illustrations will be accepted. Letters should be submitted at editorialmanager.com/jcaldentassoc.

By sending the letter, the author certifies that neither the letter nor one with substantially similar content under the writer’s authorship has been published or is being considered for publication elsewhere, and the author acknowledges and agrees that the letter and all rights with regard to the letter become the property of CDA.

CORRECTION

The July 2020 article by Felsenfeld and Nadershahi contained an error. A sentence on page 314 should read, “In 1885, the California legislature created the Board of Dental Examiners to regulate the practice of dentistry.”

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Designer Peptide for Treating COVID-19

Peptide model. (Credit: CC0 Public Domain)

“The two receptors necessary for it to work suppy an unusual level of specificity. We think the unusual nature of this pathway might restrict its side effects.”

— CHRIS McCULLOCH, DDS, PHD

A collaboration between the University of Toronto’s Faculty of Dentistry and the National Jewish Health hospital in Denver has yielded a new drug discovery that could be useful to combat inflammation of all varieties and shows promise in fighting acute respiratory illnesses such as COVID-19.

Called TAT CARMIL1, the “drug” is actually a combination of two naturally occurring peptides that when combined work together to penetrate a cell’s membrane in order to dampen an acute inflammatory response.

In this first ex vivo study, published in the journal Cell Reports, the peptide reduced collagen degradation by up to 43%. If deployed early enough, the peptide could allay some of the worst damage caused by acute inflammatory responses, according to researchers.

Here’s how it works: The peptide combines a segment of a naturally occurring protein, CARMIL1, with a peptide “vehicle,” TAT, that brings the CARMIL1 directly into the cell. That enables the CARMIL1 to calm the inflammatory storm. The CARMIL peptide effectively blocks a family of cytokines, called interleukin1, from signaling and reproducing in vast quantities.

Greg Downey, MD, pulmonologist, professor and executive vice president, academic affairs in the department of medicine at the National Jewish Hospital, who co-authored the study, calls the peptide discovery “exciting.”

“There are a lot of people looking at these areas, but this study gives the first indication of how these CARMIL proteins are involved with this pathway,” he said.

What makes the discovery unique is how precise it is. The TAT CARMIL1 peptide targets two receptors, sticking to both the cell’s surface and its cell substrate, where it adheres to other cells.

“The two receptors necessary for it to work supply an unusual level of specificity,” said Chris McCulloch, DDS, PhD, professor at the Faculty of Dentistry and a co-lead of the study. “We think the unusual nature of this pathway might restrict its side effects.”

That could make the peptide an unusually strong candidate as a potential drug. Drugs designed to work in conjunction with this peptide would need to target cells at both receptors, narrowing the potential field of candidates from tens of thousands to hundreds.

“This is a precise pathway to deal with a precise issue,” Dr. Downey said.

Next, the research team hopes to track the peptide’s success in in vitro models. Given the broad applicability of the peptide, which can be combined with other drugs such as cancer or arthritis drugs, the discovery could one day become a useful ally in the fight against all types of inflammation.

Learn more about this study in Cell Reports (2020); doi.org/10.1016/j.celrep.2020.107781. n SEP TEMBER 2 0 2 0 423

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Cure for IBD May Be Inside the Mouth Tongue Microbes Provide Window to Heart Health Microorganisms on the tongue could help diagnose heart failure, according to research presented on HFA Discoveries, a scientific platform of the European Society of Cardiology.

The study found that the composition, quantity and dominant bacteria of the tongue coating differ between heart failure patients and healthy people.

“The tongues of patients with chronic heart failure look totally different to those of healthy people,” said study author Tianhui Yuan, PhD, of the Guangzhou University of Chinese Medicine. “Normal tongues are pale red with a pale white coating. Heart failure patients have a redder tongue with a yellow coating and the appearance changes as the disease becomes more advanced.”

Researchers investigated the composition of the tongue microbiome in participants with and without chronic heart failure. The study enrolled 42 patients in the hospital with chronic heart failure and 28 healthy controls. None of the participants had oral, tongue or dental diseases, had suffered an upper respiratory tract infection in the past week, had used antibiotics and immunosuppressants in the past week or were pregnant or lactating.

Stainless steel spoons were used to take samples of the tongue coating in the morning, before participants had brushed their teeth or eaten breakfast. A technique called 16S rRNA gene sequencing was used to identify bacteria in the samples.

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A new collaborative study from the University of Michigan Medical and Dental Schools reveals that inflammatory bowel disease (IBD) may be the latest condition made worse by poor oral health.

The new mouse study, published in the journal Cell, shows two pathways by which oral bacteria appear to worsen gut inflammation. In the first pathway, periodontitis leads to an imbalance in the normal healthy microbiome found in the mouth, with an increase of bacteria that cause inflammation. These bacteria then travel to the gut.

However, this alone may not be enough to set off gut inflammation. The research team demonstrated that oral bacteria may aggravate gut inflammation by looking at microbiome changes in mice with inflamed colons.

“The normal gut microbiome resists colonization by exogenous, or foreign, bacteria,” said Nobuhiko Kamada, PhD, assistant professor of internal medicine in the division of gastroenterology. “However, in mice with IBD, the healthy gut bacteria are disrupted, weakening their ability to resist disease-causing bacteria from the mouth.”

Dr. Kamada and his research team found that mice with both oral and gut inflammation had significantly increased weight loss and more disease activity.

In the second proposed pathway, periodontitis activates the immune system’s T cells in the mouth. These mouth T cells travel to the gut where they, too, exacerbate inflammation. The gut’s normal microbiome is held in balance by the action of inflammatory and regulatory T cells that are fine-tuned to tolerate the resident bacteria. But oral inflammation generates mostly inflammatory T cells that migrate to the gut, where they, removed from their normal environment, end up triggering the gut’s immune response, worsening disease.

Read more of this study in Cell (2020); doi.org/10.1016/j.cell.2020.05.048.

Micrograph showing inflammation of the large bowel in a case of inflammatory bowel disease. Colonic biopsy.

(Credit: Wikipedia/CC BY-SA 3.0)

The researchers found that heart failure patients shared the same types of microorganisms in their tongue coating.

Healthy people also shared the same microbes. There was no overlap in bacterial content between the two groups.

At the genus level, five categories of bacteria distinguished heart failure patients from healthy people with an area

under the curve (AUC) of 0.84 (where 1.0 is a 100% accurate prediction and 0.5 is a random finding).

In addition, there was a downward trend in levels of Eubacterium and Solobacterium with increasingly advanced heart failure.

Learn more about this study on HFC Discoveries.

C D A J O U R N A L , V O L 4 8 , Nº 9

Research Discovers ‘Building Blocks’ of Enamel In a new study of human enamel, Northwestern University researchers have cracked one of the secrets of tooth decay, according to a new study published in the journal Nature. The scientists are the first to identify a small number of impurity atoms that may contribute to the enamel’s strength but also make the material more soluble. They also are the first to determine the spatial distribution of the impurities with atomic-scale resolution.

The Northwestern discovery in the building blocks of enamel, with detail down to the nanoscale, could lead to a better understanding of human caries as well as genetic conditions that affect enamel formation, which can lead to highly compromised or completely absent enamel.

One major obstacle hindering enamel research is its complex structure, with features across multiple length scales. Enamel, which can reach a

Robot Jaws Test Medicated Chewing Gum New research has shown that a chewing robot with built-in humanoid jaws could provide opportunities for pharmaceutical companies to develop medicated chewing gum. The study was published in the journal IEEE Transactions on Biomedical Engineering.

The aim of the University of Bristol, England, study was to confirm whether a humanoid chewing robot could assess medicated chewing gum. The robot is capable of closely replicating the human chewing motion in a closed environment. It features artificial saliva and allows the release of xylitol from the gum to be measured.

The study wanted to compare the amount of xylitol remaining in the gum between the chewing robot and human participants. The research team also wanted to assess the amount of xylitol released from chewing the gum.

Researchers found the chewing robot demonstrated a similar release rate of xylitol as human participants. The greatest release of xylitol occurred during the first five minutes of chewing. After 20 minutes of chewing, only a low amount of xylitol remained in the gum bolus irrespective of the chewing method used, according to the study.

Kazem Alemzadeh, PhD, who led the research, said bioengineering has been used to create an artificial oral environment that closely mimics that found in humans.

“Our research has shown the chewing robot gives pharmaceutical companies the opportunity to investigate medicated chewing gum, with reduced patient exposure and lower costs using this new method,” he said.

Learn more about this study in IEEE Transactions on Biomedical Engineering (2020); doi.org/10.1109/TBME.2020.3005863.

A close up of the humanoid chewing robot.

(Credit: Kazem Alemzadeh, PhD, University of Bristol)

thickness of several millimeters, is a three-dimensional weave of rods. Each rod, approximately 5 microns wide, is made up of thousands of individual hydroxyapatite crystallites that are very long and thin. The width of a crystallite is on the order of tens of nanometers.

These nanoscale crystallites are the fundamental building blocks of enamel.

Using cutting-edge quantitative atomic-scale techniques, the team discovered that human enamel crystallites have a core-shell structure.

Each crystallite has a continuous crystal structure with calcium, phosphate and hydroxyl ions arranged periodically (the shell). However, at the crystallite’s center, a greater number of these ions is replaced with magnesium, sodium, carbonate and fluoride (the core). Within the core, two magnesium-rich layers flank a mix of sodium, fluoride and carbonate ions.

Detecting and visualizing the sandwich structure required scanning transmission electron microscopy at cryogenic temperatures (cryo-STEM) and atom probe tomography (APT). Cryo-STEM analysis revealed the regular arrangement of atoms in the crystals. APT allowed the researchers to determine the chemical nature and position of small numbers of impurity atoms with subnanometer resolution.

The researchers found strong evidence that the core-shell architecture and resulting residual stresses impact the dissolution behavior of human enamel crystallites while also providing a plausible avenue for extrinsic toughening of enamel.

Read more of this study in Nature (2020); doi.org/10.1038/s41586-020-2433-3.

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ETHICS is knowing the difference between what you have a right to do and what is right to do. — potter pot ter stewart,, former associate justice of the u.s. supreme court

introduction C D A J O U R N A L , V O L 4 8 , Nº 9

Dental Ethics for the 21st Century Robert D. Stevenson, DDS

GUEST EDITOR Robert D. Stevenson, DDS, practiced general dentistry in the Inland Empire area. He is an assistant professor at the Western University College of Dental Medicine and served on the CDA Judicial Council.

Conflict of Interest Disclosure: None reported.

O

ne hundred fifty-four years ago, just a year after the close of the Civil War, the leaders of the American Dental Association, itself just 7 years old, met to debate the adoption of a professional code of ethics. Many of the leaders opposed the code because they felt the good dentists didn’t need it and the bad ones wouldn’t pay attention.

After heated debate, a simple code of ethics was adopted. Since 1866, the codes have been updated repeatedly to address relevant concerns of the dental profession. Despite these changes in applications, the underlying principles remain unchanged.

As the codes of ethics for the American Dental Association, the California Dental Association and other significant dental organizations have evolved, the expectations that were outlined have created a sense of professional unity. However, the discussion continues to this day as to whether the dentists who most need the codes will pay attention and whether those who pay attention really need the codes. This debate may never reach a conclusion.

Potter Stewart, a former associate justice of the United States Supreme Court, said, “Ethics is knowing the difference between what you have a right to do and what is right to do.”1 This is precisely why it is important

to review ethics on a regular basis: It is not always a simple matter to differentiate between the two.

In simple terms, ethics may be defined as the moral values that govern an individual’s behavior.

As one considers this definition, it becomes apparent that in a world full of individuals, there may be endless interpretations and applications of the basic ethical principles. As we have seen in many events in recent years, this can lead to chaotic behavior and justification of wrongful actions. A lack of ethical awareness can lead to disastrous choices.

Dentists tend to pay less attention to ethics than to clinical dentistry and business practices. That could stem from the perception that ethics have little bearing on the modern dental practice when compared to clinical and business topics.

We are now well into the 21st century. Do ethics appear to be an antiquated view of life as spelled out by ancient philosophers? Or are they still relevant in our lives? Our contention is that ethics are alive and well and relevant. The important news is that the fundamental principles of ethics have not changed. They continue to provide a foundation for our choices. But the situations in which we apply these principles continue to change. Our objective in this issue was to provide some real-world applications of ethical SEP TEMBER 2 0 2 0 427

introduction C D A J O U R N A L , V O L 4 8 , Nº 9

principles: to translate thoughts on ethical behavior into actions. Ethics do have a practical side. When ethical principles are applied consistently, relationships with patients, staff and colleagues may be enhanced.

Ethical behaviors reach far beyond the walls of one’s dental practice.

In this issue, Nick Forooghi, JD, an attorney who teaches ethics at the University of the Pacific, Arthur A. Dugoni School of Dentistry, leads off with a discussion of truth and trust as they relate to ethics and the law in dentistry. Kenneth Jacobs, DDS, a former member of the CDA Judicial Council, follows with an examination

of the conflicts between the dentist’s roles as a professional and as a businessperson. Gary Herman, DDS, a former member of the Judicial Council and the Council on Ethics, Bylaws and Judicial Affairs, discusses the importance of the treatment plan in an ethical practice. Finally, Robert Stevenson, DDS, a former chair and member of the Judicial Council, examines how dentists can utilize ethical principles to make better choices.

We hope that our readers will gain a better sense of some of the practical aspects of ethics and remain committed to following our codes

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of ethics. Regardless of how ethical we think we are, there is always some room for improvement. We encourage the reader to look for the nuggets of wisdom that can be applied in their personal and professional life.

This issue is dedicated to the many volunteers and staff who have served on the Judicial Council over the years. It has been a privilege to serve with you and to serve our members as we promoted the ethical ideals of the California Dental Association.

CDA President Rick Nagy has added the following statement: “On behalf of CDA, I extend my heartfelt gratitude to those who have served on the CDA Judicial Council and to the staff who assisted the council in leading and shaping dentistry’s future in the state of California. Through the years, the Judicial Council was tasked with promoting and maintaining high ethical standards within the dental profession as well as with developing a viable and legally enforceable code of ethics and interpreting and enforcing that code of ethics on behalf of the association, components, individual members and the public.

With the recent governance changes, oversight of the code of ethics has moved to the CDA Board of Trustees.

Thank you to Judicial Council members both past and present.

Your service was a valuable asset to CDA and no doubt has left a lasting impression on the profession of dentistry in California.”2 n REFERENCES 1. Evans WG. The motivation to be ethical. S Afr Dent J 2016 Jul;71(7):329.

2. Richard J. Nagy, DDS, correspondence with author.

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commentary C D A J O U R N A L , V O L 4 8 , Nº 9

Ethics and Law: ‘Truth’ and ‘Trust’ in a 21st Century Practice Nick F. Forooghi, JD, Esq.

AUTHOR Nick F. Forooghi, JD, Esq. , is a practicing attorney and an educator. He is the executive associate dean at Lincoln Law School in San Jose, Calif., and an assistant professor of professionalism and ethics at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco.

Conflict of Interest Disclosure: None reported.

W

hat is the “truth?”

I have to take you through a philosophical discussion before we relate this article more directly to the dental profession. But trust me — no pun intended — you will be better for taking the trouble and following me on this short journey.

As professionals in any field, medical, dental, legal and others granted the privilege of a license to practice, we all have a fiduciary duty to the people we serve. We will revisit the implications and meaning of having a fiduciary duty, but it helps first to discuss a more fundamental word — truth. We can hardly find any philosophical work in the study of ethics without a discussion of what truth is and how it relates to, or inspires, other important ethical concepts.

