journal of the american college of dentists · a publication advancing excellence, ethics,...

Journal of the

American Collegeof Dentists

Chairside Perspective on

Practice

Spring 2015Volume 82Number 2

A publication advancing excellence, ethics, professionalism,and leadership in dentistry

The Journal of the American College ofDentists (ISSN 0002-7979) is publishedquarterly by the American College ofDentists, Inc., 839J Quince OrchardBoulevard, Gaithersburg, MD 20878-1614.Periodicals postage paid at Gaithersburg,MD. Copyright 2015 by the AmericanCollege of Dentists.

Postmaster–Send address changes to:Managing EditorJournal of the American College of Dentists839J Quince Orchard BoulevardGaithersburg, MD 20878-1614

The 2015 subscription rate for members of the American College of Dentists is $30,and is included in the annual membershipdues. The 2014 subscription rate for non-members in the United States, Canada, and Mexico is $40. All other countries are$60. Foreign optional airmail service is an additional $10. Single-copy orders are $10.

All claims for undelivered/not receivedissues must be made within 90 days. If claim is made after this time period, itwill not be honored.

While every effort is made by the publishersand the Editorial Board to see that no inaccurate or misleading opinions or state-ments appear in the Journal, they wish tomake it clear that the opinions expressed in the articles, correspondence, etc. hereinare the responsibility of the contributor.Accordingly, the publishers and the EditorialBoard and their respective employees andofficers accept no liability whatsoever forthe consequences of any such inaccurate or misleading opinions or statements.

For bibliographic references, the Journalis abbreviated J Am Col Dent and should be followed by the year, volume, number,and page. The reference for this issue is:J Am Col Dent 2015; 82 (2): 1-48.

Journal of theAmerican Collegeof Dentists

Communication Policy

It is the communication policy of the American College of Dentists to identifyand place before the Fellows, the profession, and other parties of interest thoseissues that affect dentistry and oral health. The goal is to stimulate this community

to remain informed, inquire actively, and participate in the formation of public policy and personal leadership to advance the purpose and objectives of the College. The College is not a political organization and does not intentionally promote specificviews at the expense of others. The positions and opinions expressed in College publications do not necessarily represent those of the American College of Dentists or its Fellows.

Objectives of the American College of Dentists

T HE AMERICAN COLLEGE OF DENTISTS, in order to promote the highest ideals in health care, advance the standards and efficiency of dentistry, develop goodhuman relations and understanding, and extend the benefits of dental health

to the greatest number, declares and adopts the following principles and ideals as ways and means for the attainment of these goals.

A. To urge the extension and improvement of measures for the control and prevention of oral disorders;

B. To encourage qualified persons to consider a career in dentistry so that dentalhealth services will be available to all, and to urge broad preparation for such a career at all educational levels;

C. To encourage graduate studies and continuing educational efforts by dentists and auxiliaries;

D. To encourage, stimulate, and promote research;E. To improve the public understanding and appreciation of oral health service

and its importance to the optimum health of the patient;F. To encourage the free exchange of ideas and experiences in the interest of better

service to the patient;G. To cooperate with other groups for the advancement of interprofessional

relationships in the interest of the public;H. To make visible to professional persons the extent of their responsibilities to

the community as well as to the field of health service and to urge the acceptanceof them;

I. To encourage individuals to further these objectives, and to recognize meritoriousachievements and the potential for contributions to dental science, art, education,literature, human relations, or other areas which contribute to human welfare—by conferring Fellowship in the College on those persons properly selected for such honor.

EditorDavid W. Chambers, EdM, MBA, [email protected]

Managing EditorStephen A. Ralls, DDS, EdD, MSD

Editorial BoardDavid A. Anderson, DDS, MDS, MAVidal Balderas, DDSDavid F. Boden, DDSHerb Borsuk, DDSKerry Carney, DDS David A. Chernin, DMD, MLSDonald A. Curtis, DMDAllan Formicola, DDS, MSRichard Galeone, DDSPeter Meyerhof, PhD, DDSDaniel L. Orr II, DDS, PhD, JD, MDAlvin B. Rosenblum, DDSCarl L. Sebelius, DDSH. Clifton Simmons, DDSWilliam A. van Dyk, DDSJim Willey, DDS

Design & ProductionAnnette Krammer, Forty-two Pacific, Inc.

Correspondence relating to the Journal should be addressed to: Managing EditorJournal of the American College of Dentists839J Quince Orchard BoulevardGaithersburg, MD 20878-1614

Letters from readers concerning any materialappearing in this journal are welcome [email protected]. They should be no longer than 500 words and will not be considered after other letters have already been published on the same topic. The editorreserves the right to refer submitted letters to the editorial board for review.

Business office of the Journal of theAmerican College of Dentists:Tel. (301) 977-3223; Fax. (301) 977-3330

OfficersJerome B. Miller, PresidentSteven D. Chan, President-electBert W. Oettmeier, Jr., Vice PresidentThomas J. Connolly, TreasurerKenneth L. Kalkwarf, Past President

RegentsMark A. Bauman, Regency 1Thomas A. Howley, Jr., Regency 2Milton E. Essig, Regency 3Richard F. Stilwill, Regency 4Joseph F. Hagenbruch, Regency 5Robert M. Lamb, Regency 6George J. Stratigopoulos, Regency 7Rickland G. Asai, Regency 8

Theresa S. Gonzales, At LargeElizabeth Roberts, At LargeRonald L. Tankersley, At LargeStephen K. Young, At Large

Phyllis Beemsterboer, ASDE LiaisonDaniel A. Hammer, Regent Intern

Chairside Perspective on Practice 6 A Short Tour as a Staff Dentist in a Large Group Practice

A Young Dentist, DDS

9 Practice Experience with a Practice Management CompanyRon Tankersley, DDS, FACD

14 A Chairside View of Dentistry in a DSO-Managed Practice

16 A Comprehensive Health Group Practice Model Daniel Pihlstrom, DDS, and Danny White, DDS

19 The Indian Health Service Model from the Treatment PerspectiveMandie L. Smith, DDS

Manuscript 25 Retrospective Evaluation of Treatment Planning for Dental Implant

Sahng G. Kim, DDS, MS; Gunnar Hasselgren, DDS, PhD; Sasha Alexander,DDS; Seong W. Lee, DMD; Charles Solomon, DDS, FACD

ACD Gies Ethics Project Report 31 Do Patients and Dentists See Ethics the Same Way?

David W. Chambers, EdM, MBA, PhD, FACD

Departments 2 From the Editor

Every Pinohc Should Count

4 Readers RespondLetters to the Editor

46 Submitting Manuscripts for Potential Publication in JACD

Cover photograph

©2015 Jon DraperAll rights reserved.

situation would be a very large overlapfor the circles. In the best of all possibleworlds, all pinohcs would be patientsand no one would be treated unless theyneeded oral health care.There are people, perhaps 10% to

20% or more in any population, that areneither patients nor pinohcs. No needand no care. The other group to besensitive to includes the overserved—patrons of dentists who have no presentneed for oral health treatment. I have inmind routine radiographs and prophieson patients with no risk factors, aggres-sive treatment plans, some would sayautomatic extraction of asymptomaticthird molars, and esthetic work wherethe health component is difficult toidentify. There is nothing wrong withproviding these services, if patientsunderstand what they are paying for.They are patients who are not pinochs.Now for the hard part. What

characterizes an individual as a pinohc?My first approximation would be some-thing general: pinohcs are individualswhose oral health five years from nowwould be measurably worse if they failedto receive care during the current year.There is lots of room for quibble here,and epidemiologists have careers aheadof them teasing out the nuances ofoperationalizing this. But the general

Fitness centers have members,restaurants court patrons, shopsappeal to customers, most drivers

are also seat-belt users, and dentists have patients. The set of those using the services is always smaller than thenumber who could use the services but, for some reason, do not. We havenames for those who are users. But therest who could come have no name.Without a name these people fade into a vague background.The dental school where I work

moved six months ago to a mixedneighborhood in San Francisco. I drivethrough the nearby Tenderloin sectionof town with drunks wandering in thestreet and fairly regular street closuresfor police actions. A small homelessencampment has emerged across thestreet from where I park. During thehour each day I spend coming and goingthrough this neighborhood I seldomthink of optimal, continuous, compre-hensive oral health care, and never ofnew esthetic methods for provisionalcomposite resins or computer impres-sions and milled crowns.

At work I see the patients our facultyand students treat to an incredibly highstandard. They are making a worthycontribution to their patients. I just donot know what to say about the others.They have no name.I propose that henceforth we use

the term pinohc to designate Persons InNeed of Oral Health Care. The secondsyllable is pronounced “oc,” as at thebeginning of “occupation”; the “h” forhealth is, ironically, silent.What, then is a patient if not a

person who needs oral health care? Theformal definition of patient would be aperson who has agreed to the conditionsestablished by the dentist for receivingcare. Certainly, an individual whodemands treatment but is unwilling topay for it is not a patient, nor is one wholives in a remote rural area and decidesnot to drive four hours to the nearestoffice. One who does not visit a dentistfor ten years because “there is no need”would be difficult to classify as a patient.Somebody who starts a multistagetreatment and abandons it would atsome point no longer be thought of as apatient. One who puts off an occasionaltoothache is not a patient. All of thesepeople need oral health care, but theyare not patients.Think of two partially overlapping

circles. One is for patients who conformto the expectations of a dentist. One isfor pinohcs who would benefit from thekind of care patients receive. An ideal

2

2015 Volume 82, Number 2

Editorial

From the Editor

Every Pinohc Should Count

point is useful; a pinohc is one who canbe helped now to avoid future deteriora-tion in oral health. That should be thefocus of dentistry.There are multiple reasons why an

individual would be a pinohc but not apatient. They typically underestimatetheir need for care and underappreciatethe advantage of prevention. Somepinohcs simply do not know how thesystem works; having similarly struggledwith getting a driver’s license, neededhousing assistance, or legal advice. They also lack the means to get into theprivate practice system. Some pinohcsare lousy patients because they skippayments, disrupt office routine, andmake unrealistic demands. It is under-standable that dentists want very few ofthese and choose to provide charity carein foreign countries where they cancontrol this kind of exposure. There is no easy way to untangle the

multiple barriers preventing pinohcsfrom becoming patients in satisfactorynumbers. One strategy would be for theprofession to accept some measure ofresponsibility for addressing the pinochissues identified in the precedingparagraph. An alternative would be toprovide more and higher quality servicesto current patients. There are goodexamples of this model being developedby companies under the protection ofthe student debt banner. The leadconcept there is cherry-picking large

3

Journal of the American College of Dentists

Editorial

I propose that henceforth

we use the term pinohc to

designate Persons In Need

of Oral Health Care.

Our goal should be to increase

the ratio of patients to

pinohcs. The first step in this

process is to start counting all

the people who have needs

for oral health care.

margin services advertised as “smile”dentistry. There is pretty scrappycompetition for patients.

Slogans to the effect that patients’needs take priority are embarrassingwhen we realize that “patient” meansone who has accepted the dentist’sterms. Is it not a bit self-serving to claimit as a virtue putting those at the front of the line who promise to honor ourvalues? Our goal should be to increasethe ratio of patients to pinohcs. The firststep in this process is to start countingall the people who have needs for oralhealth care.The evidence of the past decade is

that the circles for patients and forpinochs are separating, with thesegment for persons in need of oralhealth growing faster than the segmentfor patients. It does not seem quite right to blame this on the pinochs, and hoping that the government willstep in to fix the problem smacks ofmagical thinking. The profession has achoice, and what the profession doeswill matter most.

To the Editor,

Kudos to the ACD Journal for payingeditorial attention to the fundamentalchanges occurring in the dental deliverysystem in this country. The classic one-dentist-per-practice cottage industry thatpatients have been used to for the pasthundred years or so is no longer thenorm. The trend is toward collaborationwhile increasing business acumen.“Group practice” now doesn’t just meana group of dentists under one roof, butcan also mean a group of practices underone brand. The latter are commonlyreferred to as “corporate practices” and/or “chains.” Under these models theindependence of the individual dentist/employee is often severely restrictedwhether the employer is a licenseddentist, or the de facto ownership is by some type of corporate DSO, which cannot legally own a dentalpractice in most states (despite theirefforts to the contrary).Unfortunately, the focus of these

models is on cost savings and businessefficiency, and thus the bottom linebecomes the top priority. Profits takeprecedence over patients. Let me be clear. If this trend continues and the focus is not reset on putting thepatient first, the ensuing ethical crisis in dentistry will result in a requiem for professionalism.

The first question in every dentalschool ethics class is, “what is a health-care professional”? Answer: a licensedexpert who puts patients’ interest beforetheir own. Simple. Ethical dentistsprovide dental care, not sell it. This iseasier to abide by for a dentist in thesecond half of a career with a fullyfunded pension plan, than it is for arecent graduate who is weighed downby six-figure debt. Many of the latter feelforced into the option of getting a job asa dentist in a corporate clinic. Entrepre-neurs need not apply. But many of theseare soon driven out by disillusionment. I am aware of the idealistic standards

espoused by defenders of corporatedentistry, but there seems to be a cleardisconnect between these platitudes andthe experiences related by some of theirex-employee/dentists, who are threatenedwith lawsuits if they divulge their hire-oncontracts. Their stories revolve aroundbeing pressured to maximize the chargesfor each appointment. Every patient gets an exam and an x-ray. Every endo-dontic treatment started is finished now;every crown gets a buildup; every 2 or 3-surface old amalgam is turned into acrown prep. If it’s on the treatment plan,they must do it. “Minimally invasive” isbanned terminology. Unbundlingtreatments and up-selling and up-codingare a part of the culture. The dentist/employee is judged solely on productiongoals and time efficiency.I realize that every testimonial I’ve

heard, and heard about, can be dismissedas “anecdotal,” but the passion withwhich they are delivered cannot.

If the trend toward commercialbusiness management controlling moreand more of dental treatment continues,the balance will eventually tip towardcommercial over professional ethics.This could increase cost, decrease access,and erode the traditional safety net.Financial decisions are too intertwinedwith treatment to be segregated fromthe operatory.The ACD and ADA need to continue

to monitor these trends in dental caredelivery systems, with the realisticperspective that there is an inherentconflict between commercial businessstrategies and the ethical practice ofdentistry. To bend these trends for thebest long-term benefit of the individualpatient requires every individual dentistto commit to the ethical principleswhich make them a professional. Thenprofessionalism will continue to definedentistry, despite any managementscenario imagined.

Victor J. Barry, DDS, FACDSeattle, Washington

Dr. Chambers:

I read your JACD editorial several timesand felt compelled to respond, given thechallenging questions it posed. To beginwith, just what does “corporate dentalpractice” really mean? I too wonder howmany definitions exist.

4


Readers Respond

Letters to the Editor

I remember that on one long day asa young resident just out of training, Itreated patients in a corporate practice.It stands out as the most difficult day inmy career. Having said that, I knowother GPs and specialists who obviouslyare better suited to that type of practicethan I was.You presented the idea of a separation

of the treatment (dentist-patient) andthe management (office-patient). This formally divides the control of these two operations as opposed to thetraditional practice in which the owner-dentist is in charge of treating the patientand running the office. On one hand, Isuppose it has potential efficiency; but italso runs the risk of removing some ofthe professional advocacy that dentistsare trained to provide. I agree with you that dentistry

has garnered much success in the last 50 years, but I would question yourhypothesis about dentistry not increas-ing higher profits without a change inthe business model.I was fascinated with the list of 15

items that a corporate practice couldaffect, which was at least twice as manyas I could think of. The most profoundthing you stated was that we should notlump all of these changes together andgive one big up-or-down vote. Regardless of these and other changes

occurring in dentistry, the sanctity of theprofession must be maintained, or elsethe patient (consumer) will find them-selves being treated by a tradesman, orworse yet—a healthcare commodity. Kudos for posing some tough

questions and being wise enough toavoid pretending that you have theanswers. I don’t think many of theanswers can even be known at this time.Finally, it is critical that we dentistsremain engaged in the conversation

and continue to protect our profession;that’s a responsibility we can’t dare leave up to anybody else.

Steve Leighty, DDS, FACDAuburn, California

Editor, JACD –

The winter number (2015) of theJournal of the American College ofDentists discusses one perspective of the new normal for the future of dentalpractice. I read with great interest the mission and goals of the practicemodels discussed. First, change is here to stay. The

Affordable Care Act (ACA) and economicsare important drivers of the change—that train has left the station. As a deanof a school of dentistry, I try to helpnavigate the uncertainty of what ourprofession will look like in the next two decades and, when I have the rareopportunity to be in a position ofinfluence, to help guide a responsible,principled pathway. Frequently I wonderhow should our educational systemchange to meet the need to educatepractitioners of the future when there isno definition for exactly how dentalpractice will change? This environment is leading our

profession in a race for relevance tomeet the oral health needs of a diversepublic where new structural frameworks,impacted by economic influences,abound. The contributors to this issue of the journal have tested new ways oforganizing, delivering, and managingdental practice and they are creatingnew categories of practice design.Capturing shifting markets of need,addressing efficiency, improvingcollaboration, looking at outcomes,improving access to dental care amongthose in need, and implementing EBD/best practices while caring for patientsare themes throughout the discussions.

In the March issue of JADA this year,the association’s Chief Economist and VPof the Health Policy Institute, Dr. MarkoVujicic, captures the sentiment of changein the question of the value propositionof oral health care. The ACA and otherinitiatives will drive the agenda forquality patient care, improved outcomes,and patient satisfaction. The externalenvironment has been changing withnew paradigms of group practice andcollaborative practice and infinitemodels that help drive the change to thenew imperatives.In the end, our dental healthcare

practice will change to more ACA-accountable care organization-typepractices. The majority will most likelybe some type of group practice that mayinvolve other health care disciplinesand/or multiple dental care providers.Yet to be determined are the myriaditerations that dental practice and dentaleducation will go through before thisround of change is done.

Marsha A. Pyle, DDS, MEd, FACDKansas City, Missouri

CorrectionPractice transition with intelligence and grace. JACD 2014, 81 (4). Page 28.The bottom two entries in the Vendorsection of the table on the upper leftwere reversed. It’s not always aboutmoney…” is a Great Move and “Don’thave staff employment contracts” is a Stumble. We regret any confusion this may have caused.

5


Readers Respond

A Young Dentist, DDS

AbstractA large group practice can be owned andmanaged by a dentist with all businessoperations internal to the organization.Under such a system there can still be aseparation of chairside and overall patientoral health considerations. Such a modelprovides benefits to some dentists—especially those beginning their careersand those who are working a few hoursper week at the end of their careers.Centralizing business functions within an office and screening them from thepractitioners who provide the care haveadvantages and disadvantages.

