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Journal of the

American Collegeof Dentists

Social Media

Winter 2012Volume 79Number 4

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 2012 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 2012 subscription rate for members of the American College of Dentists is $30,and is included in the annual membershipdues. The 2012 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. Ifclaim is made after this time period, it willnot 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, numberand page. The reference for this issue is:J Am Col Dent 2012; 79 (4): 1-84.

Journal of the


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 those

issues that affect dentistry and oral health. The goal is to stimulate this communityto 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 BoardLaura Bishop, PhDSusan Bishop, DDSHerb Borsuk, DDSMarcia Boyd, DDSKerry Carney, DDSAllan Formicola, DDS, MSRichard Galeone, DDS William Leffler, DDS, JDMichael Meru, DDSPeter Meyerhof, PhD, DDSKirk Norbo, DDSMartha S. PhillipsAlvin Rosenblum, DDSH. Clifton Simmons, DDSPhilip E. Smith, DMDJim 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

OfficersW. Scott Waugh, PresidentKenneth L. Kalkwarf, President-electJerome B. Miller, Vice PresidentBert W. Oettmeier, Jr., TreasurerPatricia L Blanton, Past President

RegentsThomas J. Connolly, Regency 1Thomas A. Howley, Jr., Regency 2Geraldine M. Ferris, Regency 3Richard F. Stilwill, Regency 4Joseph F. Hagenbrch, Regency 5Carl L. Sebelius, Jr., Regency 6Steven D. Chan, Regency 7Rickland G. Asai, Regency 8

Linda C. Niessen, At LargeRonald L. Tankersley, At LargeRichard C. Vinci, At LargeStephen K. Young, At Large

Lawrence P. Garetto, ASDE LiaisonBrooke Loftis Elmore, Regent Intern

2012 ACD Annual Meeting4 Someone Guided Your Professional Growth: Do the Same

(President-elect’s Address) W. Scott Waugh, DDS

8 You Will Look Good Treating Others with Respect—I Guarantee It(Convocation Address) George Zimmer

10 2012 ACD Awards

15 2012 Fellowship Class

White Paper19 Position Paper on Digital Communication in Dentistry

Officers and Regents of the American College of Dentists Prepared by David W. Chambers

Social Media31 People Will Talk

Steven D. Chan, DDS, FACD

40 Introduction to Social MediaMichael Meru, DDS

43 Social Media Policy in Other OrganizationsCarl L. Sebelius, Jr., DDS, FACD

48 Being Professional in the Social Media WorldSteven D. Chan, DDS, FACD

Issues in Dental Ethics56 Different Labs

Bruce Peltier, PhD, MBA, FACD; Anthony Vernillo, DDS, PhD, MBE; Lola Giusti, DDS; Larry E. Jenson, DDS, MA

Manuscripts64 Is General Dentistry Dead? How Mid-level Dental Providers

Will Affect the ProfessionEric K. Curtis, DDS, MA, FACD

72 Dentists Demonstrating Professionalism: Dentists in Private PracticeSettings Provide Free or Reduced-fee CareMatthew Kramer, DDS

Departments2 From the Editor

Lessons in Shifting the Burden: #3. The Critical Moment for Dental Ethics

78 2012 Manuscript Review Process

79 Submitting Manuscripts for Potential Publication in JACD

80 2012 Index

Cover photograph:Approach social mediawith caution.

©2013 Craig NeilMcCausland; istockphoto.com. All rights reserved.

To have maximal effect, ethicsinstruction should be applied at theright place and time. The accepted,

one-shot model is that dental school isthe right place because students areimpressionable, all in one place, andlikely to carry everything they learn inschool over into practice. I suggest a two-step alternative: the leaders in theprofession should model and enforceethics among typical practitioners, whowill then encultrate the new graduates.The second part of this plan is certainlyin place now. It is the first step—leadersdeveloping an ethical climate amongtheir colleagues—that needs the attention.

Many schools have a faculty memberwith training in ethics presenting a combination of lectures and seminar discussion. Sometimes practitioners par-ticipate in these programs; occasionallypractitioners present the entire ethicsprogram to students in a one-day session.Typically coverage includes the fivebioethics principles on which the ADAcode is based and discussion of dilemmasthat arise in practice. An example wouldbe the clash between honoring apatient’s request for esthetic treatment(respect for autonomy) when underlyingconditions point to greater needs forbasic restorative and periodontal care

(beneficence). Other cases might be theextent to which child abuse must bereported, up-coding on insurance,overtreatment, and keeping one’s handsoff patients. Of course the latter are notdilemmas at all; they are just matters ofdoing the right thing when it may beinconvenient. The question is not whatto do, but why it is not being done.

Since 1997, ethics instruction hasbeen an accreditation requirement forall dental schools. That means we have a crop of more than 60,000 young prac-ticing dentists who are (theoretically)more ethically qualified than their seniors were at graduation. Althoughwelcomed universally, the currentapproach to teaching ethics in dentalschools leaves some concerns unad-dressed. For students, fee-splitting orjustifiable criticism or selling high-endcases are hypothetical matters. It is rarethat dental school ethics programs aregrounded in the challenges studentsface, such as cheating on exams, hoard-ing patients, or studying from “leaked”National Board tests.

When the College met in Philadelphiaa number of years ago, one of theLeaderSkills programs was presented bya group from Harvard called the MakingGood Project. This organization hasworked with businesses, professions,and public organizations to understandthe forces that encourage ethical behav-ior in professional work settings andthose that present barriers. They haveconducted in-depth investigations of

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2012 Volume 79, Number 4

Editorial

From the Editor

Lessons in Shifting the Burden: #3. The Critical Moment for Dental Ethics

The first few years ofpractice are the criticalmoment. Beginners aremost heavily influenced by what they see their seniorcolleagues doing and by how those they look up to define success.

journalism, theater arts, and geneticsresearch, among others.

Their findings, summarized in thebook Making Good and on the Web siteof the same name, are consistent acrossprofessions. The first few years of prac-tice are the critical moment. Beginnersare most heavily influenced by whatthey see their senior colleagues doingand by how those they look up to definesuccess. Dentistry already has a ubiqui-tous “mentoring” program. The questionis what values the “mentors” are passingalong and who is minding them.

It turns out the schools have littlelasting effect. Students in professionalschools are the cream of the crop ofthose who can give the answer a facultymember wants to hear. They are equallybrilliant at copying the behavior of thefirst colleague they associate with andpatterning their habits to those who areheld up as models on the CE programsor in trade magazines.

Beginning professionals in theMaking Good Project consistently reportthey are aware of the new ground rulesthat apply upon entering practice. Theyare also aware—often painfully so—of the inapplicability of “school ethics” inthe real world. Almost always, and withprofessed reluctance, beginners in pro-fessions feel it is necessary to “cheat toestablish a practice” but not to maintainone. Here is a direct quote from a youngjournalist: “Cutting corners and lying…was the price we had to pay in order toadvance in our profession and maintain

our personal values. We were willing topay the price because we aspired towarda long-term goal.” Over and over, toooften for comfort, researchers heard participants express their willingness tocross lines. Often this admission wasclosely followed by an assurance thatwhen they finally achieved prominence,they would behave in a different andmorally laudatory manner.

The project also studied establishedleaders in at least some of the professionsto learn why so many of the beginnersfelt let down by them. The “successful”professionals spoke eloquently of highstandards and the honor of their profes-sions. It was easier to do so by “skippinga generation” and telling the studentswhat to do rather than working to ensurethat their colleagues were up to standard.The young professionals in the Harvardstudy were disappointed by the top people, who explained how they practicenow but passed over the challenges ofearly professional life.

What students and young profes-sionals wanted was practical help copingwith problems that beginners face. It is no surprise that the recently createdStudent Professionalism & Ethics Association in Dentistry (SPEA) that isappearing in dental schools across thecountry is student run and focused onethical issues of students and young

professionals. Check their Web site atwww.speadental.org.

The American College of Dentists has traditionally supported Sections intheir programs where Fellows make pre-sentations in schools. More recently, wehave begun to focus on the practitioner.Daylong training programs have beenoffered at annual meetings and havenow reached more than 100 Fellows. Weprovide scholarships for master’s levelethics training for practicing dentists.Our Practice Ethics Assessment andDevelopment program is a 50-hour,online training program in ethicsdesigned for the entire dental officeteam available at www.dentalethics.org.

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Journal of the American College of Dentists

Editorial

W. Scott Waugh, DDS

ACD President-elect’s AddressOctober 17, 2012San Francisco, California

Good day to each of you. Or better said in my colloquialmanner, “How are all you all

doin?” That’s how we greet our friendsand colleagues from Oklahoma! Yes, I’mfrom Oklahoma—“the land of wavingwheat that sure smells sweet when”—Oscar Hammerstein and I agree— “thewind comes right after the rain!” It is my privilege to welcome you to our 92ndAmerican College Annual Session andConvocation. It is indeed an honor for me to address you today as yourincoming president.

Greetings to President Blanton,Officers, Regents, candidates, Fellows ofthe College, Dr. Ralls, our ACD staff, andour special guests of today.

I want to especially thank myOklahoma Section and Fellows inRegency V for their support in nominat-ing me for their Regent and for theircontinued support.

Congratulations are in order for you, our newest incoming candidates, for today is a very special day. You arebeing recognized for your leadershipand commitment to your chosen profession of dentistry. I look forward to getting to know you and welcome youto the College.

In 1989, I was sitting where you are.I was excited, I felt so honored to becomea Fellow in the American College ofDentists. But like many of you, I was notfully aware of the significant role theAmerican College plays in the promotionof ethics and professionalism withindentistry. Only three and a half percentof dentists are asked to become Fellows

in the College. This recognition is not for who you knew. It is solely based onyour personal achievements. For thatyou should be proud.

Like many of you, I was very humbledwhen I received notification of my nomi-nation and when I learned who the twoindividuals were that nominated me. Dr. Dean Robertson, one of those whonominated me for Fellowship, had written my letter of recommendationwhile I was applying to dental school at Oklahoma 25 years earlier. And Dr.Dean Johnson, Professor of RemovableProsthodontics at the University ofOklahoma, whom I had worked with onseveral cases, was the other nominator.They were both pillars in our dentalcommunity. In my eyes they were thepinnacle of professionalism and ethics. I shall forever be grateful for their confidence in me. I shall always cherishtheir mentorship and guidance.

I would like to take a moment nowto introduce myself to you by telling youof my personal journey in dentistry. I had a shaky start. I was a senior in col-lege and had applied to dental school.But as you know or may have been told,in 1968 the Vietnam War was at its highest levels of intensity. I received mydraft notice 32 days prior to receivingmy acceptance letter to Baylor College of Dentistry. After making a frantic plea,

4


Someone Guided Your Professional Growth: Do the Same

2012 ACD Annual Meeting

Dr. Waugh is in private practice in Edmunds,Oklahoma.

it became clear that there would be nochanging Uncle Sam’s mind. I spent thenext 20 months in the U.S. Army, 16 ofthem in Vietnam. I was not sure mydream of dental school would ever cometrue. I served as infantry point man.Then, through a series of circumstances,I became a medic. I completed my tour asa door gunner/medic. But God was withme and I returned home uninjured. Thatwas the spring of 1970, and I enteredBaylor Dental School in the fall of 1970.