I know some who read this commentary may perceive what I write to be a “statement of the obvious.” That is exactly the point. We take what is obvious for granted at our own peril.

Truth as a concept worthy of discussion has been a core subject in philosophy for thousands of years. Ethics is often defined as “the systematic study of right and wrong.” Truth being a central topic of philosophy and so closely at the center of the study of ethics, also has a long history of systematic scholarly examination.

Our shared understanding of the word truth today has a major practical purpose in allowing each of us to navigate our daily lives both personally and in relation to other members in our society. This is the very purpose of a vast area of work referred to as “applied ethics,” which is concerned with the practical use of moral concepts in the real world.

Much in ethics and various philosophical ideas about ethics are organized around the definition of key concepts like truth, honesty and trust. Members of any society must have a relatively stable and common understanding of the meaning of these key concepts if we are to have a useful and practical application of laws and ethical codes in a given period of time.

Concepts of morality and ethics evolve over time. Therefore, we have to discuss any constancy of ethical and moral concepts based on the period in which they are expressed. This in itself is a great area of examination and debate. Even then we have a need for a dedicated law professional (attorneys) to interpret the laws in countless practical applications (case-by-case application of laws).

There are several current theories of truth in philosophy. Our contemporary understanding of “truth” is closely aligned with the “correspondence theory of truth,” the idea that “what we believe or say is true if it corresponds to the way things actually are — to the facts.”1 SEP TEMBER 2 0 2 0 431

commentary C D A J O U R N A L , V O L 4 8 , Nº 9

But, how do we know what the facts are? How can you tell a lie from a truth?

If, as unfortunately has been claimed by some, there can be “alternative” facts, then logic would dictate that there can be alternative truths as well.

What would that claim do to our essential need to rely on knowing what is “ethical behavior?” Examination of this issue should not be politicized, even though it unfortunately has been.

This seemingly obvious discussion has very serious practical implications for science, and philosophy in general, and professional ethics more specifically relevant to our short discussion here.

Thinkers, philosophers, scientists and professionals have a duty to not allow artful obfuscation or playing with facts — otherwise called lying and intentional dishonesty — destabilize the idea that in each given set of circumstances there is indeed a single truth even if it takes some work to reveal it. Arguments are fine when we are in the process of examination but must end once reliable evidence is found and only after they have been tested by the rigor other peers in that field put them through.

This relationship with the truth and the belief that truth will be revealed through observation and corroborated independently by others you respect as colleagues is most crucial in teaching ethics in professional schools because the product of these schools is expected to be trusted professionals who the public can rely on for doing the right thing, the definition of being ethical.

Comparison of “Ethics” and “Law”

You can do what is needed to keep you out of trouble or you can aspire to do even more. I am reminded that my first encounter several years ago with teaching ethics in a dental school was to hear some version of the phrase 432 SEP TEMBER

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“law is the lowest level of standards you have to meet, and if you fall below legal requirements you will be subject to sanctions and penalties.”

As an attorney who genuinely believes in the role laws play in any civilized society, I have been heard to confess that in my world “law” holds the place religion does for many. At first impression, I was aghast to consider the position of law as the lowest level of compliance below which you would get punished and that is all. The use of the word “low” can symbolize a

Facts matter because they point to the truth.

This has little to do with the law and everything to do with ethics, and we need facts we can trust. sort of predisposition to quality of expectations. However, I came to agree that this statement was actually correct in a technical and concise way.

The context where this definition arose from, and in a much-specified perspective, was a practical and truthful observation. Here is how I would restate the same relationship between law and ethics in a bit longer observation: Laws exist to provide a moral standard that a society devising them intends to uphold. The laws are to be obeyed and shall be enforced by force of mandate or otherwise subject the violator to some fine or punishment. Laws set a boundary not to be crossed, but they do not set a higher and maximum limitation on how far above this standard one can go into where aspirational ethics and voluntarily observed morality reside.

Laws are therefore a subset of ethical standards that a society decides should be mandatorily honored. What occupies the aspirational moral space above the law is therefore still ethics. The law is not intended to be a cure-all for ills, moral dilemmas, disputes and bad things that can happen. Laws are intended to be perfect, but hardly ever are. This is why laws cannot fix all of our problems nor address all ethical challenges.

Going back to what I hope universally was taught in your dental school days, in some form or another, is the definition of ethics noted above: “Ethics is a systematic study of the concepts of right and wrong.” It is impossible to relegate determination of all that could be right or wrong to our jurisprudence.

This is why we need to know and hold some truths to be self-evident.

Ethics is the realm of concepts like “veracity” and “trust” not only to the extent mandated by standards of law but following the aspirational quest for what is right. This is where students and all of us need to always return to.

When laws might prove inadequate or stand in waiting for evolution of ethics to a critical mass that will allow a new standard to become a new mandate, we only have our aspirational and voluntary understanding of ethics, morality and common ethical concepts like truth and trust to fall back on. Facts matter because they point to the truth. This has little to do with the law and everything to do with ethics, and we need facts we can trust.

Anchoring Dental Education in Trust and Truth

It pays to remind ourselves of Immanuel Kant’s posit that ethical and moral imperatives arise from morality in what is considered a rational capacity in all humans, which compels them to form what we term and refer to as “humanity.”

C D A J O U R N A L , V O L 4 8 , Nº 9

The concept of humanity manifested in individuals builds societal relationships and is reflected in groups large and small.

Kant delineates certain “moral laws” that are to be absolutely honored and not violated in these interactions and relationships. Veracity (truthfulness) is the one we are concerned with here. As we already noted, without a healthy respect and solid belief in what truth means to our everyday lives and especially in a professional setting, there can be no trust.

Kant’s ideas and work on morality and ethics have had a great influence on dental professional organizations’ views on professional ethics and societal responsibilities of dentists in the U.S. and the professionals who belong to those organizations. This is where philosophy manifests in professional day-to-day practice and serving patients.

The American Dental Association (ADA) makes use of a more concise and carefully selected subset of normative principles and imperatives that have been adopted as essential to the profession of dentistry here in the U.S. and, by extension and connection, by all individual state dental profession organizations and bodies in their individual language and impressions.

They have been interpreted and applied in various forms that conform to the same and similar group of principles and ethical values. The same attention and focus are paid to how these expressions are to become deeply embedded in dental professional education.

In the preamble of the ADA’s Principles of Ethics and Code of Conduct, we read: “The American Dental Association calls upon dentists to follow high ethical standards which have the benefit of the patient as their primary goal. In recognition of this goal, the

education and training of a dentist has resulted in society affording to the profession the privilege and obligation of self-government. To fulfill this privilege, these high ethical standards should be adopted and practiced throughout the dental school educational process and subsequent professional career.

“The Association believes that dentists should possess not only knowledge, skill and technical competence but also those traits of character that

Words like veracity need to return to the solid ground where politics and points of view of current events cannot challenge their meaning. foster adherence to ethical principles.

Qualities of honesty, compassion, kindness, integrity, fairness and charity are part of the ethical education of a dentist and practice of dentistry and help to define the true professional.

As such, each dentist should share in providing advocacy to and care of the underserved. It is urged that the dentist meet this goal, subject to individual circumstances.

“The ethical dentist strives to do that which is right and good. The ADA Code is an instrument to help the dentist in this quest.”2 By calling it essential to a dental education to honor these principles, the ADA is asking each and every person who is involved in professional development

of dentists, and most certainly in their educational experience, to honor and uphold these specified values. But how do we honor and embed “qualities of honesty, compassion, kindness, integrity, fairness and charity” in dental education?

Each of these imperatives is worthy of scholarly discussion and consideration that would take up volumes, and they do. We will here suffice to declare that the principle of veracity and its relational reference to law, trust and what we commonly refer to as truth is and has always been the foundation of an ethical professional practice.

In most recent years, the combined effects of proliferation of internet connectivity and social media, primarily Facebook, and platforms functionally designed and presented similar to Facebook (e.g., Reddit or Twitter), have pushed veracity and truth into the arena where doubt and skepticism usually dwell more often than scientific, evidence-based truth.

Until a few years ago, the words “fake” and “hoax” were not often used in common conversation. Now they are out in full force challenging the veracity of what we hear, read or think we learn. What we think we know, what we believe to be true is challenged constantly. One of the toughest challenges of our day is learning how we can agree on what the facts are when the sources reporting the news are in the thousands. We no longer have a Walter Cronkite3 to trust and rely on to report the facts. Fact checking is no longer a job title limited to media publications, and we need a user-friendly set of tools all consumers can access.

Meanwhile, we have to remind ourselves that words like veracity need to return to the solid ground where politics and points of view of current events cannot challenge their meaning.

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commentary C D A J O U R N A L , V O L 4 8 , Nº 9

In every classroom, and especially in professional schools where we attempt to teach the ability of differentiation between “right and wrong,” we have to go back to the basics and remind everyone that truth does exist, ethics matter and trust means nothing without that context supporting it.

Advancing knowledge and progress in science might change our ability to affect outcomes, but that does not make yesterday’s truth a lie today. It means simply that we are learning more and can prove what we know is in fact true.

Evidence-based practice finds and holds its place of honor only when empiricism and the quest for truth, which can withstand trial and reproduction and scrutiny of our peers, are the solid and unbending standards of measurement. Our understanding of ethics and moral imperatives such as veracity, truth and trust should not be easily malleable.

The ADA’s principles of ethics and code of professional conduct define veracity as follows: SECTION 5: Principle: Veracity (“truthfulness”) The dentist has a duty to communicate truthfully.

This principle expresses the concept that professionals have a duty to be honest and trustworthy in their dealings with people. Under this principle, the dentist’s primary obligations include respecting the position of trust inherent in the dentistpatient relationship, communicating truthfully and without deception and maintaining intellectual integrity.

Code of Professional Conduct 5. A. Representation of Care. Dentists shall not represent the care being rendered to their patients in a false or misleading manner.

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In addition to reminders of the philosophical underpinnings of professional ethics, we should not end this article without mentioning the phrase that is the exclusive cornerstone of any profession purposed and oriented to serve the public and that is also regulated and licensed; (not all professions are). That phrase is “having a fiduciary relationship.”

A patient or client places their trust in someone else who has specialized knowledge and skill the patient does not have, and the expectation that things will go well defines the fiduciary duty we have as professionals.

Medicine and dentistry, and other fiduciary professions including law, are not just another business. We spend ample time in dental school ethics classes to delineate “health care” from “commerce,” even as health care is also in part commercial. While there is a long list of differences between commerce and care, the most important one of all is that the patient (the client) places their trust in us to do what is best for them. They are the end itself and not the means for any other purpose. They trust a professional provider when they are at a disadvantage of not possessing the knowledge and training the provider has, and they hope to benefit from the provider’s knowledge by simply trusting the provider to do the right thing.

I would be remiss if in closing I fail to mention that I started writing this piece well before the COVID-19 pandemic and the crisis that ensued had taken hold.

In the aftermath of the outbreak, I have realized how critical this conversation about truth and applied ethics is to the health of our institutions. It should not be lost on anyone that our society is still debating whether or not there is in fact a true crisis or, as some surprisingly claim, a manufactured political crisis. Wearing

a mask, a simple scientific measure with well-established and tested reasons why it could be helpful, has become a political issue. It makes me sad when widely proven and reliable scientific knowledge is questioned carelessly; of course, this should make all of us very concerned. Not trusting politicians is an age-old truism whether justified or not. But when we fail to defend well-established scientific facts and our scientists have to be careful about expressing their professional opinions, it should be alarming to all. It shows how vulnerable truth can be to attacks motivated by a variety of other ends in mind. It is not dramatization to claim that the future of our society and trust in our organizations depend on how well we all defend the scientific method and existence of an empirical truth, continuing emphasis on importance of ethics and ethical thought and actions in all spheres of life. The scientific method took centuries to become a normal path for meaningful investigation. Galileo’s factual and provable belief that the Earth revolves around the sun was deemed heretical by the Catholic Church, and he was compelled to submit to a trial for holding such heretical belief. Truth might be illusive, but we know the way to find it is through methodically finding facts and patiently defending findings we believe to be true. Placed in proper perspective, this subject is about much more than truth, trust, law and ethics, but a discussion like this is a great place to start for any licensed professional entrusted to serve others. n REFERENCES 1. Moore GE, Bertrand R. Truth, section 1.1.1 The origins of the correspondence theory. Stanford Encyclopedia of Philosophy.

2. Principles of Ethics and Code of Professional Conduct.

Preamble. Chicago: American Dental Association; 2018:3–4.

3. Martin D. Walter Cronkite, 92, dies; trusted voice of TV news.

The New York Times July 17, 2009.

THE AUTHOR, Nick F. Forooghi, JD, Esq., can be reached at nforooghi@pacific.edu.

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SAN GABRIEL VALLEY: 4 Ops, Digital X-rays, 65 yrs Goodwill. Most specialty work referred out, most PPO plans are accepted. Busy road with great visibility, open 4 days/wk. Nicely appointed; excellent opportunity. #CA596 SHERMAN OAKS: 5 Ops, 4 Equip, 44 yrs goodwill. Nicely appointed in high-end bldg.

Strong hygiene program, Specialty work referred, room to grow. Legacy practice. 2019 GR $940K. #CA688 SIMI VALLEY: 6 Ops, 5 Equip, Great location, low rent, 45 yrs goodwill. 2018 GR $297K w/ $89K Adj. Net. #CA637 SOUTH ORANGE COUNTY PERIO: 4 Ops, 3 Equip, Coastal Community, Modern, Busy strip center location near hi-end residential. 2019 GR $845K. #CA643 SO CAL DESERT AREA: 4 Ops 27 yrs Goodwill. Strong hyg prog w/ hi-end patient base.

2019 GR $809K. #CA691 WEST COVINA: State-of-the-art practice with 3 Ops and is all digital and modern with 1 day of Hygiene/wk. 2019 GR $1.2M+ with Adj. Net of $420K in a great location with low rent. #CA661

SAN DIEGO EAST COUNTY: New Listing! Established practice in a convenient location with 3 Ops, 2 Equipped and Digital X-Rays. Retiring seller refers out most specialty work, opportunity for growth. 2019 GR $309K. #CA1236 ENCINITAS: 4 Ops. Busy retail center.

Remodeled 5 yrs. ago with new equipment.

Dentrix, Digital, Pano, and Laser. 4 hyg days/wk.

2018 GR $813K. #CA574 LA JOLLA: UTC Area, Leasehold with patients.

7 Ops Digital in retail center with strong anchors.

Priced to sell! #CA663 NORTH COUNTY: 5 Ops, 46 yrs. Goodwill, Dentrix, Digital, E4D, strong hyg. program, most specialty referred. 2019 GR $1.1M+. #CA689 POWAY: New Listing! 4 Ops, priced for quick sale! Desirable strip mall location. Digital, clean and modern. GR $264K. #CA1111 SAN DIEGO: New Listing! Rare opportunity in prime location. Solid practice with 17 yrs Goodwill. 5 hyg days/wk. 6 Ops, 5 Equip, digital X-rays, Pano. Most specialty work referred out.

2019 GR $1.1M+. #CA1448 SAN DIEGO: New Listing! 7 Ops, 5 Equipped, located in a large retail center. EagleSoft, PPO/ Cash, 3 year average collections of $509K. #CA687

OUT OF CALIFORNIA CENTRAL COAST, OREGON: Minutes to the ocean. 3 Dr. days/wk, 2 hyg days/wk. 2019 GR $404K, positioned for growth, Doctor is retiring. #OR112 HILLSBORO, OR: New Listing! 5 Ops, Scan-X, Pano, Laser, and recent cosmetic upgrade. Great NP flow with 7 hyg days/wk. and 4 Doctor days.