As a new graduate in acompetitive job market, I eagerlytook a job offer as an associate

dentist in a large group practice. Thebusy multiple-operatory practice, run bya single owner dentist who no longerpracticed chairside, was modern andclean, with all of the diagnostic tools and dental materials I was used tohaving in dental school. After a handfulof working interviews in older offices,this paperless and high-tech practice was very attractive to me. The modelalso provided in-office specialty care byprosthodontists, orthodontists, periodon-tists, and endodontists. The opportunityto work with more experienced dentistsand specialists on complex cases wasappealing, especially in the beginning ofmy career. It was much like an extensionof dental school.I joined this group of 12 general

dentists and specialists, who were invarying stages of career development. In addition to several younger newgraduates like myself, there were alsoexperienced dentists who had been atthis practice for decades, dentists whohad owned their own practices in thepast and decided to become associatesafter selling their practices, and part-time dentists who did not want tomanage their own practice. On anygiven day, there were five to six generaldentists working and oftentimes aspecialist as well. Staggering dentists’schedules allowed the office to offerappointments from early morning into the evening.

Staff as the Backbone of the OfficeMy training consisted of learning theelectronic records system and practicingrecommended doctor-patient scriptswith the veteran RDA managers of thepractice. The scripts were intended tostandardize certain aspects of theinteractions between providers andpatients, such as greeting new patientsand handing off the patients to thefinancial coordinator to discusstreatment plans. The experienced RDAsproved to be central in this practice withregard to orienting new dentists. Duringthe working interview and short trial-employment period, I was assistedexclusively by the experienced RDAs who assessed the personality fit of newdentists and were given the responsibilityof transitioning new dentists into thepractice. They set the friendly and caringattitude of the office through theirpatient interactions and often had morerapport with established patients thanthe dentists did.After the initial training period, I

was assisted by any of the several RDAson a rotating basis. The assistantsranged in experience from interns of thelocal community college RDA programto those having more than 20 years ofRDA experience. There were no assistantassignments to a specific dentist, andinstead the RDAs rotated among thedentists. Since dentists’ schedules were

6


A Short Tour as a Staff Dentist in a Large Group Practice

Chairside Perspective on Practice

The author of this personal narrative hasasked to remain anonymous.

so varied, rotating the assistants madesure that the assistants could haveschedules independent of the dentistsand no dentist would be pairedconsistently with an inexperienced RDA. There were no hygienists on staff,

so the general dentists were responsiblefor completing all the prophies, scalingand root planing, and periodontalmaintenance for their patients. Mostpatients appreciated having the dentistperform their cleanings and often notedto me that they never had a dentist clean their teeth before. I found thatcompleting the prophies was helpful forgetting to know new patients andassessing their level of oral health, butrecall exams and routine prophiesbecame tedious over time when mypatient volume was more establishedand I needed time in my schedule formore productive procedures. Since the office hired part-time

specialists, the office preferred to referout procedures as little as possible. Thiswas very convenient for patients, whowere able to go to one office for all oftheir treatment. The office was set up for specialists to provide the full range of procedures, which most often wereimplant placements, endodonticretreatments, and apicoectomies. Inmost cases, the ability to have a quickconsult with a specialist to determineacceptable treatment options or to givespecific instructions regarding aparticular patient’s treatment wasclinically advantageous as well. However,this practice model was not withoutlimitations. I could not choose the

specialists I preferred. Also, when I didrefer a patient to an outside specialist,usually to an oral surgeon for morecomplex surgical procedures withsedation or due to scheduling constraintsfor urgent endodontic procedures, I wasquestioned by the practice managers,who would have preferred to keep thoseprocedures in-house.

What Was Expected of MeAlthough there was no direct pressurefrom the management to produce acertain volume each day, the compen-sation model for both the practitionersand the scheduling coordinators wasdesigned to motivate the whole team to keep a full and busy schedule. Mycompensation was based solely on apercentage of collections. Bonuses werein place for the scheduling coordinators.The schedule was managed by the frontoffice staff, but I was able to lengthen orshorten appointments as needed. Most of the patients lived and

worked near the office, where severallarge businesses were located. Thus, themajority of the patients in the practicewere insured through their employers.The practice accepted PPO and fee-for-service insurance plans. Due to theevening and weekend appointmentavailability, I saw a fair number ofemergency patients as well. New patientsand emergency patients were distributedto dentists based on availability in theschedule. Some new patients requested

7



My job was to work in

the patient’s mouth, one

appointment at a time.

More or less everything

else was the responsibility

of others.

the previous treating dentist’s clinicalnotes were not clear about the nextphase of treatment or if the patient wasnot aware that he or she would beseeing a different dentist. On the otherhand, the flexibility in provider coveragewas beneficial for ensuring emergencycare for my patients while I was out sickor on vacation. As an independent contractor, there

were no paid vacations or sick days, butsince there were several dentists whocould cover, there was less pressure forme to be present for the patients or forthe practice’s bottom line. With the large number of providers

and back office auxiliary staff, thepractice provided on-site CPR and OSHAcontinuing education. Occasionally,dental company representatives gavelunch presentations regarding thematerials that were used at the practice.Under independent contractor status, noadditional continuing education wascovered by the practice.

A Narrow Perspective on theProfessionMy job was to work in the patient’smouth, one appointment at a time. More or less everything else was theresponsibility of others.During the three years I worked at

this office, I came to appreciate theseparation between the financial aspectsof practice and the chairside treatment ofpatients. The office policy on treatmentwas quite restrictive, going so far as toblock dentists’ access to financialmodules in the electronic records. Afterexplaining the clinical aspects of thetreatment plan with a patient, a frontoffice team member would inform thepatient about the treatment cost andinsurance coverage, if any. For me, this separation relieved me

from having to explain costs to patients,thus gaining the trust (or at least

quieting the cynicism) of patients whomight be quick to make a direct linkbetween treatment cost and dentists’pay. In this model, the dentist is allowedto focus on the job he or she was trainedto do, i.e., treating patients, and the front office is trained and responsible fora different aspect of care, i.e., collecting/billing insurance. This particular office was a very

successful example of this practicemodel. This model offered a hassle-freeopportunity for dentists to providetechnical treatment to patients withoutworrying about the many tediousbusiness aspects of running an office.For patients, the practice provided manyconveniences that a traditional officecould not, including one-stop specialistcare and weekend appointments. Ultimately, the office’s policy of

excluding providers from access tofinancial information became a problemof transparency for me, since mycompensation was based on a percen-tage of collections and the collectionnumbers were never disclosed. Thecompensation was also at the low rangefor associates in my area. Working latehours and weekend days becamestrenuous as well, so, after three years, I left to pursue an associate opportunityin a smaller practice. I was not an anomaly. The office

saw several dentists leave well beforereaching the three-year mark. As I thinkback on the efficient training by staffmembers and the staff management ofthe long-term care of patients, I wonderwhether turnover is built into thispractice model. Many young dentists usethis as an opportunity to build up speedand then go on to more comprehensivepractice models. I wonder about thepatients though. ■

8



This model offered ahassle-free opportunity for dentists to providetechnical treatment topatients without worryingabout the many tediousbusiness aspects ofrunning an office.

specific practitioners based on onlinereviews or referrals. After the newpatient exam and treatment planning,patients could schedule treatment withany of the dentists. The schedulingcoordinators tried to keep patients withthe dentist who made the treatment planto preserve continuity of care, and mostpatients preferred to stay with thedentist who saw them first. However,patient preference and schedulingconvenience took precedence overstaying with the same practitioner. There were very few instances when

this became problematic, such as when

Ron Tankersley, DDS, FACD

AbstractThis article describes the experiences of a dentist using a contracted dentalservices organization to manage thebusiness aspects of a multisite grouporal and maxillofacial practice. The needfor help with management functionsfirst became apparent in medicine, andseveral models emerged there. Themodel used in this practice sought totake advantage of specialized expertisewithout reducing practitioners’ controlover dental decisions, including thosegoing beyond narrow clinical decisions.Personal experiences and suggestionsfor best fit between practices oncontracted services are presented.

Istarted my private practice with nobusiness education or experience. By the time that I completed my

residency in oral and maxillofacialsurgery, those rare “practice manage-ment” classes during dental school werea distant memory.Fortunately, in 1971 managing the

business aspects of a dental practice waspretty simple. It required diligence, butlittle business acumen. I was able tosecure a practice loan without collateral.Managing personnel, payroll, accountspayable, and accounts receivable were“logical.” There were no onerousgovernment regulations. For those whoconducted themselves in an ethicalmanner, there were few legal concerns.So, initially, I managed those aspects ofthe practice myself. Many of mycolleagues at that time delegated thoseresponsibilities to trusted members oftheir allied dental staffs.Government-sponsored dental

benefits programs were in their infancyand most patients had no dental benefitsplans. Fees for some oral surgeryprocedures, such as biopsies, removal oftumors, facial trauma, and removal ofimpacted third molars, were usuallyreimbursed by medical insurance. But,insurers only required a description ofthe procedure and the fee forreimbursement. So, initially, I delegatedthat responsibility to my receptionist.

The Emerging NeedDuring the ensuing years, I built twonew dental facilities and added threepartners. Managing the business ofdental practice became increasinglydifficult. Federal regulations concerninghuman resource management,occupational safety, disease control,taxation, patient privacy, and controlledsubstances became increasinglyonerous. Insurance and dental benefitscompanies developed increasinglyburdensome credentialing proceduresfor the doctors, more difficult-to-understand criteria for benefitscoverage, and inexplicably complexclaims forms. To some degree, therewere legal concerns with almost everyaspect of practice.Eventually, the practice used

accountants and attorneys on a regularbasis. Those practice managementfunctions that involved specialrequirements, rules, and regulationswere delegated to personnel with therequisite knowledge. The dentistsperiodically met with the practicemanager for updates on the status of

9


Practice Experience with a Practice Management Company


Dr. Tankersley recentlyretired from a multioffice oral and maxillofacial practicein eastern Virginia. He is amember of the Board ofRegents of the AmericanCollege of Dentists and servedas an uncompensated memberof the board of the manage-ment services organization hedescribes in this article; [email protected].

fees, partner compensation, third-party payer participation, marketing,personnel, and practice expansion. Westill regard such decisions as essentialelements of dentistry.In addition to private practice, I was

involved in both teaching and organizeddentistry. So, I understood the impact of the changing environment ongraduating dental students, residents,and my colleagues. As an OMS, myinvolvement with local hospitals gaveme a clear view of the environment’sdramatic impact on medical practices.It was becoming increasingly

difficult for traditional solo practices and partnerships in medicine to survive.Hospital corporations were developingand aggressively marketing largephysician networks. Traditional solopractitioners and partnerships inmedicine were unable to compete withthe corporate networks in purchasingpower and negotiating with third-partypayers. More importantly, for all intentsand purposes, individual offices were“shut out” of referral networks. Theimpact on their incomes and futuresbecame undeniable.So most physicians in my area of

the country felt compelled to sell theirpractices to hospital corporations.Unfortunately, the authority to hire, fire,and determine the salaries of practicepersonnel was a contractual prerequisite.The corporations could also restricttreatments, set requirements for thenumber of patient encounters per day, establish production goals, and even terminate physicians from theirown practices.

Identifying a SolutionA group of local physicians realized that traditional private practice wasunrealistic in this new environment. To be competitive in the medicalmarketplace, they needed the ability to(a) offer a network of multidisciplinaryproviders, (b) enhance negotiations withthird-party payers, (c) make economy-of-scale purchases, and (d) effectivelymarket their practices. But they wantedto maintain control over the clinicalmanagement of their patients and theirpractice model. They determined that accomplishing

those goals would require a large groupof physicians to consolidate theirbusiness functions under first-classbusiness leadership. So, they formed aphysician-owned corporation. Theircorporation selectively invites to jointhem only highly reputable local physi-cians who share their vision. It providesmanagement services, but does notinterfere with patient treatments. Itadvocates for ethical guidelines andterminates those physicians who violatethem. To this date, it successfullycompetes with the local hospital corpor-ations and is recognized for providingstate-of-the-art, ethical medical care.I personally knew many of the

physicians involved in the formation of this physician-owned medicalcorporation. Because of the concomitantchanges occurring in the dental practiceenvironment, I believed that someaspects of their endeavor might beapplicable to dental practice.In 1998, an OMS surgeon in

Oklahoma perceived the need for apractice management company for oralsurgeons. As a practicing dentist whowas also deeply involved in training OMSresidents, he realized that they lackedthe background and skills required tocompetently start a new practice intoday’s complex business environment.

If there were a management company toprovide those services, new practitionerscould concentrate their efforts ondeveloping the clinical aspects of theirpractices. A mutual colleague suggestedto him that I may be interested inexploring the development of such anorganization. So he contacted me.Over the next few months, a group

of oral and maxillofacial surgeons whoperceived the need for professionalbusiness management of OMS practices,particularly for new or solo practi-tioners, met several times. We came tothe consensus that we should form apractice management company. Weagreed that the company should providebusiness management services thatwould not interfere with dental practicedecisions or “own” the practices. Thecompany should provide the businessaspects of human resource functions,but the number of personnel and theirsalaries should be at the discretion of thepractice. But, the company should serveas a resource concerning “best practices”in personnel management, if requested. I serve as an uncompensated board

member of the resulting practicemanagement company. As with moststart-up businesses, there were severalstructural adjustments necessary duringthe first few years. But, the company’smission and the services that we providefor the practices never changed.Today, the practice management

company provides human resourcesservices, including payroll management.It manages accounts receivables,submission of insurance claims,insurance and hospital credentialing,accounts payable, retirement accounts,and payroll. It also provides accounting

10



and business-related legal services.Contracting dentists are providedperiodic financial reports, which can be individually customized. There arequarterly meetings between the dentistsand representatives from the manage-ment company to discuss the interfacebetween the business and the practiceaspects of each office. Fees for the management services

are based on the actual cost of providingthe services, as a percentage of eachpractice’s total revenues. If desired,personal financial planning and taxservices are available for an additionalfee. Contracting practices use manage-ment’s Internet-based proprietarypractice management software. Practiceinformation, including schedules,financial data, digital x-rays, and patientinformation are always available withInternet access.My practice began using the

company’s management services in1998. I was involved with hands-onpractice management until 2008. At thattime, competing professional activitiesnecessitated that I leave those functionsto my partners. I retired from practice in January 2015. The remainder of mydiscussion describes some of my experi-ences as a contracting dentist with themanagement company. I will also sharesome of my observations and recom-mendations based on those experiences.

ExperiencesAccurate and timely practiceinformation is essential for themanagement contractor to provide itsservices. Implementing the proceduralchanges necessitated by that needrequired considerable effort. Most of thiseffort has included training staff anddentists to properly use the company’spractice management software. Butother changes were also necessary. Forexample, vendors were directed to send

routine practice bills directly to themanagement company. Practicepersonnel were trained to transmitcopies of invoices after verification of therespective deliveries. Although theprocedural changes were significant, thecompany’s trainers did a good job offacilitating them with minimaldisruption. Of course, for a new practice,this would be initial employee trainingrather than retraining.Since insurance claims submissions,

billing, payroll, reimbursements, andpayables were done by the company, thepractice required fewer in-houseadministrative personnel. But, as amultidentist, multifacility practice, westill needed to retain someadministrative staff for “internal”management. So, our reduction in staffsalaries was more modest than would beexperienced by smaller, less-complexpractices. However, the company’sexpertise in claims submissions,accounts receivables, and financialmanagement quickly increased bothgross and net practice revenues. Our staff quickly embraced

management’s Internet-based centralappointment scheduling. As a multi-dentist practice with several facilities, theability to customize the schedules to theneeds and desires of each dentistresulted in reduced schedulingfrustrations and increased production.Management reports include the

individual dentists’ procedures,production, collections, percentagecollections, and write-offs. Theimplications of this data are discussed atquarterly meetings. Positive trends are

11



[We regard decisions on]

fees, partner compensation,

third-party payer

participation, marketing,

personnel, and practice

expansion…as essential

elements of dentistry.

explained and continuation of theenvironment that created them isencouraged. Negative trends, such asdecreased time-of-service collections,reduced third-party reimbursements,changes in referral patterns, and erosionof important clinical aspects of thepractice, are also noted. Suggestions forreversing those trends are explored.But there are no attempts to alter thedentists’ clinical management of patients.Subsequent to contracting for

management services, the practice made major equipment purchases andbuilt two new facilities. Once wecommunicated our goals to themanagement company, it took the leadin negotiations with vendors, landlords,and financial institutions to ourspecifications. It also provided legalservices, such as establishing limitedliability corporations for the newfacilities and forwarding the pertinentinformation to state agencies.Management’s facilitation of these

major practice events significantlydecreased the personal hassle involved.The collective experience of thecompany’s team exceeded that of any ofour partners or the local professionalsthat we had previously employed.Coordination of services within thecompany, made legal and accountingfunctions seamless. The collective assetsof the company and their relationshipwith financial institutions expeditedfinancing at favorable rates.

The practice also added new partners.Again, the coordinated efforts of man-agement’s professional team greatlysimplified the legal, accounting, andcredentialing issues—but not the selectionor need for changing the number ortypes of practitioners. After we deter-mined the terms of the agreements, thecompany developed the partnershipcontracts and explained the legal aspectsof them to the new partners. Thecompany also completed and submittedall information necessary for hospitaland insurance company credentialing.Periodically, cash-flow problems in

the practice occurred that would havepreviously resulted in significant short-term decreases in dentist compensation.Knowing our practice assets andbusiness trends, the managementcompany used its collective resources tominimize reduction in dentists’compensations during those timeswithout violating its fiduciaryresponsibilities.There were also a few isolated

incidents that are noteworthy:• A new partner with a history ofsuperb clinical practice had a prob-lematic financial situation. Thecompany’s professional managementteam expeditiously straightened outhis financial position.

• A former practice manager forgedsignatures on several reimbursementforms. Members of the managementcompany recognized the forgery,informed the partners about theincidents, and assisted in takingappropriate action. Since handlingpractice reimbursements was part ofthe practice manager’s duties, it isunlikely that the dentists would havedetected these forgeries on theirown. Because of the managementcompany, we handled this situation

12



For practitioners wishingto maintain control of their dental decision-making, but wanting theenhanced businessexpertise and marketingadvantage of a largergroup, contracting with a practicemanagement company is a viable option.

in a timely manner with minimaldisruption to the practice.

• The practice underwent a ratherextensive audit of implant salestaxes. With management’s help, theaudit was concluded withoutnegative consequences.

Quite frankly, I’m not aware of anybusiness-related problem that we encoun-tered that the company’s professionalstaff had not previously encountered.