Shortly after my return I was intro-duced to a beautiful blonde on a blinddate. I’m so fortunate to say that after 42 years, Sheri is still my best friend, thewind beneath my wings, and best of all,mother to our three children. She hasstood beside me throughout my dentalcareer and leadership opportunities. I am forever grateful for a lifetime ofdevotion and support.

I have practiced in a general dentalsetting for 38 years in Edmond, Oklahoma.I have a wonderful staff that understandswhat is required to conduct a patient-centered practice, and I practice withtwo dedicated colleagues, who I’m proudto say, were inducted into the Collegelast year.

My foundation came from two loving parents, Woody and Pal Waugh,who taught me that with hard work, astrong unwavering value based life, and a strong faith-centered foundation,anything could be accomplished. Thereare many, many others that have had a positive influence on me, and to all Isay thank you.

Ninety-two years ago dentistry wasin a difficult position. There were no

standards in dental education, commer-cialism was rampant, and professionaljournals were little more than a collectionof articles by uncredentialed authorsthat made many unsubstantiated claims.We were mostly, in the public’s eyes,nothing more than a trade. Sadly, ourrecognized trademark was the red-white-and-blue barber pole. Dentistryfaced many serious challenges. Therewas an increasing threat from propri-etary dental schools and deceptiveadvertising. Perhaps this sounds all toofamiliar today, doesn’t it?

The American College was foundedby a group of dental leaders from theAmerican Dental Association and dentaleducators. Their vision was to “cultivateand encourage the development of ahigher type of professional spirit and a keener sense of social responsibilitythroughout the profession.” That vision and goal continues today, and itremains strong.

The mission statement of the Collegeis to promote excellence, ethics, profes-sionalism, and leadership. The AmericanCollege of Dentistry has been a beaconand guiding force in helping to establishthese standards through the years.

Recently through the leadership andguidance of Dr. Steve Ralls, our ExecutiveDirector, the College has developed aseries of online courses in dental ethicsand dental leadership. Many dentalschools use these courses in their ethicsclasses. I will also tell you that manystate boards require ethics as a continu-ing education requirement and rely on

5



Ninety-two years ago

dentistry was in a difficult

position. We were mostly,

in the public’s eyes, nothing

more than a trade.

these courses as a resource. The Collegehas become a clearinghouse for ethicsresources and ethics-related materials,including a collection of ethical dilem-mas written by Dr. Tom Hasegawa andoriginally published in the Texas DentalJournal. All of these courses can be easily accessed by going to our Web site.We are presently working with CreightonUniversity by offering scholarships topracticing dentists who wish to studydental ethics.

In addition, the College has publishedThe Ethics Handbook for Dentists andethics wallet cards. These are distributedto all first-year dental students. I wouldalso like to point out that the College hassponsored several ethics summits. Mostrecently, the College, through a collabo-rative effort with the ADA, was heavilyinfluential with the Joint Subcommitteethat addressed integrity issues in dentaleducation. Other summits that theCollege has sponsored focused on com-mercialism and truth claims in dentistry.At this very meeting, the ExecutiveDirector and Officers met with theCorporate Dental Practice GoverningBody to explore the possibility of conven-ing a summit in the near future.

As you can see, the College has manyongoing activities. It has been referred toas the “conscience of dentistry,” and assuch we have an obligation to continueto hold up ethics as a cornerstone of our profession.

I am an eternal optimist and I believeour profession will endure the externalinfluences that challenge our core values.We have only to look in the Yellow Pagesfilled with promises, false or misleadingcredentials behind a name, and cheatingscandals in our dental schools. Dentistsrefer to other dentists as competitors, notcolleagues. Excessive overtreatment iscreeping in—all for greed. This tarnishesour image.

We cannot rely on the College tostand up against lack of professionalismentirely on its own. But you can counton our being in the front line. I reallybelieve that our efforts to stem the tidemust come from the grassroots activitiesof our Sections. That is where the rubbermeets the road. The College can have adirect influence through the member-ship and Section activities. Each Sectionis encouraged to be involved in one ormore activities. We are not a “gold watch”organization. It is our responsibility tohelp our colleagues understand that dentistry is a calling, not just anotherjob, and that patients are not a com-modity to be coaxed into treatment butto be treated in a fair, respectful manner.

Many of our Sections sponsor WhiteCoat ceremonies. What a tremendoustime it is to have a positive influence onour very newest colleagues. OtherSections provide one-on-one guidancethrough ethical dilemma programs atdental schools. Students enjoy the opportunity to have an open dialog with practicing dentists, hearing theirperspective on various dilemmas thatchallenge our ethics. Other Sections support dental students by granting

scholarships and some are involved with mentoring. Not only do they mentor dental students, but they alsocoach new colleagues who locate theirpractice in the same community.

One of the newest opportunities forSections is to become involved with aSPEA chapter. SPEA stands for StudentProfessionalism & Ethics Association inDentistry. This movement was started atthe University of Southern California bystudents who recognized an opportunityfor students to improve the ethical cli-mate in schools. Although only in itsinfancy, many chapters have been started.In Oklahoma, our SPEA chapter had itsfirst meeting in September. To show you how important this is to students,there were over 80 students present atthe inaugural meeting. This is studentorganized and student driven. TheOklahoma Section of the AmericanCollege of Dentists voted to support thisclub by providing financial aid for theirmeetings. (As a side note, we had amember at our meeting who immediatelystepped up and made a pledge of match-ing funds.)

The College has endorsed this neworganization and helps by sponsoringspace and providing speakers for theirnational meeting which is held in con-junction with our own meeting. Themembers of the Oklahoma Section willonly be used as resource advisors.

Let me touch on a subject that isnear and dear to me: that is mentoring.There is no greater way to have directinfluence on a desired outcome than

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mentoring. Even Socrates pondered the question: Can ethics be taught? His conclusion was that the greatestinfluence is that which is shown byexample. I know that each one of you, as you listen to me, is thinking of anindividual or several individuals thathave had a direct influence on you, your chosen profession, or your chosenlifestyle. Is it your parents, a pastor, ateacher, a professor, or colleague thathelped you formulate the values thatguide you today?

I strongly urge you to get involved,ask young practitioners to lunch, offer to help them diagnose and sequence acase, invite them to a study club, orinvite them to your local dental societymeeting. Taking the first step and opening the door may be all it takes toestablish a meaningful friendship. Yourinfluence may be all that is required tohelp steer a struggling colleagues in the right direction.

A couple of years ago, I received a letter from a new graduate. He startedhis letter like this:

“I’m writing you this letter becauseI’m really troubled by stories some of my classmates have told me about thedentistry they have encountered sincegraduating. I know you sit on the ADAethics board, and I thought I would letyou know about this information andask what if anything I can do to correctthis situation that jeopardizes theintegrity of our profession.”

WOW! That is a plea from one of ouryoung colleagues who is worried aboutthe future of his new profession. Herelated stories of Medicaid fraud, over-

treatment, fraudulent up-coding of insurance claims, and unnecessary procedures being done—all in the nameof greed.

He went on to say, “I think thesethings need to be talked about in dentalschool and call them what they are:fraud. I remembered that you and someof your ACD colleagues came to ourschool and talked to us about ethics.More of those talks need to take place.”

You see, you never know how valu-able your time can be when mentoring ayoung, bright star in our profession.

I’m proud to say the apple does notfall far from the tree; this young man’sfather is being inducted into Fellowshipthis year. I am sure it will not be longand his son too will be inducted.

In conclusion, I again want to con-gratulate you, our newest inductees. Butas you can tell from my remarks, muchwill be expected from you. This indeed isa critical time for our profession, andyour influence is needed more than ever.And to you, our more mature, seasonedFellows, thank you for taking time tonominate deserving candidates andthank you for your involvement in ACD activities.

I am grateful for this opportunity to serve as your President. I promise todo my best. I can assure you that yourBoard of Regents and our ACD staff arehere to assist, encourage, and motivate.Thank you and enjoy this wonderful day!■

7



I know that each one of

you, as you listen to me, is

thinking of an individual or

several individuals that have

had a direct influence on

you, your chosen profession,

or your chosen lifestyle.

George Zimmer, AB

Convocation AddressOctober 17, 2012San Francisco, California

George Zimmer opened the first Men’sWearhouse clothing store in 1973 inHuston, Texas. Since then Mr. Zimmer has led the company through every phaseof its growth. He attributes much of thecompany’s success to integrating his servant leadership values in the corporateculture. These core corporate values of collective trust, honesty, respect, integrity,authenticity, celebration, good will, andcaring for each other stand side by sidewith other essential principles like hardwork, accountability, loyalty, and commit-ment to customer service. His humanitydeveloped simultaneously with the growthof his business acumen which, together,created a Fortune 1000 company with a corporate culture that has been recognized, with eleven appearances, in Fortune’s 100 Best companies to Work For.

Iappreciate the opportunity to speak toa group of dentists without lying down.Today I want to share some of my

thoughts about the key to organizationalsuccess—specifically Men’s Wearhouse—and close with some general commentsabout business ethics.

We started Men’s Wearhouse in 1973and had the usual start-up challengesduring our first years. But we learnedquickly and refined our business prac-tices over the first decade as we grew to20 stores located in Texas and the BayArea. In the early 1980s—during theTexas-centered oil crisis—our bank loanwas called, and even though we hadbeen profitable for ten years, we had toscramble to save our business.

And we would not have been able to do that if employee morale and confidence had not remained strong. But we trusted each other and that trustcontinues to be the key ingredient to our success today. When employees trustthe company, they naturally choose towork toward company goals.

And here is how to make that happen.Trust is, of course, built over time. Westrive to be authentic and transparentwhen communicating to employees. Tobe trusted, it requires that you displayboth competence and character. Ourmanagement training program empha-sizes developing both these traits. Wetrain our managers to strive to become“servant leaders” who focus on helpingtheir team reach their goals and treatthem with respect, fairness, and compas-sion. We do not tolerate selfish managers

who push their teammates to makethemselves look good. Servant managersare trusted.

We start building trust with ouremployees by trusting employees fromthe moment we hire them. And theyappreciate that we do not believe in poly-graphs, drug tests, or secret shoppers. Ifyou do not demonstrate trust with youremployees, how can you expect them totrust you?

We invest an unusually large amountin training our employees. We fly all our3,000-plus store managers to Californiafor annual training meetings, and non-management employees are trained inour stores throughout the year. Ouremployees recognize that we believe inthem and trust them enough to makethat investment.

Also, we promote from within whenever we can, instead of lookingoutside the company when opportunitiesarise. Employees appreciate that theirgrowth does not go unnoticed and thatthe company is loyal to them.

There are tangible results from trustwithin our organization. This includeslower turnover, fewer lawsuits andWorkers’ Compensation claims than normal, and our shrinkage is only about10%. [Editor’s note: Shrinkage is undesiredreduction in inventory caused by theft,spoilage, loss, and mishandling, all ofwhich must of course be passed on to

8


You Will Look Good Treating Others with Respect — I Guarantee It


George Zimmer is founderand CEO of Men’s Wearhouse.

customers in higher prices. Recent datafrom the state of California place averageshrinkage at 30%.]