Near key employers, on a major thoroughfare.

Room to expand. GR $1.1M+. #OR1355 SOUTHWEST PORTLAND: 7 Ops, 6 Equip, Dentrix, Digital, Pano. Well-maintained leased space. 2019 GR $598K. #OR115 BURIEN AREA, WA: 3 Ops, Busy Area w/foot traffic. Very low overhead and good cash flow.

Could relocate in Bldg to bigger suite. #WA102

Southern California Office

1.888.685.8100

commentary C D A J O U R N A L , V O L 4 8 , Nº 9

Business Ethics and Dental Professionalism Kenneth Jacobs, DDS

a b s t r ac t The distinctions between business ethics and dental

professional ethics have become less clear due to intrinsic and extrinsic factors influencing the dental profession. Although these influences are powerful and pervasive, dentists’ special relationships with patients and underlying values set dentistry apart from the typical business endeavor and help to establish a means for ethical decision-making. These influences and characteristics will set the tone for dental professionalism going forward.

AUTHOR Kenneth Jacobs, DDS, has practiced general dentistry for over 30 years in Beverly Hills, Calif.

He is an adjunct clinical instructor at the Herman Ostrow School of Dentistry of USC where he teaches ethics and professionalism.

He is a fellow of the American College of Dentistry and served on the CDA Judicial Council.

Conflict of Interest Disclosure: None reported.

P

atient or consumer? In 2013, the Dental Board of California mandated that all dental offices conspicuously display new signage, in addition to the already cumbersome messages currently required, which states the following:1 Notice to Consumers: Dentists are licensed and regulated by the Dental Board of California 877.729.7789 www.dbc.ca.gov There are similar postings required by the Department of Consumer Affairs in other professional settings such as for podiatrists, physicians and hospitals.

These signs are meant for individuals receiving care or their representatives to be better able to report an incident of concern to the proper licensing board for possible investigation. Empowering

people by giving them such contact information is a valuable tool, but there is a subtle yet profound point that was overlooked in the language used in the posting. How and when did the receiver of health care services become a “consumer” instead of a “patient?”

This insidious transformation is more than just semantics and is seen in other examples throughout the health care environment. Several dental plan carriers refer to the “customer” portion of payment instead of “patient” in their estimate-of-benefits language. Even while attending organized dentistry meetings and practice management seminars, references are made to “consumer” as opposed to “patient” in regard to those we care for in the dental setting. The two terms are not interchangeable, but may be, at best, complimentary in certain contexts. Being a patient implies a sense of passivity, yet along with it, there are SEP TEMBER 2 0 2 0 437

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protections that a consumer may not be able to claim. The term “doctor” does grant a degree of power, but with this power comes great responsibility in the care for the patient. Despite the nuanced wording, several studies demonstrate the preference by the receivers of care to be called “patient” rather than “consumer” or “customer.”2,3 Fortunately, a few astute members within organized dentistry identified this subtle shift in terminology such that the Dental Board of California revised the posting to delete the “consumer” portion so that only “notice” appears in the header. It is interesting to note that the similar displays in other professional settings such as hospitals, physician and podiatrist offices still refer to “consumers.” So what is the origin of this shift in perception? How did we get here? Since when did the state of the doctor-patient relationship resemble a retail transaction rather than the trusted professional connection? What is in a name anyway? In a broader sense, is the patient versus consumer designation an indication that the lines of business ethics and dental professional ethics have blurred to the point where they are becoming practically indistinguishable?

Business Ethics and Dental Professionals

The acclaimed Nobel Prize-winning economist Milton Friedman concludes in his Friedman Doctrine regarding the social responsibility of business that “there is one and only one social responsibility of business, to use its resources and engage in activities designed to increase its profits so long as it stays within the rules of the game, which is to say, engages in open and free competition without deception or fraud.”4 In other words, Freidman contends that a company has no social responsibility to the public or society, 438 SEP TEMBER

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but only to its employer shareholders as long as they play within loosely defined parameters. Contrast Freidman’s notion of business purpose and ethics from the early 1970s with the purportedly more socially conscious business model of today’s environment. As described recently in the Los Angeles Times,5 currently there has been a move toward a warmer, fuzzier business model in which capitalism is no longer that of the single-minded, make-money-atall-costs endeavor, but rather one that seeks to include social consciousness

For those of us in the health professions and in dentistry in particular, it is interesting to witness the narrowing of the divide between business and professional ethics. in dealing with its stakeholders. In a seemingly significant shift in philosophy, Business Roundtable released an updated statement in August 2019 on the purpose of a corporation.6 Within the confines of the free-market system, 181 CEOs from a vast array of business sectors committed to lead their companies for the benefit of all stakeholders including customers, employees, suppliers, communities and shareholders. By delivering value to customers, investing in employees, dealing fairly with suppliers, supporting communities, embracing sustainable environmental practices and generating long-term value for shareholder investment, each company pledged all of these attributes for the future of their businesses, communities and country.

Business Roundtable’s current platform sounds worthy and plausible, but will there be actual change beyond rhetoric? Are these changes a defensive move to ward off further government regulation in the future or a genuine shift in business policy? Will the changes become part of the fabric of each of the 181 signers’ companies? Or once there is a major economic downturn will stock buybacks and cost-cutting measures take precedence over the commitment to all of the stakeholders? Freidman’s model and the latest iteration of Business Roundtable may aspire to the level of trust and integrity intrinsic to that of professional ethics, but only time will tell which priorities are sustainable.

For those of us in the health professions and in dentistry in particular, it is interesting to witness the narrowing of the divide between business and professional ethics. That is not to say companies are any less willing to make profits or that dental practices should abandon their core ethical principles to become more like retail establishments.

Even though the American Dental Association (ADA) publishes numerous volumes of material to assist its members in operating successful businesses, there are still certain basic concepts that distinguish a professional dental practice from a retail establishment. Dentistry has traditionally been a professional service business in which the products are the services provided to patients rather than to customers. This product is based on the distinct needs of those individuals performed by highly trained and skilled professionals. An NBA player may be a professional in the sense of possessing unique ability and is highly compensated as compared to an amateur “nonprofessional” athlete.

In contrast, the dental professional is obligated historically by virtue of

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an implied contract with society and through licensure to ethical standards that the paid athlete, entertainer or, for that matter, a corporation is not. Dental professionals are expected to be trusted role models in society whereas athletes and corporations can only aspire to be as such.

In fact, in some instances, professional athletes ask society not to view them as role models, but to instead look toward doctors, teachers and parents as examples.

Although the business community has decided it is time to be more responsible in its actions with society, during the past century, dentists have been committed to individual patients’ needs and public service along with individual practice success. The struggle is to find the desired balance between viable dental business and the essence of an admired profession.

As in the broader business community, the evolution of professional ethics in dentistry is being influenced by various intrinsic and extrinsic factors. Concurrently with this struggle, there appears to be four emerging factors influencing the current landscape within dentistry and consequently what the dental profession will resemble in the future.

Factors Influencing Dental Professionalism

As described in the soon to be published American College of Dentists report “A New Professionalism,” 7 four essential factors are concurrently influencing the practice of dentistry.

The challenges of individual practice styles, pervasive commercial influences, fragmentation throughout the profession and the disruptions caused by technology of previously accepted clinical and management methods are molding the future of dental professionalism. Once perhaps an enticing reason to enter dentistry, individual practice offered great satisfaction.

Dentists take appreciable consideration to establish their own style of providing care.

A dentist’s philosophy of clinical practice may consist of the employment of auxiliaries, the utilization of preferred materials and the emphasis of certain technical competencies. Furthermore, the individual dentist may emphasize various methods of practice management philosophy.

Outside finance companies, dental product manufacturers and management consultants influence desired practice methods. With the convergence of these elements and

The impact of commercial business model ethics upon dental professional ethics has the significant potential to alter the nature of rendering dental services. in conjunction with burdensome regulations, a prolific scientific knowledge base and ever-present personal demands, there is a tendency to inhibit rather than encourage engagement between practitioners.

An individual’s ethical philosophy of practice without engagement and common understanding is difficult to assess and implement. The small ethical decision moments we each experience on a daily basis should meet the needs of the patient and dentist. Codes of ethics may be a starting point, but they can be confusing, subject to interpretation and difficult to apply. The individuality of dental practice can be an ethically confounding aspect of the currently emerging dental professionalism.

The pervasiveness of commercialism has in many circumstances transformed the process along such that dental care increasingly resembles a bundle of commoditized transactions instead of a professional service provided within a trusted relationship to improve oral health. The branding of dental practices as “institutes,” “centers” or “academies” mirrors that of retail establishments. This combined with the proliferation of claims of superiority, as exemplified by pronouncements of “best dentist,” “No. 1 dentist” and “top dentist” all ironically within close geographical proximity, shifts the emphasis from genuine collaborative patient care among colleagues to that of aggressive competition. Receivers of service become customers, which alters the nature of the dentist-patient relationship and helps to further increase the outside influences of investment bankers, management consultants and lawyers. The impact of commercial business model ethics upon dental professional ethics has the significant potential to alter the nature of rendering dental services within this landscape.

As individual practitioners have engaged less within the dental community at large, membership in the ADA has decreased, leaving less of a unified voice for dentists. Yet, special-interest groups such as ethnic dental societies, recognized specialty organizations and other specific interest groups have become more pervasive.

Along with these varied groups comes unique sets of goals, philosophies and ethical standards. With such diversity among the many participants within the profession, there is an alarming lack of engagement with each other and a failure of leadership to break down barriers. The result of this fragmentation SEP TEMBER 2 0 2 0 439

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creates an opportunity for confusion as to the rules of the game along with a lack of respect and understanding of each of our differences in the approach to ethics.

Traditionally, technological advances in dentistry have been slowly and methodically adopted with some never being fully utilized and others pervasively incorporated into practice over time. Yet currently, as in most aspects of modern life, the disruption of processes and the tools created by technology into modern dental practice have seeped into every aspect at a never seen before pace. We can glance into the future by looking to see what is happening currently in dental school education across the country. Technology is being used to create innovative learning environments in which the digital workflow is optimizing every aspect of dental education. Course work and clinical work are video teleconferenced to remote sites. Data analytics are used to support student success and predict clinical outcomes. Electronic records and research are connected across networks to provide greater access to information in real time. Those students graduating from institutions having technology ingrained within the educational process will know little of the past analog world.

These same new dentists who have grown up in the digital world will expect the seamless continuation of technology upon embarking on their careers. Technology may be the single most influential factor in changing the way dental services are distributed and performed. Along with the digital age comes great entry costs and the influence of the providers of the technology who in many instances wish to partner with dentists on an ongoing basis in the form of updates, upgrades and additional fees. The need to have the latest and greatest places pressure on dentists to keep up with the “competition” or be perceived as less 440 SEP TEMBER

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competent. To proclaim possession of the newest devices can be even more powerful in some instances than the actual use of the device in practice. Unfortunately, occasionally patients unwittingly become the proving grounds for these advances in which tweaks are necessary to improve the technology’s performance.

Direct-to-consumer technology is also disrupting the delivery of care. Do the receivers of the technology’s products transform into “consumers” rather than “patients” when the dentist is largely bypassed in the equation? The ethical

Technology is being used to create innovative learning environments in which the digital workflow is optimizing every aspect of dental education. challenge in the utilization of new technologies is to successfully integrate the touchstones of trust and integrity so that innovation will enhance not overrun basic professional values.

The Dentist-Patient Relationship

The vast array of factors affecting the practice of dentistry can be overwhelming in the context of integrating these changes into everyday practice. The desire may be for some to disengage rather than embrace the inevitable. Perhaps with useful decisionmaking tools to process and assimilate the information, we can work toward understanding the circumstances in which dentistry will operate in the future.

Before an ethical decision-making process can be proposed, a framework for dentist-

patient interaction should be considered as a foundation so that decisions can be made for the mutual benefit of the parties involved. As presented by Ozar et al.,8 the interactive model of the dentistpatient relationship seeks to describe an ideal scene that sets goals to maximize patient autonomy while the dentist contributes their abilities, expertise and protections to the patient as an ethical professional. In this model, collaboration is the foundation with the dentist and patient having equal standing within the interactions of making choices.

Although the relationship is said to be equal, it originates from differing grounds. The patient brings their values and independence knowing it is their life that will be directly impacted by the interaction. Concurrently, the dentist brings the qualities of being able to apply their knowledge and skills in enhancing the patient’s ability to take control of their bodies. The exchange is far more interactional than the mere signature on a boilerplate informed-consent document. In this model, dentists and patients are seen as being on the same team, so to speak, such that each party’s unique contributions of judgments, choices and values can coalesce to produce shared actions. Within this framework, the obligation is to the patient’s autonomy through education, unbiased discussion rather than sales pitches disguised as informed consent and an overall commitment to the patient’s well-being. Care and collaboration are paramount in this model rather than competition and one-sided gains as might be seen in a typical business relationship.

The ideal model can perhaps even be taken a step further as described by Chambers,7 such that each participant will “act so that no one involved in or affected by our actions, including ourselves, would be motivated to act

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differently.” Thus, it can be conceived that all involved will thrive when each party grounds the relationship in ethics.

Core Values

Of course, a model of an ideal dentist-patient interaction is valuable as a concept to aspire, but also presumes both parties are willing participants.

Is it possible in today’s landscape that the ideal relationship proposed here is becoming less of a likely interaction?

Consumers by definition may act differently than patients. Furthermore, is an increasingly fragmented profession of individual practitioners struggling with how to deal with quantum leaps in technology sending the best messages to the public? Is society truly still interested in having the continued trusted relationships an ideal model represents or is the preference merely a series of transactions based on conveniences, potentially manipulated online reviews or third-party payer dictates?

These factors make it even more crucial for the dentist-patient relationship to have grounding in the core values of the dental profession.

The combination of an ideal interaction between dentist and patient along with essential core values establishes a reference that can be communicated among fellow professionals and then ultimately utilized to serve the public.

As described by Ozar et al.,8 dentistry’s central practice values are practiced by dentists but for the benefit of patients. No one dentist establishes these professional values that are received by patients, rather they evolve over time through dialogue between the dental profession and society. These values are central practice in that they represent the essence and permeate every aspect of the dentist’s professional life. In all professions, there are values

that are essential to its particular practice.

Within dentistry, six hierarchically ranked central values can be identified: ■ The patient’s life and general health.

■ The patient’s oral health.

■ The patient’s autonomy.

■ The dentist’s preferred patterns of practice.

■ Aesthetic values.

■ Efficiency in the use of professional resources.

This approach is designed in a preferential manner to maximize the central values so positive outcomes can

aesthetics and the resilience to maintain such a status, we can prioritize oral health next in line as a value as long as a life-threatening circumstance does not exist. As previously discussed, patient autonomy is of primary importance in the dentist-patient collaboration. Yet, a dentist would be potentially acting unprofessionally by complying with a patient request that endangered the patient’s oral or general health. The dentist’s preferred patterns of practice include a wide range of considerations.

Treatment philosophies, practice location, equipment selection, auxiliary utilization and management styles are among the many practice-pattern choices the dentist Aesthetic values must be makes. In some instances, there may be small differences and in others a wide considered in the dentistschism between patient desires and a patient relationship in that dentist’s practice patterns. Keeping in appearance can have a mind the ideal interactive relationship in which it is the dentist’s role to enhance psychological connection to the patient’s ability to maintain control oral and general health. over their body, practice patterns might not be in line with patient autonomy.