Observations and RecommendationsThere is some truth to the complaintthat dental schools have historicallyfailed to provide predoctoral studentswith all of the management expertiseneeded to run a solo practice. But thereare no grounds for worrying that today’sgraduates are unfamiliar with providingcare in a computer-assisted efficientlystructured system managed to optimizepatient benefit. All dental schools nowuse some variation of the model I havedescribed throughout theirundergraduate and residency programs.Increasing numbers of practicing

dentists and new graduates are electingto join corporate dental practices. Thosecorporate dental practices operate on adifferent model and have a significantability to influence the patient careprovided by the dentists who contractwith them. The essential distinction iswhether dentists can terminate thecontract of their management firm orwhether the management firm canterminate the contract of dentists. Togrow and protect their “brands,” somehigh-end corporations may expect highstandards of care from their dentists.But, since non-dentist corporatestockholders want a good return on

their investments, many dentalcorporations will unfavorably influencethe quality of care by restrictingtreatment options, mandating materialsused, or instituting production quotasand bonus systems. They may also stepinto nonclinical areas that are stillfundamentally dental, such as practicelocation, hours of operation, and thepublic’s image of what oral health careshould be.For practitioners wishing to maintain

control of their dental decision-makingbut wanting the enhanced businessexpertise and marketing advantage of a larger group, contracting with apractice management company is aviable option.However, making such a decision is

like any other a professional makes.Practice management companies arestructured in a variety of ways and havedifferent levels of business expertise and scope. So dentists should carefullyresearch their options.With a good management company,

most practice information is readilyavailable through the Internet. However,some information is available onlythrough the management company. In addition, professional managementoften makes accounting and adminis-trative decisions that most dentists finddifficult to understand because of thecomplexity of today’s financial and legalenvironment. So trust in the integrityand competence of the managementcompany is crucial. Without that trust,the relationship can quickly unravel.Contracting with a practice

management company should be a value proposition. A dentist needs to feelconfident that the management fees are appropriate for the market. Also,good management companies provideservices often not used by practiceswithout professional management, such as detailed budgeting and strategic

planning. These services can be avaluable asset to the practice. But theyonly have value if properly used.Practices unwilling or unable to

eliminate key management positions ormanagement functions should considermanagement companies that offer a la carte services to avoid duplication of services and expenses. But, dentistsshould keep in mind that the coordi-nation of those individual managementservices within one company typicallyenhances their value.

SummaryPractitioners who want to maintainautonomy in dental decision-making,but desire the advantages of a largerclinical network, the marketing andnegotiating advantages of a largergroup, and business management bybusiness professionals, should considercontracting with a healthcare-savvypractice management company. If the practice management

company is trustworthy, competent, and provides the desired services, it can enhance a practice’s businessfunctions and marketing position whilepermitting dentists to concentrate ontheir area of expertise, providing goodoral health care.■

13



AbstractOver the past 18 months, 11 young dentistsagreed to share their perspective on whatit means to work chairside in an officewhere a dental support organization hasthe capacity to manage dental aspects of the practice, such as hiring, financialarrangements, and office hours andlocations, and where dentists are not ableto terminate the management company. All of them have backed out. The reason isthe same for each; they had signedcontracts that blocked them from tellingtheir stories or even sharing their contracts.The Journal reached out to the owners ofseveral such organizations, asking for awaiver of this restriction or, absent that,for them to at least provide chairsidedentists who could speak freely.

These pages provide the best picture wehave been able to form of what dentistswho work for DSOs that manage officeshave to say about dentistry.

14


A Chairside View of Dentistry in a DSO-Managed Practice


15



These pages provide the

best picture we have been

able to form of what dentists

who work for DSOs that

manage offices have to

say about dentistry.

Daniel Pihlstrom, DDSDanny White, DDS

AbstractPermanente Dental Associates includes 17 offices in the Pacific Northwest. Among the distinguishing characteristics of this model are a predominantly HMOstructure and integration of care in ageneral medical program. Staff dentists are on salary and are largely relieved ofthe business details of practice. Ultimatecontrol of the system is vested in a group of shareholders—the dentists who practice chairside. One of theshareholder-practitioners discusses hisperspective on this system.

Permanente Dental Associates, PC (PDA) provides dental careprimarily in partnership with

Kaiser Foundation Health Plan (KFHP).Together when KFHP insurancecompanies partner with Permanentedoctor groups they form the KaiserPermanente (KP) brand.KP Dental began as a federally-

funded research project in the late1960s. Since becoming a free-standingprogram within Kaiser Permanente’sNorthwest Region in 1974, it has grownfrom a single 12-operatory dental officeto 17 dental offices that serve more than 235,000 members in the Portland-Vancouver metro area, Longview,Washington, and Salem, Oregon. It isone of the largest group-practice dentalprograms in the country.Currently, the Northwest is the only

KP region in the United States with adental program. Based on a prepaiddental care model (HMO), KP Dental has expanded to offer PPO plans, anindividual and family plan, coverage forMedicare and Medicaid recipients, and a discount dental program.KP Dental acts similarly to an

accountable care organization (ACO)with regard to care coordination,capitated arrangement, and focusedoutcomes, though, unlike a full ACO, it isa completely integrated medical providerand payer. PDA is one of the earliestadopters of an integrated care deliverymodel, with a focus on dental care aspart of overall health care.

KP Dental has been continuouslyaccredited by the AccreditationAssociation for Ambulatory Health Care since 1990 and was the first in the Northwest to achieve dental homeaccreditation. It has experienced stronggrowth, gaining approximately 64,000members (a 37% increase) over the pastten years. January 2016 membership isprojected at 240,287.

Ownership StructureCurrently, PDA has nearly 100shareholder dentists of the 142 dentiststhat make up PDA. A Dental Director(elected by the shareholders) and his orher dentist leadership team provide theoperational oversight of the clinicalpractice. The Dental Director reports tothe Board of Directors composed of sixshareholder dentists that are also electedby the shareholders of the corporationfor three-year terms. PDA is a professional corporation

(PC) that is owned and governed by itsshareholder dentists. The general careerpath for a new associate is to transitionto shareholder after approximately threeyears. This model of being dentist-owned

16


A Comprehensive Health Group Practice Model


Dr. Pihlstrom (top) is AssociateDirector for Evidence BasedCare & Oral Health Researchand Dr. White is a Profes-sional Director and GeneralDentist at Permanente DentalAssociates in Portland, Oregon; [email protected].

and governed has led to a high level ofprofessional satisfaction for its dentists,evidenced by its employee makeupwhereby 70% of its dentists buy into thepractice as shareholder owners. Theaverage tenure of its dentists is 11 yearsfor dentists who have been with PDA formore than one year. Practice models are varied, difficult

to define, and guaranteed to changeeven more rapidly in the future thanthey have in the past. The most criticalfeature of these alternatives is who getsto make the final decisions. In ourmodel, key decisions like the size of aclinic, location, services provided, andeven the cost of building the clinic are alljointly decided by the dentist corporationand the insurer. This mutual decisionmaking process is a hallmark of ourpractice because it comes closest tomaking improved oral health the drivinggoal. Categories and definitions areperhaps the least important part ofunderstanding the changing practicemodels in our profession. More importantis how these models impact care forpatients, dentists, and staff; and howthey might change the future of dentistry.

InterviewThe focus of this theme issue is howvarious group practice models look tothe dentist at chairside. To find out whatit means to practice in an organizationbased on a comprehensive view ofhealth, I sat down with Dr. Danny White,Professional Director and GeneralDentist at the Tigard, Oregon, Kaiser

Dental Office to discuss his thoughts onthe practice model and how it impactshim as a dentist.

How long have you been in yourcurrent position? What do you do?

Dr. White: I have been with the groupfor six years. Prior to that I was in aprivate practice for 24 years. I am ageneral dentist engaged in all aspects ofmanaging my patient pool. Basically, Itake care of all my patients’ oral healthneeds, treatment plans, patient concerns,patient referrals, emergencies, etc.

What attracted you to the position,did you have any hesitancy, and whatelse did you consider but not follow?

Dr. White: After many years in privatepractice I decided to make a change andrelocate to another part of the country.At the time, I had considered privatepractice but the business aspect was notmy favorite—I wanted to focus on patientcare. I like the fact that in my currentpractice I am not always on call anddon’t have to carry a pager everywhere I go, unlike my experience in a privatepractice. Also, during my 24-year careerrunning a private practice, I think I tooktwo two-week vacations the entire time.I also had to arrange for someone tocover emergencies in my absence frommy practice. Plus, there was theoverhead of a private practice and the

17



KP Dental acts similarly to

an accountable care

organization (ACO) with

regards to care coordination,

capitated arrangement and

focused outcomes, though,

unlike a full ACO, it is a

completely integrated

medical provider and payer.

sense that while you are away you arenot producing anything. Here you aregetting paid when you go on vacation—you can truly walk away and not worryabout the practice. You know yourcolleagues will cover for you and yourpatients while you are away. In addition, the compensation and

benefits are more of a known entity inmy current practice. I was initiallyhesitant to work in an HMO-stylepractice. Was I going to be told how Ihad to treat patients? I knew colleaguesin private practices that took HMOpatients and had to limit care in order tomake it work. I didn’t want that. Andthat is certainly not the case here.I looked at a few group practices and

corporate dentistry organizations in thearea. Some seemed more like a steppingstone practice with lots of early careerdentists. It seemed like they were onlythere until something else came along.That didn’t seem like the case here andthe fact that my current practice isconnected with a medical organizationpiqued my interest.

How does your current position fitinto your career plans?

Dr. White: This is a great place to finishmy career. I have had an opportunity to see both sides of dentistry. I reallyenjoyed my private practice; however, Iam really enjoying this practice too. Forme, not having to be worried about thebusiness aspect is huge at this point inthe game. The idea of phasing downinstead of having to quit dentistry isreally appealing to me, and that’s anoption in my current practice. As long

as I have stuff to offer, I want to be partof dentistry as long as I can.

What were the greatest surprises ordiscoveries (both positive andnegative) you encountered?

Dr. White: Positive discoveries? I knewthat not having to be running thebusiness was a positive thing. Noteveryone likes running a dental office,and there is so much that they don’tteach you in dental school about thebusiness aspects of dentistry. Nowadays,you can take additional classes on thebusiness of dentistry or even hire apractice management organization, butthat really wasn’t the case when I startedmy practice. Also, being in privatepractice can cloud your judgment whenit comes to patient care. I had knowndentists in my community that wereknown for overtreating patients. Here, Ihad concerns initially that my treatmentplans would be limited or I would be toldwhat treatments I could or couldn’t do.But that have never been the case. I like the connection we have between

the medical and dental systems. Forexample, I had a new patient once whohad a very bad looking oral lesion.Because my dental office is located in amedical building with an ENT depart-ment, I walked the patient up and withinno time he had been biopsied anddiagnosed with oral cancer. That wasjust amazing and great for the patient. It can be difficult here to refer to a

specialist quickly. In my private practice,if I needed patients to see an endodontist,they could get an appointment in acouple of days. I could decide to start theendo or not. But here I have to managethose patients more because the wait tosee a specialist is much longer. Of coursewe can refer to specialists outside theprogram if we need to, but access issuesand demand is just greater here and itcan create challenges with getting inpatients in a timely manner.

What are the advantages anddisadvantages of separating themanagement and treatment functionsof dentistry for patients, dentists, and the profession?

Dr. White: For the patients, the dentistscan focus on patient care and not haveto worry about meeting bottom lines orfinancial aspects. In our model, the goalis to get the patient to a state of healthand maintenance, because if we can, inthe long run the patient is going to beeasier to care for and have fewer needs.That’s not always the goal in privatepractice. The disadvantage for patientshere is access. It can take longer to getthe care completed here. For dentists, theadvantages are that you don’t have toworry about overhead, collections, claimsgoing out, patients paying their portions,etc. Not having to worry about thepractice management side of it is huge. At chairside, each dentists makes

his or her own professional decisions. At the level of the overall organization,we have a management team that looksafter the business decisions, and in ourcase, management even includes expertstrained in and responsible for qualityand overall patient health outcomes.Like some other large group models, we have shareholders who oversee themanagers. But in our case, the share-holders are the dentists who treat the patients.For the profession, I think the

advantage is that it creates a really goodopportunity for dentists who don’t wantto run a practice themselves. They canpractice in a really good environmentwhere they can focus on patient care, getpaid well, and not have those worriesabout the business. Plus being part ofthe patient’s healthcare team is a hugeadvantage in our program.■

18



Mandie L. Smith, DDS

AbstractThe nonprofit dental delivery model isappropriate for the needs of specificpatient populations. The Indian HealthService is an example of how care can be provided where traditional fee-for-service and indemnity mechanisms may be insufficient. Separating care frommanagement in this context gives dentistsgreater power over individual treatmentdecisions, increased choice of patient-relevant care options, and control overdevelopment of the practice model and its evolution. The needs of variouspopulations groups and the funding orprofit model inevitably influence thecomposition of the dental team andassignment of dental duties.

In 2002, I began my dental career in an Indian Health Service hospitalin western Alaska. With tundra and a

horizon as far as the eye could see,Bethel, Alaska, is a hub for 48 villagesspread across an area the size of thestate of Oregon. Many young profes-sionals have been drawn to this remotecommunity for its novelty, uniqueness,and cultural richness. Lifelong friendshipsare made, partly through the hardshipsof isolation from the outside world.There are no roads out; they all termi-nate in the tundra. The reality thataccess to care here is a critical deficiencyand a daily struggle for the people of the Yukon-Kuskokwim region was over-whelming for this South Texas graduate,but it also solidified my calling to publichealth dentistry as a career choice. I had a deep desire to help those

with the greatest need. I knew that Icould go into private practice anywhere,but it was not just anywhere that I coulduse my skills to make such a difference.Besides, only in Alaska can you travel by floatplane or a dog sled to get to work for the day. The adventure ofAlaska superseded any thoughts ofprivate practice ownership or ideals of a conformed lifestyle in a big city.Understandably, my choice is not foreverybody, but it is my passion.The majority of patient care in

Bethel is urgent, with severe dentaldecay and dental infections being the

norm. I was relying on my experiencedcolleagues as a safety net for the firstyear of practice. It was humbling torealize that my newly earned title ofdoctor and all of my years in schoolwere only a foundation for my practice.It is not uncommon to have 20emergency walk-ins per day, all withurgent needs. I became adept atemergent care, trauma, and severedental infections in the first two years.This public health experience wasexhilarating for a new graduate. Everyday brought new experiences and animmense number of challenges. I wasable to gain speed and skill without thedemands of managing a practice. It wasnot long after confidence began to settlein and the glow of excitement began tofade that I sought more comprehensivecare efforts. I was compelled to seekfurther training through a two-yearadvanced education in general dentistry(AEGD) program, which I completed in2008 in Bethel.

Beyond my advanced education, I also worked closely with the first DentalHealth Aide Therapists (DHAT) in 2005-2006. This new mid-level providercategory was heavily scrutinized by theprofession during its infancy. The workof the DHATs is how the gap in access to

19


The Indian Health Service Model from the Treatment Perspective


Dr. Smith is deputy chief at the Southeast AlaskaRegional Health Consortium(SEARHC) Sitka, Alaska;[email protected].

care for this region is being closed.Alaska’s health care system has suffereda shortage of healthcare providers formany years, especially in the ruralcommunities. This led to innovativeworkforce development strategies suchas the creation of the Dental HealthAides and Community Health Aideprogram in the Alaska tribal healthsystem (Branch, 2014). Corporate practice models may be

economically viable where patients areconcentrated to take advantage ofeconomies of scale. They will not workin rural areas. Along with the shortageof dental providers, Alaska Native peoplesuffer significantly higher decay ratesthan the United States populationgenerally, and they seldom have theresources to afford care in traditionalsettings. This compounds the access-to-care demands in rural Alaska. A study bythe CDC in 2008 reported children fromthe Alaska region had 1.5 to 4.5 timesthe number of DMFT (decayed-missing-filled-teeth) than same-aged UnitedStates children and 1.6 to 9.0 times thenumber of decayed teeth. The DHATswere providing care to their own people,their families, and their culture in thesehigh-need villages (Byrd, 2011).

Acceptance of non-native individualshad to be earned and was not easilygiven among the indigenous population.The DHATs had roots in these villages,and the community was proud to havethem back contributing a service locallythat otherwise had to be accessedthrough expensive travel to healthcarefacilities. The Alaska workforce has torecruit all dentists from out of statebecause there is no in-state dental school.The idea of developing local dental pro-fessionals was paramount to improvingthe oral health of remote-area Alaskansand bridging the access-to-care gap.

Having exposure to the overalllifestyle and witnessing the limitedaccess to care issues in western Alaskatransformed my idea of what healthcareaccess should be. The approach toimproving oral health by drilling andfilling more teeth seems to me naïve.There simply is no way to “manage” this needy population to oral healthusing a commercial model. At full staffof 14 dentists, there were still notenough resources to even approximatedisease control in this region. It wasdevastating to realize that my educationand experience was not enough to solvethe insurmountable dental disease andaccess to care issues that existed in theYukon Kuskokwim Delta. It was veryclear to me that a traditional model of practice would not be effective intreating, managing, and maintainingthis high-caries-risk population.

Although public health dentistry is significantly rewarding, the workexhausts one’s motivation. I wanted tobe part of a large-scale mission toimprove the overall health status of theAlaska natives. I conducted a pilotproject using the Community HealthAides located in the remote village ofPilot Station, Alaska. The object was totrain these aides to apply fluoridevarnish at routine visits, such as regularphysicals, well-child visits, and annualimmunizations. Switching the approachto prevention at the first medical pointof contact was a novel idea at the time. The preliminary results of this

project revealed a reduction in the decayrate from 20.9% to 6.7% in school-agedchildren (Smith, 2008). Because of thesample size, the results only confirmedthat this method was worthy of furtherresearch. Other health programs werequickly brought to life in the local healthcorporation using prevention directivesin attempts to decrease decay as atransmissible disease. Working in thisenvironment, alongside communities

struggling to improve the health statusof their members, solidified my careerpath. I was dedicated to serving theAlaska Native people.