It is also important that our customerstrust the company. We train our storemanagers to act as though the customeris always right—even when they arewrong. And our return policy—which isprinted on our receipts and very wellknown—really is: “I guarantee it.”

Because we trust our employees, itcreates a trust feedback loop where ouremployees go the extra mile for theircustomers. Here is an example. We sup-ply the tuxedos for one-quarter millionweddings and twice that number ofproms each year. These are specialevents in people’s lives. When a tuxrental mistake is made, our employeesextend themselves to correct it. We havehad employees personally deliver a tuxto the groom so close to the ceremonythat they made the wedding pictures andstayed for the wedding itself.

And our shareholders trust usbecause we focus on long-term profits.We do not chase short-term results.

Our vendors trust us because westrive to build loyal, long-lasting relation-ships with them. We do not squeezethem for the last nickel in negotiations,despite our leverage in the industry.

I am often asked what I think aboutbusiness ethics. In business, doing theright thing, the ethical thing, is not free,but it is not that expensive either. In fact, in the long run it is less costly thansurrendering to illusive little tricks.

Our ethics start with how we treatour employees. It is not a cost, it is an

investment, and one that can pay huge dividends. From the bottom-lineperspective, the positive human energyand collaboration that is created atMen’s Wearhouse offsets the possible lostprofit opportunity from being too harsh,too tough, or too focused on maximizingprofits down to the last dollar.

In today’s world, businesses must be defined and evaluated by more thanjust maximizing shareholder value. AndCEOs will not do it by themselves. It isalso up to shareholders and board ofdirectors to make this happen. And forme, dealing with tough decisions is compounded by my being the spokes-person for our company.

Business today is frequently attackedabout its lack of ethical business prac-tices. There are many buzzwords usednowadays when people talk about doingbusiness the right way. For example, youhear terms like: “socially responsiblebusiness,” my favorite “conscious capitalism,” and “the triple bottom line,”which includes business impact on theenvironment as well as profit-and-lossstatements and balance sheets.

These are all great, but let’s not forgeta simple rule that has guided humanrelations for thousands of years: “Dounto others as you would have others do unto you.”

In my business journey, as well asmy life, following the Golden Rule hasserved me well. Try it. You’re going tolike the way you feel. I guarantee it!■

9



In business, doing the

right thing, the ethical thing,

is not free, but it is not that

expensive either. In fact,

in the long run it is less

costly than surrendering

to illusive little tricks.

Ethics and ProfessionalismAward

The Ethics and Professionalism Awardrecognizes exceptional contributions byindividuals or organizations for effectivelypromoting ethics and professionalism indentistry through leadership, education,training, journalism, or research. It isthe highest honor given by the Collegein this area. The American College of Dentists recognizes the StudentProfessionalism & Ethics Associationas the recipient of the 2012 Ethics andProfessionalism Award.

In March 2007, a group of students atthe Herman Ostrow School of Dentistryof the University of Southern Californiamet with Dr. Alvin Rosenblum, Professorof Dental Ethics, to discuss how theycould become more proactive in promot-ing ethics at their school. What ensuedwas the first of several brainstormingsessions that led eventually to the creation of the Student Professionalismand Ethics Club (SPEC). The first SPECevent open to students, faculty, and staff was held in October of 2007, withan attendance of over 100.

Shortly thereafter, SPEC began workon a start-up kit, with the goal of aiding

other schools in establishing local SPECchapters. The group was recognizednationally and has received support fromthe American Student Dental Association(ASDA), the American College of Dentists,and the American Society for DentalEthics. ASDA passed a resolution encour-aging the establishment of organizationslike SPEC at every dental school.

A steering committee of ten dentalstudents from across the country—withthe guidance of faculty—met in May 2010 at the Herman Ostrow School ofDentistry to lay out the strategic plan forforming a new national organization.SPEC was renamed the StudentProfessionalism & Ethics Association inDentistry (SPEA).

With the support of the AmericanCollege of Dentists, SPEA embarked onexpanding its reach and invited studentrepresentatives from dental schoolsacross the nation to meet at the ACDAnnual Meeting. In October 2011, repre-sentatives from various dental schoolscollaborated and discussed the futurepath of the organization. The bylawswere ratified and SPEA became a newnational organization. Steps have beentaken to codify this new status. A secondnational meeting will occur October 18-19, 2012 in San Francisco.

Currently, more than half of U.S.dental schools have SPEA chapters.Many ACD Sections are helping thesefledgling chapters with financial andpersonnel support. SPEA is a national,student driven association that wasestablished to promote and support

students’ lifelong commitment to ethicalbehavior in order to benefit the patientsthey serve and to further the dental profession. The objectives of the associa-tion are: “Act as a support system forstudents in strengthening their personal and professional ethics valuesby providing a resource for ethics education and development, fostering anonpunitive, open-forum environmentfor ethics communication, and promot-ing awareness of ethics standards andrelated issues within dentistry and collaborating with leadership of the dental profession to effectively advocatefor our members.”

Accepting the award is Mr. Sean D.Gardner, Executive Chair of the StudentProfessionalism & Ethics Association.

The Ethics and ProfessionalismAward is made possible through the generosity of The Jerome B. MillerFamily Foundation, to which we areextremely grateful.

William John Gies AwardThe highest honor the College canbestow upon a Fellow is the WilliamJohn Gies Award. This award recognizesFellows who have made broad, excep-tional, and distinguished contributionsto the profession and society whileupholding a level of leadership and pro-fessionalism that exemplifies Fellowship.The impact and magnitude of such contributions must be extraordinary.

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2012 ACD Awards


The recipient of the 2012William John Gies Awardis Dr. Marcia A. Boyd. Dr.Boyd is widely recognizedfor her highly significant

contributions to organized dentistry,dental education, oral health care, andher community. Her record is repletewith a variety of outstanding accomplish-ments in a multitude of venues. Dr. Boydis held in the very highest regard by her peers. Her achievements and contri-butions include:• Recipient of four honorary degrees,

LHD, University of Detroit Mercy;DSc, McGill University; DSc,University of Montreal; and DSc,Dalhousie University

• Honorary Member, Canadian DentalAssociation (first woman)

• Honorary Member, American DentalAssociation (first Canadian woman)

• Distinguished Service Award,Canadian Dental Association (highest honor)

• Distinguished Service Award, Collegeof Dental Surgeons of BritishColumbia (first woman, highesthonor)

• Distinguished Service Award,American Dental EducationAssociation (first woman, highesthonor)

• First Canadian Regent, AmericanCollege of Dentists

• First woman Canadian President,American College of Dentists

• First woman Canadian President,American College of DentistsFoundation

• Dean, Faculty of Dentistry, University of British Columbia

• First woman President, Associationof Canadian Faculties of Dentistry

• Founding President, IADR/AADREducational Research Group

• Inaugural Award for LifetimeAchievement in Dental Education,ADEA Gies Foundation

• Founding Board Member, Pacific Oral Health Society (nonprofit dentalclinic for the disadvantaged)

• Co-chair, Best Ethical Practices TaskForce, British Columbia Task Force

• First Award for Teaching Excellence,University of British Columbia (dentistry)

• First woman Dental Board Member,National Institute of Nutrition,Canada

• First woman Assistant Dean,Associate Dean, Dean Pro Tem inCanada

• First woman to chair a site visit, chair an Undergraduate ReviewCommittee, and chair theDocumentation Committee,Canadian Dental AccreditationCommission

• First woman Clinical Examiner andChief Written Examiner, NationalDental Examining Board of Canada

• First woman recipient of the GiesAward, International Federation ofDental Education Associations

From Dr. Boyd’s acceptance remarks:President Blanton is a colleague whom Iadmire greatly for her many talents andher leadership skill. In addition, she is alady that I am proud to call my friend.

First let me congratulate the newFellows and welcome you to the AmericaCollege of Dentists. Well deserved! But letme also congratulate the “old” Fellows,as we all recall how very special this convention day is and was for each of us, and how we continue to live up to the expectations of our nominatorsand the Mission of the College. Well done everyone!

My thanks to everyone: To the nominators and supporters; the CollegeAwards Committee; my marvelouslyamazing, hard-working, and always sup-portive friend in the BC Section; indeedall Fellows of the college that I have hadthe pleasure to meet and get to knowover the years, and of course my family.

I am truly grateful for your trust andthe opportunities I have been given. Soin truth, I really share this honor witheach of you.

In closing, let me add that being the first woman to receive the William J. Gies Award is particularly special and I am so very humbled, honored, and proud to be able to say that I amnow—after all these year—truly “one of the Gies!”

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Honorary FellowshipHonorary Fellowship is a means tobestow Fellowship on deserving non-dentists. This status is awarded toindividuals who would otherwise becandidates for Fellowship by virtue ofdemonstrated leadership and achieve-ments in dentistry or the communityexcept that they are not dentists.Honorary Fellows have all the rights and privileges of Fellowship except they cannot vote or hold elected office.This year there are two recipients ofHonorary Fellowship.

Ms. Valerie J. Fridley isthe Executive Director ofthe Southern MarylandDental Society and in thiscapacity has directed its

day-to-day operations for nearly 30years. In that time she has become widely recognized for her leadership and accomplishments for the society and for her community. Ms. Fridley hasbeen invaluable in the furtherance ofdentistry in Maryland. Highlights of heraccomplishments and credentials include:• Registered Medical Radiological

Technologist, Paul HimmelfarbSchool of Radiologic Technology,Cafritz Memorial Hospital

• Executive Director, SouthernMaryland Dental Society (almost 30 years)

• Established the first component-based dental assisting school in thestate of Maryland; this program

served as the benchmark for allother components and the MarylandState Dental Association in develop-ing their dental assisting schools

• Helped to design and was instrumen-tal in setting the guidelines andpolicies for ethics hearing and peerreview within the SouthernMaryland Dental Society

• President, Association of ComponentSociety of Executives of the AmericanDental Association

• Member, Executive DirectorsAdvisory Council of the AmericanDental Association (EDAC)

• Started the first Maryland compo-nent-based training program for thedental assistants with on-site facilityin 1990; the SMDS EducationalFacility has trained over 7,500 dentalassistants in radiology expandedfunctions, general and orthodontics,infection control, basic dental chairside assisting, dental assisting(front desk), and understanding dental insurance and coding for the assistant

• Oversees the operations of the largestcomponent of the Maryland StateDental Association

• Treasurer and Vice President,Auxiliary of the Knights of Columbus

• Charitable interest work, Our Lady ofSorrows Catholic Church

• Concessions Stand Manager,Women’s Athletics, Elizabeth SetonHigh School

• Event Planner, Women’s BasketballBoosters, University of MarylandWomen’s Basketball Team

• Event Planner, Women’s LacrosseBoosters, Virginia PolytechnicInstitute and State University