In such a situation, emphasizing the be achieved over less desirable ones. The goal for all parties to thrive together and emphasis is on the process such that the to not feel a need to act otherwise, there goals are shared and transparent. In contrast could be several outcomes. Options might to health care’s HIPAA protections, the involve the complete revision of a practice lack of transparency in the multibillionpattern, patient choice shift through dollar business of electronic data collection education or ultimately disengagement and monetizing would be inconceivable between the parties in the relationship. and illegal. It would be safe to say that Aesthetic values must be considered in although a dentist’s primary concern would the dentist-patient relationship in that be a patient’s oral health, life and general appearance can have a psychological health would typically take precedence. connection to oral and general health.

Of course, we realize the important Further consideration must also be relationship between the two, but it would given that in many instances, perceived be unwise for a dentist to act in a manner intraoral aesthetics vary between that would place a patient’s life in danger. personal, professional and community The state of oral health as with general standards. Yet, to potentially violate a health is not a simple matter to define. For practice pattern of damaging otherwise our purposes now, if we think in terms of healthy oral structures to comply with a a condition of being pain/infection-free patient request for a particular perceived along with individually tailored function/ aesthetic procedure would be acting SEP TEMBER 2 0 2 0 441

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unprofessionally even though respecting patient autonomy. Efficiency in the use of professional resources is a component of dentistry’s central values in that time, effort, materials and expertise should be judiciously utilized, as these resources are not unlimited. This value would take a relatively lower position in the hierarchy than the other concerns that might more commonly relate directly to an individual patient’s well-being.

Ethical Decisions

This value-optimizing hierarchical method can be effectively utilized as an aid in the ethical decision-making process. In any given dentist-patient situation, the priority is given to the highest-ranking value. Thus, in considering extensive dentoalveolar surgery along with placing multiple dental implants for a medically compromised patient, the patient desire to function better (autonomy) and improve their chewing ability (oral health needs) could potentially be outweighed by the general health and life value considerations if such treatment would harm the patient’s overall health.

Of course, there are many straightforward scenarios, whereas other ethical dilemmas require more intense considerations. The use of the central practice values will not necessarily make ethical decisionmaking simple but can provide a general structure to start the conversation.

As proposed by Peltier,9 five steps are included in his discussion of how to use the central practice values to aid in an ethical decision-making process. Of course, the discourse on how to make an ethical decision is broad and deep with no one process able to satisfy all situations.

The proposed steps can be effectively used as a tool in the decision-making process though.

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For most ethical decisions, these five steps can be followed as a framework while keeping in mind the interactive relationship of dentist-patient and the central practice values. Of course, in some situations the chosen path may become apparent in fewer steps.

■ Make a list of the available choices including ones that are liked and disliked.

■ Make a list of the professional values that come into play.

■ Determine the possible positive and negative outcomes of the actions on the list.

■ Rank the list of choices relative to the values involved within the hierarchy.

■ Justify the rankings with the possible outcomes or consequences and reconcile them with the values of the profession.

The ethical decision-making process can sometimes seem somewhat mysterious rather than a thoughtful consideration of information and possible outcomes. There is no one absolute method. Sometimes even engaging friends, family, colleagues, mentors, educators, religious leaders or even a gut check can be helpful in the process.

Using as many of the five suggested steps as applicable along with a firm footing of interactive relationships and central practice values, let’s take a look at the multifaceted example of developing a professionally ethical advertising and marketing campaign for a dental practice to clarify the process.

1. Available choices: Advertise now?

Delay to another time? Never endeavor into the advertising realm? If so, in what or how many different media — print, online, radio, television, sky writing?

Hire a media manager to handle the project or do it without

experienced help? How much exposure is needed? What will be the cost of the campaign? If the choice is to not develop a program, how else will it be possible to reach potential patients?

2–5. Professional values to consider and possible consequences/ justifications to consider: ● Use of professional resources is not an overwhelming factor in this scenario, but certainly spending an overabundance of effort on the advertising campaign may or may not be a wise use of more patientoriented time. Typically, an advertising and marketing effort requires repeated exposure to be effective.

Financial resources could be wasted if not used wisely, thus leaving less resources available for other practice operations. ● Aesthetic values could be relevant in that some prospective patients may be interested in these services and a well-conceived truthful advertisement could aid in matching dentists and prospective patients. Yet, an overblown ad campaign could give a patient unrealistic expectations of results damaging the dentistpatient relationship from the onset. Conflicts could arise between dentistry’s traditional values regarding aesthetics and more fashionable market-based trends. ● A dentist’s preferred pattern of practice would weigh significantly on the decision of whether to or how to advertise. Heavily advertising on the radio or a

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television campaign may suit some dentists whereas others may be more comfortable with an informative newsletter periodically distributed to existing patients. Others may prefer to use no external marketing, relying solely on internal word-of-mouth practice promotion. Each of these choices could be wellsuited to achieve a dentist’s particular style of practice. ● Patient autonomy as discussed previously is central to the interactive relationship such that the dentist’s primary contribution is to provide the patient with trusted assistance necessary to make choices pertaining to their oral and overall health. Yet, unlike a business-model marketing campaign in which a businesscustomer relationship might be described as “buyer beware,” the dentist-patient relationship is steeped in the professional responsibility of the dentist to respect and support the patient’s ability to make autonomous decisions. Thus, a positive outcome of marketing in a manner that is truthful and patient-benefit centric enhances patient autonomy through its motivational and educational effects. Conversely, pursuing a marketing campaign that is filled with exaggerated claims demonstrated by perfect-smile, tooth-model images rather than actual patients, confusing fee offers and claims of superiority such as “top dentist,” “No. 1 dentist” or “best dentist” would have

a negative effect on patient autonomy. A patient would have no objective means to decipher which dentist is top or best or which procedures were actually performed by the dentist in a particular timeframe with fees that are not relatable to a specific procedure. Dissemination of such claims in which there is no supportive verifiable criteria would not aid the patient’s ability to make informed autonomous choices.

Perhaps the process would even be hindered by overstated assertions, as these stray from the principles of truly ethical interactive relationships and central values. As a natural extension, a claim by a dentist to be “top,” “best” or “No. 1” would necessarily mean that all other dentists are none of those things. Strangely, within the same geographical location, it is not uncommon to find dentists making those claims. The potential message to the public in such a campaign is one of competition in an aggressive marketplace in which trust and integrity are diminished. ● Oral and general health values can be well served when marketing and advertising efforts are supported by the other underlying central values in dentistry. A well-crafted and thoughtful campaign based with its origins in the professional ethical values of truth and integrity can help stimulate patients of various levels of sophistication to

realize the importance of oral health care and its relationship to overall health.

Conversely, advertising containing mixed messages and unsupported information could repel patients who are truly in need of what dentistry has to offer. Of course, there are other methods and individual conclusions that can be reached, but as demonstrated using a combination of central values and interactive relationships in a thoughtful format, an individual dentist’s decision on a host of issues can be broken down into more straightforward components.

The goal of this uncoercive process is to yield what is professionally desirable for the mutual benefit of the parties concerned.

Summary

In a world of multiple conflicting considerations, what does the future hold for professionalism in dentistry? Of course, there is no one simple, clear answer with so many at the table and so much at stake.

Considering the average educational indebtedness incurred by new graduates is approaching $300,000,10 third-party payer dominance in setting reimbursement structures and government regulatory intrusion, the actual undertaking of performing dentistry almost seems mundane.

This in combination with the challenges of patient procurement, rising operational expenses and staffing all packaged up as the cost of doing “business,” it is a wonder that there are still willing entrants to the SEP TEMBER 2 0 2 0 443

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profession. It is inconceivable that the trajectory of these trends will be slowed as time passes. As described by Chambers,7 the emerging professional tide is being shaped by several crucial factors.

Individual dentists are practicing in relative isolation with great leeway regarding ethical values. There is a trend of replacing trusted ongoing relationships with bundles of commercial transactions.

Fragmentation amongst organizations exists creating less engagement along with mixed interpretations of ethical behavior. Management of technological advances will be increasingly necessary to preserve the primary professional obligation of appropriate care versus service over utilization. Dentistry’s destiny will not be determined in isolation.

Individual practitioners and organizations need to understand the value of a professional community engaged with the public in order to positively shape the future. Ethnic, recognized specialty, public health, special interest, dental schools, government and commercial enterprises must be willing to engage

with full understanding that society is rapidly evolving. This should not be attempted on a large-scale effort only, but by each party in conjunction with small daily ethical changes in once otherwise routine behavior. Although there are great expectations placed on individual dentists and the profession in its entirety, we must remember that dentists are merely human and their organizations are the same with all of the trappings that come along. Yet, dentistry’s ace-inthe-hole superpower is its foundation of ethical interactive relationships combined with core values in ethical decision-making, which traditional business still struggles to integrate.

Among the present essential tasks is the call to interested leaders throughout the profession to show the way through engagement at every level that ethics is not only a means of judgement and punishment, but a mutually beneficial attribute on par with technical acumen and business prowess that can be uniquely merged for the shared betterment of dentists and patients alike. n

REFERENCES 1. Dental Board of California. Adopt Section 1065 of Division 10 of Title 16 of the California Code of Regulations. www.dbc.ca.gov/ formspubs/1065mt.pdf.

2. Deber RB, Kraetschmer N, Urowitz S, Sharpe N. Patient, consumer, client or customer: What do people want to be called?

Health Expect 2005 Dec;8(4):345–51. doi: 10.1111/j.13697625.2005.00352.x.

3. Deber RB, Kraetschmer N, Urowitz S, Sharpe N. Do people want to be autonomous patients? Preferred roles in treatment decision-making in several patient populations. Health Expect 2007 Sep;10(3):248–58. doi: 10.1111/j.1369-7625.2007.00441.x.

4. Friedman M. The social responsibility of business is to increase its profits. The New York Times Magazine Sept. 13, 1970. umich.edu/~thecore/doc/Friedman.pdf.

5. Edgecliffe-Johnson A, Mooney A. Touting kinder gentler values in business. Los Angeles Times Dec. 26, 2019. www.pressreader.com/ usa/los-angeles-times/20191226/281840055578687.

6. Business Roundtable. Business Roundtable redefines the purpose of a corporation to promote ‘an economy that serves all Americans.’ www. businessroundtable.org/business-roundtable-redefines-the-purpose-of-acorporation-to-promote-an-economy-that-serves-all-americans.

7. Chambers DW. Ethics Report: New Professionalism. 4th draft.

Gaithersburg, Md.: American College of Dentists; June 2019.

8. Ozar DT, Sokol DJ, Patthoff DE. Dental Ethics at Chairside: Professional Obligations and Practical Applications. 3rd ed.

Washington, D.C.: Georgetown University Press; 2018.

9. Peltier B, Jenson L. Dental Ethics Primer. Gaithersburg, Md.: American College of Dentists; 2017.

10. American Dental Association Health Policy Institute. Health Policy Institute: Educational debt in numbers, 2019 graduating class. www.ada.org/en/publications/new-dentist-news/2020-archive/ february/health-policy-institute-educational-debt-in-numbers.

THE AUTHOR, Kenneth Jacobs, DDS, can be reached at kjjdds@msn.com.

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Treatment Planning: Making a Case for Its Ethical Importance Gary Herman, DDS

a b s t r ac t The treatment planning process is a continuing source of problems

associated with current practices in dentistry; it is difficult to teach well and deals with a wide range of ethical principles and behaviors that are critical to the maintenance of the profession and to successful practice today.

AUTHOR Gary Herman, DDS, teaches at the University of California, Los Angeles, School of Dentistry and lectures on ethics, dental law and patient management. He is past chair of the ADA Council on Ethics, Bylaws and Judicial Affairs and was a member of the CDA Judicial Council.

Conflict of Interest Disclosure: None reported.

W

hen I was asked to contribute to this issue featuring ethics, I chose to focus on a topic that is both significant and timely. Treatment planning is an important procedure in dentistry for several reasons. The treatment planning process is a source of problems for many dentists currently practicing. It is difficult to teach well in school due to the complexity of options and the variability of faculty,1 and it deals with a wide range of ethical principles and behaviors that are important to the profession and to a successful practice.

I will make a case that helps dental practitioners in different practice settings understand that spending the time and effort at the beginning of treatment is a good way to develop patient rapport, prevent misunderstandings and provide a basis for patient communication that will help achieve the goal of patient-centered, ethical quality care.

What Is Treatment Planning?

A treatment plan is defined by the American Dental Association (ADA) as “the sequential guide for the patient’s care as determined by the dentist’s diagnosis and is used by the dentist for the restoration to and/or maintenance of optimal oral health.2 Although that sounds relatively simple and straightforward, the process of achieving that plan is complex, with many places for individual variations, personal practice values as well as many opportunities to skip steps and take shortcuts. Treatment planning has three primary and necessary components that are integral to the overall process: the patient examination, the development of the treatment plan and the treatment presentation.

The first component of treatment planning is the examination. All examinations should include a thorough evaluation of the patient’s past and present medical history, the patient’s medications and supplements, recent

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medical interventions including hospitalizations and, if necessary, consultations with the patient’s physician to clarify information and suggest modifications to treatment, if needed. It is appropriate to include the recording of vital signs, especially blood pressure. This may help find patients who have undiagnosed disease as well as those patients whose disease is not as well controlled as it should be.

The examination should continue with thorough intra- and extraoral examinations as all dentists are trained to perform. A detailed description of a complete patient examination goes beyond the scope of this article; however, it should include more than just teeth. Periodontal and endodontic considerations must be included. The patient’s oral hygiene and motivation must be evaluated.

Missing and hopeless teeth, evaluation of caries risk, prosthetic replacement options, temporomandibular joint issues and addressing a patient’s chief complaint, if any, are all integral to the process.

The next aspect of the treatment planning process is synthesizing the patient data and creating a problem list. The list includes procedures that should be addressed, regardless of whether treatment is delivered or deferred. Once the problem list is established, it is time for the dentist to compile a sequential treatment plan or several plans to address the options for comprehensively treating the patient’s needs and wants. It should be noted that the problem list should be developed after a general discussion with the patient regarding their specific concerns.

The activity discussed thus far leads to the treatment presentation. This final part of the process is, arguably, the most ethically relevant. The treatment presentation is critical to providing the patient with the information in a form the patient can understand regarding dental 448 SEP TEMBER

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options, the risks and benefits of each option, the costs and time of treatment as well as the risks of not treating the problems. All of this information is vital to obtaining a free and fully informed consent from the patient, a primary ethical concern of all health care professions.

The Ethical Significance of Treatment Planning

Ethical principles have been developed by the profession, in this case dentists, to provide guidance to members of the profession on actions that strengthen the profession and protect the patient. The earliest guide to the ethics of dentistry in the United States, originally adopted in 1866, was the ADA Principles of Ethics and Code of Professional Conduct. The document was divided into four basic principles and has specific conduct attached to each principle. Those principles were autonomy, nonmaleficence, beneficence and justice.3 Today, those four principles still remain and have been joined by an additional principle: veracity.

Dentistry 150 years ago presented a picture of a trade being transformed into a profession, with training predicated upon education rather than apprenticeship.

At the time, the field of dentistry was full of charlatans, patent medicines and individuals with widely differing skills attempting to treat the public. The organization of the profession was built upon the responsibility to focus on the rights of and the benefits to the patients, above all else. The four principles adopted all speak to the protection of and benefit to the patient, not the dentist.