Delivering Care in a Nonprofit ContextI now hold a deputy chief position at the Southeast Alaska Regional HealthConsortium (SEARHC), which is a tribal,hospital-based dental clinic in Sitka,Alaska. Sitka is the site of the mainhospital servicing Southeast Alaska. TheSEARHC dental program is a complexprovider hierarchy. The staff includesprimary dental health aides, dentalhealth aide therapists, registered dentalhygienists (RDH), staff dentists, andadvanced education in general dentistry(AEGD) residents, along with a robustpedodontic program. The SEARHCdental program developed a cariescontrol and prevention protocol with the foundation based on a medicalmethodology, involving the entireSEARHC dental staff. Diagnosing cariesrisk at each patient exam was the keytool in this protocol. This protocol servedto establish consistency among providersin treatment planning and patient recallintervals. This unique work environ-ment offers preventive services, diseasecontrol, comprehensive care, andadvanced specialty services. This work-force model using paraprofessionals and mid-level dental providers is in placethroughout the consortium. Once again,I find myself working directly withprimary dental health aides (PDHAs)and DHATs. This delivery model differsfrom some commercial approaches thatuse “reverse delegation,” having recentdental graduates perform routineprophylaxis, for example.The PDHAs are prevention specialists

that work closely with our RDHs and

20



work off of a dentist’s treatment plan.There are three different levels of trainingfor a PDHA, with each certificationproviding a higher level of preventiveservices. These services include, but arenot limited to, topical applications ofiodine, chlorhexidine varnishes, fluoridevarnishes, and sealants. They alsoprovide patient education in cariologyand details on preventive products suchas xylitol, as well as saliva and cariesscreening tools. Each patient is provideda customized educational experiencebased on the results of the screeningtools and the dentist’s prescription.Dental disease is being treated as aninfectious disease here at SEARHC. The dental health aide therapists

are another set of providers that play a critical role in the caries controlprogram. The DHATs have a limitedscope and their main focus is diseasecontrol. The majority of the DHATproduction is operative. After workingwith several DHATs for over ten years, Iam impressed with the clinical abilitiesand high-quality proficiency that comesout of the Alaska-based DHAT trainingfacility. The training consists of anintense, two-year, hands-on clinicaltraining that includes an in-depthexperience with operative dentistry. The DHAT scope of practice limits theirpractice to preventive and operativedentistry. They are fully capable ofdiagnosing caries, but are limited intheir involvement with comprehensivetreatment plans. Complex diagnosticskills, beyond caries detection, are not an emphasis in the training program.DHATs provide high quality workman-ship. Independent studies of the clinicalperformance and patient managementtechniques of DHATs show that thetherapists are performing well andoperating safely within their scope ofpractice (Wetterhall & RTI, 2010). Using community dental providers

(PDHAs and DHATs) is not intended to

replace the RDH or the dentist, butrather to be an additional team memberwho works as a part of a more robustdentist-led team. The addition of thesePDHAs and DHATs to the dental teamopens opportunity for our patientpopulation to receive advance dentalservices, such as endodontics, prostho-dontics, and oral surgery, by our staffdentists, because the more basic care is performed by these new teammembers. The downside is that staffdentists and RDHs can becomeoverwhelmed because more difficultcases are loaded into these providers’schedules on a daily basis. The overallgoal is to increase access to care, alongwith more comprehensive services to the community of Southeast Alaska. A typical adult high-caries-risk

patient that comes in for an exam isinitially seen by a dentist. After a fullmouth series of radiographs and apanoramic film, the dentist will devise a treatment plan to include urgent needs and disease control. The nextappointment will be with a DHA, whichcan usually take place that week or thenext week. This is an educational visit,including complete salivary testing, thathelps encourage personal owner-ship ofthe patient’s oral condition andtreatment needs. The process of caries isdiscussed in detail. Patients are amazedthat a cavity is a bacterial infection andthe bacteria can be transmissible. This is the foundation of the treatment plan:to eradicate the bacteria and restore thedentition from the previous destructionof the bacteria. The next appointmentsare “caries control.” If there are urgentneeds, the next appointment is with adentist (an AEGD resident or facultygeneral dentist) to include extractions,endodontic, and complex cuspalcoverage restorations. If the needs arestraightforward operative, the next

21



Corporate practice models

may be economically

viable where patients are

concentrated to take

advantage of economies

of scale. They will not work

in rural areas.

appointment is with the DHAT. The goal is to complete caries control withinthree months of the exam. At eachappointment, either iodine applicationsor chlorhexidine varnish is applied. RDH appointments are made after opencavitations are filled and the patient isgiven a RDH recall depending on thepatients periodontal risk. After cariescontrol is complete, the patient returnsto the DHA for a two-week follow-up tohave a salivary testing completed again.Hopefully, the bacterial load is insignifi-cant and the oral environment is stable.At this point, the patient is appointedwith a dentist for a prosthetic consult toreview the needs for restoring occlusion,if needed. In many cases the treatmentplan stops at the prosthodontic consultwhen finances are limited.

For pediatric patients, exams arecompleted by one of our pediatricspecialists or a general dentist, dependingon the site. If the child has four quad-rants of decay and is two years old orolder, he or she is considered for theOperating Room for Full Mouth DentalRehabilitation. Otherwise the child isappointed within our clinic for cariescontrol completion. The high-riskpediatric patients are followed up by aDHA for three-month recalls and fluoridevarnish applications. The DHAs are acritical resource to our program, as theyprovide the majority of the preventivecare in our clinic.The AEGD program has contributed

to improving the access to care andproviding advance services at a reducedrate for the Southeast Alaska indigenouspopulation. The program expanded in2013 to five AEGD dental residents. Thishas brought a positive contribution toencounters, production, and access tospecialty services, such as periodonticsand implants, which were not offeredbefore. However, incorporating dentalresidents into a group practice takes

time and resources from the experiencedfaculty dentists. The experienced dentistssee fewer patients in order to directlysupervise and support the residents.Procedures typically take longer whenperformed by residents. The positiveperspective is that AEGD residents havebeen able to provide services at a moreaffordable cost for the patients as well assecuring donated materials and grantfunding. Since the dental program has expanded to include a teachingcomponent, it has drawn specialists toprovide advance hands-on practicumsfor the residents and the full-time facultyat SEARHC. The dentist is the first point of

contact for new adult patients. Thisallows for a thorough exam with acaries risk and periodontal riskassessment. Depending on the age andthe risk of the patient, the dentist willthen appoint them with the appropriateteam provider and the cascade ofappointments begins.My typical day involves wearing

many hats. I have a vested interest in mystaff, clinic, and patients. I find myselfjuggling and constantly reprioritizingmy time. Patient care is my passion. Itreat the more medically compromisedand high-anxiety patients in our clinic. I provide the full spectrum of dentistry.Many days I have to switch gears from aprovider to a teacher, from a surgeon toan educator, and from a healer to asupervisor. Luckily, I welcome changeand embrace the variety of the day. It is truly never boring.

What Dentists Do at ChairsideStaff dentists are the key players in this team model. Staff dentists are high producers of services. They areencouraged to operate at the upperlimits of their scope of practice. Theyfunction as primary providers anddelegate treatment needs to other mid-level providers, as appropriate. They

22



This unique workenvironment offerspreventive services,disease control,comprehensive care, and advanced specialtyservices. This workforcemodel using paraprofes-sionals and mid-leveldental providers is in place throughout the consortium.

triage walk-ins. This can become acumbersome task, with up to ten walk-ins a day. They are also the mainproviders traveling to remote villages byfloatplane. These visits are usually a five-day field trip focusing on diseasecontrol. I have heard dentists who workin corporate practices speak enthusias-tically about not having to worry aboutthe management aspects of practice sothey can concentrate on what they aremost trained to do and most like to do.This concept is carried even further inthe model I work in. Dentists delegateand supervise many routine tasks sothey can focus on those aspects ofdentistry that require the greatest skilland provide strong personal satisfaction.A positive impact to the overall

dental program has been provision ofmore service. Of the 15 staff dentists atSEARHC, we have ten residency-trainedgeneral dentists and three specialists.The overall outcome is not onlyincreased access to advanced services,but highly trained dentists with anexpanded scope in skill and knowledge.Some of these services, such as complexoral surgery, periodontal surgeries,complicated endodontics, and implantplacement, would not be possiblewithout these program advancements.The scope of services provided hasexpanded with the specialty trainingsand allows for more complete care at alocal level. The overall encounters havesubstantially increased with the additionof the resident program and created anet increase of available appointments. One of the most rewarding observa-

tions of the SEARHC dental program has been the effect of the expandedpedodontic services in all of SoutheastAlaska. The services have expandedfrom 400 patient visits in year 2005 to3,200 patient visits in year 2014. The

services have also extended from the mainclinical site in Juneau, Alaska, to overseven remote sites in Southeast Alaska. There are many benefits and

challenges with a group practice non-profit model. The SEARHC dental budgetconsists of 50% Indian Health Servicefunds, while the other half is a collectionof third-party payments (insurance,grants, Medicaid, and private pay). Oneof the important characteristics of bothoperations management and clinicaltreatment is that production is notrelated to the take-home pay for staffdental providers or outside equity interests.There is no extrinsic reward for thenumber of procedures accomplished:there is intrinsic reward for better oralhealth among those served. All dentalproviders are on a fixed pay scale that isnot associated with production. With aflat fee per visit Medicaid reimbursementrate, some preventive services arereimbursed above the usual andcustomary fee, while other advancedservice fees are reimbursed at a lowerthan the usual and customary fee. Thatbeing said, some of our mostexperienced clinicians bring in lessrevenue related to their productioncompared to a dental health aide (PDHAor DHAT) that is providing high levels ofpreventive services with a high returnfee for service. Prevention services are highly

encouraged in this model practice.SEARHC values that are supported inincreasing these preventive servicesinclude (a) raising the health status ofthe Southeast Alaska Native people tothe highest possible level and (b)promoting and encouraging healthylifestyle choices among the people ofSoutheast Alaska. From a managementperspective, production per provider isstill evaluated as a critical element inretention of quality providers.Another challenge in the Indian

Health Service practice model is that alarge portion of the population we serve

is on a fixed monthly income, and theystruggle with meeting their financialobligations. Any cost out of pocket fordental services is considered a significantluxury. Most patients seen at the cliniccannot afford advanced fixed prostheticsthat dentists recommend to restorefunction and esthetics. Providers arereluctant to push for treatment plansthat consist of crowns and bridges, givena large majority will never be able to pay for the service. Providers are morelikely to treatment plan a cusp-protectedalloy to extend the tooth’s longevity—which is a covered tribal service—andthe procedure takes just as long as acrown preparation.With the growth of the dental

program to include direct supervision ofDHATs and dental residents, expandingservices and increasing availableappointments have been more attainableand an added benefit to this practicemodel. The faculty dentists are willing toteach and provide consultations withoutit affecting their compensation. Some ofthe faculty dentists’ job descriptions havechanged to less production and morehands-on teaching without a reductionin pay; it is an accepted change in dutyand not seen as a burden. Well-managedclinic schedules are critical to thispractice model. The scheduling can betaxing with a large group practicehaving several dental providers, eachhaving a different scope of expertise forpatient care. Not every dental providercan provide the same type of service.This can be considered difficult tomanage for schedulers and providers. All members of the team have to have athorough understanding of the role ofeach provider and the service needed, sopatients can be scheduled appropriately. There are many advantages of

separating budget management andclinical treatment in the nonprofit group

23



practice model. I have been able to focussolely on patient needs instead of beingmotivated by monetary compensationfor the services I provide. Time usuallydoes not equate to money for theindividual practitioner, only to thequality of care provided. I have been ableto provide clinical consultation to DHATsin preceptorship, faculty coverage to theAEGD residents, and quality care for myown patients. It has been greatlyrewarding to see the growth in thedental providers over a short period oftime. I have the advantage of being alifelong student in this practice model aswell. My strengths as a provider haveexpanded over my career, with theexposure to hands-on training providedby traveling specialists in our clinic. Thisadditional direct continuing educationcreates “super-general dentists.” Thescopes of the remote general dentists arevast and have a broader scope of practicethan typical private practice counter-parts. Remote general dentists in thispractice model tend to handle difficultand advance cases versus referring themout to a specialist. The result is expansionof the covered services for our patientpopulation and a reduction in cost to theclinic by eliminating the referral.

Measuring Our ImpactThere are many benefits of working foran Indian Health Service facility likeSEARHC. The consortium covers theproviders with liability and workerscompensation insurance. They alsoprovide an entire human resourcesdepartment to assist in recruitment,termination, separation, and retirement,as well as the full spectrum of employeeevaluations. This can be seen as a hugeload off of a new dentist looking to ease into the work force without the

headache of finding and managingclinic personnel. The consortium alsoprovides a robust benefit package forhealth care and retirement incentives.These are all bonus additions to thesalary offered. The dentist salary is theirtake-home pay. There is no overhead ofclinic operating costs that has to comeout of the dentist salary. It is a stablecompensation that provides security andpeace of mind. A Dental ManagersCommittee focuses on administrativeobjectives, such as clinic expansions,program growth and modifications ofpolicy and procedures. The staff dentistsare not burdened with budget concernsor operating expense decisions. Supplyordering, organization of operatories,management of lab cases, scheduling,dental assistant assignments, billing,collections, and clinic oversight are alldelegated to other team members. Thisallows the dentist to provide completeattention on patient care. Another positive for this practice

model is the camaraderie amongstcolleagues. There is a network of profes-sionals, all with diverse backgrounds,coming together with the same enthu-siasm for helping others. Consults andsecond opinions can be provided topatients immediately. A team approachto difficult cases can be scheduled withinthe clinic. The safety net of multipleproviders in a clinic provides securityand confidence to less-experiencedproviders. There is a peace of mindleaving the clinic at the end of the day.Most of the providers are able to leavethe workload and stress at work andenjoy personal time outside the clinic.Many remote areas in Alaska provide anexceptional outdoor experience. It is notuncommon to kayak to work, hikeduring one’s lunch hour, and fish on theweekend. The value of a work-lifebalance is priceless for these providersseeking this lifestyle practice choice. The concept of “growing your own”

providers and advancing the training of

our existing staff is vital to the success of Alaska’s dental workforce. The work-force model of focusing on prevention,using mid-level providers, and distributingthe patient load among providerscontinues to be of value in closing accessto care gaps in Alaska. My desire forimproving the oral health of thispopulation is my drive and motivation.My hope is to continue to improve theaccess to care in Alaska by retaininghighly trained dental professionals in an underserved part of our nation.In the past 13 years, I have developed

a keen admiration for the Alaskan Native people. Each tribe has a story; a rich history of customs and sacrifice.Tribal values reside in the family unitand include a deep respect for thesimplicity of nature. As much as I feelmy contributions are improving theirquality of life, their culture has trans-formed mine. Through my experience ofworking in the Indian Health Service inAlaska, I have become more diversifiedin my practice and more accepting in my personal life. And so the journeycontinues… “And I will take the road less traveled by.” ■

References

Branch, K. (2014). Alaska health workforcevacancy study 2012. Anchorage, AK:University of Alaska Anchorage.Byrd, K. K. (2011). Morbidity and mortalityweekly report, 60 (37), 1275-1278.Smith, M. L. (2008). The role of para-professionals in oral health promotion ingeographically isolated communities.Unpublished manuscript. Contact author at [email protected], S., & RTI International. (2010).Evaluation of the Dental Health AideTherapist workforce model in Alaska.Research Triangle Park, NC: ResearchTriangle Institute.

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Sahng G. Kim, DDS, MSGunnar Hasselgren, DDS, PhDSasha Alexander, DDSSeong W. Lee, DMDCharles Solomon, DDS, FACD

AbstractThis retrospective study investigates thediagnostic rationale for the extraction ofteeth and their replacement withimplants in a dental school setting. Mostof the teeth were extracted forrestorative reasons (62.7%). The otherreasons for extraction were periodontal(35.1%) and endodontic (1.3%). A panelof endodontists disagreed with thetreatment-planning dentists’ decisions in40.3% of the cases. Slightly more thanhalf, 52.9%, of the disagreements werefor restorative reasons. Most of thedecisions in disagreement were made bygeneral dentists (60.6%), far fewer byprosthodontists (25.5%), periodontists(12.2%), and oral surgeons (1.6%). Anextensive review of the literature isprovided.

There seems to be a general sense inthe dental community, that dentalimplant placement has supplanted

tooth preservation therapies, includingendodontic, periodontal, and restorativetreatments in many treatment-planningdecisions (Lang and De Bruyn, 2009;Petropoulos et al, 2006). This observationis even more evident in a dental schoolsetting where students are in attendancefor a prescribed period of time andtherefore are anxious to experience theimplant modality to the greatest extentpossible. This trend is certainly energizedby the implant manufacturers, who spendheavily in advertising their products and subsidizing implant programs in the dental schools. Thus, it may bereasonable to assume that more toothextractions for implant placement arecurrently performed in teachinginstitutions than in the past. In fact, atour institution, while 1,000 implantswere placed in the academic year of this study (2009-10), twice that number were placed during the most recentacademic year (2013-14).Outcomes of dental implant therapy

have been primarily used to rationalizetooth extraction over tooth retention inmany cases. However, there are studiesshowing that survival of natural teeth,even those with questionable prognoses,is better than expected after toothpreservation (periodontal) therapy andmay not be different from the survival ofdental implants in long-term follow-ups(Holm-Pedersen et al, 2007; Salehrabi &Rotstein, 2004; Greenstein et al, 2009).

Holm-Pedersen and colleagues(2007), in a comparison study of teethand dental implants, stated that after ten years of service, oral implants do not surpass the longevity of evencompromised but successfully treatednatural teeth. Salehrabi and Rotstein(2004), in an eight-year retention study,reported a 97% survival rate ofendodontically treated teeth, which iscomparable to that of the dentalimplant. Greenstein and colleagues(2009) reported that with periodontalsurgery and maintenance even angularbony defects fared as well as horizontalsites in terms of long-term retention and stability. The Department of Perio-dontology at Michigan has documentedover 25 prognosticators that should beused to decide on the retention of anatural tooth (Avila et al, 2009).Therefore, a high survival rate of dentalimplants reported in the literatureshould not be considered the sole factorduring treatment planning to decidewhether a tooth is treated for preser-vation or extracted for an implant. Until now, no studies have investigated

the reasons for extraction of teeth thatare specifically planned for dentalimplant placement. Previous studieshave not factored in any treatment plans

25


Retrospective Evaluation of Treatment Planning for Dental Implant

Manuscript

All authors are faculty members in the Division of Endodontics, College of DentalMedicine, Columbia University in New YorkCity; [email protected].

and have only discussed reasons forextraction according to geographicregions (Aida et al, 2006; Byahatti &Ingafou, 2011; Chen et al, 2008;Chestnutt et al, 2000; Chrysanthakopoulos,2011) and different practice settings(Alomari et al, 2013; Byahatti & Ingafou, 2011; Chestnutt et al, 2000;Chrysanthakopoulos, 2011; Dikbas et al,2013; Jafarian & Etebarian, 2013;Montando et al, 2012; Touré et al, 2011).Furthermore, in those studies, thereasons for tooth extraction wereidentified by either treatment-planningdentists (Aida et al, 2006; Byahatti &Ingafou, 2011; Chen et al, 2008; Chestnuttet al, 2000; Chrysanthakopoulos, 2011;Dikbas et al, 2013; Jafarian & Etebarian,2013; Touré et al, 2011) or independentreviewers of tooth extraction cases(Alomari et al, 2013; Montando et al,2012). The aim of this retrospectivestudy is to identify the reasons forextraction of teeth and their replacementwith dental implants by the dentalschool faculty, and to investigate thediscrepancies in diagnostic rationalesused in treatment planning decisionscompared with a panel of endodontists.

Materials and MethodsThe protocol for this retrospective cross-sectional study was approved by theInstitutional Review Board at ColumbiaUniversity Medical Center. A total of 946 dental implants placed during theacademic year from July 1, 2009 throughJune 30, 2010 were reviewed. The 479implants that were placed in edentulousareas where the teeth had been previouslyextracted were excluded from the study.We cannot emphasize enough thepositive impact that implant placementhas had on oral health over the last 30years, allowing patients to have fixedprostheses when, previously, removable

appliances were the only option. Theremaining 467 teeth that were extractedand replaced by dental implants, wereincluded in the study. The data collectedincluded age, sex, location of theextraction site, and reasons for toothextraction based on the treatment-planning dentists’ notes. Data on thetreatment-planning dentists were furtherbroken down by area of specialty,including general dentists, prosthodon-tists, periodontists, oral surgeons, andendodontists. Five reviewers (CS, GH, SL, SA, SK) evaluated the reasons fortooth extraction and determined theiragreement or disagreement with eachspecialty. All reviewers were calibratedprior to their evaluation of the reasonsfor tooth removal in order to determinewhether a tooth needed to be extractedbased on the following criteria: (a)restorative reasons for teeth beingdeemed unsalvageable, including grosscaries, perforations and fractures, or (b)periodontal reasons, including severeperiodontal disease and poor crown-to-root ratios. Any disagreement amongreviewers was resolved by collectivediscussion. No attempt was made todetermine agreement by the panel withcases that were treated endodontically.