Ms. Beth Truett hasserved as the ExecutiveDirector of Oral HealthAmerica since 2008. Inthis capacity she has

implemented numerous importantchanges that positively impact dentistryand oral health care. Ms. Truett hasserved in numerous high-level leader-ship positions and brings a wide rangeof experience to Oral Health America.Ms. Truett’s record of accomplishmentsis summarized below:• BS, Food and nutrition, Valparaiso

University• Master’s degree, divinity, McCormick

Seminary, Chicago • Master’s course work, Hospitality

management, Florida InternationalUniversity

• Certificate, Nonprofit management,Indiana University School ofPhilanthropy

• Executive Director, Oral HealthAmerica; developed strategic plans,in concert with the board, to re-envision and re-energize a 55-year-old organization; renewed andstrengthened relationships with den-tal organizations and corporations,establishing OHA as a preferred collaborative partner; envisioned afive-point strategy for improvingaccess—to education and care—forolder adults, through creation of theWisdom Tooth Project; establishedthe “Fall for Smiles” campaign, with cooperation from associations,government agencies, corporationsand like-minded nonprofits, toemphasize the importance of professional and personal dentalcare, coupled with healthy foods and tobacco avoidance

• Executive Director, Chicago Lights (anonprofit organization serving theneeds of 7,000 Chicagoans living inpoverty; established a new nonprofitorganization from a group of existing

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programs and doubled the organiza-tion’s revenue in five years; establisheda program for teens, giving themtraining in seeking and keeping ajob, with opportunities for four yearsof summer internships to provide ahead start in going to college orobtaining employment

• Senior Vice President, McGettiganPartners (a $35 million marketingservices company serving the phar-maceutical, financial, and technologysectors); re-branded company andhelped established a Global BusinessSolutions unit, assisting pharmaceu-tical companies to consolidate meetingand marketing expenses in theUnited States and Western Europe

• Senior Vice President, IVI (a $900million for-profit serving the traveland meeting needs of Fortune 500companies; purchased by WorldTravel Partners in 1993)

• Worked on team at Kraft Foods that created and implemented thecompany’s first multicultural advertising and PR campaign

• Inducted into Leadership America, an international organization recognizing women for career andvolunteer leadership

• Established a youth tennis programthat grew from serving nine to one hundred low-income Chicagochildren

• Mentors young women through theAssociation of FundraisingProfessionals

• Created a national tour program forthe Frank Lloyd Wright PreservationTrust to educate people about thework of America’s most famousarchitect

• Member, Board of Directors forVoices for Illinois Children

• Member, ADA’s Give Kids a SmileNational Advisory Council

• Trustee, Fourth Presbyterian Churchof Chicago

Outstanding Service AwardThe Outstanding Service Award recognizes Fellows for specific effortsthat embody the service ideal, emphasizecompassion, beneficence, and unselfishbehavior, and have significant impact on the profession, the community, or humanity.

The recipient of theOutstanding ServiceAward is Dr. Allan J.Formicola. Dr. Formicolahas served dentistry in

numerous high-level capacities for manyyears. He served for many years as thedean, College of Dental Medicine,Columbia University. His impact on den-tistry, his community, and mankind arenoteworthy. Dr. Formicola has epito-mized service through numerousmeaningful activities and programs,local, national, and international. Hisrecord of accomplishments and serviceis summarized as follows:• BS, Zoology, Michigan State

University• DDS and MS in Periodontics,

Georgetown University, School ofDentistry

• Lieutenant, Dental Corps, U.S. NavalReserve

• Assistant Professor, GeorgetownUniversity, School of Dentistry

• Private practice, Silver Spring,Maryland

• Assistant Professor, University ofAlabama, School of Dentistry andDental Research Institute

• Chair, Department of Periodontics,University of Medicine and Dentistryof New Jersey

• Associate Dean for Academic Affairs,University of Medicine and Dentistryof New Jersey

• Acting Dean, University of Medicineand Dentistry of New Jersey

• Dean (23 years), College of DentalMedicine, Columbia University; established the Center for CommunityHealth Partnerships, the latter merging with the Center for FamilyMedicine; now Dean Emeritus andProfessor Emeritus

• Established the CommunityDentCare Network in NorthernManhattan; provides oral health careto low-income residents of Harlemand Washington Heights; care is provided in eight public schools, amobile van and in neighborhoodclinics; developed the Thelma Adair Medical and Dental Center incentral Harlem

• Established the Northern ManhattanCommunity Voices Collaborative: Acollaboration of the dental, medicaland public health schools; educated1,000 community health workers

• Co-directed the Pipeline, Profession& Practice: Community-Based DentalEducation Program, the largest foun-dation demonstration grant everprovided to dentistry, which funded23 dental schools to add culturalcompetence training and servicelearning in community based sites;also funded dental schools to improverecruitment and enrollment ofunderrepresented minority students

• Co-directed the Macy Study: NewModels of Dental Education, whichmade recommendations on financingof dental education and the mannerin which school dental clinics areoperated

• Vice Chair, Commission on DentalEducation

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• Member, Joint Commission onNational Dental Examinations

• Chair, Publication ReviewCommittee, American Academy ofPeriodontics

• President, William Gies Foundationfor the Advancement of Dentistry

• President, American Association ofDental Schools (now ADEA)

• Published 75 journal articles, twobooks, and several chapters and special reports

• Doctor of Humane Letters, HonorisCausa, University of Detroit Mercy

• Distinguished Alumni Award,Georgetown University

• Harlem Hospital Second CenturyAward

• Distinguished Service Award,American Dental EducationAssociation

• Presidential Citation, AmericanDental Association

Section Achievement AwardThe Section Achievement Award recognizes ACD Sections for effectiveprojects and activities in areas such asprofessional education, public education,or community service.

The 2012 recipient of the SectionAchievement Award is the NorthernCalifornia Section. The NorthernCalifornia Section is recognized fordeveloping and implementing its program entitled, “Professionalism—Your Responsibility to Your Patients,Your Community, and Your Profession.”The program introduced the concept ofprofessionalism to senior dental studentsat the six California dental schools.

Section Newsletter AwardEffective communication is a prerequi-site for a healthy Section. The SectionNewsletter Award is presented to an ACDSection in recognition of outstandingachievement in the publication of aSection newsletter. The award is based

on overall quality, design, content, andtechnical excellence of the newsletter.The Mississippi Section is the winner ofthe Section Newsletter Award for 2012.

Model Section DesignationThe purpose of the Model Section program is to encourage Sectionimprovement by recognizing Sectionsthat meet minimum standards of per-formance in four areas: Membership,Section Projects, ACD FoundationSupport, and Commitment andCommunication. This year theMississippi Section, New York Section,Northern California Section, QuebecSection, and Tennessee Section earnedthe Model Section designation.

Lifetime Achievement AwardThe Lifetime Achievement Award is presented to Fellows who have been amember of the College for 50 years. This recognition is supported by the Dr. Samuel D. Harris Fund of the ACDFoundation this year’s recipient’s are:

Hector BethartPaul W. EvansWilliam L. Glenn, Jr.Jess Hayden, Jr.Walter N. JohnsonCharles A. McCallumFrederick PflughoeftEdwin W. RobertsDaniel J. RossiWilliam E. SchieferJohn P. ScullinJames H. Sherard, Jr.Charles G. SleichterJames H. SommersRay E. Stevens, Jr.Lawrence A. Weinberg

14



Congratulations to all 2012 ACD Award winners!

The Fellows of the AmericanCollege of Dentists representthe creative force of todayand the promise of tomorrow.They are leaders in boththeir profession and theircommunities. Welcome tothe 2012 Class of Fellows.