Treatment Planning Is the Heart of a Primary Ethical Principle

Treatment planning, as described above, is the primary concern of the first principle identified by the founders of

organized dentistry, specifically: “Under the principle of patient autonomy, the dentist’s primary obligations include involving patients in treatment decisions in a meaningful way, with due consideration being given to the patient’s needs, desires and abilities …”4 Even the preamble of the ADA code “calls upon dentists to follow high ethical standards which have the benefit of the patient as their primary goal.”4 It could be argued that once the founders of the ethical principles wrote the preamble, their goal would be likely to address their greatest concern first. By this reasoning, the concept of patient autonomy would have likely been one of the most important concerns that the profession chose to enumerate.

Treatment Planning Is Represented in All of the Ethical Principles

Besides being the highlight of the first principle providing patient autonomy, treatment planning and presentation can be found playing a role in the other principles. The next principle listed is nonmaleficence, commonly known as “do no harm.” Generally speaking, it relates to providing good care based upon training and practice. It also addresses issues related to referrals to specialists when indicated. In the discussion of referral for a second opinion, the dentist rendering the opinion should have the interest of the patient in mind and not a vested interest.

Providing good care frequently comes down to an evaluation as to whether the standard of care has been met or not. This does not only refer to the end result of the product of dental treatment but would certainly also be considered when evaluating the process that results in the determination of a treatment plan.

A dentist who has a dissatisfied patient can certainly be evaluated as to the results of the treatment performed. It is

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fairly straightforward to establish if the dentistry provided meets the standard of care. Additionally, the dentist may find it necessary to show the process used to establish the particular treatment choice or choices given to the patient. It is likely that the standard of care would be applied to the overall process of determining necessary and appropriate treatment as well as the acceptability of the specific treatment rendered. A cursory review of disciplinary actions against dentists shows many instances where dental care options were not discussed or documented; treatment options were limited to a choice of one, when multiple options were available; and specific treatment options were being offered when the treatment was of questionable value or not necessary.

As a principle, nonmaleficence seems to be appropriately included in the discussion of diagnosis, treatment planning and treatment presentation as areas where the standard of care can be applied and where practicing below that standard of care can cause harm to the patient.

The principle of beneficence, that is “doing good,” specifically states that the most important action is the “competent and timely delivery of dental care within the bounds … presented by the patient, with due consideration being given to the needs, desires and values of the patient.”5 The treatment planning process fits well into this principle.

Providing the patient with the ideal as well as other acceptable treatment options meets the guidance above and is even more appropriate when viewed with the further requirement not to provide different treatment plans for people with different types of practice arrangements.

Proper treatment planning should provide a plan that provides optimum care for the patient. If the patient has few resources, alternative plans that are less expensive

are not only nice, they are necessary.

The principle of beneficence admonishes dentists to make sure they are diagnosing for the patient within their circumstances, not based on a third-party contract and how that will affect the dentist.

Justice, or fairness, is probably the principle least obviously associated with treatment planning. That being said, the principle of justice includes the concept of justifiable criticism. If presented with the responsibility to provide a second opinion, it is likely that in order to provide that opinion, one must evaluate

The organization of the profession was built upon the responsibility to focus on the rights of and the benefits to the patients, above all else. the original treatment plan to determine if it is within the standard of care. It would be necessary for the examining dentist to thoroughly look at both the original and next dentist’s treatment plan in order to determine if the treatment is not only sound, but also appropriate.

The final, more modern, ethical principle is veracity. To that end, the essence of an appropriate treatment plan is truthfulness. Dentists generally have an advantage over most patients in that they have a greater understanding of both the patient’s condition and the available treatment options. If the treatment plan is complete, thorough, well presented and fully factual, including risks, benefits and alternatives, its veracity will likely be recognized by the patient and, through truth, will lead to trust.

Consequences of Failures in Treatment Planning

Another way of looking at the importance of the treatment planning process is to examine failures of that process and evaluate the results of those failures. To that end, the Dental Board of California provides the public with information regarding disciplinary activity against dentists. The dental board receives complaints from patients and other sources, including other dentists, insurance carriers and law enforcement.

After preliminary investigation, the dental board may choose to fully investigate and, when appropriate, place specific requirements on licensees as a condition of discipline. These actions often include required educational classes in specific areas that the board feels would address the deficiencies of the dentists being disciplined.

To evaluate the comparative frequency of topics requiring remediation, the monthly reports regarding dental board remediation, known as the Hot Sheets, were reviewed for October 2018 to December 2019. All dental board actions, which included probation of the dentist or a letter of public reproval for the dentist, were examined to determine if the disciplinary order contained a remedial education requirement. The specific educational topics needed were logged.

It should be noted that some dentists had no requirements and others had several areas that required remediation.6 The results of this dental board evaluation revealed 25 remediations for treatment planning, 25 for recordkeeping, 16 for ethics, seven for practice management and 39 for didactic training (various disciplines; no single discipline had more than eight).

This data does not readily lend itself to complex statistical analysis, but an overview does help draw some useable SEP TEMBER 2 0 2 0 449

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inferences. Although treatment planning and record-keeping were equally represented as the most frequent remedial topic, it should be understood that complaints to the dental board are never for poor record-keeping. This is always an ancillary finding when the dental board investigates a complaint and tries to decipher the dentist’s records to evaluate the complaint.

That is not to say that poor recordkeeping is not an ethical lapse. In such cases, it could be assumed that the principles of nonmaleficence and veracity are both potentially violated.

Another valuable insight occurs when one looks at those cases where treatment planning is required along with record-keeping. Of the cases requiring treatment planning remedial education, fully one-half of those also included an additional requirement for record-keeping. In general, it can be concluded that problems associated with treatment planning are a significant factor in patient complaints to the dental board, whether the patient realizes it or not. Failure to inform the patient of what will occur, failure to provide options of care and failure to receive informed consent may all result in a less than complete treatment plan.

The occurrence of both treatment planning issues and record-keeping problems is not likely coincidental.

As described, the treatment planning process is detailed, comprehensive and may be quite time consuming. Most dentists find chart documentation to be time consuming as well. Do these dentists find crown preparations a timeconsuming process? The short answer is no because they are generating income when preparing a crown, but not when preparing a procedural note in the chart or gathering essential data to help 450 SEP TEMBER

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deliver a thorough, well-documented and easy to explain treatment plan.

In dentistry, the common excuse regarding lack of time to do a thorough exam and treatment plan could be further expressed as “time is money.” Although anecdotal, many dentists complain that their patients will not allow them to charge for examination or discussions or at least will complain. The patients only want to pay for tangible dentistry.

This seems to illustrate that in some way the profession has lost its way.

In comparison, medicine charges principally for examinations and patients expect to pay for them.

Conversely, in dentistry, whether due to a focus on product advertising or by not consistently explaining charges, many dentists seem to feel compelled to undercharge or undervalue their time related to examination and diagnosis.

It is human nature to expend time and energy when there is a probability of achieving a reward, whether this relates to managing a dental practice or playing golf. Without a reward, it is easier to extinguish a behavior. If a dentist chooses to do a cursory evaluation and delivers an immediate treatment plan to the patient, there is a danger of providing an incomplete and inappropriate plan. Additionally, there is a likelihood that the plan will not include all options and likely will not have achieved the patient’s full understanding. These factors all lead to the potential of a failure to provide a free and fully informed consent.

Surprisingly, in that situation there is a significant possibility that the dentist may be actually decreasing the chances of obtaining the patient’s acceptance.

Dentists need to be reminded that the time needed to perform a

thorough examination and develop a comprehensive treatment plan is necessary. It ensures that patients are well-informed, aware of all of the options, feel their questions and concerns have been addressed and carry the opinion that the dentist has their interests at heart. This is a scenario that will lead to the best outcomes both for the patient and the dentist.

Conclusions

The treatment planning process is the primary focus of the very important ethical requirement of autonomy of the patient in dentistry, historically and today. It is also represented and discussed in all of the remaining ethical principles of the profession.

It is recommended that dentists should reflect on the fact that one of the most important things we do is provide patients with our time.

Taking shortcuts to decrease the time spent with patients examining, planning and obtaining consent can have a substantial effect on the dentist’s success and overall satisfaction of their profession. It can also significantly affect the satisfaction of the patient. n

REFERENCES 1. Gordon SR, Kress GC. Treatment Planning in Dental Schools.

J Dent Educ 1987 May;51(5):224–8.

2. American Dental Association. Glossary of dental clinical and administrative terms. www.ada.org/en/publications/cdt/ glossary-of-dental-clinical-and-administrative-terms.

3. Transactions of the American Dental Association at its Sixth Annual Session. Dental Cosmos 1866 Sept;8(2):88–90.

4. American Dental Association. Principles of Ethics and Code of Professional Conduct. 2018:4.

5. American Dental Association. Principles of Ethics and Code of Professional Conduct. 2018:6–7.

6. Dental Board of California. Hot sheets — summaries of administrative actions, October 2018 through December 2019. www.dbc.ca.gov/consumers/hotsheets.shtml.

THE AUTHOR, Gary Herman, DDS, can be reached at ghermandds73@gmail.com.

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How Dentists Can Avoid Bad Choices Robert D. Stevenson, DDS

AUTHOR Robert D. Stevenson, DDS, practiced general dentistry in the Inland Empire area. He is an assistant professor at the Western University College of Dental Medicine and is responsible for ethics and jurisprudence education. Dr. Stevenson also served on the CDA Judicial Council.

Conflict of Interest Disclosure: None reported.

E

veryone faces an array of decisions every day. These range from very simple choices to extremely complex ones. At one end of the spectrum, decisions require little thought; they are made almost automatically. At the other end, decisions may demand significant mental effort. The intensity of consideration does not always correlate with the seriousness of the decision.

This paper will leave the serious philosophical discussions for the philosophers. Instead, it will attempt to answer the question of how one can avoid making bad choices. Principles of ethics and professionalism will be evaluated in the context of the professional codes of ethics of dentistry. Emotional intelligence will be introduced as a skill to guide wise decisions.

Everyone makes choices that fall on various points along the spectrum.

The associated consequences will also vary. Those who experience the extreme consequences tend to be the outliers. These are the individuals who often appear in the news.

Why do people make bad choices? Can one who is innately “good” make a bad decision? And once that choice is made, does the individual become innately bad?

Many years ago, a railroad mixup occurred in which a passenger car traveled from Oakland, Calif., to Newark, N.J. Much to everyone’s

consternation, the baggage car did not make the same journey.

As railroad workers retraced the paths of the two cars, they discovered that a switchman in St. Louis carelessly moved a small piece of steel just three inches, then pulled a lever to uncouple the car. That small action sent the baggage car to New Orleans instead of to Newark.

In similar fashion, small decisions can derail one’s ambitions or send them far from the intended goal.

Each individual’s character is the result of many small decisions: They become the product of their choices.

Consider that for a moment. The decisions an individual has made in life have led them to where they are today. At various points in their life, a dentist made decisions that led them to dental school. Once in dental school, the dentist made many different decisions that helped them complete the requirements for graduation. Poor choices may have delayed their graduation. Some decisions were made that determined where and how the dentist practices.

Although no one intends to stray as far as the baggage car did, occasionally poor choices are made that can lead one far from their intended destination.

Some of those choices have minimal effects. Others are more significant and bring weighty consequences.

Most dentists will be able to avoid the epic bad choices that make the SEP TEMBER 2 0 2 0 451

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news, but no one leads a mistakefree life. While dental codes of ethics emphasize acting in the patient’s best interests, this discussion will also include unethical acts outside one’s practice.

When a dentist makes an outstandingly bad choice, it becomes public knowledge. One can easily find accounts of dentists who have overtreated patients, committed insurance fraud or made bad treatment decisions. Others were convicted of crimes ranging from substance abuse to arson.

How can a good dentist make choices that will keep them on the right track and help them avoid bad behavior?

To begin with, let us look at business ethicist Chuck Gallagher’s insights.

Gallagher suggests that bad behavior comes from the confluence of need, opportunity and rationalization. He states that among fraud auditors, these are referred to as the “fraud triangle.”1 In a dental practice, need equates with the business pressures the dentist faces as they strive to meet production to pay bills and earn a living. But other needs may also influence a dentist to err when the opportunity arises. Gallagher remarked that “without opportunity, there is no fuel for the potential unethical fire.”2 Rationalization is sometimes referred to as the glue that holds unethical behaviors together.

Rationalizations are the excuses one gives for their own unethical behaviors. Continued rationalization will dull one’s sense of responsibility for their own wrongful actions and facilitate additional poor choices.

Despite best intentions, there is a gap between how individuals see themselves and how they behave. This gap also suggests a need for additional ethical training and an even greater 452 SEP TEMBER

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need for training in the ability to assess oneself in connection with their own ethical standards. This gap could be filled in part by regular review of the codes of ethics provided by our various professional organizations.

Ethical Considerations

When evaluating behaviors, it is often effective to bring ethics into the conversation. This provides common ground for dentists of varying backgrounds to understand one another.

Without this foundation, cultural,

While dental codes of ethics emphasize acting in the patient’s best interests, this discussion will also include unethical acts outside one’s practice. religious and other differences may cloud the understanding. These codes were created to guide the dentist in navigating the ethical challenges that confront everyone. The dental profession has promoted ethical behavior through its codes for many years.

The California Dental Association (CDA),3 American Dental Association (ADA),4 American College of Dentists5 and other dental organizations have all developed or adopted codes of ethics and professional behavior. These codes serve as guides for professional behavior for each dentist as they strive to make good decisions in practice and in life.

The codes also serve as a reminder that, “The privilege of being a dentist comes with a responsibility to society and to

fellow members of the profession to conduct one’s professional activities in a highly ethical manner.”6 The codes are “intended to heighten ethical and professional responsibility, promote ethical conduct in dentistry, advance dialogue on ethical issues and stimulate further reflection on common issues in dental practice.”7 The principles of ethics and the core values, along with the associated advisory opinions, form a foundation for understanding as well as an incentive for improved behavior.

Remember, each dentist recommits to abiding by these principles every year as they renew their membership in organized dentistry.

Nevertheless, these codes of ethics may be considered somewhat limited in their scope, as their application is primarily directed toward service to the public, conduct in a dental office and between practitioners and promotion of dental services8 as well as for the benefit of the patient.9 Only Section 4 of the CDA Code, Violation of State and Federal Laws, refers to activities outside the office.10 The ADA Principles of Ethics and Code of Professional Conduct mentions five key ethical principles, which are reviewed below.

Autonomy is perhaps the most important ethical principle. Autonomy is understood as one’s right to selfdetermination: the right to make choices and to act on them. The professional codes refer to this as “patient autonomy,” but that does not eliminate the dentist’s own right to self-determination. Either way, this right is not ethically absolute.

The thoughtful dentist endeavors to respect their own autonomy through making good decisions.

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The principle of nonmaleficence frequently conflicts with autonomy.

The ethical dentist strives to avoid harming others. An individual’s freedom to choose should not cause harm to another individual.

When making a bad choice, one may lose sight of this limitation.

Beneficence is centered on the dentist’s duty to act for the benefit of others, particularly in relation to the patient. Helping others was the reason many practicing dentists and students gave for wanting to become dentists.

The obligation of beneficence outside the practice may be inferred, but it is not expressly stated. However, the obligation to do good does not end when the office doors are locked.

The principle of justice may also conflict with autonomy. Ethically stated, justice equates with fairness.

The right to choose may infringe upon another’s right to be treated fairly. Choosing to practice while impaired, just like choosing to drive while impaired, is an example of a violation of justice because of the unfair harm to others that may ensue.