ResultsThe mean age of the 255 patients was56.5 (±14.2) years. The ratio of male tofemale patients was 49:51. The maxillaryarch was the more frequent site forimplants replacing teeth, with themaxillary premolar being the mostcommon location (n=107; 22.9%),followed by the maxillary incisor (n=82;17.6%), and then the maxillary molar(n=77; 16.5%). The molar was the mostcommon mandibular site (n=61; 13.1%),followed by the mandibular canine(n=39; 8.4%), the mandibular premolar(n=37; 7.9%), and the mandibularincisor (n=39; 7.5%). The maxillarycanine was the least extracted tooth type(n=29; 6.2%).26


Manuscript

There is a differencebetween the criteria weused in our retrospectiveand chart-based reviewand the criteria used bythe treating dentists.

The major reason for extraction ofthe 467 teeth was restorative (n=293;62.7%), followed by periodontal consi-derations (n=164; 35.1%). Only ten teethwere extracted for endodontic reasons.The panel agreed with 59.7% of the

decisions to extract and disagreed with40.3%. Most of the disagreements werewith the general dentists (60%), farfewer with prosthodontists (25%), andeven fewer with periodontists (12%).

DiscussionThis study was a retrospective evaluationof clinical decisions and identified thereasons for saving a tooth or replacing it with an implant. All our decisionstherefore, were based on the review of chart notes and interpretation ofradiographs. We were not able toexamine the patients or to evaluate thepatient's expectations and attitudesabout their dental care. In certain cases,had we been present at the treatmentplanning session, we might have agreedthat implant treatment would have bestserved a particular patient. Since we as endodontists have a high

confidence level in our treatments, andtherefore a natural, built-in bias, thehigh rate of disagreement (40.3%) withthe treatment planning dentists, can beunderstood. It does suggest however,that due to our high rate of disagree-ment with the rationales for extraction,there is a difference between the criteriawe used in our retrospective and chart-based review and the criteria used by the treating dentists. Clearly, the implant modality

represents one of the major advances indentistry, giving us the ability to replaceremovable prostheses, however, in ourzeal to fully experience the art andscience of implant placement in thedental school setting, we must notabandon our ethical and moraldedication to serving our patients in

their best interests. This study is not anindictment of any particular category ofdentist. It rather exposes the need for adifferent type of treatment planningexperience. Currently, in our institution,a student brings a new patient to theinstructor for that day and together they work up the treatment plan. Theinstructor is usually a general practi-tioner, who may not possess particularskill sets in treatment planning. This is a random event, and depending on theday and the attending instructor, verydifferent plans might be created. In the present study, restorative

reasons for extraction were the mostcommon (62.7%), which is consistentwith most of the previous studies (Aidaet al, 2006; Byahatti & Ingafou, 2011;Chen et al, 2008; Chestnutt et al, 2000).Chrysanthakopoulos (2011) showed thatdental caries (45.6%) was the mostcommon reason for extraction based onthe evaluation of 2,418 extracted teeth.Byahatti and Ingafou (2011) showedsimilar results, finding the main reasonfor tooth extraction was due to dentalcaries (55.9%) in their study of 9,570extractions. While several other studiesshowed similar findings (Aida et al,2006; Alomari et al, 2013; Chestnutt etal, 2000; Jafarian & Etebarian, 2013), afew studies reported periodontal diseaseto be the main reason for extraction(Dikbas et al, 2013; Montandon et al,2012). Montandon and colleagues(2012) showed that the periodontalreason was the most common inpatients older than 45, whereas dentalcaries was the major reason in patientsup to 44 years old. Dikbas and colleagues(2013) found that 59.1% of extractionswith full crowns were due to periodontalreasons. It is reasonable to assume thattooth extraction as a result of restorativereasons would decrease significantly forteeth with full-coverage restorations, andthus the periodontal reason was foundto be the second most common reasonin a majority of studies (Aida et al,

2006; Alomari et al, 2013; Byahatti &Ingafou, 2011; Chestnutt et al, 2000;Chrysanthakopoulos, 2011; Dikbas et al,2013) and became the primary cause forextraction in this study. Indeed, in thestudy that reported that the periodontalreason was the most common, 76.5% of the extracted teeth were coronallyrestored (Touré et al, 2011), while the restorative reason (gross caries) was the most common reason in thestudy, where 57.4% of extracted teeth did not have coronal restorations (Zadiket al, 2008).

Perhaps our great disagreementwith the “restorative” treatment plannerswas due to the fact that the restorabilityof a tooth is often subjective, except inobvious cases such as vertical rootfractures or poor crown-to-root ratios.On the other hand, our disagreementsfor periodontal reasons were far fewer(16.17%). This is because the decision fortooth extraction is based on a thoroughreview of multiple clinical parameterssuch as alveolar bone level, furcationinvolvement, tooth mobility, andprobing depth obtained from clinicaland radiographic examination in adental school environment (Avila et al,2009). Thus, the periodontists’ decisionswhether to extract or retain a tooth were based on more criteria and thisdocumentation was available during our review. We agreed with 70.5% ofextraction cases determined by perio-dontists, which was far more than thoseof restorative dentists. In studies that investigated extrac-

tion of root canal-treated teeth, the mostfrequently identifiable reasons were alsoeither restorative (Chen et al, 2008;Zadik et al, 2008) or periodontal (Touréet al, 2011). Many treatment planners do not regularly consider endodontic

27


Manuscript

retreatments in situations where anendodontic case is deficient, yetendodontists today routinely performthese procedures, both surgically andnonsurgically. The success rates ofnonsurgical root canal retreatment were reported to be approximately 77%in meta-analysis studies (Ng et al, 2008; Torabinejad et al, 2009). A cleardistinction must be made between thetraditional endodontic surgicaltechnique and the current microsurgicalapproach. In recent systematic reviews,the success rates of endodonticmicrosurgery ranged from 89% to 94%(Setzer et al, 2010; Song et al, 2011;Tsesis et al, 2009). Endodonticmicrosurgery is characterized by a small osteotomy, an adequate root-endresection with a minimal bevel, aretentive root-end preparation withoutthe alteration of original root canalmorphology, and a root-end filling with adequate sealing materials, allperformed with a high-powermagnification and illumination.Resurgery could be considered in caseswhere the previous root-end surgery didnot address the main etiological factors(Song et al, 2010). For example, if theroot-end surgery had been performedwith a traditional surgical techniquecharacterized by a large osteotomy, aroot-end resection with a greater bevel, a root-end preparation with burs, a root-end filling without an adequateseal, and lack of a high-power magni-fication, it could have been retreatedsurgically with a microsurgicaltechnique. Song and colleagues (2011),in their prospective study, showed a92.9% success rate after endodonticresurgery with a microsurgicaltechnique. This is in stark contrast toPeterson and Gutmann (2001), who

reported a 35.7% success rate with thetraditional surgical technique. During the review of cases,

numerous teeth were found to have been extracted because they weredetermined to be unrestorable based onan unfavorable crown-to-root ratio,taking into account the amount of toothstructure that would remain after cariesexcavation and subsequent crownlengthening for a full coverage restora-tion. The concept of crown-to-root ratiowas well illustrated by Shillingburg andcolleagues (1997), who reported that 1:1 is a minimum crown-to-root ratio for a tooth to be used as an abutment.However, other clinical outcome studiesdid not fully support the idea ofdetermining restorability based only on this one criterion. Nyman andcolleagues (1975) showed that teeth thathad a far greater than 1:1 crown-to-rootratio due to advanced periodontaldisease could be retained with stabilityfor 2 to 6 years after periodontaltreatment, when the teeth were used asabutments for extensive fixed partialdentures. In addition, McGuire and Nunn (1996) demonstrated that, basedon the observation of 2,509 teeth underperiodontal maintenance therapy, long-term tooth survival could not bepredicted by an initial prognosis whenall clinical parameters were used aspredictors, although an unsatisfactorycrown-to-root ratio adversely affected theinitial prognosis. Furthermore, there isno clear guideline for a minimumcrown-to-root ratio in non-abutmentteeth. Therefore, it is reasonable to statethat there is a dearth of evidence for the crown-to-root ratio as a singularpredictor for tooth retention. Thedecision to extract should be based onmultiple clinical parameters includingtooth mobility, periodontal bone loss,root configuration, and the direction ofocclusal forces as well as the crown-to-root ratio (Grossmann & Sadan, 2005).

The misconception about theprognosis of root canal-treated teethwith post-retained restorations may beunjustifiably employed as a reason fortooth extraction. It was thought thatteeth with post-retained restorations hada negative influence on long-term toothsurvival. However, no significantdifference was found in tooth survivalbetween full-coverage restorations withand without a post and core buildup(Bitter et al, 2009; Ng et al, 2010).Sorensen and Martinoff (1984) revealedthat a post placement did not have asignificant effect on tooth survival, basedon their evaluation of 1,273 endodonti-cally treated teeth over a 25-year period.Thus, the mere presence of a post andcore should not be considered tonegatively influence tooth survival.When dental implant placement is

considered as a treatment plan in ateaching institution, posterior teeth thatare supported by sound alveolar boneare likely to be primary candidates.Therefore, both molars and premolarsthat might have been retained withtooth preservation therapy owing togood bone quality are likely to be thesame candidates for tooth extraction and dental implant placement when thepressure to find implant candidates isintense, given a fixed patient pool in thedental school environment. This mightexplain why more premolars areextracted for dental implant placementcompared with the numbers in theprevious studies. The frequency ofextraction of anteriors was similar tothat in the previous studies (Aida et al,2006; Alomari et al, 2013; Chestnutt etal, 2000: Jafarian & Etebarian, 2013;Zadik et al, 2008) or periodontal (Moritaet al, 1994; Touré et al, 2011). This maybe because the anterior regions are lesspreferable sites for dental implants dueto the bone quality and the higher

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Manuscript

technical skills required to meet estheticdemands. The least frequently extractedtooth type was the canine, which is inagreement with other studies (Chestnuttet al, 2000; Jafarian & Etebarian, 2013;Zadik et al, 2008). This may be becausethe strong bony support around a long single root in this tooth type canwithstand advanced periodontal diseasesas well as provide a greater chance ofbeing properly restored. Pecora and colleagues (2012) stated

that “excessive extraction of teeth andreplacements with implants was ourcontemporary dilemma.” These authorssay that “in no way does the longevity of oral implants surpass that of naturalteeth, even of those that are compromisedfor either periodontal or endodonticreasons”. The periodontal ligament’sstress-absorption capabilities, as well asits ability to act as a local defense mechanism againstthe bacterial population, representssignificant advantages over an implantthat lacks a periodontal ligament(Pecora et al, 2012). A criticalobservation, often overlooked, is thatimplant-supported restorations cannotcompete with the natural tooth withregard to physical, biomechanical, andsensorial properties. Unlike an implant,a natural tooth has a periodontalligament with receptors that allow it toadapt to proprioceptive and mechanicalforces. Stereognostic ability (recognizingan object by touch) is impaired insubjects rehabilitated with osseo-integrated implants by up to one-third(Jacobs et al, 1997), compared tosubjects with natural teeth.Implant placement may be easier

and faster to execute, and perhaps morelucrative outside the dental schoolsetting, than root canal therapy andperiodontal maintenance. But thisshould never be a consideration intreatment planning if we are to preserveour ethical professionalism.■

ReferencesAida, J., Ando, Y., Akhter, R., et al (2006).Reasons for permanent tooth extractions inJapan. Journal of Epidemiology, 16 (5),214-219.Alomari, Q. D., Khalaf, M. E., & Al-Shawaf,N. M. (2013). Relative contribution ofrestorative treatment to tooth extraction ina teaching institution. Journal of OralRehabilitation, 40 (6), 464-471.Avila, G., Galindo-Moreno, P., Soehren, S.,Misch, C. E., Morelli, T., et al (2009). A novel decision-making process for toothretention or extraction. Journal ofPeriodontology, 80 (3), 476-491. Bitter, K., Noetzel, J., Stamm, O., et al(2009). Randomized clinical trial comparingthe effects of post placement on failurerate of postendodontic restorations:Preliminary results of a mean period of 32months. Journal of Endodontics, 35 (11),1477-1482.Byahatti, S. M., & Ingafou, M. S. (2011).Reasons for extraction in a group of Libyanpatients. International Dental Journal, 61(4), 199-203.Chen, S. C., Chueh, L. H., Hsiao, C. K., Wu,H. P., & Chiang, C. P. (2008). First untowardevents and reasons for tooth extractionafter nonsurgical endodontic treatment inTaiwan. Journal of Endodontics, 34 (6),671-674.Chestnutt, I. G., Binnie, V. I., & Taylor, M.M. (2000). Reasons for tooth extraction inScotland. Journal of Dentistry, 28 (4), 295-297.Chrysanthakopoulos, N. A. (2011). Reasonsfor extraction of permanent teeth inGreece: A five-year follow-up study.International Dental Journal, 61 (1), 19-24.Dikbas, I., Tanalp, J., Tomruk, C. O., &Koksal, T. (2013). Evaluation of reasons forextraction of crowned teeth: A prospectivestudy at a university clinic. Acta Odonto-logia Scandenavia, 71 (3-4), 848-856. Greenstein, B., Frantz, B., Desai, R., et al(2009). Stability of treated angular andhorizontal bony defects: A retrospectiveradiographic evaluation in a privateperiodontal practice. Journal ofPeriodontology, 80 (2), 228-233.

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Many treatment planners

do not regularly consider

endodontic retreatments

in situations where an

endodontic case is deficient,

yet endodontists today

routinely perform these

procedures, both surgically

and nonsurgically.

Grossmann, Y., & Sadan, A. (2005). Theprosthodontic concept of crown-to-rootratio: A review of the literature. Journal ofProsthetic Dentistry, 93 (6), 559-562.Holm-Pedersen, P., Lang, N. P., et al. (2007).What are the longevities of teeth and oralimplants? Clinical Oral Implant Research,18 Suppl, 15-19.Jacobs, R., Serhal, C. B., & van Steenberghe,D. (1997). The stereognostic ability ofnatural dentitions versus implant-supportedfixed prostheses or overdentures. ClinicalOral Investigations, 1, 89-94.Jafarian, M., & Etebarian, A. (2013).Reasons for extraction permanent teeth ingeneral dental practices in Tehran, Iran.Medicine and Principles of Practice, 22 (3),239-244.Jung, R. E., Pjetursson, B. E., Glauser, R., etal. (2008). A systematic review of the 5-year survival and complication rates ofimplant-supported single crowns. ClinicalOral Implant Research, 19 (2), 119-130.Lang, N. P., & De Bruyn, H. (2009). FirstEuropean consensus workshop in implantdentistry university education: Therationale for the introduction of implantdentistry into the dental curriculum.European Journal of Dental Education, 13Suppl, 19-23.McGuire, M. K., & Nunn, M. E. (1996).Prognosis versus actual outcome. III. Theeffectiveness of clinical parameters inaccurately predicting tooth survival.Journal of Periodontology, 67 (7), 666-674.Montandon, A., Zuza, E., & Toledo, B. E.(2012).Prevalence and reasons for tooth loss ina sample from a dental clinic in Brazil.International Journal of Dentistry, 2012,719-750.Morita, M., Kimura, T., Kanegae,M., Ishikawa, A., & Watanabe, T. (1994).Reasons for extraction of permanent teethin Japan. Community Dentistry and OralEpidemiology, 22 (5 Pt 1), 303-306.

Ng, Y. L., Mann, V., & Gulabivala, K. (2008).Outcome of secondary root canaltreatment: A systematic review of theliterature. International EndodonticsJournal, 41 (12), 1026-1046.Ng, Y. L., Mann, V., & Gulabivala, K. (2010).Tooth survival following nonsurgical rootcanal treatment: a systematic review ofthe literature. International endodonticsJournal, 43 (3), 171-189.Nyman, S., Lindhe, J., & Lundgren, D.(1975). The role of occlusion for thestability of fixed bridges in patients withreduced periodontal tissue support. Journalof Clinical Periodontology, 2 (2), 53-66.Pecora, G., Perrotti, V., Lezzi, G., Pontes, A. E., & Piatelli, A. (2012). Dental implantsor traditional treatments: A contemporarydilemma. In D. Schwartz (Ed.), Ridgepreservation and immediate implantation.Chicago, IL: Quintessence Publishing, pp. 1-8.Peterson, J., & Gutmann, J. L. (2001). The outcome of endodontic resurgery: A systematic review. InternationalEndodontics Journal, 34 (3), 169-175.Petropoulos, V. C., Arbree, N. S., Tarnow,D., et al. (2006). Teaching implant dentistryin the predoctoral curriculum: A report fromthe ADEA Implant Workshop's survey ofdeans. Journal of Dental Education, 70 (5),580-588.Salehrabi, R., & Rotstein, I. (2004).Endodontic treatment outcomes in a large patient population in the USA: An epidemiological study. Journal ofEndodontics, 30 (12), 846-850.Setzer, F. C., Shah, S. B., Kohli, M.R., Karabucak, B., & Kim, S. (2010).Outcome of endodontic surgery: A meta-analysis of the literature—part 1:Comparison of traditional root-end surgeryand endodontic microsurgery. Journal ofEndodontics, 36 (11), 1757-1765. Shillingburg, H. T., Hobo, S., Whitsett, L.D., Jacobi, R., & Brackett, S. E. (1997).Fundamentals of fixed prosthodontics. 3rded. Chicago, IL: Quintessence, 85-103.Song, M., Kim, H. C., Lee, W., & Kim E.(2010). Analysis of the cause of failure innonsurgical endodontic treatment bymicroscopic inspection during endodonticmicrosurgery. Journal of Endodontics, 37(11), 1516-1519.

Song, M., Shin, S. J., & Kim, E. (2011).Outcomes of endodontic micro-resurgery:A prospective clinical study. Journal ofEndodontics, 37 (3), 316-320. Sorensen, J. A., & Martinoff, J. T. (1984).Intracoronal reinforcement and coronalcoverage: A study of endodontically treatedteeth. Journal of Prosthetic Dentistry, 51(6):780-784.Torabinejad, M., Corr, R., Handysides, R., & Shabahang, S. (2009). Outcomes ofnonsurgical retreatment and endodonticsurgery: A systematic review. Journal ofEndodontics, 35 (7), 930-937.Tsesis, I., Faivishevsky, V., Kfir, A., & Rosen,E. (2009). Outcome of surgical endodontictreatment performed by a moderntechnique: A meta-analysis of literature.Journal of Endodontics, 35 (11), 1505-1511.Tsesis, I., Rosen, E., Taschieri, S., et al.(2013). Outcomes of surgical endodontictreatment performed by a moderntechnique: An updated meta-analysis ofthe literature. Journal of Endodontics, 39(3), 332-339. Touré, B., Faye, B., Kane, A. W., et al. (2011)Analysis of reasons for extraction of endodontically treated teeth: A prospective study.Journal of Endodontics, 37 (11), 1512-1515.Zadik, Y., Sandler, V., Bechor, R., &Salehrabi, R. (2008). Analysis of factorsrelated to extraction of endodonticallytreated teeth. Oral Surgery, Oral Medicine,Oral Patholology, Oral Radiology andEndodontics, 106 (5), e31-35.