Stephen H. Abrams Scarborough, ON

Syed Tamijul Ahsan RatanDhaka, Bangladesh

Charles E. Albee Suncook, NH

Jacqueline S. Allen Phoenix, AZ

Jorge A. Alvarez Van Nuys, CA

Arthur N. Anderson IIINashville, TN

K. David Anderson Tuscaloosa, AL

Sebastiano Andreana Buffalo, NY

Lisa R. Antonoff New York, NY

Kolman P. Apt Herndon, VA

Patricia E. Arola Washington, DC

Yakir A. Arteaga New York, NY

Michael G. Arvystas New York, NY

David C. Ash Canton, OH

Michelle B. Asselin Fresno, CA

George H. Bailey Dixon, MO

Terry L. Barnfield Salem, IL

Ingrid V. Beard-Howell APO, AE

William D. Beck Flint, MI

Avram S. Berger Torrington, CT

Daniel C. Berman Chicago, IL

Morris E. Bernstein Eads, TN

Marc J. Beshar New York, NY

Janine J. Bethea Marietta, GA

John L. Blake Long Beach, CA

John E. Boland Corte Madera, CA

Scotty L. Bolding Springdale, AR

James S. Bone Kerrville, TX

Jennifer J. Bone Kerrville, TX

Nicholas J. Bournias Grosse Point Shores, MI

Grace Bradley Toronto, ON

Daniel M. Briskie Grand Blanc, MI

Joel F. Brodsky Lakewood, CA

Mark J. Bronsky New York, NY

Andrew B. Brown Orange Park, FL

Carolyn W. Brown Columbia, SC

Kevin P. Bryant Chattnooga, TN

William D. Brymer Vancouver, BC

Fred L. Bunch Stockton, CA

Jay A. Burleson Jonesborough, TN

Mark A. Byron Parkersburg, WV

Eduardo Calderon Santiago, Chile

Richard S. Callan Evans, GA

Jean J. Carlson Cambridge, MD

William B. Carroll Draper, UT

Rupali Chadha New Delhi, India

Bonnie Chandler Toronto, ON

Eros S. Chaves Morgantown, WV

Chris Chondrogiannis New York, NY

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2012 Fellowship Class


James L. Chrisman Tupelo, MS

Alma J. Clark Martinez, CA

George H. Clayton Brentwood, TN

David L. Clemens Wisconsin Dells, WI

Michael Cohen Medina, WA

Robert D. Coles Surrey, BC

Gregory J. Conte San Francisco, CA

Noble P. Cooper, Jr.Columbia, SC

David S. Cornell Mississauga, ON

Jennifer J. Cornell Clarksville, TN

Gary L. Crawford Provo, UT

Jean L. Creasey Nevada City, CA

William G. Crews Huntington, WV

Theodore P. Croll Doylestown, PA

Kenneth O. Crosby Fresno, CA

Yasmi O. Crystal Bound Brook, NJ

Frank T. Dalton Corinth, MS

Michael D. Danner Pekin, IL

Christopher C. Delecki Seattle, WA

Aron E. Dellinger Leo, IN

Eric L. Dellinger Fort Wayne, IN

Neal A. Demby Brooklyn, NY

Mark S. Denny Richardson, TX

Harinder Dhanju Surrey, BC

Michael A. Dill Scotch Plains, NJ

Michael Diorio Denver, CO

Michael E. Dix Overland Park, KS

John C. Dixon Charleston, WV

Louis Drouin Pointe-Claire, QC

Walter R. Easter Pleasanton, CA

Greggory N. Elefterin Canton, OH

Andrea P.Z. Esteves Vancouver, BC

Glen J. Fallo APO, AE

Nava Fathi Gilroy, CA

David A. Felton Morgantown, WV

Elie M. Ferneini Waterbury, CT

Howard A. Fetner Jacksonville, FL

Charles M. Fischer Mission Viejo, CA

Peter C. Fritz Fonthill, ON

Staci N. Gaffos Columbia, SC

Christopher W. Gall Griffith, IN

Isabel Garcia Bethesda, MD

Raul I. Garcia Wellesley Hills, MA

Jerome M. Gibson San Antonio, TX

Martin R. Gillis Liverpool, NS

James D. Gossett New Braunfels, TX

Edward T. Graham Stockton, CA

Peter M. Greco Bryn Mawr, PA

John L. Greenwood Fremont, CA

Scott I. Gritz North Potomac, MD

Thomas A. Gromling Stephens City, VA

Jane Grover Jackson, MI

Steven P. Hackmyer San Antonio, TX

Hal E. Hale Wichita, KS

Kevin J. Hale Grand Blanc, MI

Pamela R. Hanson Waukesha, WI

Felicity K. Hardwick Nanaimo, BC

Lisa A. Harpenau San Francisco, CA

James E. Haubenreich Lexington, KY

Jianing He Plano, TX

Gregory P. Heintschel Petoskey, MI

Gary M. Heir Bayonne, NJ

Donna Hellwinkel Reno, NV

Kathryn G. Henry Tulsa, OK

Robert J. Herman Tulsa, OK

Craig W. Herre Leawood, KS

Kenneth C. Ho La Canada, CA

Annie C. Hornett St. Anthony, NF

Peter J. Hornett St. Anthony, NF

Lee A. Hovious Knoxville, TN

Philip M. Howard Hamilton, OH

George J. Hucal Springfield, VA

Robert T. Huff Calgary, AB

Ryan J. Hughes Lake Oswego, OR

Jeffrey P. Huston Lodi, CA

Susan Hyde San Francisco, CA

Terence A. Imbery Yorktown, VA

Thomas G. Ison Louisville, KY

Leticia G. Jeffords San Antonio, TX

Harold S. Jeter South Point, OH

Jason L. Jeter Visalia, CA

Vanchit John Indianapolis, IN

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Mark Johnston Lansing, MI

Gregory B. Jones Hermiston, OR

Randolph P. Jones Oklahoma City, OK

Richard C. Jordan San Francisco, CA

Nadim J. Jubran Maryville, TN

Leslie Karns Draper, UT

Thomas W. Kauffman Marietta, GA

Paul Kavanagh Laval, QC

William J. Kemp, Jr.Amarillo, TX

Jin Y. Kim Diamond Bar, CA

Kenneth A. King South Jordan, UT

Michael W. King Jackson, TN

David W. Klein Bloomington, MN

Chase F. Klinesteker Grand Rapids, MI

Prabha Krishnan Forest Hills, NY

William N. Langstaff Villa Park, CA

Dave C. Lee Fayetteville, GA

Luis P. Leite Charleston, SC

Thomas E. Lenhart Clayton, CA

Lynn M. Lepak-McSorley New Berlin, WI

Rory S. Levitan Crown Point, IN

Robert H. Levy Dallas, TX

Elizabeth T. Lewis Canton, GA

Kurt S. Lindemann Kalispell, MT

Dale R. Linton Bountiful, UT

Marshall S. Lipscomb Denton, TX

Todd C. Liston Layton, UT

Renee F. Litvak New York, NY

Angela M. Lueck Milwaukee, WI

Steven O. Lusk Tulsa, OK

David P. Lustbader Quincy, MA

Harry R. Mack, Jr.Nashville, TN

Derek R. Mahony Surrey, United Kingdom

Ronald M. Mancini Bethesda, MD

Maria C. Maranga Aquebogue, NY

Richard Marcus Scarborough, ON

David O. Marks Tulsa, OK

Cynthia J. Marshall-Petroff Norton, OH

James E. Martin IIIPensacola, FL

Rand T. Mattson Roy, UT

Lee S. Mayer Louisville, KY

Theresa G. Mayfield Louisville, KY

Chester V. Mayo Virginia Beach, VA

Delwin K. McCarthy Cerritos, CA

Dan T. Meadows Memphis, TN

Joseph B. Michael Norfolk, VA

Andrew S. Middleton Hattiesburg, MS

Travis T. Miller Orange, TX

Stanley A. Montee Clarksville, TN

Lawrence P. Montgomery IIIChalfont, PA

Arthur C. Morchat Gladewater, TX

Maritza Morell Lawrence, MA

Steven S. Moss New York, NY

Barbara A. Moyer Littleton, CO

David J. Moyer South Portland, ME

Steven R. Nelson Denver, CO

Mark M. Norris Vancouver, BC

Terry L. Norris Owensboro, KY

W. Benjamin Norris Jasper, FL

Reza Nouri Vancouver, BC

Gayle Obermayr Sebring, FL

Craig L. Oldham Brandon, FL

Barney T. Olsen Sandy, UT

R. Pierce Osborne IIFayetteville, AR

Larry M. Over Eugene, OR

Ernest N. Oyler, Jr.Cleveland, TN

Rosaura Pacheco Fresno, CA

William B. Parker Fort Lauderdale, FL

David C. Parsons Queensbury, NY

Gregory S. Peacock Merritt, MI

Stephen J. Peirce Bradenton, FL

W. Thomas Pelton Yuba City, CA

Donald J. Peretti Billings, MT

Kenneth S. Peters Highlands Ranch, CO

Joyous C. Pickstock Nassau, Bahamas

Sherry C. Pippen Monticello, MS

Constantine L. Politis Oak Park, IL

Robert S. Portenga Traverse City, MI

James L. Posluns Toronto, ON

Peter H. Pruden Huntington, NY

Robert P. Pulliam Nashville, TN

Wayne C. Radwanski Austin, TX

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Curtis D. Raff San Francisco, CA

George F. Richards South Jordan, UT

Robert D. Richards Houghton, MI

Paul L. Richardson Loma Linda, CA

Elizabeth Roberts Randolph, NJ

John F. Robison State College, PA

Tyrone F. Rodriguez Moses Lake, WA

Patrick L. Roetzer Benicia, CA

Richard J. Rosato Concord, NH

Toni M. Roucka Burlington, WI

Joseph L. Rumfola East Concord, NY

Debra M. Ryken El Cajon, CA

Benjamin Saleh Town of Mount Royal, QC

Javid J. Salehieh Cupertino, CA

Sergio Sanchez Las Condes Santiago, Chile

Gerald B. Savory Boulder, CO

Philip L. Schefke Willow Springs, IL

P. Michael Schelkun Warminster, PA

Peter Schelkun Milwaukee, WI

Jeane L. Schoemaker Ft. Morgan, CO

Todd R. Schoenbaum Los Angeles, CA

Brian K. Schroder San Antonio, TX

Gail E. Schupak New York, NY

Bruce A. Scott Walnut Creek, CA

Tracy A. Scott Escondido, CA

Phillip F. Sehnert Lewisville, TX

Diane W. Sherman Encinitas, CA

David M. Shipper New York, NY

Brian Shue El Centro, CA

Irvin B. Silverstein La Mesa, CA

Richard A. Simpson Tuscaloosa, AL

John L. Sinclair, Jr.Kalamazoo, MI

Medha Singh Newton, MA

William H. Smartt Knoxville, TN

Allen D. Smith London, ON

Gerald M. Smith Thunder Bay, ON

James A. Smith Portland, OR

Kevin S. Smith Oklahoma City, OK

Linda L. Smith San Antonio, TX

Jordan L. Soll Toronto, ON

Heiko Spallek Pittsburgh, PA

Stephen J. Spencer Great Falls, MT

Howard Steiman Ajax, ON

William L. Steinman Montreal, QC

John D. Sterrett Maryville, TN

Gregg A. Stewart Winter Garden, FL

Steven J. Stoll Neenah, WI

Kurt D. Stormberg La Mesa, CA

Robert P. Stowe Winston-Salem, NC

Richard D. Talbot Citrus Heights, CA

Timothy S. Taylor Trimble, MO

Robert H. Thalgott Las Vegas, NV

Joe J. Thomas Vero Beach, FL

Stephen P. Tigani Washington, DC

Julia H. Townsend Los Gatos, CA

Richard W. Van Gurp Charlotte, NC

Stacey K. Van Scoyoc Bloomington, IL

Kent L. Vandehaar Chippewa Falls, WI

Alexa Vitek DeWitt, MI

John E. Volz Rochester, MN

Danny D. Watts Austin, TX

Thomas S. Weil Austin, TX

Arnold E. Weingarten Toronto, ON

Rebecca C. Weinman Atlanta, GA

Bradley A. Weiss Evanston, IL

Vernon R. Willcox Edmond, OK

Laura Williams East Wenatchee, WA

Richard L. Williams San Antonio, TX

Edwin L. Wilson, Jr.Norman, OK

J. Douglas Wilson Conifer, CO

Kevin Drew Wilson Amherst, NH

Robert J. Wilson, Jr.Gaithersburg, MD

Michael D. Wise Herts, England

Andrew M. Wojtkowski Clemmons, NC

Lawrence E. Wolinsky Dallas, TX

Mark E. Wong Houston, TX

Debra A. Woo Boulder Creek, CA

David C. Woodburn Amarillo, TX

Carol A. Wooden Smyrna, GA

Arthur Worth St. Thamesville, ON

Jack S. Yorty Morgantown, WV

Brenda J. Young Fairfax, VA

Douglas A. Young San Francisco, CA

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Officers and Regents of the AmericanCollege of DentistsPrepared by David W. Chambers

AbstractDigital communication offers advantagesand challenges to dental practice. As dentistry becomes comfortable with thistechnology, it is essential that commercialand other values not be accepted on a par with professional ones and that thetraditional dentist-patient relationship notbe compromised by inserting third partiesthat introduce nonprofessional standards.The Officers and Regents of the AmericanCollege of Dentist have prepared this background and position paper as a guideto the ethical use of digital communicationin dental practice.

There are eight principles:1. The professional relationship betweendentist and patient should not be compro-mised by the use of digital communication.2. Digital communication should not permitthird parties to influence the dentist-patient relationship.3. Dentists should exercise prudence toensure that messages are professional and cannot be used in unprofessional ways by others.4. Personal data should be protected andprofessional communication should be separated from personal communication.5. Dentists should be generally familiarwith the potential of digital communication,applicable laws, and the types of informa-tion patients have access to on the Web.6. Practitioners should maintain an appro-priate distinction between communicationthat constitutes the practice of dentistryand other practice-related communication.7. Responses to criticism on digital mediashould be managed in a professional manner.8. Dentists should be prepared to makemore accommodations to patients thanpatients do to dentists in resolving misunderstandings about treatment.

Electronic media have createdentirely new ways for people tocommunicate. New media have

altered what we discuss. They also havethe capacity to build new relationshipsand change existing ones, and they leavea footprint. Finally, they are evolving at arate that is currently faster than mostusers can keep up with, faster than society can absorb and respond to, andin ways that are not easily predicted.