Veracity emphasizes one’s duty to be honest and trustworthy in one’s dealings with people. It connects closely with integrity.

Batson and Thompson stated: “It is often assumed that moral individuals want to be moral, to display moral integrity. But our research suggests that at least some individuals want to appear moral while, if possible, avoiding the cost of actually being moral. We call this motive moral hypocrisy.”11 Their paper brings out an important point. Most people intend to behave ethically (or morally), but when faced with a difficult decision, they may not be willing to pay the price to act according to their beliefs.

The opportunity costs associated with ethical behavior may be prohibitive for some, while others find them very affordable. Why is this the case? Why do some dentists consistently make wise choices while others struggle?

Published studies help to shed some light on these questions.

Studies

In a recent study, Chambers evaluated discipline records in four states, including California. He categorized discipline according to dentist age, demographics

Choosing to practice while impaired, just like choosing to drive while impaired, is an example of a violation of justice because of unfair harm to others that may ensue. and category of violation. He grouped violations under technical incompetence, practice management problems or personal issues. He found that violations in one category were often connected with violations in one of the other categories.12 Chambers reflected that “dentists ‘learn’ either good or bad habits and perfect them over time” and suggested that this comes in part as practice circumstances interact with care patterns.13 This agrees with Gallagher’s statements referenced above.

Papadakis is known for her studies correlating behavior in medical school and discipline by state medical boards.

In a review of UCSF graduates who were disciplined by the California Medical Board, she concluded that, “We have, for the first time,

demonstrated that unprofessional behavior in medical school is associated with unprofessional behavior in practice.”14 In a follow-up study, she examined graduates from three medical schools and board discipline in 40 states. The study found that medical students who were disciplined for professionalism were three times more likely to be disciplined as practitioners by their state medical board.15 Papadakis did not categorize infractions in her studies.

Munk evaluated 1,100 disciplinary action reports from 21 states. He categorized the dentists’ infractions as cognitive intelligencerelated, technical intelligence-related and emotional intelligence-related. In his analysis, the cognitive category was limited to organic mental conditions; the technical category included dental hand skills as well as critical thinking skills; and the emotional category included criminal violations as well as moral and ethical violations.

The focus of Munk’s study was on the emotional intelligence-related infractions.

He found that multiple studies have been done on students and emotional intelligence but stated that, “No published studies have been found that attempt to correlate emotional intelligence instruction with the behavior of practicing dentists.”16 Munk stated further that the focus of dental education “is on developing students’ cognitive intelligence (thinking) and technical intelligence (doing), while emotional intelligence (being) receives less emphasis.”17 This may be a key to helping good dentists avoid bad choices.

Emotional Intelligence and Ethical Behavior

Emotional intelligence was first defined as “the ability to monitor one’s own and others’ feelings and emotions, to discriminate among them and to use this information to guide one’s thinking and actions.”18 An emotionally intelligent individual can: 1) identify what they are feeling; SEP TEMBER 2 0 2 0 453

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2) interpret their emotions; 3) understand how their emotions can impact others; and 4) regulate their emotions.19 These characteristics connect well with the ethical values described earlier.

It should be evident that developing these skills will enhance one’s ability to make good, ethical decisions.

Goleman identified five elements of emotional intelligence: self-awareness, self-regulation, empathy, motivation and social skill.20 Development of these skills will augment one’s ethical abilities; weakness in one or more areas could contribute to ethical or moral lapses. Each element will be examined briefly in connection with ethical principles.

Self-awareness is closely related to veracity and autonomy because an individual must be honest with themselves and exercise their right to choose. It is a key skill in avoiding bad decisions.

D. Todd Christofferson, who was Judge John Sirica’s law clerk as the Watergate scandal unfolded, recently reflected on this: “A weak conscience, and certainly a numbed conscience, opens the doors for ‘Watergates,’ be they large or small, collective or personal — disasters that can hurt or destroy both the guilty and the innocent.”21 Self-awareness and conscience are often intertwined as individuals ponder decisions and particularly as they seek to avoid making bad decisions. This may also be connected to self-assessment, a vital skill in professional development.

Dental students are expected to assess their personal performance in a wide range of competencies so they can improve their skills. However, less emphasis is given to personal and behavioral self-assessment in favor of assessing hand skills.

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Without a sense of selfawareness, making ethical decisions would be virtually impossible.

Self-regulation is connected to justice and autonomy. It stems from being true to one’s character. Self-regulation is closely related to integrity and requires accountability. Accountability arises both internally and externally.

As dentists, there are many sources of external accountability, including peers, mentors, family members or religious leaders. Stricter providers

Goleman identified five elements of emotional intelligence: self-awareness, self-regulation, empathy, motivation and social skill.

of accountability include the dental board and government agencies that dictate professional behaviors. These external entities are frequently required to act when an individual’s self-regulation is inadequate, often with unpleasant consequences.

Of course, CDA and other professional organizations have expectations as well, and they have developed systems of accountability to assist members in self-regulation.

These include peer review and codes of ethics. These may seem punitive at first glance, but their true intent is to assist members in their self-regulation and accountability to the profession, their patients, their colleagues and their community.

Self-regulation helps one to consider others and fosters good ethical decisions.

Empathy relates to many ethical principles, particularly beneficence, nonmaleficence and justice.

The codes of ethics for the ADA and CDA emphasize the importance of acting in the patient’s best interest. This requires empathy and its associated skills. For example, when a dentist decides to overtreat, to provide unnecessary treatment or even inadequate treatment, they demonstrate a lack of empathic skills.

Empathy provides a foundation for good ethical decisions as one considers the best interests of others; it may motivate the dentist to consider the effects of their actions.

Motivation is another important element of emotional intelligence.

By nature, dentists tend to have strong intrinsic motivation. Nearly all dentists have the innate desire to excel professionally. Extrinsic factors also motivate dentists as they pursue financial and other goals.

These motivations sometimes conflict with ethical principles and concepts.

For example, when the motivation to pay one’s student loans, business loans or other debt conflicts with the commitment to act in the patient’s best interests. These are thorny ethical issues and require serious consideration by the dentist who endeavors to be ethical.

Balancing one’s motivations can be a daunting task. A system of accountability helps to maintain motivations within ethical and legal limits.

A strong support system may be necessary to meet these challenges.

Social skill is the final element in emotional intelligence. Social skill enables the individual to put his emotional intelligence into practice.

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Dentistry has long been a solo profession, and professional social networks in the current generation of practicing dentists may be weak.

In social settings, including conversations with patients, dentists can practice their emotional skills and strengthen their emotional intelligence. Social interactions can assist in developing self-regulation and empathy. Connections with the right people can increase motivation and help provide a balance. And being with peers will certainly increase one’s self-awareness.

Social settings can help dentists strengthen their resolve to act ethically.

Emotional intelligence empowers people to use their emotions as a point of reference rather than as a basis for a decision. This can be a vital skill as one strives to make better decisions, particularly under stress. Support for the concept also comes from others.

Côté commented, “People often make decisions that are influenced by emotions that have nothing to do with the decisions they are making …

People who are emotionally intelligent don’t remove all emotions from their decision-making. They remove emotions that have nothing to do with the decision.”22 Developing and exercising emotional intelligence may help dentists avoid bad decisions.

Reviewing the disciplinary actions studied by Chambers and

by Munk suggest that nearly all the bad actions that led to discipline might have involved a high-emotion situation. It follows that having a mechanism for dealing with choices that arise when a dentist is in a state of high emotion could effectively preclude many of the bad actions.

Sometimes, the dentist does not have time to evaluate their choices or

desired outcomes. They must act quickly.

These decisions occur frequently in practice; they may also occur outside the practice and have distressing outcomes.

The dentist with a high emotional quotient will often make decisions proactively. For example, an early decision to avoid dishonest business practices or to avoid driving while intoxicated can make choices easier during crunch time. An emotionally intelligent individual is more likely to recognize when to call on those proactive decisions.

Dentistry’s professional codes of ethics are an important tool for the dentist who wishes to make good decisions consistently.

Since its introduction, emotional intelligence has gained support, although some consider it a pop psychology fad. Nevertheless, the elements of emotional intelligence complement ethical principles and deserve serious consideration.

Applications

More studies are needed to demonstrate the value of emotional intelligence in enhancing the ethical and professional behavior of dentists.

Nevertheless, the problem of good dentists making bad choices remains.

The question “Why?” remains largely unanswered. The focus has been largely on damage control and not on prevention. For some dentists, it seems simpler to prevent caries than to prevent bad behavior.

In conclusion, it seems appropriate to ask two final questions: ■ How can bad decisions and bad actions be avoided?

■ Is it feasible to help others avoid bad decisions and bad actions?

Avoiding bad actions is the work of a lifetime. The question suggests the need for preventive measures. Dentists are trained not only to manage medical emergencies in their offices, but also to recognize and prevent them. They all have an emergency kit to assist patients in this important responsibility.

It may be much easier to recognize the onset of a hypoglycemic episode than to recognize an approaching bad decision. A proactive preventive approach should be utilized, in which the dentist focuses on their guiding principles and determines ahead of time to act on them. Decisions based on one’s identified core values will help to maintain one’s values and integrity.

This is an integral part of self-awareness.

Bernard Knight, who served as acting general counsel of the U.S. Treasury at the height of the financial crisis earlier this century, said, “Core values are key to avoiding ethical violations. This is because most ethics violations are not intentional. They occur because decisions are being made based on the wrong values or on emotion.”23 He also warned that, “In the moment, we can all rationalize behavior that on reflection was inappropriate.”24 Dentistry’s professional codes of ethics are an important tool for the dentist who wishes to make good decisions consistently. A strong emotional intelligence will add significantly to the value of the codes of ethics.

The second question also deserves additional study. Is it feasible to help others avoid bad decisions?

And at what cost? Many dentists are professionally isolated. They practice SEP TEMBER 2 0 2 0 455

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alone and may not have significant social contact with their colleagues.

Chambers opines that, “It may be unsound for the leadership of organized dentistry to shun the small number of unprofessional practitioners,” but he also feels that “the reputation of dentistry … cannot be controlled by the profession at a national level.”25 This hints that perhaps improving social skills through personal connection is the most effective means of managing and preventing bad actions. A proactive involvement among colleagues locally may be the best means of prevention. Peer pressure or peer support among friends can become very motivational. Renewed focus on an individual’s personal values and commitments is the foundation.

A common view that colleagues are now competitors can be a complicating factor. Sometimes this creates a wariness that makes personal outreach more difficult. This ties in with Batson and Thompson’s comments on moral integrity26 and the difficulties in managing opportunity costs. Is it possible for an individual to help another in paying the opportunity costs to act ethically?

Chambers concludes that, “Dentists are human. In any population there will be a range from the outstanding to those who are having difficulty leading the kinds of lives to which we all aspire. …

The profession has more conspicuously engaged indirectly with this issue at the policy level than through direct action by individual dentists being proactively involved with their colleagues or by reporting unprofessional behavior. This is an issue for the entire profession, working with others.”27 This is a challenge to each dental professional, both to act in the interest of our colleagues and to accept mentoring and advice that they may provide. Neither comes easily.

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If the leaders in the dental profession accept Chambers’ conclusions, then the ethical focus of the dental profession should emphasize education and prevention over enforcement and punitive measures for those who fall short of the ethical ideal.

This approach may require more effort than current methods, but it has the potential to yield positive results. Further study and discussion are needed on this concept.

There is evidence that incorporating the principles of emotional intelligence into dental education and into the professional canon may have a positive effect on dentists’ decisions. Again, further study is indicated to confirm this.

Effective self-assessment of one’s behavior and accepting accountability for one’s choices will help to create respect for the dental profession and lead to increased personal and professional satisfaction. Better decisions will likely follow this increased satisfaction.

William J. Gies advised: “Follow impulses and leaderships that represent ideals; that point the way to your professional destiny; that express integrity, fidelity, service and lofty purposes — the finest that is in you individually and professionally!”28 If we do this as a profession, and stay on the right track, perhaps we can do no better. n REFERENCES 1. Gallagher C. When Ethics Fail: How Good People Make Unethical Decisions. stopdoingnothing. com/being-a-leader/ethics-fail-good-peopleunethical-decisions. Accessed Aug. 22, 2019.

2. Ibid.

3. CDA Code of Ethics. Sacramento, Calif.: California Dental Association; 2018.

4. Principles of Ethics and Code of Professional Conduct.

Chicago: American Dental Association; 2018.

5. Ethics Handbook for Dentists. Gaithersburg, Md.: American College of Dentists; 2018.

6. CDA Code of Ethics. Sacramento, Calif.: California Dental Association; 2018:5.

7. Ethics Handbook for Dentists. Gaithersburg, Md.: American College of Dentists; 2018:ii.

8. CDA Code of Ethics. Introduction. Sacramento,

Calif.: California Dental Association; 2018:1.

9. Principles of Ethics and Code of Professional Conduct. Preamble. Chicago: American Dental Association; 2018:3–4.

10. CDA Code of Ethics. Section 4. Sacramento, Calif.: California Dental Association; 2018:3.

11. Batson CD, Thompson ER. Why don’t moral people act morally? Motivational considerations.

Curr Dir Psychol Sci 2001 Apr;10(2):54–57. doi.org/10.1111/1467-8721.00114.

12. Chambers DW. Disciplined dental licenses: An empirical study. J Am Coll Dent 2018; 85(2):30–39.

13. Ibid.

14. Papadakis MA, et al. Unprofessional Behavior in Medical School Is Associated With Subsequent Disciplinary Action by a State Medical Board.

Acad Med 2004 Mar;79(3):244–9. doi: 10.1097/00001888-200403000-00011.

15. Papadakis MA, et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med 2005 Dec;353(25):2673– 2682. doi: 10.1056/NEJMsa052596.

16. Munk LK. Implications of state dental board disciplinary actions for teaching dental students about emotional intelligence. J Dent Educ 2016 Jan;80(2):14–22.

17. Ibid.

18. Salovey P, Mayer JD. Emotional intelligence.

Imagin Cogn Pers 1990; 9:185–211. doi. org/10.2190/DUGG-P24E-52WK-6CDG. 19. Cherry K. Habits of Emotionally Intelligent People.

2020. www.verywellmind.com/the-7-habits-of-emotionallyintelligent-people-2795431. Accessed Feb. 20, 2020.

20. Goleman D. Emotional Intelligence 10th ed. New York: Bantam Books; 2005.

21. Christofferson DT. Reflections on Watergate. Deseret News June 15, 2017. Accessed July 1, 2017.

22. Côté S. Higher emotional intelligence leads to better decision-making. www.sciencedaily. com/releases/2013/11/131119153027. htm. Accessed Jan. 29, 2020.

23. Knight B. 6 core values and 5 emotional intelligence skills leading to sound ethical decisions. www.ipwatchdog.com/2017/07/05/6-corevalues-5-emotional-intelligence-skills-sound-ethicaldecisions/id=85213. Accessed Jan. 27, 2020.

24. Ibid.

25. Chambers DW. Disciplined Dental Licenses: An Empirical Study. J Am Coll Dent 2018; 85(2):30–39.

26. Batson CD, Thompson ER. Op. cit.

27. Ibid.

28. Gies WJ. Ethics Handbook for Dentists.

Gaithersburg, Md.: American College of Dentists; 2018.

THE AUTHOR, Robert D. Stevenson, DDS, can be reached at rstevenson@westernu.edu.

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C D A J O U R N A L , V O L 4 8 , Nº 9

COVID-19 and Informed Consent: What You Need To Know TDIC Risk Management Staff

C

OVID-19 has no doubt impacted every aspect of our lives. After months of practice interruption, many dental practices have resumed routine care, and dentists are taking extraordinary steps to protect the safety of their patients and staff.