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David W. Chambers, EdM, MBA, PhD, FACD

AbstractThe most common approach to ethics in dentistry and bioethics generally isthrough principles. To be effective,principles must be interpreted inparticular situations, and the skill ofinterpretation requires many years ofpractice with feedback. The opinions of91 dentists and 54 patients regardingmultiple potential actions and justifica-tions for these actions were gathered foreight dental ethics cases. The summaryresponses of dentists and patients havebeen integrated as feedback in an onlineethics education exercise that individualdentists can use (see www.dentalethics.org/idea). The dataset of responseswas also analyzed for general findings. It emerged that patients and dentistsagree to a substantial extent on theaverage approaches, but they differsystematically on certain of the details.Some ethical issues stimulated a narrow range of responses while others,especially those of a nonclinical naturewere regarded as ambiguous and are thus good candidates for future ethicstraining. A factor analysis revealed a five-dimension structure underlying dentalethics. Patients are most apt to viewdentistry using a lens of oral healthoutcomes while practitioners prefer tostress the process and the technicaldimensions of practice. The largest areaof difference was patients’ much greaterinterest in dentists assuming an activerole as patient oral health advocates with their colleagues.

There are troubling situations indentistry where there is reason tofollow one course of action and

also reason to pursue a contrary path.This is one of the characteristics of aprofession that calls for the highestlevels of skill and integrity. Doing thewrong thing for the wrong reason canundo beautiful technical work andbiological acumen. Deciding whether tohonor a patient request (respect forautonomy) for a treatment that is ofquestionable value (nonmaleficence) is a problem that arises from time to time.Deciding whether to take action, and if so what action, and for what realmotives, when a colleague’s work ispretty regularly seen to be below thestandard of care is a test of loyalty—tothe profession and to the public. Theseare called ethical dilemmas becausethere is something worthwhile to be saidon both sides of the matter. Other timesbehavior is simply wrong but tempting.It is hard to think of circumstances thatwould justify overtreatment, upcodinginsurance claims, or permitting a hostilework environment, but it happens.Although these are not dilemmas, wemight still expect to see a range ofbehavior, supported by interpretations ofparticular circumstances and personalvalue systems. Patients bring their own moral

standards to the table. Some are likely tobe sensitive to and speak up aboutparticular tough choices that dentistsface and overlook others. Some patientsuse highly personal ethical maps. Thosewho are not patients—including public

policymakers, bloggers, and those whovigorously avoid dentists—cannot beprevented from having opinions aboutwhat is right and wrong in dentistry.In the past few decades, the

professions have addressed these issuesunder the heading of “principles.” Anethical principle is an abstract standardfor appropriate behavior. Veracity (truthtelling) and justice (fair distribution ofbenefits and burdens) are examples. The Belmont Report (1979), the firstcomprehensive American statement ofethical policy in medicine, identifiedthree principles: respect for persons,benefic-ence, and justice (NationalCommission for the Protection ofHuman Subjects of Biomedical andBehavioral Research, 1979). The field ofbioethics exploded in the years following,and Tom Beauchamp and JamesChildress’s Principles of BiomedicalEthics (2009) has become the funda-mental expression of professionalprinciples. Beauchamp and Childress’sfour cardinal principles are (a) respect for autonomy, (b) nonmaleficence, (c) beneficence, and (d) justice. TheAmerican Dental Association added afifth principle, veracity, which accountsfor about 40% of the Code of ProfessionalConduct and covers mostly dentist-to-dentist issues. The American Society forBioethics and Humanities uses a codewith seven principles. The American Bar Association identifies eight. The

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ACD Gies Ethics Project

Do Patients and Dentists See Ethics the Same Way?


American Medical Association Code ofEthics has nine principles.Principles offer general guidance,

but they are blunt instruments. Specificissues can often be categorized undermore than one principle, and thesesometimes “guide” action in contrarydirections. The tension betweenconflicting principles is well known.Both the ADA, in their Principles ofEthics and Code of ProfessionalConduct, and Beauchamp and Childress(2009) acknowledge this, and profes-sionals are usually counselled to “usetheir personal judgment to reach a‘balanced’ resolution.” The problem isthat there is no principle that determineswhen “balance” has been achieved(Thornton, 2005). Principles need someform of further support to finish the job (Jonsen, 1991). The bulk of ethics training—both in

dental schools and where it appearsoccasionally in CE formats—as well ascodes of conduct—are intended asinterpretations of the principles. This issometimes called the Ethical Syllogism(MacIntyre, 1988). It works like this:Major Premise: Beneficence consists indoing what is best for the patient. MinorPremise: If patients are only informed oftreatment options that I favor based onmy training, they will always pick soundtreatments. Conclusion: It is beneficentto steer patients in informed consenttoward optimal oral health. There are no debates in dentistry over whetherrespect for autonomy or justice, forexample, are sound ethical principles.They are. All of the discussion turns onwhether specific behaviors are bestinterpreted as good examples of theprinciples. Learning to become aprofessional entails learning how one’scolleagues interpret the principles.

Despite their open-endedness,principles are a solid place to start inethics training for professionals.Particular problems can be examinedthrough the lens of multiple principlesto give them depth and to reduce thechance of overlooking somethingimportant. Some interpretations ofspecific cases are clearly wrong andothers are among the several alternativeacceptable options. Interpretation isnecessary, but all interpretations are notequally valid. Becoming a mature ethicalprofessional means a long period ofstudy of a wide range of concrete casesand gradually building interpretativeskill. The principles can be memorizedin less than a minute: becoming anethical professional requires a lifetime ofpractice.Not all practitioners interpret ethical

principles the same way. A doctrinaireinsistence on the letter of the law in thekingdom of one’s own office may satisfythe urge of consistency. Some dentistsuse a shallow grounding in ethicsbecause they are confident that they can“just do the right thing.” It would be easyto maintain these positons if patients,staff, and associates can be dismissed fornot seeing things as the owner-dentistdoes. In fact, principles may not even benecessary in such cases. Being aprofessional means contributing to andlearning from the collective wisdom ofone’s colleagues and other importantpeople. Principles begin to play a usefulpurpose when dentists look to theircolleagues and others to see whetherbetter alternatives exist. Ethics becomespart of the language in the conversationsthat make it possible to grow profes-sionally. Absent comparisons of specificethical cases, practitioners are apt tostagnate at the level of moral maturitythey had when leaving dental school oreven earlier in their lives. It may come as a surprise that there

are no American journals for dental

ethics. Of the more than 20 in variousprofessional fields, there are multipleexamples in medicine, nursing, law,business, clergy, education, and even themilitary services. This is very likely areflection of the fact that all of theseprofessions are practiced in settingswhere professionals interact with eachother in public. Since 1998, accredita-tion standards for U.S. dental schoolsrequire documented compliance withthe standard that students “must becompetent in the application of theprinciples of ethical decision makingand professional responsibility” (Councilon Dental Accreditation 2013; Standard2-20). This is managed in some schoolsby an hour or sometimes several hoursof seminar discussion of cases. This isnot enough (Bertolami, 2004).There are several theories of moral

development. James Rest (1973) hasextensively studied and modifiedLawrence Kohlberg’s (1968) develop-mental stages model of moral reasoning.There are three levels in this characteri-zation of ethics, each having to do withthe reasons one uses in reaching moraldecisions (and less so with the actionsthemselves). Rest identifies these levelsas (a) “pre-conventional,” where thestandard is to follow authority and dowhat is rewarded and avoid what ispunished; (b) “conventional,” do whatyour peers expect of you; and (c) “post-conventional,” where abstract norms areweighted as a philosopher might. I willuse the more descriptive labels: “self,”“group,” and “ethics” as these appear tocapture where individuals orient forfinding the ultimate standard for ethicaldecision making in various cases.The challenge is to create a safe

environment for all dentists who tradi-tionally work in isolation to comparenotes, try alternatives, and get feedbackto build moral skill. We need a platform

32



for interaction, and it needs to be prettylarge, open to all, and easily available24/7 for extended periods of time.As a step toward creating an

opportunity for dentists to engage inpublic interpretation of prototypicalethics cases, the American College ofDentists has created a set of eight casesfor discussion. These are available inwritten form and will soon be availablein video format. But there is a significantlimitation to the effectiveness of readingabout ethics. There should be some wayof experimenting with options andlearning what one’s colleagues woulddo. Perhaps it would even be useful toknow what a representative sample ofpatients thinks of these situations. Okay, let’s find out. There are two

goals in this report: (a) introduce aplatform for building interpretative skills in practical ethics for practitionersthat can be accessed conveniently from one’s office and (b) begin tounderstand the norms patients anddentists hold regarding various aspectsof dental practice.

Materials and MethodsEight cases were developed, representinga range of problematic situations thatcould arise in dentistry. There areexisting collections of cases in variousstyles, but I have followed the model ofthe late Jim Rule in his wonderful bookEthical Questions in Dentistry (2004).Rule’s cases are longer and moredetailed than many in circulation, butthey were not written to illustratepredetermined theoretical positions.Although length slows down the reader,it also reduces the chance that one willimagine unstated facts or screen outinconvenient parti-culars from “skeletal”cases to make them fit abstractprinciples or personal preferences.

A little of life’s messiness is necessary to be realistic. Although all the caseshave multiple dimensions andinteresting paths to follow, they are not all dilemmas. The goal is to involvereaders in the cases, not for them to be theoretical commentators. The full text of the cases can be seen atwww.dentalethics.org/idea. The stemtheme for each case and the actions andreasons are shown here in Table 1.Each case is followed by four to six

potential actions, and readers are invitedto indicate on a five-point Likert scalehow appropriate each action would be.The scale has anchor points of“absolutely,” “probably,” “50:50,”“doubtful,” and “no way.” The actionsare not mutually exclusive. It might be“absolutely” appropriate to initiate twoor more actions at the same time andgive just a little possible credence to athird that is similar to a choice thatshould be avoided entirely. There isseldom exactly one response to anethical challenge. Usually there areseveral appropriate things that could bedone and more than one way to get itwrong. But a forced selection on beha-vior is important in ethical situations.Too often we mistake performing ananalysis of the situation and anenumeration of relevant principles foran ethical choice. They are not. The onlyway others will know whether we areethical is by watching what we do.Each case is also accompanied by

from four to six “reasons” or importantconsiderations or ethical goals. Thereasons are similarly graded on a Likertscale as “decisive,” “important,” “notclear,” “little importance,” or “irrelevant.”One could think of the reasons as“justifications” or things that might besaid in defense if questioned about whatwe had done. These reasons representsome of the goals one has in mind whentaking action. Again, the reasons are notmutually exclusive. Much of our action is

intended to simultaneously optimizeseveral goals and stay out of troubleeverywhere it might turn up. Thestructure of the actions and reasons isintended to place respondents in arealistic situation rather than as anacademic exercise of picking the rightanswer on the best theoretical grounds.Dental school may be like that, but life is not.Norms were constructed from a

sample of dentists and patients, each of which reported what they would doand why for all eight cases. The sampleof dentists consisted of 91 national andsection officers of the American Collegeof Dentists who were surveyed by mail.The sample of patients was taken fromthe attendees of two churches in Sonoma,California, totaling 54 responses. In addition to full descriptive

tabulation of the results, t-tests wereperformed for differences betweengroups (dentists vs. patients), F-ratioswere calculated for homogeneity ofvariances between multiple groups, afactor analysis with varimax rotationwas performed to identify the latentstructure in respondents’ views of oralhealth, and correlation matrices werecreated to reveal associations among the variables.This project was approved in

the exempt category by the IRB at theUniversity of the Pacific, #13-63.

ResultsBoth dentists and patients were able touse the cases in the format presented.The results are summarized in Table 1and have been converted to feedbackavailable in the online version of thecases. Additionally, these data have

33



Table 1. Responses of Patients and Dentists to Eight Ethics Cases

1. Service (Robin Hood): Patient who has immediate need and has used current insurance eligibility requests that dentist perform work but date the insurance claim a month later so as to qualify for coverage.

Actions

1.41# 1.39* 10 16 18 20 37 [TF] Perform the needed work and submit the claims with later date .30 .88 4 2 0 9 85

1.60# 1.25 7 22 18 31 22 Perform the work only if Professor X can pay the cash 2.50 1.29 30 23 24 18 8

3.08# .84 35 41 20 4 0 [TF] Offer to perform the work at a reduced rate as a public service 2.52 1.03 17 39 28 13 4

2.00 1.23 13 18 42 11 16 Make inquiries concerning other dentist said to postdate claims 1.72 1.22 11 18 19 39 14

Reasons

2.82* .83 18 52 26 2 2 [S] Legal, contractual arrangements with insurance companies 3.27 1.05 51 39 1 3 6

3.41 .50* 41 59 0 0 0 [G] Patient’s oral needs and pressing circumstances 3.21 .79 37 53 6 3 1

3.15 .81 37 45 14 4 0 [E] Dentist’s personal values regarding service 2.77 .92 45 42 7 4 2

1.93 1.42 14 27 27 4 29 [S] Potential inaccurate dating of the procedure will be detected 2.19 1.71 26 19 6 9 40

2.62 1.26 23 45 15 4 13 [E] Dental codes and standards in the community 2.52 1.39 28 36 14 6 17

3.66* .47+ 66 34 0 0 0 Overall sense of what is right 3.86 .35 86 14 0 0 0

2. Third Opinion (Justifiable Criticism): Strong indications of faulty restorative work, undiagnosed periodontal problems, and overcharging the patient.

Actions

3.06 1.18 46 33 8 8 6 Contact dentist who did the work to get his or her side of the story 2.93 1.27 44 30 8 11 7

2.32# .96 11 34 32 23 0 [PE] Lodge a formal complaint with the dental society or dental board 1.44 .93 2 8 35 40 15

1.83 1.32 11 28 15 28 19 [PE] Suggest patient return to first dentist, do nothing else 1.92 1.29 17 18 19 35 12

3.80 .45 82 16 2 0 0 Inform the patient of her present condition, as you see it 3.80 .48 84 13 3 0 0

1.18# 1.30# 7 14 11 27 41 [TF] Suggest indirectly to colleagues unnamed dentist not up to par .29 .53 0 0 4 21 75

Reasons

2.96* .52* 12 73 15 0 0 [S] Patient’s recollection of what was done and when 2.69 .85 10 62 17 8 52

2.26* 1.07 11 32 38 11 9 [G] Professional code against unjustifiable colleague criticism 2.64 1.06 20 45 20 10 5

Mean SD %Strong %Neutral %Strong Support Reject

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1.22 1.20 2 18 18 24 38 [S] Dentists are independent; their practices are their business .92 1.08 1 11 14 26 48

3.78 .42 78 22 0 0 0 [E] Current health needs of the patient 3.69 .46 69 31 0 0 0

1.82 1.17 5 27 32 18 18 [S] Complexity and uncertainty of interpersonal relationships 2.00 1.16 7 32 32 16 15

1.78 1.16 2 28 30 20 20 [S] Patient personality and motives 2.05 1.06 3 35 36 13 13

3.65 .52 67 31 2 0 0 [E] Dentists have obligation to all patients and profession generally 3.56 .52 57 42 1 0 0

3. Who Cares (Generalist-Specialist Relations): Two periodontists in town suddenly both stop returning patients to the referring general dentist and advise patients that they all need “advanced care” that only they can provide.

Actions

1.71+ 1.34 13 16 22 27 22 Confine comments to reinforcing the desirability of optimal care 2.32 1.25 20 27 27 14 11

2.84 .92 24 43 27 4 2 Suggest that patient make an appointment to be seen by specialist 2.82 1.19 32 41 8 13 6

2.33# 1.03 8 45 22 20 4 [TF] Invite specialists to lunch to discuss apparent change in referrals 3.40 .83 55 35 5 3 1

3.13# .89+ 42 33 21 4 0 [TF] Explore GP-specialist roles with component ethics committee 1.86 1.21 11 22 23 31 13 [PE]

Reasons

2.43+ 1.17 8 59 14 4 14 [S] Patient’s financial situation 2.00 1.14 0 50 15 21 14

2.67# .97+ 19 44 26 9 2 [S] Implication that generalist is not competent to maintain patient 3.25 .69 38 50 11 1 0

2.96 .81 26 49 21 4 0 [G] Changing trust levels between patient and generalist 3.04 .81 28 54 13 3 1

3.57# .57* 61 35 4 0 0 [S] Accuracy of informed consent so patient understands all choices 3.02 .90 29 53 12 2 3

3.48* .58+ 52 44 4 0 0 [E] Patient’s freedom to choose the level of care they desire 3.16 .79 32 59 4 2 2

3.21 .76 35 55 8 0 2 [E] Importance of optimal oral care 3.37 .62 41 57 1 0 1

4. Fair Payment (Patient attempts to renege on payment): Patient attempts to renege on part of payment for large completed treatment plan based on failure of part of it that the dentist recommended against.

Actions

.35 .79# 0 6 0 17 77 Agree to patient’s suggestion to cut payment .16 .40 0 0 1 14 85

2.06 1.22 15 26 17 36 6 Dismiss patient through a formal process and write off the bad debt 1.94 1.16 8 26 29 25 12

35




(Table 1, Continued)

(Continued)

36



2.88 .96 26 48 16 8 2 [PE] Refer patient to peer review for adjudication of disagreement 2.67 1.13 28 33 22 14 3

2.01# 1.30+ 14 27 20 23 16 [TF] Negotiate compromise treatment, partial, extended payments 1.19 1.03 1 15 11 47 26

Reasons

2.73+ 1.06+ 16 63 8 6 8 [G] Dentist’s reputation in town 2.26 1.17 9 47 16 18 10

3.14 .82 33 53 10 2 2 [E] Get patient to accept responsibility for both financial and 3.35 .73 43 52 1 2 1 health issues

3.46+ .58 50 46 4 0 0 [S] Chart notes of options presented, written financial arrangements 3.67 .56 71 27 1 1 0

2.49 .86 2 60 30 2 6 [S] Potential for protracted dispute and lost time in the office 2.17 1.05 2 51 15 25 7

3.08 .82 29 57 6 8 0 [E] Addressing patient’s compromised dental condition 3.02 .74 22 65 9 3 1

2.09 1.15 6 40 23 19 13 [G] What other dentists might do in a similar situation 2.16 1.14 6 44 24 14 13

5. Coach (Hostile Work Environment): Hygienist complains that patient (“Coach”) is verbally sexually harassing her.

Actions

1.19 1.10+ 6 4 21 40 29 Registered letter dismissing Coach, citing illegality of harassment 1.06 .82 1 4 18 54 23

3.20 .95 46 36 12 4 2 Talk to Coach, explain perceptions, warn of possible termination 3.37 .74 48 45 2 4 0

2.73 .95 33 31 17 13 6 Encourage hygienist to talk with Coach, help her be assertive 2.53 1.23 23 38 16 16 8

2.40 1.31 26 30 11 28 6 Call a staff meeting to discuss the issue 2.68 1.26 32 31 17 12 8

.29 .59* 0 2 0 22 76 [RA] Dentist does nothing; this is an employee-customer relationship .16 .40 0 0 1 13 86

Reasons

2.70+ 1.02 12 66 10 4 8 [G] Reputation of the profession in the community 2.30 1.28 12 48 12 11 16

2.49+ 1.20 16 47 22 2 13 [R] Civil liberties and personal autonomy 2.84 1.00 25 49 15 8 3

3.18 .44+ 20 78 2 0 0 [G] Employee morale 3.34 .60 40 56 3 1 0

3.06+ .85 31 51 14 2 2 [S] Legal considerations 3.40 .73 52 38 8 2 0

2.88 .94 21 58 13 4 4 [S] Verbal skills and confidence of the dentist and the hygienist 3.06 .77 28 54 13 4 0

3.35 .75 49 39 10 2 0 [E] Dentist’s personal standards of interpersonal respect 3.36 .90 54 37 2 4 2



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6. Tooth Colored Restorations (Informed Consent): Three dentists compare different philosophies regarding treatment presentation of amalgam or composite on posterior restorations. Dr. A aggressively steers all patients toward composite; Dr. B explains both options and lets patients decide; Dr. C simply does what he thinks is best in each case without engaging the patient in the decision.