Digital communication media areexploding. While household budgets forclothing and other items are shrinking,the digital budget is increasing rapidly.In terms of convenience and content,tablets outperform movie theaters.Handheld devices have more computingpower than computers that filled roomsa few decades ago. There are apps forselecting apps. Few can name all thesocial media programs that exist, andthe list will change next month. The big-box stores that threatened to dominateAmerican commerce a decade ago arebeing shouldered aside by online shop-ping. Students can “fact-check” theirprofessors while the lecture is in progress.

Some dentists are digital communi-cation mavens, both personally andprofessionally. Others are reluctant. Stillothers contract for media services. Themajority are perhaps fragmentary users.Regardless of dentists’ attitudes and talentswith digital media, their practices areaffected by patients who are skilled inplacing a digital interface between them-selves and professionals.

Commercial firms have also insertedthemselves into the dentist-patient relationship. They have not asked nor do they need permission to do so.

Integrity of Dental ValuesUncompromised by Digital MediaIn October 2011, the Board of Regents ofthe American College of Dentists createda task force to explore the impact of digital communication on dentistry,with a view toward preparing a positionpaper on the subject. The resulting position paper was approved by theboard in October 2012.

The intent of this position paper is to inform dentists of some of the effectsof digital communication on dental practices. Dentistry is based on a set of professional values that guide practi-tioners toward improving oral healthconsistent with the dignity of the patient.These values are expressed in the objectives and codes of the AmericanCollege of Dentists and the codes ofother professional organizations. Digitalcommunication is also embedded in its own value structure. These values are more diffuse and not necessarilyconsistent with professional values. The overarching theme of this positionpaper is that dentists should live theirprofessional values uncompromised,regardless of their involvement in digitalcommunication. Further, it is incumbenton dentists to be familiar with digital

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Position Paper on Digital Communication in Dentistry

White Paper

communication and its potential impacton dentistry, regardless of the extent towhich they use these media.

A Classification of DigitalCommunicationThe term “digital communication” isintentionally general: it is used to indicatea broad class of technology and uses,including cellphones, Google searches,turnkey electronic dental records, cus-tomized Web sites, e-mail, YouTube, sitesthat gather and disseminate informationabout dentists, Facebook and its manycousins, health-related apps, tablets forpatients to enter health histories, andmany others. To the extent that tradi-tional forms of communication such asthe Yellow Pages, newsletters, and phonecalls share the functional characteristicsof digital communication their use is incorporated into this position paper.

The physical characteristics and business names of digital communicationdevices is diverse and rapidly changing.The best way to understand this field is interms of functional features. Despite theirrange of manifestations, digital commu-nication shares these characteristics:• Rapid, almost instantaneous

dissemination of content• Extremely low cost for multiple

distribution• Longevity of content, will not go

away• Potential for anonymity and aliases• Inexpensive and rapid creation,

editing, and updating• Privileging of short messages• Privileging of visual content• Partial regulation• Increased difficulties maintaining

security• Conflicted understanding of privacy• Large participation but fragmented

across platforms

• Senders and receivers need not sharetime and place

• Easy and almost costless duplicationand forwarding

• Potential for misrepresentation andunintended use by others

• Potential for sharing content out of context

The intended use of digital com-munication is an accepted means ofclassification. There are three broad categories: (a) broadcast, (b) relation-ship, and (c) transaction.

Broadcast. The broadcast functionof digital communication is a one-to-many dissemination of a fixed message.The typical Web page or blog is just afancy, inexpensive Yellow Pages ad, billboard, catalogue, or other generalmessage. Some dentists are producers of broadcast digital communication; allare consumers. Wikipedia, online dentaljournals, information about dental prod-ucts, and room availability for conventionsare examples of sites to which dentistsrefer for packaged general messages.Organizations of all types, from a localrestaurant to the American DentalAssociation, create an image of them-selves and reveal selected information totargeted audiences. By extension, theseimages also affect the public’s percep-tions of the dental profession generally.

Commonly, broadcast digital mediaare intended to distribute uncustomizedinformation. Information is selected bythe producer, not the consumer; it is notindividualized, but instead tailored to ahypothetical “modal customer”; it isintended to put the best face forward;usually it has high visual contentbecause attention span will be short.Sometimes called “Web 1.0,” broadcast-function digital communication isone-directional. The trend is for suchsites to invite transfer to other two-waycommunication media (the second function), such as a phone number orTwitter feeds or to sections that handlebusiness transactions (the third function).

Broadcast function sites often discourageinteractive communication and mayspecifically state that no reply will beresponded to. Success of Web 1.0 systemsis measured in “hits” or “eyes.”

Relationship. Web 2.0 is the commondesignation for a second function of digital communication designed to buildrelationships through exchanges of messages. Those who are struck by thebanality of Facebook postings havemissed the point. The message is subor-dinate to the relationship. Twitter limitsthe number of characters in a messageto 140, forcing canned abbreviations.The small screens on handheld devicesdiscourage depth of communication ormanagement of complex issues.

Social media can be used to veryquickly spread tiny bits of informationthrough a network, but the work of net-work building must have taken placepreviously. Relationship-building digitalmedia define status. Celebrities losemuch of their legal protection fromdefamation because they are “public” figures and the number of their contactsis media content. Social media representa challenge to established power becauseit is not based on established position ordepth and accuracy of information, noris it vertically structured. Every user ofsocial media is at the center of his or herWeb, and importance is a function of thenumber and richness of the cascadingrelationships. Cellphones and text messaging can be grouped under thisheading. Web 2.0 measures success interms of followers, members, subscribers,and the like.

Transaction. Digital media are rap-idly beginning to manage transactions,and this is the third function. Dentistsand their office staff can purchase supplies, register for meetings, pay pro-fessional dues, participate in surveys,and contract with Web designers usingelectronic media. Patients can locate

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dentists, make appointments, pay bills,and fill prescriptions on the computer.Within the office, functions such asobtaining informed consent, patient education, and graphically assisted treatment presentations are becomingelectronic. The situation has come furtherin medicine, where patient questions toproviders are taken on the computer,chronic conditions are managed byteams of mid-level providers reachingout to patients before symptoms appear,and consultations among professionalsand even diagnoses are mediated elec-tronically and in the complete absence of a physical patient. The impact of thetransaction function of digital media ismeasured in traditional business termsof time saved, accuracy, number of transactions, and profit.

The reason for offering this brief categorization of the three functions ofdigital communication is to demonstrateits reach, to show that dentists mayoccupy various roles in the network, todraw attention away from the gadgetsand the apps and focus it instead on theeffects that can be expected from variouspatterns of use of digital media. It is the effects of electronic communicationthat count. Dentists will participate indigital communication in many ways,and success will be defined differentlyacross practices. It is the fit between the practice and the media that matters, not just getting the currently most fashionable equipment.

Principles for Professional Use of Digital CommunicationEight principles are presented to guidethe use of digital communication as aneffective extension of dental practice.Where the relationship between newmedia and dentistry is synergistic, wehave noted ways dentists can enhanceoral health care by taking advantage ofnew ways to communicate. Where thereare conflicts, these are pointed out,including possible adverse effects and

appropriate precautions. The term“should” and cognate phrases are usedin their ethical sense, calling dentists tohigher ideals. Although there are legaland regulatory considerations in the use of digital media, such as HealthInsurance Portability and AccountabilityAct (HIPAA), the positions presentedhere are aspirational rather thanrequirements.

1. The professional relationshipbetween dentist and patient should notbe compromised by the use of digitalcommunication.

The relationship between dentistsand patient is special and essential toappropriate care. Although the termdentist-patient relationship will be usedfor convenience, this should be under-stood in the broadest sense of includingthe entire dental office team, the dentalprofession generally, and individualswho are not patients of record but are inneed of oral health care. This relation-ship is based on trust. It is impossible forpatients to know all the necessary detailsof their current oral condition, its likelycourse, alternative interventions, or eventhe competency of particular dentists toprovide the best care. Similarly, dentistshave to trust patients to provide accuratehealth status information, followthrough on their part of care, and payfor services. Further, dentists have awide range of individual strengths andskills, and patients represent individualcombinations of medical, dental, andpersonal needs and values.

Dentistry is a relationship that isintensely customized and based on trust.It cannot be turned into a commoditywithout compromising it. A commodityis something of value that has been standardized and stripped of its uniquefeatures to the point where each unit isinterchangeable and the only way to add value is to compete on price.

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The professional relationship

between dentist and

patient should not be

compromised by the use of

digital communication.

A traditional idea in dentistry, and one that the American College ofDentists believes should remain centralto its identity, is the five Cs of compre-hensive, continuous, competent,compassionate, and coordinated care.Appropriate care addresses all of thepatient’s oral health needs, not just onesthat the patient picks out because ofuninformed interest or the dentist identifies because of personal preferenceor potential for other returns. It is alsocontinuous, both over the number ofappointments needed to achieve stabilityand via recall. Competency for the leveland type of practice is assumed by thepatient and should be guaranteed by theprofession. The phrase compassionatecare is redundant, but it reminds us that“care” is not synonymous with “treat-ment.” Finally, the capacity of one officeshould never place a limit on the poten-tial for the health of any patient. Whereappropriate, care should be enhanced byreferral to a specialist while the generalpractitioner retains overall managementresponsibility, cooperation with insur-ance and other financial resources, andattention to total health by coordinationwith all health professionals.

This general ideal can serve as astandard against which to evaluate theuse of digital communication.

New patients can be recruited byelectronic means. It is certain that individuals use their computers andhand-held devices to make contacts andform first-impressions of potential prac-tices. In this sense, the ethical issue iswhat image the practice provides for thegeneral public in its broadcast of one-to-many messages. Information aboutpractice type, including limitation ofservices based on advanced training orlimited practice type, office location,hours, languages spoken, and even practice philosophy (family-oriented,

comprehensive, community-based) areall appropriate. Insurance acceptance,credit availability, and other featureshaving to do with payment are morenuanced. It is assumed today that standard financial arrangements will beavailable in all businesses, so dentistrymay be well served to avoid any referencethat might be construed as suggestingthat oral health care is a commodity.Perhaps the most informative statementalong these lines would be that insuranceplans are not accepted.

Because search behavior of electronicmedia is dominated by superficial andquick searches for “hits,” a position nearthe top of a search algorithm and a qual-ity visual image are critical. One gets tothe top of a page by paying for it, by hav-ing been successful in previous searches,and by using key phrases that match the terms potential users will use inbeginning their searches. A patient whois interested in “sleep dentistry” is notseeking a definition of sleep dentistry(they have already searched the Web ingeneral if they have any appreciablelevel of curiosity). They want to see theterm on the office Web page, surroundedby other symbols they associate withquality care. In general, Web 1.0 usersare not interested in reading a Web pagebut they can, in a fraction of a second,form an impression of the office fromthe overall appearance of the page.