While dental practices are learning more every day about how to best provide care during the pandemic, there are still many unanswered questions that create uncertainty, stress and unease.

The Dentists Insurance Company’s Risk Management Advice Line is continuing to receive calls from practice owners about how to navigate issues related to COVID-19. These inquiries range from how to obtain enough PPE to how to address staff who are fearful of returning to work. Many calls concern informed consent and communicating any risks of contracting the virus in a dental setting.

Informed consent is a fundamental component of managing risk in dentistry. It’s more than just a form.

It is a dialogue between a dentist and patient about the nature of the recommended treatment; the risks, complications and benefits of treatment; and alternatives to the recommended treatment, including no treatment at all. A signed informed consent form is considered the first line of defense when facing a professional liability claim.

Attorney Art Curley, JD, of Bradley, Curley, Barrabee & Kowalski PC in Larkspur, Calif., discussed consent in the era of COVID-19 during a recent webinar hosted by TDIC. He stated that at its most basic level, the agreement to undergo

People know that contracting the virus is a risk anywhere they go in public, whether it’s to the dental office, the grocery store or the bank.

treatment by health care providers is implied by the mere reason a patient walks into an office for dental care. With COVID-19, people know that contracting the virus is a risk anywhere they go in public, whether it’s to the dental office, the grocery store or the bank.

“Everybody knows COVID-19 is out there. This is one thing that nobody can say ‘I’ve never heard of it,’” Curley said. “So, they’re consenting to come to

answers

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SEPT. 2020

RM MAT TERS C D A J O U R N A L , V O L 4 8 , Nº 9

a dental office, knowing anything they do in public has a risk of contracting COVID-19.”

Some dentists who called the Advice Line have asked whether they should require a separate informed consent form related to COVID-19; however, TDIC does not recommend practice owners use a form specific to COVID-19. A separate form may lead to a false sense of security and does not provide immunity for dentists who are negligent in following current and appropriate infection control guidelines.

Rather, standard informed consent forms are sufficient, assuming these forms

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address the risk of possible infection.

All forms should include acknowledgment of the risk of infection from dental treatment, including COVID-19. TDIC offers sample forms in nine languages.

It should be noted that performing treatment without informed consent can set the stage for a liability claim, as it is below the standard of care.

However, informed consent forms are not waivers. They neither relieve dentists of their responsibilities nor protect dentists from providing treatment below the standard of care.

“Informed consent is not a substitute for substandard care. A patient cannot

2020

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consent to substandard care,” Curley said in the webinar.

While a signed and dated form is important, the form is only one part of a broader process. More important is an open, two-way conversation with patients to ensure they understand all the risks involved. This conversation is a good time to let patients know of the steps being taken to protect their safety with regard to COVID-19, such as hand hygiene, aerosol management, cleaning and disinfection procedures and other controls following OSHA and CDC guidelines. During these conversations, patients should be given the opportunity to ask questions and be given honest, straightforward answers.

All of these discussions should be well documented and kept in the patient’s chart.

Should a patient refuse to sign an informed consent form for whatever reason, it is advised to postpone the procedure.

Staff should inquire as to why the patient refuses to sign the form. If, after further explanation, the patient still refuses, this is a sign of noncompliance and a dismissal may be in order, following formal patient dismissal protocols.

Curley also addressed the concern of whether a dentist could be held liable if a patient believed they contracted the virus within a practice. While Curley stated that there have been no documented cases of COVID-19 being contracted from a dental office as of this writing, it is possible for a patient to make such a claim. But following all OSHA and CDC infection control guidelines — and, more importantly, documenting those actions — can protect you from liability.

“The standard of care is infection control,” Curley said. “If you violate infection control, it’s presumed you’re negligent and anything that happens after that is considered your fault.”

Dental staff should also openly and thoroughly discuss and document the

C D A J O U R N A L , V O L 4 8 , Nº 9

steps they have taken to screen both staff and patients for COVID-19. Each dental team member should be screened at the start of their shift, including having their temperature taken and a symptom assessment performed. Note, employers are not allowed to require an employee to take a COVID-19 test prior to returning to work.

For patients, screening should include a temperature reading and updated health history. Patients should be asked whether they have symptoms, whether they have been in contact with someone who has tested positive and whether they have traveled to an area with high numbers of

positive cases. TDIC’s online resources for managing risk during COVID-19 include a link to a downloadable patient screening form that can be signed by patients acknowledging they will notify the office should they become ill with COVID-19 symptoms. Practice owners should also be aware that they have an ethical — and possibly legal — obligation to notify patients if a staff member they have been in contact with tests positive for COVID-19. Check with your local county health department for guidance on how to proceed.

The implications of COVID-19 will continue to evolve and change

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6181 CARMEL VALLEY VILLAGE - START-UP Slam dunk for nominal investment. 48-year history providing dental care at same location. Great curb appeal. Fully equipped & furnished 4-ops. $1+ Million/year location. Only practice in Village. Next practice 10-minutes away; then 17-minutes to practices in Carmel. Landlord is daughter of original dentist who worked as hygienist for her Dad & later her Husband; and transitioned to Manager.

Shut-down April. Purchase equipment & furnishings, enter into Lease and open doors. Patients return. Operate out-of-network Great 2nd office for Monterey / Salinas Area dentist or starter for go-getter.

6180 SAN FRANCISCO CONCIERGE PRACTICE Averages 3-to-5 Dentist patients day. Available Profits totaled $391,500 in 2019 with 9-weeks off. Located in service & shopping area of high income zip code with average household income of $286,800. Décor, delivery systems, technology reflect $258,000 in upgrades. Fees will not change. Collected $796,500 in 2019. Full Price $550,000.

6179 CENTRAL MARIN COUNTY Extremely strong foundation as evidenced by 7-days of hygiene. Beautiful office and great location.

Collections last 3-years have averaged $870,000. Owner is conservative with patients well educated on issues occurring in their mouths.

6178 DESIRABLE CONTRA COSTA COUNTY COMMUNITY Located in tony community where median household income is $157,450. Collections in 2019 totaled $780,000 reflecting nice growth from 2018’s totals of $655,000. And Owner just raised UCR Fees by 11.4%. Patient rich. 5-days of hygiene. Paperless and digital. Beautiful office with lots of nice upgrades.

6177 SALINAS During Great Recession, Salinas dentists did well as Salinas Valley is one of California’s most productive agricultural regions and is the engine driving this area’s economy. As such, Salinas shall bounce back quickly from Covid Hangover. Under-performing practice collected $935,000 in 2019. 5-days of Hygiene. Housed in beautiful 6-op suite. Condo optional purchase. Great platform to bring in specialists.

6176 SANTA CRUZ Delta PPO practice seeks Successor skilled in placing implants. Last 2-years averaged $1,180,000 in collections and $735,000 in Available Profits. $480,000 invested in technology to make this possible.

4-days of Hygiene. Full Price $675,000.

6174 HUMBOLDT COUNTY’S UNIVERSITY COMMUNITY – ARCATA Best location, great foundation. Owner works 3-day week by choice. 2019 collected $360,000. Practice wants to be full time. Full Price $50,000.

6172 WALNUT CREEK – OUT-OF-NETWORK 2019 collected $850,000 with Profits of $430,000. 4-days of Hygiene. Requires skilled, easy temperament and great communicator as Successor. Seller shall work-back to assist in transition.

6171 SANTA ROSA Great DNA in long-established practice. Strong patient foundation per 6+ day Hygiene Schedule. 2019 collected $990,000 with Available Profits of $338,000. Great Team. Full Price $213,750.

6170 MANTECA / RIPON AREA 2019’s revenues totaled $860,000 with Available Profits of $352,000. 5-days of Hygiene. Refers endo, most OS and implant placements. Extensive patient base. Successor should contract with specialists to perform referred work. Facility perfect for making this a fullservice practice. Full price $450,000.

6165 ROSEVILLE ORTHO – OUT-OF-NETWORK Stanford Ranch. $455,000 invested in build-out, furnishings, computers and equipment. 3-chair Bay. Digital Pan with Ceph. Averages 3 New Patients per month. Full Price $125,000.

6164 SAN FRANCISCO’S UNION STREET – OUT-OF-NETWORK Highly regarded as evidenced by 9-days of Hygiene per week. Collections topped $2 Million each last 3-years with Profits averaging $1 Million.

Paperless. 3D Cone Beam.

Great Time to Think about Change. Not doing the Type of Dentistry You would like to do? Look to Tom Fitterer & PPS to plan your future.

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BAKERSFIELD AREA Small city. Seller built 4,500 sq.ft. beautiful home for $450,000. (Cost $1.5 million in OC.) Hi identity dental building. 7 Adec ops. 3,000 sq.ft. next to Health Center for 1.2 million people. Established 32 years. Grossing $1 Million. Buy all at Bank Appraisal, 5 Dentists serving 40,000 market area patients.

BEAUMONT AREA 8,000 new homes to be built 5 minutes away. Retiring DDS established 1988. 1,550 sq.ft. 3-ops. Rent $1,650. Average Gross $365,000.

BEAUMONT / BANNING Senior DDS Grossing $250,000. 1-op. Rent $960 per month. Take home $200,000.

EAST LOS ANGELES 60 years old. 3-ops. Rent $1,600. Part-time Senior Grossing $285,000 on 2-days. Do $500,000 on 3.5 days. Hi visibility. Bargain at $195,000.

HEMET - HISPANIC AREA Includes Dental Building. Established 50-years.

Absentee Seller. This is a neglected practice. Beautiful 5-op office. Open part-time.

Will do $500,000 first year. $1 Million in 3-years like one prior owner. Pay Mortgage that never goes up. Part-time Seller will transition. Cerec. $250,000 buys practice.

Small down buys building. Historic location. Live in apt if you like during week, live on beach on weekends.

GP INNOVATOR Gross $1,700,000. Net over $1 Million. Nothing fancy, low tech dentistry. Full Price $1,500,000.

INLAND EMPIRE - UNION PRACTICE Gross $550,000 2.5 days by choice. Net $350,000. 5-ops.

INTERSECTION OF 210 / 57 Hi identity. 25-years old. Unbelievable state-of-art.

10-ops, new everything. Recent $500,000 renovation. Cone beam, Cerec, lasers.

Grossing $1,100,000. Seller has 2-practices, cannot do both justice. This is a $2,000,000 location.

LA HABRA - HUGE SHOPPING CENTER Well maintained. PT Seller will stay.

6 ops.

LAGUNA WOODS Grossing $800,000 part-time. Should gross $1,000,000.

MARINA DEL REY Take home $1 Million Net. HMO checks $5-to-8,000/month.

Resume required ORANGE COUNTY Established 1970. Near Chapman / Tustin intersection.

Grossing $400,000. Merge or Grow PALM DESERT Hi identity. Established 2007. Terrific one girl staff. Mostly Hispanic. Low overhead. Rent $1,600. Gross near $300,000. Semi-retire on 2-or-3 days. 4-ops, 2-equipped.

PALM SPRINGS AREA $1,500,000 includes specialists. Grow to $2,000,000+.

8-ops. Best buy.

TORRANCE – PACFIC COAST HIGHWAY Market to Palos Verdes to LAX area. 50-to-70,000 autos pass daily. Across street from major retailers with Hi Identity.

High Tech Adec like-new, 6-ops, no expense spared. $5,000 HMO checks pays 56% of cost to buy. Within 36-months, Buyer will net $50,000 a month. After 5-years, Net of $1,000,000 per year is achievable goal.

REDONDO BEACH Semi-retire. Work 2-to-3 days, low overhead. Established 20years. 2-ops. Super staff. Rent $1,550. Seller refers a lot. Full Price $118,000.

SAN DIEGO GROUP 4-office DSO grossing $3.7 Million.

SOUTH BAY OPPORTUNITY For talented GP to Net $50,000/month.

TEMECULA SHOPPING CENTER High visibility. 5-ops. Grossing $40-to-50,000 month. Absentee owned. Hands on owner will double first year.

Bargain.

THOUSAND OAKS Classic practice. Established 42-years. One Partner willing to work back 3-to-5 years. Grossing $1 Million. Refers lots to Specialists. 5-ops. Owners own 25% of Building housing 4 Dentists including Ortho. Great for Specialist or GP. UPLAND Established 38-years. 3-ops. Grossing $330,000. 2000 active patients

Regulatory Compliance

C D A J O U R N A L , V O L 4 8 , Nº 9

Who Determines Dental Infection Control Standards?

CDA Practice Support

F

our months after a national emergency for the novel coronavirus was declared, dental infection control procedures were still a work in progress. CDA Practice Support heard from dentists who were confused after hearing about and reading the conglomeration of guidance and orders issued by national, state and local government agencies as well as those published by CDA and the American Dental Association. For example, some questioned the recommendation to use respirators and others asked if complying with certain recommendations, such as installing sneeze guards, was mandatory.

Some of this confusion originates from a lack of basic knowledge about the roles of respective agencies and how they influence each other. This article briefly describes their scopes of work as they relate to infection control in dentistry.

Most dental health care workers know that the U.S. Food and Drug Administration (FDA) clears medical and dental devices for use in the U.S. and the Centers for Disease Control and Prevention (CDC) issues infection control guidance.

However, the work of a CDC department, the National Institute of Occupational Safety and Health (NIOSH), is not as well understood. NIOSH conducts research and makes recommendations for the prevention of work-related injuries and illness. Like the CDC, it is not an enforcement agency and does not issue regulations. It does issue recommendations that can be adopted by other entities to be part of regulations enforced by the U.S. Occupational Safety and Health Administration (OSHA) or its state counterpart Cal/OSHA. NIOSH’s role in approving respiratory protection equipment became more important in dentistry because of the shortage of the NIOSHapproved, FDA-cleared “disposable filtering facepiece respirator” commonly

known as the surgical N95. It is standard health care practice to utilize FDAcleared respirators, and the FDA does not clear every NIOSH-approved respirator. Because the pandemic created a severe shortage of surgical N95s, the FDA issued a series of emergency use authorizations allowing health care providers to use other NIOSH-approved respirators and specified respirators manufactured outside the U.S. that meet another country’s standards for respiratory protection. The emergency use authorizations allowed health care providers to use for patient care NIOSH-approved nonsurgical N95s, NIOSH-approved half- and full-face elastomeric respirators and specified KN95s and other respirator models manufactured outside the U.S.1 Use of NIOSH-approved powered air purifying respirators for particulate protection does not require an FDA emergency use authorization.2 Additionally, the FDA issued emergency use authorizations for respirator decontamination systems. Because of the emergency use authorizations, health care workers have greater options for personal protective equipment.

An FDA guidance3 issued several years ago and unbeknown to most dentists required dental practices to change the way they managed dental burs, which had not been labeled as one-time use devices until then. The FDA directed device manufacturers to provide reprocessing instructions for their devices. A device without reprocessing instructions would be considered a single-use device. The CDC recommends and the Dental Board of California requires that single-use devices be disposed of after use; reprocessing them is not permitted. The dental board did not have to change its regulations to mandate the disposal of dental burs after a single use because the FDA changed its standard.

Both the dental board and Cal/OSHA look to the CDC recommendations as a starting point for creating infection control regulations. Although neither state agency has adopted COVID-19-specific regulations, Cal/ OSHA can enforce a safety standard by utilizing the aerosol transmissible disease (ATD) and injury and illness prevention (IIP) regulations and CDC COVID-19 guidance for dentistry.