Actions

3.33* 1.03# 61 22 12 2 4 [Pt] Off base to offer only composite and replacing sound amalgams 3.82 .47 85 12 3 0 0

3.31+ .95# 56 27 8 8 0 [Pt] “Selling” perhaps unneeded dentistry as “patient education” 3.63 .53 66 32 2 0 0

.66 .77 0 2 12 36 50 [RA] Patients asked to decide when not really qualified to judge .58 .82 0 2 14 23 60

.60 .96 2 4 8 23 63 [RA] Carrying informed consent too far .66 .85 0 4 11 30 54

3.08 1.12 44 36 10 4 6 [PE] Off base to consider only dentist’s values 3.25 1.01 56 25 12 3 4

.96 1.22 8 4 10 31 47 Informed consent is unnecessary in such cases .76 1.16 7 3 8 23 59

Reasons

3.38 .72 46 50 2 0 2 [E] Patient autonomy: patients have ultimate say over their own care 3.53 .58 57 39 4 0 0

2.19* .95 2 42 37 12 8 [E] Dentist autonomy: dentists allowed to practice as they think best 2.72 1.00 12 68 7 7 7

.77 .94 2 4 12 35 48 [G] Patients question dentist damages the professional relationship .73 .92 0 4 19 22 54

.68+ .92* 4 2 2 43 49 [S] Dentists should only offer the most esthetic and expensive care .37 .62 1 0 1 27 71

2.23 1.38 12 46 12 8 22 [S] Dentist’s comfort level talking about alternatives and costs 1.89 1.29 8 35 14 24 19 with patients

1.60 1.24 0 28 26 16 30 [S] Whether patient seems intelligent and to value high-end care 1.46 1.19 3 20 22 27 28

2.81 1.04 19 62 8 4 8 [S] Amount of experience dentist has with the procedures 2.66 .95 10 64 14 7 6

7. Full Care (Pro bono Work): As a member of a local service organization that does charitable work, the dentist visits a nursing home is town and discovers substantial unmet need.

Actions

.49 .79 2 0 6 29 63 [OH] No action–society and insurance have set compensation too low .73 .86 0 5 13 33 49

.28+ .50+ 0 0 2 23 74 [OH] No action–no lasting impact, might be seen as interference .51 .67 0 1 6 36 57

3.42+ .66 49 45 4 2 0 [OH] Work to start program that involving other local dentists in care 3.11 .83 36 44 16 4 0

3.24# .74 40 46 12 2 0 [OH] Volunteer one day a month in the nursing home, no matter what 2.57 .97 17 39 31 11 2



(Continued)

Reasons

2.71 1.08 16 61 12 2 10 [G] Reputation of the profession in the community 2.88 .96 23 56 10 8 3

3.70 .46 70 30 0 0 0 [E] Patient’s oral needs 3.57 .50 57 44 0 0 0

1.67 1.09 0 29 29 24 18 [S] Each provider community and funder functions independently 1.93 1.05 6 24 40 20 11

8. Who Decides? (Patient Autonomy): Patient indicates strong preference for veneers in aesthetic region and a disinclination to have needed restorative and periodontal work done first.

Actions

1.66# 1.15+ 6 18 30 28 18 [OH] Convince patient that veneers are not always the best choice here .73 .86 0 5 13 33 49

3.26# .84 42 51 2 4 2 [OH] Try to convince patient of dentist’s plan for long-term oral health .51 .67 0 1 6 36 57

2.70* .82 13 53 25 9 0 Suggest cleaning, replacement filling; postpone full treatment plan 3.11 .83 36 44 16 4 0

1.92# 1.13 8 23 37 19 13 [OH] Say you value needs above wants and suggest another dentist 2.57 .97 17 39 31 11 2 [Pt]

2.11# 1.10 8 34 30 19 9 Begin work while continuing to educate patient during treatment 1.44 1.21 5 21 16 33 26

Reasons

2.87 .79 13 70 9 6 2 [E] Patient autonomy (right to choose what they feel is best) 2.84 .82 14 69 9 7 2

3.44 .63 52 40 8 0 0 [E] Patient’s comprehensive oral needs 3.55 .52 56 43 1 0 0

2.75 .57* 4 67 27 2 0 [E] Dentist’s autonomy (right to choose what they feel is best) 2.85 .89 17 65 7 9 2

1.98# 1.13 6 29 38 12 15 [S] Legal considerations 2.88 1.06 27 52 9 7 6

2.74 1.00 15 56 21 0 8 [S] Verbal skills and confidence of the dentist and the hygienist 2.72 .90 12 62 14 8 3

1.55# 1.14 4 14 41 16 25 [S] Prospect that such a patient will become a management problem 2.56 1.08 14 54 15 11 7

NB: The top line in each pair describes patients’ responses; the bottom line describes dentists’ responses. The means and standarddeviations are shown in the first two columns of each set. Higher numbers represent greater agreement with the action or reason or largerstandard deviations. Differences between patients and dentists that are significant at p < .05 are marked with a +; *represents differencesat p < .01; # identifies differences significant at p < .001. The numbers in italic are percentages in each group choosing each of the fivepossible responses, with strongly agree on the right. The single letters in square brackets designate level of reasoning: [S] = self, [G] =group, and [E] = ethical. The double letters in square brackets refer to a five-dimension structure derived from factor analysis to characterizethe various types of ethical actions. [OH] = oral health outcomes, [TF] = technical focus, [PE] = professional engagement, [RA] = respect forautonomy, and [Pt] = paternalism.

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been analyzed by various statisticalmeans to reveal the structure of dentists’and patients’ views of ethical issues indentistry, as reported below.

Skill Building

In the computerized version of the cases,dentist and patient norms appear on the screen as soon as the reader makeshis or her choices for the case. Thisprovides instant feedback that takes theplace of group discussion in live seminarsettings. Currently, the feedback ispresented as percentages of patients and dentists selecting each position onthe Likert scales for each action and foreach reason. Those using the onlineform of these cases can see how theirchoices would be viewed by the publicand by colleagues. Consider an example from the case

on hostile workplace environment(Coach). One of the actions offered torespondents was to ignore the hygienist’scomplaint that a patient was makinginappropriate remarks on the groundsthat such matters are personal betweenthe staff and the patient. Dentistsoverwhelmingly rejected this as a way of handling the matter, 86% saying “noway” and 13% saying “probably not.”Any dentist working through this casewho thought seriously about duckingthe issue would have to be nimble increating an excuse for why he or she isdifferent from others in the profession.As it happens, patients see this situationthe same way. Among patients, 76% saiddo not avoid the issue in the strongestpossible terms and another 22%considered this a doubtful alternative.Any dentist still thinking that theproblem should be left to sort itself outon its own now has to fabricate ajustification for the public. Dentists andpatients also tended to agree on the

reasons various actions should or shouldnot be taken when hostile workplaceenvironments occur. This patterns isshown in graphic format in Figure 1.Patients and dentists were of a

common mind that employee morale,the law, value in good interpersonalcommunication skills, and the dentist’ssense of integrity are strong reasons forconfronting the issue. Slightly lessimportant were reasons such as abstractmatters of civil liberties and the dentist’sreputation in the community. There are examples such as this

throughout the cases where patients and dentists agree that certain actionsand reasons are obviously correct. There are also situations that are morechallenging. For example, patients anddentists often disagree regarding adentist’s responsibility for challengingcolleagues who are doing faulty work.Not all issues are ones where there isnear uniformity on the right action orright reason. For example, dentists are ofmix mind regarding whether to dismissa patient who reneges on payments; the entire range from “absolutely” to “no way” being advocated by manyrespondents. All of these outcomeswhere there is no consensus can bevaluable for stimulating reflection.

Principles are like a handpiece: they are a tool for doing better dentistry.Knowing about principles is likeknowing about handpieces. The realresult comes from repeated practice inindividual situations. The eight ethicscases in this program are like themannequins that students used inpreclinical technical. They are a goodplace to start learning.

Understanding the Norms

This database can also be studied tolearn about patients’ and dentists’ viewsof dental ethics. Are there patterns in theway the public or practitioners expectdentists to behave generally or whatreasons are appropriate for the waydentists should act? Do patients placemore or less weight on ethics and dothey see particular situations the same way dentists do? Do we need CEcourses on personnel law or on inter-professional management of patients?This is a rich dataset in which to exploresuch questions.The full descriptive results are

displayed in Table 1. Patients’ responses

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Figure 1. Dentist is justified in overlooking harrassment of employee by patient as this is a private matter.

are on the top line and dentists’responses are below them in each pair.The highest score possible is 4.0, thelowest is 0.0, and the midpoint is 2.0.Means and standard deviations areshown, and symbols are used to flagstatistical significance differencesbetween groups. The symbol * indicatesthat the difference between patients and dentists is significant at the conven-tional p < .05 level; + denotes highersignificance (p < .01); and # indicatessignificance at p < .001. The absence of a symbol means that no statisticallysignificant difference was detected.Differences between standard deviationswere also tested for significance becauselarge ranges may indicate ambiguity ordisagreement within each community of respondents. Thus, it matters bothwhere the center of opinion is on eachissue (whether the peak of the curvemoves right or left) and how widely

spread the opinions are (how flat thecurve is). The double initials in squarebrackets signal classifications of actionsinto one of five categories based on thefactor analysis to be described below.Single initials ([S], [G], or [E]) are forgiven reasons using the relabeled RestThree-factor Model of moral reasoning.Figure 2 is a graphic representation

of one of the 84 elements in Table 1,Case 3, “Who Cares”, action alternative 4.It shows the percentage of respondentsselecting each of the five options fromstrongly favorable to strongly unfavor-able for taking up with the componentsociety the issue of specialists notreturning patients to the referringgeneral practitioner. On average,patients tend to favor raising theconcern at the professional level (3.13,where 2.00 is neutral) while dentists shyaway from that (1.86). This difference is statistically significant at p < .001.

Further, the standard deviation forpatients is .89 compared to the statis-tically significantly larger standarddeviation of 1.21 for dentists. Dentistsare more divided in their opinions thanare patients. Graphically, the differencesin appropriateness of the action is clearas a shift in the two peaks on the curve.Graphically, the difference in consensusof opinion is represented by the overallflatter curve for the dentists. In the set of 37 possible ethical

actions, the most prominent differencesbetween patients and dentists includethe following. Dentists are more apt tofavor upfront payment, comprehensivetreatment plans, limited informedconsent, and confidential managementof differences among colleagues.Patients value adjustments of paymentalternatives and spacing of treatment,full informed consent, better education,active and open engagement of colleagueswho are not practicing at the standard of care, and greater involvement ofdentists in the general oral health needsof the community. A striking illustration of the

divergence in valued actions concerns apatient who requests veneers on teethwith questionable anatomical support.Should the dentists educate the patientregarding a long-term treatment planbased on health instead? Ninety-threepercent of patients say “yes” while 93%of dentists say “no,” the apparent reasonbeing partially related to suspicions thatthis is an “independently minded”patient. More than half the dentists(56%) would refer such patients out oftheir practices, a policy endorsed by only31% of patients. Another such exampleof divergent opinions regardingmanagement of patients whoseexpectations differ from those of thepractitioner involves renegotiatingtreatment and payment for a patientwho is dissatisfied with the initial

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Figure 2. Involve Component Society with Evidence of Dentist Not Treating to Standard of Care

work performed by the dentist and notinclined to pay for it. Both patients anddentists agree strongly that letting thepatient off the financial hook isinappropriate. But the typical responseamong patients is to explore breakingtreatment plans and payments intosegments. Among dentists almost 75%would look unfavorably on this action.Patients are more apt than dentists tofavor referring the patient to peer reviewfor adjudication of the disagreement.

Agreement between Dentists and Patients The Likert responses on each item were converted to a 4-to-0 scale and theaverage was taken for each item forpatients and for dentists, collapsing thedataset to 37 actions and 47 reasons. Thecorrelation between patient and dentistaverage scores for actions was r = .806.The correlation across averages for thereasons was r = .911. There is very highglobal agreement between dentists andpatients in how to act and why acrossthe eight cases studied.

Is There One Best Answer (Issue Ambiguity)?There was consensus on some actionsand reasons contrasted with a range ofresponses on others. Only a dentist whowas outside the tight range would needto worry about these ethical issues, andby definition there will be few of them.The profession needs to turn its attentionfirst to those issues where there is littlesettled opinion. Those challenges wheredentists agree with each other andpatients are in agreement that somethingelse should be done are also critical andwill be discussed below. How wide is the range of preferred responses? Table 2 presents the results of the

first of several analyses intended to show

the underlying structure in these data.Of the 37 action items and the 47 reasonitems, there were none where a singleone of the five scale values was agreedby either patients or dentists. In 55% ofactions and 68% of reasons, all fivealternatives from “absolutely/decisive”all the way to “no way/irrelevant” wereselected by somebody. This diffusepattern was also reflected in the modalresponses. Where there was consensus,the distribution will be peaked and alarge proportion of the responses will bein the mode (most commonly chosenalternative). The mode could range froma low of 20% (meaning that all fivealternatives were chosen an equalnumber of times) to 100% (meaningthat one alternative was alwaysselected). Across all 84 items, theaverage modal response clustered near50%, meaning that the most popularaction or reason was favored by roughly

half of the respondents. Alternatively,patients or dentists who chose theresponse favored by most of their peerswere in disagreement with half of thosein their group. Patients and dentistswere equally spread on both actions andreasons. Dentists were equally spread ontheir choices of actions and reasons, butpatients were slightly more concentratedon reasons than on actions. Items withlarge standard deviations tended to havelarger numbers of missing values, r =.197. This can also be interpreted as asign of ambiguity—respondents simplychose not to register an opinion and,presumably, would try to avoid ratherthan address such challenges.

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Table 2. Range of Reasons Given for Various Ethical Actions Chosen by Patients and Dentists.

Actions Reasons Patients Dentists Patients DentistsAlternatives used (%) 1 0 0 0 0 2 0 0 9 6 3 11 16 15 6 4 24 24 21 19 5 65 59 55 68

Mean modal response (%) 46.2 50.1 52.2 53.5

Mean SD 1.00 .93 .89 .89

NB: “Alternatives used” designates proportion of the five available alternatives selected by any respondent per item. For example, 5 means that at least one person chose eachalternative; 3 means that two of the alternatives were not used; 1 would indicate completeunanimity. The average modal response is the percentage of respondents selecting thecommonly chosen alternative. This number would range from 20% if all five responseswere chosen by an equal number of respondents to 100% in the case of unanimity. Bypaired-comparison t-tests, dentists tended to be more concentrated in their most preferredaction than were patients (t = 1.79), but there were no differences between dentists andpatients on reasons (t = .80). Reasons were more concentrated than were actions inpatients’ minds (t = 1.98, two group t-test), but not for dentists (t = 1.01). Mean standarddeviation across items was not different across patient or dentist groups or for actionscompared with reasons (F-test all under 1.75).

The issues that drew the widestrange of opinions for both patients anddentists (standards deviations above1.25) included truthfulness in filinginsurance claims, taking actionregarding other dentists’ questionablebehavior, involving all staff in the hostileworkplace matter, and extent of informedconsent deemed appropriate. Providingcare when the patient is making irregu-lar payments was more of an unsettledissue for dentists than for patients.

Matching Actions to Reasons It is possible that there are tightconnections between actions and thereasons used to justify them—each actionbased on a dominant reason. It is alsopossible that reasons support multipleactions. To explore this possibility, all

correlations were calculated betweenactions and reasons and the averagetaken on a case-by-case basis. Theaverage across all eight cases was r =.104. This means that reasons were notspecific to actions. Further evidence fornegligible action-reason pairing wasfound by locating those cases where asingle reason was associated with asingle action. Only 26% of the reasonsmotivated a single action (operation-alized as a correlation significant at thep < .05 level), while 40% motivatedmultiple actions and 34% were notsystematically associated with any action.Analyzed from the opposite perspective,31% of the actions were significantlyassociated with a single reason, while44% had multiple motivations, and 25%had none. This finding raises questionsabout grounding ethical analysis inprinciples, or at least in expecting to find that principles lead predictably to actions.

Level of Ethical JustificationForty-seven different reasons for ethics in dentistry is too many to work with.We need to find meaningful groupings.When psychologists, rather thanphilosophers, study ethics, they look tolevels of reasoning or to the sourcesof these standards. A well-establishedclassification system is James Rest’sthree categories, which I have modifiedslightly to emphasize the location of thestandard for making ethical choice. Eachof the reasons for actions in this studywas assigned to one of the categories ofSelf, Group, or Ethics, and the results are summarized in Table 3. Self and Group justifications were

valued to about the same extent, but the Ethical reasoning category waspreferred or given stronger credibility.This grouping was statistically signifi-cant. There were no differences betweenpatients and dentists on this score. The literature generally reports thatindividuals seldom come up with fullyEthical justifications on their own(McNeel, 1994). This study found thatwhere such reasons are provided, theycarry weight.

Underlying Structure, EthicalDimensions of DentistryThirty-seven different courses of actionis also too many to work withindividually. It is human nature to lookfor patterns. One might be tempted tosay, for example, some dentists aremaster technicians and others are bornsalesman. Some are both and some areneither, but the typology still makessense. Some office staff have names forcertain kinds of patients. Every case doesnot fit perfectly in such systems, but wekeep using them because on the wholethey guide action with few surprises.There is a formal statistical procedurecalled factor analysis that uses thecomputer to identify natural dimensions

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Table 3. Average (Standard Deviation) of Endorsed Reasons forActions Classified by Moral Reasoning Level

Self Group Ethical F p

Total Sample 2.35a 2.53a 3.20b 7.67 .001 (.80) (.71) (.45)

Patients 2.30a 2.54a 3.21b 8.77 .001 (.75) (.73) (.45)

Dentists 2.39a 2.50a 3.19b 5.50 .007 (.89) (.75) (.51)

Patient-Dentist Difference

t .34 .11 .10

NB: Types of action were identified from a factor analysis and only those actions with significant loadings were scored for each action type. In some cases, thedirection of scoring was reversed based on factor loadings. The three levels of moralreasoning were categorized based on an approximation of Rest’s typology. The F- and p-values on the right reflect one-way ANOVA tests across action types of moralreasoning levels. The t-values at the bottom of each column represent t-tests fordifferences between patient and dentists. Values having the same superscripted letter cannot be distinguished based on post-hoc Duncan multiple-range tests acrosstypes of actions or levels of moral reasoning. There were no significant differencesbetween patients and dentists.