The ethical issue associated withbroadcast digital media is the difficultyof establishing personal relationshipswith patients. Because it is difficult tohonestly express factors associated withthe quality of care indicated by Web 1.0format, there is a temptation to empha-size other characteristics. The proportionof Americans visiting the dentist has notincreased noticeably in the past decade(it may have actually decreased slightly),but the number of patients changingdentists has grown. It is likely thatbroadcast digital communication haspromoted “churning”: patients moving22


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Dentistry is a relationshipthat is intensely customized and based on trust. It cannot beturned into a commoditywithout compromising it.

from one dentist to another. This represents a threat to the value of continuity of care.

It should also be borne in mind thatthe use of broadcast digital communica-tion is one-way and there is a certaingenerality about where the message iscoming from. That means there is noopportunity in the communication itselffor correcting misconceptions. What ismore troublesome about the communi-cation channel itself is that the messagecan be and usually is interpreted as coming from “dentistry.” The attractiveexpected outcome is what “dentistry”has to offer, and the one that mostattracts the would-be patient’s attentionis just the best of what dentistry has tooffer. All digital communication betweendentists and the public speaks for theprofession as a whole. The potential forbroadcast digital messages regardingdentistry to reach the multitudes under-scores both the legitimacy and theimportance of the profession as a whole,taking an interest in what individualdentists are saying to the public aboutoral health.

A second characteristic of broadcastdigital communication, one that is not as large a concern for relationshipbuilding and transactions, is anonymityand image manipulation. Traditionally,individuals sought out professionalsbased on their reputations amongacquaintances. This was followed by aface-to-face meeting and the beginning ofcare that, if all progressed satisfactorily,grew into a relationship. Positive relation-ships feed positive reputations. Thedentist-patient relationship was personal,customized, and based on the outcomesof care. Digital communication has thepotential for short-circuiting this cycleand distorting the dentist-patient rela-tionship. When dentists seek patientsbased on a promised image of care, the

relationship collapses into one involvingproviders and customers. Dentists compete on criteria that can be stan-dardized, such as appearance and price.Customers shop. What has happened inthese cases is that expectations based on anonymous and mass-produced (ormarketing-manufactured) images hasbeen substituted for personal dental care.All five Cs are put at risk: comprehensive,continuous, competent, compassionate,and coordinated care are left off to theextent that they cannot be quicklydepicted on a computer screen. It is alimp answer to say that digital commu-nication allows us to better give thecustomer what he or she wants. This is a substitution of commercial for profes-sional values. If such customers wantedveneers on periodontally involved teeth,no professional should accede.

A large positive potential exists for digital communication to build relation-ships between existing patients and thepractice. This is the function that wasmanaged traditionally by the officenewsletter. Patients begin to identifywith the practice when they see theircomments or images on the office Website. They will check to see whether theirFacebook postings have been respondedto. The practice is building a communityby hosting a site. The important valuespromoted by an effective office Web siteinclude all but one of the five Cs: com-prehensive, continuous, compassionate,and coordinated care. These four are fertile fields for effective use of socialmedia. Competence of the dentist andstaff is the one value that cannot beenhanced through the use of electroniccommunication. Claims of competence,even indirect ones such as announcingthat the dentist has been selected forsome form of distinction, are inappro-priate and unnecessary in electroniccommunication designed to build rela-tionships between the office and thepatient. Use of the initials FACD in elec-tronic communication with patients is

contrary to the Code of Conduct of the College precisely because it can bemisinterpreted as a claim of competence.

Electronic transactions are justbeginning to become a part of dentalpractice. To the extent that they ease anyperceived barriers to care they offergreat potential. The largest issue withrespect to digital support for transactionsin the dental office is that most suchapplications are purchased from outsidevendors. Care should be taken to ensurethat the services match both the needsof the office and the characteristics ofthe range of patients served. Additionalcare is required to make certain thatpatient privacy, confidentiality, and secu-rity are honored. It is also appropriate toinquire of vendors with respect to thefull-value proposition or business model.It can happen that the fee paid to vendorsis only a small part of the benefit theyderive from an arrangement. Access toinformation about patients can often be of great value to vendors, as can connection with the dentist’s businessrelationships, reputation, and even control over access to patients.

2. Digital communication should notpermit third parties to influence the dentist-patient relationship.

Some dentists are quite adept atdeveloping and using digital communi-cation as an extension of their practices.Most copy general trends in the profes-sion and must rely on commercialvendors and consultants. This situationis much like the relationships that existbetween dentists and equipment manu-facturers, brokers, insurance companies,and advisers, including practice manage-ment consultants. The role of thirdparties in dentistry is to assist the dentistin providing more and better dental care

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than would be possible otherwise.As dentists seek assistance in

designing and implementing digitalcommunication systems in their practices they should be aware of thepotential for introducing the virus ofcommercialism that sometimes accom-panies these applications. There is novalue in equipment sales or softwaredevelopment that corresponds to theoral health promotion value or dentistryor the professional value of promotingthe patient’s long-term interests. Advice,services, and equipment are sold to dentistry as commercial transactions,and the standards governing these salesdo not extend to cover the same range ofvalues that prevail in dentistry. It is thedentist’s responsibility to ensure thatdecisions about digital communicationplace commercial interests in a positionsubordinate to oral health.

Dentists are open to introducingthird-party influences in all three typesof digital communication: broadcast,relationship, and transactions.

Web designs, communication prac-tices, building of electronic communities,and computerized interfaces with customers that are most effective in commercial applications are not auto-matically the best ones for a dentalpractice. The operative question is notwhat other users are doing or whatfinancial rewards others have gained butwhether patients have better oral healthas a result of the practice adopting certain kinds of digital communication.

The common commercial index ofsuccess, number of “hits,” is of doubtfulvalue. The true professional value is oral health outcomes. Discounts andgiveaways orient patients to cost ratherthan health. Chaining and hosting—rewarding patients for using their computers to promote your practice—

are mistaken notions of what dentistryoffers. Advertising prices and offeringguarantees may be acceptable to otherclients for whom Web designers’ work or some things which a practice mightbe tempted to copy, but they risk beingfalse or misleading in dentistry becauseof its custom nature. Unqualified priceofferings can drift toward “bait andswitch” practices. The common thread inthese examples is that nonprofessional,commercial values may creep in whendigital communication is designed byoutside vendors or borrowed from sourcesthat do not understand the professionalnature of dentistry. It is the dentist’sresponsibility to ensure that inappropriatethird-party influences are kept in place.

In extreme cases, third parties insertthemselves into dentistry by becomingco-providers of care. Groupon is anexample where a for-profit company hasattempted to broker increased numbersof patients to the dentist in exchange forlower cost to the patient. The prospectthat a third party could make a profitfrom such a model presumes that thereis an excess margin in dental fees. Thereare also third parties who are willing to provide ancillary dental services, suchas lab testing, financial services, andpatient education to be accessed fromthe Web pages of practices. This normallyincludes a financial return to the dentistfor allowing others to become partnersin patient care.

It is embarrassing to Google-search adentist’s name and find half a dozen sitesintroducing that dentist. It is sometimesthe case that dental trade associationgroups that dentists join will sell personaland practice information to vendors as asource of non-dues income. The AmericanCollege of Dentists does not engage insuch practices. These sites offer unrelatedservices, such as listings for other dentistsin the area, advertisements in the mar-gins, and even an opportunity to rate thequality of the dentists one has not yetseen. Typically, such sites offer patient

education information about such topicsas disciplined licenses (which they minefrom public records available to allthrough state Web sites) as a value-added feature. Other vendors are moredirect, offering to give an opinion with-out being asked. For example,organizations now notify dentists thatthey have been recognized and offer topublicize this fact for a fee. In all of thesecases, a third party with some sort ofcommercial interest is seeking to insertitself between the dentist and the poten-tial patient. This is perfectly acceptablein a commercial culture. Dentists shouldregularly monitor their electronic publicimage. To the extent that all dentistsoffer excellent care based on the five Cs,there is no commercial value that thirdparties can profit by selling. Third-partyinformation is only valuable to theextent that it guides patients and othersthrough a fragmented profession.

3. Dentists should exercise prudence toensure that messages are professionaland cannot be used in unprofessionalways by others.

The communication between dentists and patients is inherently indi-vidual, personal, and complex. Thediscussion of how best to manage oraldiseases, their complications, and theeffects these have on patients’ lives isbest done in an environment of trust,give and take, and where there is anopportunity for immediate responses topatient’s concerns and an opportunity to evaluate nonverbal and other circumstantial factors.

There are aspects of dental commu-nication that do not require this level ofinteraction and may be well suited todigital communication. These includeinformation about the practice locationand characteristics such as office hours,bills sent to patients on a monthly pay-ment program, and information sharedas a community outreach, such as back-

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ground information about an upcomingpublic water fluoridation campaign.

Although it is impossible to preventall cases of others misusing messagesand information that appear in digitalformat, reasonable precautions includepassword protection and other securitypractices, legal disclaimers accompanyingpostings, care in distributing messages,and prudence regarding content. Thelast suggestion—not saying anything onewould be embarrassed to read on theInternet with one’s name attached to it—probably affords the greatest degree ofprotection. Care should be taken toensure that professional communicationmatches the media used. Three factorsare especially important.

First, no claim should be made in apublic forum that is not universallyapplicable to all patients or the public. If there is any question whether a statement on the office Web, in a textresponse to a patient, or through a com-mercial service will have to be qualifiedonce there is a direct relationshipbetween the dentist and the patient, it isquestionable whether such a statementshould be made. Claims such as “one-day tooth straightening” and “painlessdentistry” either are misleading orinvolve puffery, a watering down of pro-fessional communication. An office thatblogs about how friendly it is to every-one runs the risk of not being able todismiss patients or cultivate a “selectclientele” without broaching hypocrisy.Adding quibblers such as “generally” willmake the lawyers happy but may stillleave a bad taste about the profession asa whole in the mouths of patients. Theethical principle of veracity is defined byphilosophers as not allowing others tomaintain misbeliefs that are detrimentalto them. This is a higher standard thantelling the truth.

Second, care should be taken withclaims and information where otherscan hijack the information for theirown, nonprofessional purposes.

Politicians, CEOs, actors, and sports starsare not the only ones who have been bit-ten by an unflattering remark capturedon a cellphone. The concept of “goingviral” means that digital content hasescaped the control of the originator.That can be an attractive prospect in thecase of flattering messages, but devastat-ing if the message has negative overtones.The important thing to remember is thatthere are reasonable controls on the con-text of direct communication betweendentists and patients that disappear whenthe content becomes digital. Digital content has a life of its own, and it is anindefinitely long life.

Third, consumers of messages ondigital media are often unclear about thesource of the message. The reputation ofevery dentist is affected by the actions ofheavy users of media, regardless of theirown attitude toward it. Many dentists ortheir office staff have been confrontedwith a computer printout of an unsub-stantiated treatment or of price quotesfrom other offices. Some messages arenaturally easier to express digitally.Usually attractive outcomes are betterunderstood by the public than improve-ments in health. Simple and quicktreatments are easier to explain thancases involving staging, tradeoffs, andcomplex decisions. Inexpensive, singleprices are easier to grasp than fees con-tingent on the multiple factors of thecase. Because digital communicationfavors short, standardized messages, it is intrinsically biased toward misrepre-senting the most appropriate forms of oral health. That is the case beforeconsidering the attractiveness of digitalmedia in the hands of those who inten-tionally misuse it for personal gain.