The IIP regulation, which is unique to California, requires an employer to identify and evaluate workplace hazards, to mitigate unsafe or unhealthy conditions, to implement safe work practices, to educate employees and to investigate injuries and illnesses. Under the ATD regulation, a dental practice is required to include in its IIP program specific steps to prevent an individual with an ATD from being treated. If the practice fails to do so, it must comply with the same requirements as larger health care facilities — mandatory vaccinations and testing and creation of a written ATD plan, for example. n REFERENCES 1. U.S. Food and Drug Administration. Personal protective equipment emergency use authorizations. www.fda.gov/ medical-devices/coronavirus-disease-2019-covid-19emergency-use-authorizations-medical-devices/personalprotective-equipment-euas. Accessed July 13, 2020.

2. U.S. Food and Drug Administration letter to the Centers for Disease Control and Prevention, March 28, 2020. www.fda.gov/media/135763/download.

3. U.S. Food and Drug Administration. Reprocessing medical devices in health care settings: Validation methods and labeling. March 2015. www.fda.gov/regulatory-information/ search-fda-guidance-documents/reprocessing-medical-deviceshealth-care-settings-validation-methods-and-labeling.

Regulatory Compliance appears monthly and features resources about laws that impact dental practices. Visit cda.org/ practicesupport for more than 600 practice support resources, including practice management, employment practices, dental benefit plans and regulatory compliance.

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CARROLL &COMPANY 4408 SONOMA COUNTY Beautiful 2,100 sq. ft., 6 op practice, 4 doctordays & 3 hygiene days per week. Average gross receipts $1M+.

Asking $590K. 23-year perio practice, also ideal for GP; loyal, seasoned staff and great location.

4407 SAN MATEO GP Exceptional 5-operatory San Mateo practice in popular health provider neighborhood generating significant daily business draw. Beautiful 2,200 sq. ft. seller-owned facility, handsomely equipped to highest standards. Average GR $1.4M, average overhead 61%. Seasoned and loyal staff. Seller willing to help for a smooth transition.

4417 SANTA CLARA GP Offering 40+ years of goodwill in wonderful

Santa Clara location. Nicely appointed office with 4 fully equipped ops in approximately 1,500 sq. ft. Traditional family practice focused primarily on restorative dentistry and hygiene care, referring out most specialities. Average 2-3 hygiene days/week. Average GR $650K with average adj. net of $304K. Asking $415K. Seller willing to help for smooth transition.

4394 SANTA CRUZ GP Retiring seller offering 33+ years of goodwill in stunning 1,534 sq. ft. facility with 4 fully-equipped ops. Pristine leasehold improvements/gorgeous cabinetry make this a must-see! Prime corner location with dedicated parking lot, situated in one of the most desirable areas of Santa Cruz, close to shoreline and tourist attractions. 2019 GR $887K with adj. net of $353K. 1,500+ active patients with average of 19 new patients/month. Seller works 3+ days/week with 5+ days of hygiene.

Asking $729K. 4405 LOS GATOS GP 30 year practice in beautiful modern, office and desireable location with two LD5 year options to extend lease. $1.2M SO average gross receipts with 56% average overhead. Asking $986K. 4382 MONTEREY COUNTY GP Established practice in Monterey County, California Coast. Multiple ops can expand, approx. 900 active patients, 4 days of hygiene per week. Ideal for a mature, experienced dentist for this adult-focused practice in an Extraordinary location. Periodontal emphasis with communicative technology in each operatory for multiple crown and implant restorative procedures. Loyal, committed staff will remain through transition. Future opportunity to purchase office building.

4351 SEBASTOPOL AREA GP & BLDG. Beautiful, modern practice in seller-owned building (available for purchase); 3 fully-equipped ops, room for a 4th. Pristine equipment including digital X-ray, most purchased 2016-2018. 2019 GR annualized at $679K+ with adj. net of $210K. Average 3.5 doctor days/week and 4 hygiene days/week. 800 active patients, all fee-for-service. 70+ years of goodwill = long-standing, loyal patient base in scenic vineyard country. Asking $305K for practice, $425K for building. Owner/doctor willing to help for smooth transition.

4406 PALO ALTO GP Offering 50+ years of goodwill in growing practice close to Stanford University. Great Palo Alto location with incredible visibility. 7 ops in recently remodeled 2,152 sq. ft. office. 1,400+ active patients. Pre-Covid hygiene schedule running at 8 days/week. 2019 GR $1.5M+ with adj. net of $518K. Services provided are typical of practice with emphasis on Restorative dentistry. Asking $1,185,000.

4399 SAN JOSE GP Gorgeous office in pristine condition located on a views of the eastern foothills. well-traveled thoroughfare with incredible NG 12-13 new patients per month. Approx.

DIwith Approx. 2,000 active patients N E 8 hygiene days/week.PAverage GR $1.3M. Asking $977K.

carroll.company

dental@carrollandco.info

“Matching the Right Dentist to the Right Practice�

4415 WATSONVILLE GP & BLDG Offering 35 yrs of goodwill in the growing coastal community of Watsonville. Charming and renovated 4 op office in 1,320 sq. ft. Approx.

G 450 active patients with anIN average of 10 new patients/mo. Incredible ND management systems in place. Endo, Oral upside potential withEexcellent P Surgery and all Ortho procedures referred out. Last 2 yrs average Gross Receipts $275K with average adj net of $159K on just 1.5 doctor days/ week. Bldg condo is also available for purchase. Asking price $175K for practice and $300K for condo.

4360 SALINAS GP Seller transitioning into retirement and offering wellestablished practice located near downtown Salinas and Salinas Valley Memorial Hospital. Average Gross Receipts $250K. Asking $133K. 4416 SF FACILITY Located on Lyon street, closest major cross street Lombard. 1,600 sq. ft. turn-key dental facility. This street level space has over $350,000 of improvements completed for professional use and ready to go as a dental office. Asking $35K. 4392 SAN JOSE GP Offering 40+ years of goodwill. Excellent location in beautiful bldg on well-traveled thoroughfare. 6+ ops in 1,882 sq. ft. Lots of natural light with views of the eastern foothills. 1,800 active patients. 8 hygiene days/wk. Average GR $900K with adj. net of $295K. Terrific upside potential. Asking $558K. Owners will help for smooth transition.

4387 SF GP 50 year Nob HIll neighborhood practice with approximately 1,000 active patients. Almost no Delta Premier patients. Average GR $600K. Seller transitioning into retirement. Asking $315K. 4362 MARIN COUNTY GP 36 years of goodwill, Seller-owned 1,550 square foot facility with 5 fully-equipped ops. Prime position in charming town; desirable area known for temperate weather, easy, outdoor living and natural beauty. No Delta Premier patients. Excellent reputation and word-of-mouth referrals. Retiring seller will help for smooth transition. Average Gross Receipts last 2 yrs is $450K. Asking $248K for the practice. Bldg condo is available for purchase.

4389 SALINAS GP Stable, 2400+ patient base. Seasoned and dedicated staff. Practice with an emphasis on Restorative treatment. 4 doctor days & 5 hygiene days per week. Average GR $910K. Asking $670k. Retiring owner.

4375 LOS GATOS DENTAL FACILITY Unique opportunity in highly desirable area! Seller offering two full suites of state-of-the-art equipment and modern, 2-operatory facility including furniture, fixtures and leasehold assets in medical office building adjacent to Los Gatos Community Hospital. Asking $250K. UPCOMING: REDWOOD SHORES GP, NAPA GP & PALO ALTO GP

Mike Carroll

Pamela Carroll-Gardiner

Mary McEvoy Carroll

CalRE# - 00777682

(650) 362-7004

(650) 362-7007

Ethics

C D A J O U R N A L , V O L 4 8 , Nº 9

Everything You Wanted To Know About Ethics in Dental Marketing but Were Afraid To Ask Ronald V. Surdi, DDS

N

ow that I’ve caught your attention, I will attempt to provide some insight on current marketing in dentistry and some of the history in light of the celebration of 150 years of the California Dental Association.

Change is good, change is inevitable.

Dentistry as a profession is being challenged. We make a commitment to stay up with the times as stated in the CDA Code of Ethics. Besides learning new procedures, keeping up with the ever-changing world of technology is essential. How technology affects our profession and businesses is also part of this whole new world equation.

As a former member of the investigative panel subcommittee of the CDA Judicial Council, I observed a number of dentists’ websites. Many of these websites were welldone professional advertising masterpieces.

Therein lies my realization about new-age marketing. When advertising exaggerates the truth and complicates or muddles the public’s opinion with claims of superiority, it could be in conflict with the Code of Ethics, Section 6, Representation and Claims. This section states: “In order to properly serve the public, dentists have the obligation to represent themselves in a manner that contributes to the esteem of the profession. It is unethical for a dentist to mislead a patient or misrepresent in any material respect either directly or indirectly the dentist’s identity, training, competence, services, or fees. Likewise, it is unethical for a dentist to advertise or solicit patients in any form of communication in a manner that is false or misleading in any material respect.”

The Judicial Council further interpreted this section in an advisory

opinion: “Subjective statements about the quality of dental services can raise ethical concerns. In particular, statements of opinion may be misleading if they are not honestly held, if they misrepresent the qualifications of the holder or the basis of the opinion or if the patient reasonably interprets them as implied statements of fact. The fundamental issue is whether the advertisement, taken as a whole, is false or misleading in a material respect.”

It was obvious that most of the websites I observed were created by marketing firms versus by the dentists themselves.

It is imperative for us as accountable professionals to evaluate the information being put on our own websites. For example, utilizing suffixes after one’s name, whether easily recognized or not, implies superiority.

Also, it is unlikely that you are or were “the best cosmetic dentist” in your city. If you are sharing a patient’s opinion that you are the best dentist, the ad should indicate that it’s a patient’s testimonial.

Another commonly made claim for “painless” dentistry reminds me of the historical figure Painless Parker from the early 1900s. Way back when dentistry was first becoming a profession, Painless Parker was a street dentist described as “a menace to the dignity of the profession” by the American Dental Association. His office building became adorned with nightmares of alliteration: “Proclaimed by Public, Press and Pulpit;” “Painless Parker Is Positively Perfect.” According to a New York Times article: “A quintessential snake-oil salesman in goatee, top hat and cutaway coat, he established the first — and presumably last — sidewalk dental show.

A brass band would play, spangled girls would wiggle and contortionists would perform sideshow acts to drum up a crowd;

Dr. Parker would orate on the horrors of tooth decay then ask for customers.

A stooge would volunteer, and Parker, operating at his portable dental chair, would pretend to yank out his molar effortlessly, displaying to the audience a tooth he had already palmed. Did that hurt? Didn’t feel a thing.”1 More recent history of advertising in dentistry is exclusively from my perspective. Having graduated from dental school in 1984, the goal of many graduates back then was to just “hang a shingle” in a good location where there was a need for a new dentist. The paradigm was that you would soon be discovered as being an ethical provider exhibiting the principles of competence, compassion, veracity, professionalism and beneficence. Community involvement and personal recommendations provided a tried and true internal marketing methodology. High-visibility locations and ads with numbers like 123-BESTDDS and catchy fictitious names became trendy external marketing practice.

Clearly, times are no longer as simple as this and websites, advertising and reviews have become accepted methods to attract patients.

The story of Painless Parker is something I will leave for you to ponder as you research your own professional ethical online presence. reference

1. Pollak M. Was Painless Parker a Vaudeville Joke or a Real Brooklyn Dentist? The New York Times Sept. 26, 2014.

Ronald V. Surdi, DDS, is a member of CDA and the Harbor Dental Society.

He volunteers at the Ostrow School of Dentistry of USC and served on the CDA Judicial Council.

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Tech Trends

C D A J O U R N A L , V O L 4 8 , Nº 9

A look into the latest dental and general technology on the market

Elgato HD60 S USB Video Capture Card ($179.99, Elgato) As the world adjusts to the new pandemic normal, the built-in camera has become one of the most-used technologies that people rely on now to “see” each other. While these cameras are easy to use and can be high quality, applications like telehealth, video production and podcasting can demand ultrahigh resolution, atypical camera placement and video feeds from specialized devices like intraoral cameras and DSLRs with macro lenses. Capturing or streaming video from these sources is not always as simple as plugging in a device and hitting record; when simultaneous video capture and streaming are required, the technological headaches quickly pile up. Video capture devices like the Elgato HD60 S take the guesswork out of this process, and while it is far from being the only video capture device on the market, its durability, ease of use and predictability have made it an industry standard. As Elgato’s slogan says, “Stream and Record. Instantly.”

The HD60 S is a USB 3.0 device that is slightly smaller than a cellphone. It has four ports: a USB-C port that connects to a computer to pass data and supply power, an HDMI input that takes video from most video sources, a 3.5 mm audio port and an HDMI output that can pass video to a monitor or television. The setup process is simple, but not fully automated, prompting users to make a handful of critical selections that could negatively impact performance. The sum of this hardware and software allows users with a single button press to connect a video device — such as a digital camera or camcorder — directly to a computer, see what the camera is recording on the computer screen and simultaneously record this video to a hard drive, broadcast the video to another application like Zoom and show this video on another monitor. The video quality on both the recording and stream are at 1080p with a respectable 60 frames per second. By streamlining the capture of high-quality video, practitioners can better share clinical procedures with peers, create media for patients and appear more professional in virtual meetings. For those looking to impress with their videos, the Elgato HD60 S video capture card is a powerful tool to help tame the digital media creation process.

— Alexander Lee, DMD 466 SEP TEMBER

2020

Pokémon Smile (Free, The Pokémon Company) With the pandemic having no clear end in sight, adjustments to daily life are a frequent necessity. While there is no substitute for regular dental visits, parents can actively promote good oral hygiene habits for their children in a fun, engaging and clever way during quarantine with Pokémon Smile.

Based on the popular fictional characters, Pokémon Smile combines augmented reality, artificial intelligence and gaming to encourage kids to have good toothbrushing habits and skills at home.

Pokémon Smile requires the use of the front-facing camera on a mobile device along with parental supervision for children. Each family member can create a profile and select a Pokémon to begin.

Once a game starts, the goal is to defeat harmful bacteria through good toothbrushing. The screen displays a video of the child, a Pokémon cap overlay on top of their head and the game on the bottom where bacteria are covering a row of teeth. With the timer ticking the seconds down, children follow an odontogram on the bottom right that highlights the area where they should be brushing.

Through the camera video, the app detects toothbrush position and movement and provides feedback to keep children on track to defeat the bacteria. As time runs out, children are successful in their fight and are rewarded through the release of a Pokémon character and corresponding cap that can be selected for the next game. At the end of every game, children can select one of a few pictures automatically taken of themselves during the game and decorate it with stickers and other images that can be saved in the camera roll to be shared with others.

Parents can customize the timer and enable brushing reminder notifications at specified times. With over 150 Pokémon to release, children can expand their Pokédex through good toothbrushing habits as they defeat bacteria both in the game and in their mouth.

— Hubert Chan, DDS

®

This September is unconventional CDA Presents The Art and Science of Dentistry will be an innovative virtual convention this fall. From the convenience of your home or office, take part in engaging education — from required C.E. to new insights on clinical care and practice management. Get expert guidance and connect with exhibitors with our dynamic digital platform. Plus, access on-demand courses and exhibits for 60 days.

• THREE DAYS of exciting education • LIVE C.E. for the whole dental team • 40+ COURSES by leading speakers • INTERACTIVE, real-time exhibit hall Join us September 10–12, 2020. Registration is open right now at cda.org/cdapresents.

Journa C A L I F O R N I A

D E N TA L

A S S O C I AT I O N