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Table 4. Factor Structure Among 37 Actions on Eight Cases, 148 Combined Patients and Dentists.

Factors Oral Technical Professional Respect for Paternalism Health Focus Engagement Autonomy

Variance (%) 17% 16% 9% 8% 7%

Action Case

No action; society and insurance have set compensation too low Full care -.813

No action; no lasting impact; might be seen as interference Full care -.723

Work to start program that involves other local dentists in care Full care .681

Volunteer one day a month in the nursing home, no matter what Full care .648

Convince patient that veneers are not always the best choice here Who decides -.614

Say you value needs above wants and suggest another dentist Who decides .512 .527

Try to convince patient of dentist’s plan for long-term oral health Who decides -.762

Perform the needed work and submit the claims with later date Service -.424

Offer to perform the work at a reduced rate as a public service Service -.526

Negotiate compromise treatment with partial or extended payments Fair payment -.669

Suggest indirectly to colleagues that unnamed dentist is not up to par Third opinion -.594

Invite specialists to lunch and discuss apparent change in referrals Who cares .602

Explore GP-specialist roles with component ethics committee Who cares -.426 .530

Lodge a formal complaint with the dental society or dental board Third opinion .701

Suggest patient return to first dentist, do nothing else Third opinion -.604

Refer patient to peer review for adjudication of disagreement Fair payment .681

Dentist does nothing; this is an employee-customer relationship Coach -.485

Patients asked to decide when not really qualified to judge Tooth colored -.782

Carrying informed consent too far Tooth colored -.811

Off base to offer only composite and replacing sound amalgams Tooth colored .760

“Selling” perhaps unneeded dentistry as “patient education” Tooth colored .717

in data based on how respondents group their responses. Factor analysiscalls out dimension rather than clusters,so a particular item can “load” (havecommon properties) on several factors.Combined patient and dentist responsesfor all 37 actions were submitted toprinciple components factor analysiswith a varimax rotation. Factors wereretained based on analysis of scree plots, eigenvalues above 1.0, andmeaningfulness of suggestedinterpretations. Table 4 shows the fivefactors that were extracted, whichtogether account for 57% of thevariance. Only items with significantfactor loadings are reported.Table 4 shows a very clean, five-

factor structure. Most actions load on asingle one of the five underlyingdimensions. The most prominent factoris labeled Oral Health orientation. Itemsloading on this factor mention positive

patient health status independent oftreatment activity. The second mostprominent factor (Technical Focus)selected for specific treatment,appropriateness of selected treatment, ormanaging work flow or financialrelationships. Professional Engagement,the third factor, included itemsdescribing dentist-to-dentistrelationships. The fourth factor was theclassical ethical principle of Respect forAutonomy. A final dimension has beenincluded for the sometimes mentionedpractice of Paternalism. Actions loadingon this factor involved behavior wherethe dentist alone determines what is inthe patients’ best interests. The samefactor structure emerged when separatefactor analyses were conducted forpatients and for dentists.Occasionally in such situations, a

global factor emerges in a preemptiveposition that explains most of the

variance. This was not the case here, but had that been so, it would havesupported the view that there is a globalconstruct—“being ethical”—whichcharacterizes some dentists but notothers. This analysis suggests thatethical dental practice is more nuancedand situation-specific.

Ethical Dimensions of Dentistry asSeen by Dentists and Patients More than half the variation (57%) inthe actions chosen by patients anddentists in these ethical dental situationswas explained by a five-factor structure.If we know where people stand on thesedimensions, we will be able to predictwith some confidence how they will actwhen presented with ethical challenges.It would be helpful to know whether thisfive-factor structure is applicable to bothpatients and dentists independently. Theanswer is sketched in Table 5.

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Table 5. Average Preferences (Standard Deviations) for Actions of Various Types Among Patients and Dentists(only items identified in factor analysis included).

Oral Technical Professional Respect Health Focus Engagement Autonomy Paternalism F p

Total Sample 2.80a 3.23a 2.44a 4.48b 3.10a 3.97 .008 (1.01) (.96) (.67) (.17) (.72)

Patients 3.37ab 2.75a 2.88a 4.48b 2.86a 2.52 .08 (1.14) (.84) (.39) (.20) (.81)

Dentists 2.22a 3.71ab 2.34a 4.48b 3.34ab 4.09 .02 ( .89) (.89) (.62) (.18) (.67)

Patient–Dentist Difference

t 1.72 1.91 2.34 .02 .80

P .04 .03 .01

Higher numbers represent greater endorsement. Only items significantly loading on the identified five-factor structure were included in the calculations.

Respect for autonomy, willingness to include others in the decision makingprocess, appeared as a leading ethicaldimension for both patients and dentists.After that, some differences begin toemerge. Patients placed a greater salienceon behavior that ensures positive oralhealth outcomes than did dentists.Dentists focus more on the technicalaspects of dental treatment. Patientswere very significantly more concernedthat dentists should engage in profes-sional interactions with colleagues onpatients’ behalf than were dentists.

Ethical Dimensions of Dentistry andLevels of Ethical ReasoningTable 6 shows the correlationcoefficients between moral reasoninglevel and types of actions most valued bypatients and by dentists. This is asummary of the extracted fivedimensions of actions and the threelevels of reasons instead of the nearly400 relationships in Table 1. Patientsfavoring Self-focused, rule-basedapproaches over other types of ethicalreasoning tended to devalue both oralhealth outcomes and respect forautonomy. Those with Group orienta-tions were what might be called “casual”with regard to the way dentists preferredto run their practices. The general norm

in the patient community containsambivalent expectations. Those patientswho placed a high value on understand-ing issues from the Ethical point of viewwere keen on respect for autonomy, theywant to be independent moral agents. Dentists presented a slightly different

picture of the relationship between levelof ethical reasoning and their structuringof ethical actions. Self-focused reasoningwas associated with actions keepingpractitioners out of engagement withtheir colleagues or the professionalgenerally. Group thinking was associ-ated with attention to the business ofdentistry and technical performance.The dominant norm by which dentistsjudge each other appears to be perfor-ming technically fine treatment andrunning a successful practice. HigherEthical reasoning was negativelyassociated with paternalism. Seeking thegrounds for ethical practice in generalstandards was considered inconsistentwith acting as one’s own standard.

Discussion Eight detailed cases of ethical situationsthat arise in and around dental practicewere reviewed by 54 patients and 91dentists. The respondents indicated theirdegree of agreement with multiplecourses of actions and justificatoryreasons in each case. This dataset was

used to create an online interactiveethics learning platform whereindividual dentists can compare theirconsidered actions and reason againstnorms from their peers and from asample of patients. The dataset has also been analyzed in detail to identifythe underlying structure of ethics indental practice.Although there is substantial agree-

ment on actions and reasons at theaggregate level (patients as a cohort anddentists as a cohort), there are patternsof particular differences that deservefurther exploration. Such topics asjustifiable criticism, informed consent,financial arrangements and patientresponsibility, and dentists’ role in oralhealth beyond the purely technical taskssuggest themselves as very promising for policy discussion and education.These are areas where wide differencesof opinion appear and where a range of opinions exists among dentists. Thepublic and the profession seem to havedifferent perspectives on the primacy of technical procedures and oral healthoutcomes and on how far paternalismshould be carried. Another place wherepatients and dentists seem to be looking

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Table 6. Associations between Action Types and Moral Reasoning Level.

Patients Dentists

Self Group Ethical Self Group Ethical

Oral Health -.365+

Treatment Focus -.302* .222*

Professional Engagement -.312*

Respect for Autonomy -.378+ .269*

Paternalism -.265*

Only significant correlation coefficients are shown. * = p < .05 + = p < .01

in different directions is on the dentists’obligation to engage colleagues or the profession as a whole on thepatients’ behalf. Policy discussions, code revision, and

continuing education should focus onthose issues where there are materialdifferences in the courses of actionpreferred by patients and dentists andwhere dentists exhibit a range ofopinions on situations. Practical dentalethics is complex. There is little evidencein this study for grounding dental ethicsin theories of ethics. There was noevidence for a general construct—“ethical dentist”—that applies across theboards or for courses of actions to flowdirectly from principles. John Stuart Mill (1863/1910, p. 24) seems to havebeen correct in noting “there is no caseof moral obligation in which somesecondary principle is not involved.” The fact that a factor structure with fivedimensions emerged rather than aglobal “ethical/not ethical” dichotomy isconsistent with the literature, includingthe classical Hartshorne and May (1928)study showing that children would steala lunch but not a pencil or cheat on atest but not in a game, and variousindividual combinations. It is not customary for professions

to include patients or the public in thedevelopment, interpretation, orimplementation of their ethics codes.Jürgen Habermas (1990) offers a helpfulrule in this regard: all competentindividuals who are affected by adecision should be allowed to participatein the decision. Competence in the case

of individuals in need of oral health careobviously extends beyond the technicalaspects of treatment, as evidenced by the content of most professional codes,and participation can certainly berepresentative. To the best of myknowledge, no lay individuals wereinvolved in the development of the ADAcode and its exact shape and use arestrictly controlled by the House ofDelegates. By contrast, InstitutionalReview Boards which are required topass on all research involving humansubjects in America are not permitted byfederal regulation to take a vote on anyspecific proposed project unless there isat least one lay committee memberamong the quorum (See Code of FederalRegulations, 45 CFR 46).The level of justification or touch-

stone source of deciding what is right todo that was supported by the data in thisanalysis seems intuitively correct. TheSelf as standard was associated withunattractive actions for both patientsand dentists. These included diminishedconcern for oral health outcomes,limited professional engagements, andlow respect for autonomy. Accepting the norms of one’s reference Groupappeared to be matched with focus ontechnical and business aspects ofpractice for dentists and with somedistancing from these characteristics by patients. There is a sense in whichthis is the public face of dentistry, withpractitioners focused on aspects ofdelivery while patients accept thiswithout enthusiasm and wanting moreattention on oral health outcomes. Ahigh level of Ethical reasoning emergedas antithetical to paternalism or theimposing of ones views on others.The five-factor structure of dental

ethics issues produced by the factoranalysis approach seems face valid. Oral health outcomes and technical and practice excellence should be oneveryone’s list as highly valued signs of

the best practices and as reflections ofthe fundamental integrity of dentists.These concepts are present in variousplaces in the ADA code and the codes ofspecialty and other dental groups.Paternalism (or more properly

limited appeal to it) and individualmembers and the profession’s active self-policing on behalf of patients appearedas dimensions of both patient anddentist’s ethical framework. It seems asthough this matters a bit more topatients than to dentists. There isresearch evidence suggesting thatProfessional Engagement, especiallyamong the most ethical members of theprofession, is a more powerful influenceon the ethical character of dentistrythan are enforcement actions againstthose who bend or break the rules(Chambers, 2014a). This is an area theprofession will find fruitful to explore.Respect for autonomy was the only

ethical dimension that emergedprominently in the present dataset ofethical concerns that is also one of thefive organizing principles in the ADAPrinciples of Ethics. But the fit is not astight as we would hope. This is the firstof the Belmont principles (“Respect for Persons”). The ADA version waschanged to feature “Patient Autonomy”(Chambers, 2014b). Certainly respect isimplied if not stated, but there aresignificant differences between patientsand persons. Much of the public wouldnot consider itself currently to bepatients of record of a dentists, and someof the ethical issues studied here, such asagreement on treatment plans, care forinstitutionalize individuals in need oftreatment, and agreement on paymentand selecting and following treatmentplans, are exactly about who should beconsidered a patient. I have long argued

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(Chambers, 2003; 2013) that dentists areentitled to exactly the same respect thatpatients and the public at large have. I would prefer the Belmont language ofpersons, not patients.Finally we must return to the

beginning and see what has beenlearned about the role of principles indental ethics. Philosophers have shownclearly that we can get the job of ethicsdone just as well without as withprinciples (Hooker, 1999; Dancy, 2004;Rorty, 1999). A case can be made thatpatients and dentists can agree witheach other generally in practice withoutsharing a common language or use ofprinciples. There was very little supportin these data for a direct connectionbetween reasons for ethical behaviorand the actual actions chosen. The five-factor structure for ethics that emergedfrom analyzing the choices patients anddentists actually made did not matchwell with systems of principles derivedby philosophers. Aristotle seems to have held

reservations about the usefulness ofethical principles. “If theories weresufficient of themselves to make mengood, they would deserve to receive anynumber of handsome rewards…. But itappears in fact that, although they arestrong enough to encourage andstimulate the young who are alreadyliberally minded, although they arecapable of bringing a soul which isgenerous and enamored of noblenessunder the spell of virtue, they areimpotent to inspire the mass of men”(Aristotle, 1920; 343-344).Principles are useful as theoretical

organizers, as the carrying cases forexamples of the behavior dentists expect of each other and the publicexpects of dentists. But they are not thebehavior itself or even possibly not thebest characterization of the patterns of that behavior.

Further work is needed along theselines to clarify what will most improveoral health and how dentists can knowthey are on the right path. Working withcases, lots of them over a long timeframe and with feedback fromcolleagues and the public, bid fair toserve this need.■

ReferencesAristotle (1920). The Nicomachean Ethics.J. E. C. Welldon, Trans. London: Macmillan.Beauchamp, T. L., & Childress, J. F. (2009).Principles of biomedical ethics, 6th ed.New York, NY: Oxford University Press.Bertolami, C. (2004). Why our dental ethicscurricula don’t work. Journal of DentalEducation, 68 (4), 414-425.Chambers, D. W. (2003). Standards.Journal of the American College ofDentists, 70, 61-64.Chambers, D. W. (2013). Would someoneplease explain what it means to beethical? CDA Journal 41 (7), 493-497.Chambers, D. W. (2014a). Computersimulation of dental professionals as amoral community. Medicine Health Careand Philosophy, 17, 467-476.Chambers, D. W. (2014b). Does the ADAhave a code of ethics? CDA Journal, 42(12), 813. Council on Dental Accreditation (2013).Predoctoral dental education standards.Chicago, IL: American Dental Association.Dancy, J. (2004). Ethics without principles.Oxford, UK: Oxford University Press.Habermas, J. 1990). Moral consciousnessand communicative action. C. Lenhart & S.W. Nicholsen, Trans., T. McCarthy, Intro.Cambridge, MA: MIT Press.Hartshorne, H., & May, M. A. (1928).Studies in the nature of character. NewYork, NY: Macmillan. Hooker, B. (1999). Rule-consequentialism.In H. LaFollette, Ed. The Blackwell guide to ethical theory. Oxford, UK: Blackwell,183-204.Jonsen, A. R. (1991). Casuistry asmethodology in clinical ethics. Theory andMedicine, 295-307.

Kohlberg, L. (1968). The child as a moralphilosopher. Psychology Today, 7, 25-30.MacIntyre, A. (1988). Whose justice?Which rationality? Notre Dame, IN:University of Notre Dame Press.McNeel, S. P. (1994). College teaching andstudent moral development. In J. R. Rest,& D. Narváez, Eds. Moral development inthe professions: Psychology and appliedethics. Hillsdale, NJ: Lawrence ErlbaumAssociates, 27-49.Mill, J. S. (1863/1920). Utilitarianism.A. D. Lindsay, Intro. London, UK: J. M. Dent & Sons.National Commission for the Protection of Human Subjects of Biomedical andBehavioral Research (1979). The BelmontReport: Ethical principles and guidelinesfor the protection of human subjects inresearch.Washington, DC: Department ofHealth, Education, and Welfare.Rest, J. (1973). The hierarchical nature ofstages of moral judgment. Journal ofPersonality, 41, 86-109.Rest, J., Narvaez, D., Bebeau, M. J., &Thoma, S. J. (1999). Postconventionalmoral thinking: A neo-Kohlbergianapproach. Mahwah, NJ: Lawrence ErlbaumAssociates.Rorty R. (1999). Ethics without principles.In R. Rorty, Philosophy and social hope.London, UK: Penguin, Books, 72-90.Rule, J. T. & Veatch, R. M. (2004). Ethicalquestions in dentistry, 2nd ed. Chicago, IL:Quintessence Publishing.Thornton, T. (2005). Judgment and the roleof the metaphysics of values in medicalethics. Journal of Medical Ethics, 32 (6),365-370.

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Manuscript Submission

Manuscripts for potentialpublication in the Journal of the American College of

Dentists should be sent as attachmentsvia e-mail to the editor, Dr. David W.Chambers, at [email protected] transmittal message should affirmthat the manuscript or substantialportions of it or prior analyses of thedata upon which it is based have notbeen previous published and that themanuscript is not currently underreview by any other journal.Authors are strongly urged to

review several recent volumes of JACD.These can be found on the ACD Web site(www.acd.org) under “Publications.” In conducting this review, authorsshould pay particular attention to thetype of paper we focus on. For example,we normally do not publish clinical casereports or articles that describe dentaltechniques. The communication policyof the College is to “identify and placebefore the Fellows, the profession, andother parties of interest those issues that affect dentistry and oral health. The goal is to stimulate this communityto remain informed, inquire actively, and participate in the formation ofpublic policy and personal leadership to advance the purpose and objectives of the College.”

Generally, the journal does notpublish editorials, testimonials, announce-ments, or personal accounts. We do notaccept offers for placement from agents.Discussions of policy are only consideredif both sides of an issue are fairlydeveloped. The minimum length ofmanuscripts is usually over 2,000 worldsin order to allow full development ofimportant positions.There is no style sheet for the

Journal of the American College ofDentists. Authors are expected to befamiliar with previously publishedmaterial and to model the style of formerpublications as nearly as possible. A “desk review” is normally provided

within one week of receiving a manu-script to determine whether it suits the general content and quality criteriafor publication. Papers that holdpotential are often sent directly for peer review. Usually there are sixanonymous reviewers, representingsubject matter experts, boards of theCollege, and typical readers. In certaincases, manuscripts will be returned to the authors with suggestions forimprovements and directions aboutconformity with the style of workpublished in this journal. The peerreview process typically takes four to five weeks.Authors whose submissions are

peer-reviewed receive feedback from this process. A copy of the guidelinesused by reviewers is found on the ACDWeb site under General/Publications/JACD and is labeled “How to Review a

Manuscript for the Journal of theAmerican College of Dentists.” Anannual report of the peer review processfor JACD is printed in the fourth issue of each volume. Typically, this journalaccepts about a quarter of the manuscriptsreviewed and the consistency of thereviewers is in the phi = .60 to .80 range.Letters from readers concerning

any material appearing in this journalare welcome at [email protected] should be no longer than 500words and will not be considered afterother letters have already been publishedon the same topic. [The editor reservesthe right to refer submitted letters to theeditorial board for review.]This journal has a regular section

devoted to papers in ethical and profes-sional aspects of dentistry. Manuscriptswith this focus may be sent directly to Dr. Bruce Peltier, the editor of theIssues in Dental Ethics section of JACD,at [email protected]. If it is not clearwhether a manuscript best fits thecriteria of Issues in Dental Ethics, itshould be sent to Dr. Chambers at the e-mail address given above and adetermination will be made.

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