4. Personal data should be protectedand professional communicationshould be separated from personalcommunication.

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A traditional idea in dentistry,

and one that the American

College of Dentists believes

should remain central to its

identity, is the five Cs of

comprehensive, continuous,

competent, compassionate,

and coordinated care.

United States law has establishedstandards for healthcare professionalswith regard to their communicationabout patients. Certain individuals andentities are entitled to access to thisinformation, including patients them-selves, insurance companies, and thecourts under some circumstances.Others are specifically excluded fromseeing the information. The HIPAA regu-lations are over 1,000 pages long. The“P” in HIPAA does not stand for privacy.The word is “portability,” as in HealthInsurance Portability and AccountabilityAct. The underlying issue addressed inthis legislation is that patient informa-tion will be ballooning in value andflying around at fantastic rates once ithas become digitized, thus formal standards are needed.

The three fundamental standards inHIPAA are privacy, confidentiality, andsecurity. These are not three terms forthe same general idea; they are threeways that the information about peopleis part of the dignity of the person.

Privacy refers to the right to refuse toreveal personal information. If a patientis coerced or tricked into revealing infor-mation about their sexual preferences,their income, or their health status toindividuals who have no business know-ing this, their privacy has been violated.This is true even if that information isnot shared with anyone else. In an elec-tronic world where there is so muchpersonal information in cyberspace, wehave become concerned that we shouldnot have to reveal anything more aboutourselves than we choose to, unless thatinformation is needed for legitimate purposes. Usually, we must be informedabout privacy policies, although the noti-fications are now so ubiquitous, lengthy,and expressed in such legal languagethat in fact we may not actually beinformed. Think of a violation of privacy

as looking for information that oneshould not have.

Confidentiality is sharing informa-tion you have, whether obtained byappropriate means or otherwise, withpeople who have no business knowingit. Most of the “privacy” issues involvingelectronic information are really concernsabout confidentiality. Selling mailinglists, leaking classified information, andgossiping about famous patients are violations of confidentiality.

Security, the third function, meanstaking reasonable precautions to ensureprivacy and confidentiality. Unauthorizedindividuals should not be placed in positions where they may overhear private details. Charts should be storedin locked cabinets. Staff should betrained. And suspected breaches must be reported according to the regulationsof federal and state laws.

Broadcast digital communication isnot likely to be an issue with regard topersonal information—it is the dentistwho is making revelations. Transactiondigital communication is especially at risk as it contains health history,financial, and other sensitive matters.Relationship digital communication may become an issue as cellphone communications and texts can now besubpoenaed and may be inadvertentlysent to the wrong people. Hosted Websites may post information that later isrecognized as inappropriate. The dentistshould make a determination in buildingrelationships where the proper boundaryis between professional and nonprofes-sional communication.

It would also be out of bounds tobrag about well-known patients on the practice Web site. If permission had beengiven for such posting it would not beillegal, just very bad taste. Facebook and

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Patients have unprecedented access to health information and misinformation on the Web.

other social media sites should be closelyand continuously monitored and inap-propriate postings removed immediatelyin cases where that is possible. In fact, itwould be good practice to have a clearpolicy regarding publication of personalinformation printed on the site.Transaction electronic sites, such as payment systems, automated health histories, and insurance apps need to becarefully designed and monitored forconformity with HIPAA regulations. It isprudent to give training and guidelinesto all staff members, and to log in fromtime to time as a potential user of one’sown digital communication to see whatit looks like from the outside.

A slippery area is the dentist’s per-sonal media use. Occasionally, theformal office protocol is immaculate, butthe line between personal and profes-sional communication of the dentistbecomes blurred. Dentists should notbecome faceless, unreachable non-enti-ties. Neither should they be everyone’s“hangout buddy.” Virtually all professionsexcept dentistry have formal language in their codes of professional conductregarding avoidance of dual relation-ships. Dentists should protect against the ambiguities of indistinct professionalboundaries by maintaining separate e-mail addresses, Facebook and othersocial media accounts, and cellphones.One is for the dentist as a person andone is for the dentist as a professional.Communication to patients or staff thatcomes over the wrong channel is apt tobe misinterpreted. A legal action shouldnever open a dentist to requests foraccess to personal communications justbecause they have been blended withprofessional ones.

Although the dentist is ultimatelyresponsible for all practice communica-tion, it may prove useful to delegatecontinuous monitoring of the officesocial media site to a staff member forthe sake of consistency and immediate

attention. First, the staff member hasmore time. Second, there needs to be abuffer in decision making between therequest and the dentist as the ultimateresponsible authority. And third, patientsmay overuse direct access to the dentistand they might interpret everything the dentist says as professional commu-nication. Diagnosing on the cellphone is very risky business.

5. Dentists should be generally familiarwith the potential of digital communi-cation, applicable laws, and the typesof information patients have access to on the Web.

Digital communication affects allpractices, even those where the dentist ispersonally determined not to participate.Because of the nearly universal use ofdigital communication and the inevitabil-ity of having to make decisions about itsbenefits and its abuses, dentists shouldknow enough in a general way to makeethical decisions and to seek competentadvice when that would be helpful. At a minimum, dentists should be able todistinguish between those opportunitiesthat help or harm patient care based on informed opinion rather than vagueawareness of “trends.”

There are no general laws or ethicalprinciples that apply exclusively or in aspecial way to professional use of digitalcommunication—with the exception ofHIPAA and perhaps some others. Specialcases may come to light, and dentistsshould seek the advice of qualified coun-cil if that is suspected to be the case. Theobligation that cannot be avoided is tothink through the effects of using digitalcommunication and then to apply thesame standards of law and ethics thatwould be applied to the same effectswere they the results of any other actionnot involving digital media. The five Csof comprehensive, continuous, compe-

tent, compassionate, and coordinatedcare can serve as a guide.

Dentists should also be familiar with applicable law and regulationregarding practices involving digitalcommunication and ethics and profes-sional standards that guide their use.Among the issues that are essential arerelationships with third parties (as inresponsibility for patients), relationswith other practitioners (as in fee splitting), privacy, confidentiality, andsecurity (as in HIPAA), and copyright,libel, and conflict of interest matters.Various codes of professional conductand ethical guidelines are also relevant.For example, mention of branded prod-ucts or treatment modalities on one’sWeb site may constitute an endorsementand create an undisclosed conflict ofinterest. Colleagues may come to regardclaims or even the general appearance of broadcast sites as claims of superiority.And, of course, every practice or state-ment that is ethicalyl questionable whenpresented in any other medium is equally suspect in digital format.

A 2009 study of all dental practicesin San Francisco revealed that 11% ofdentists practice in offices that marketthemselves by a fictitious name that doesnot include the identity of the dentists. It might be imagined that these practiceshave distanced themselves to someextent from direct personal relationshipswith patients. Disconcerting is the factthat less than half of these practices with fictitious business names have registered the name with the state dentalboard, a requirement for licensure. Thesame study found that 24% of practiceslist a Web site. Likely the number is

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greater today. There was no difference inthe average age of dentists who haveWeb sites and those that do not.

Patients have unprecedented accessto health information and misinforma-tion on the Web. No one can “unring”that bell. It then behooves dentists to beat least familiar with both commonlyused patient sources of information and with the more widely circulating claims.A dentist should count it as fortunatewhen patients present questions aboutsuch claims and ask for a professionalopinion. The alternative of patients sim-ply matching their uninformed opinionswith dentist Web sites that contain thekey words they are looking for is border-line collective malpractice. But dentistsshould be informed well enough aboutwhat patients are finding to have anhonest discussion that extends beyondtheir own scientifically-based knowledge.It is an irony that in an age of massiveinformation available to the public, professionals now have the additionalresponsibility of being familiar with themisinformation that patients are apt toencounter and of having the skills to guidepatients to sound oral health choices.

6. Practitioners should maintain an appropriate distinction betweencommunication that constitutes thepractice of dentistry and other practice-related communication.

Some dental treatment is accom-plished without the use of a handpiece.For example, a patient may phone withpostoperative pain and be instructed bythe office staff to take analgesics andcontinue self-monitoring. It might beargued, if the case fails, that the staffmember was practicing dentistry with-out a license. Similarly, patients may relyon information posted on the office Website in a way that causes complications.Although disclaimers can be added to

digital communication, it is unclear atthis point the extent to which this consti-tutes legal protection. There have beenreports from the medical communitythat physicians responding to text messages from patients have increasedlegal exposure.

The fact that dental licensure in theUnited States is managed at the statelevel raises additional concerns becauseelectronic media know no geographicboundaries. Charts, prescription infor-mation, photographs, and radiographscan be transmitted electronically, oftenwith no clear identification of the location from which they originated. Ifpatient advice, professional consultation,diagnosis, or direction of care given bystaff is interpreted as constituting dentaltreatment that crosses jurisdictionalboundaries, the dentists may be practic-ing without a license.

7. Responses to criticism on digitalmedia should be managed in a professional manner.

It is unlikely that the growing availability of electronic media has orwill increase the proportion of actualnegative experiences in dental practice.The ratio of patients upset with theircare and the ratio of patients who aredifficult to manage are likely constants.What is rapidly changing is the capacityfor these disagreements to be played out in front of a large audience and theprospect that third parties will becomeinvolved. In two studies of dentists’ preferred response for managing issuesof a technical nature or those involvingstaff, patients, financial matters, andoffice routine, the overwhelming “go-to”strategy was face-to-face communica-tion. This is judged by dentists to be boththe most commonly used approach tosolving problems as well as the mosteffective one. Appropriate adjustmentsare made and reputation is maintainedmost effectively through personal conversations. Such conversations areincreasingly taking place in public. It

will become more difficult for dentists to exercise control over oral health com-munication.

Increasing caution is required withregard to communication in the officeregarding patients and one’s professionalcolleagues. It has always been unprofes-sional to make disparaging commentsabout patients, especially those thatinvolve value judgments. With moreoffice records being in electronic format,even including texting and cellularphones, the prospect is growing thatdamaging remarks will be uncoveredduring the discovery phase of a legalaction. Sophisticated electronic searchalgorithms exist for finding information,and data has an increasing life span and is becoming almost impossible todispose of. A more professional level ofdiscussing patients and of discussionswith patients is now required. Trainingof the office to ensure that this standardis the dentist’s responsibility.

There have been clear examples ofdentists’ reputations being unfairlyimpugned by patients spreading reportsof what they interpret as poor treatment.Various electronic media have been usedfor this purpose, including postings ondentists’ Web sites, postings on patients’own sites, and postings on public sites,as well as traditional word of mouth.Some of this damage has been justifiedand some has not. More people arereached by digital postings, messagestend to be more strongly worded becausethe writer must justify the position,blasts reach people who are not in aposition to know all of the relevant facts.These circumstances narrow the possibleactions a dentist can take in response.

The new reality of wider publicscrutiny of practice invites any of several responses.

Improved patient relationships in the office are the preferred strategy. This

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takes the form of full communication,more extensive involvement in informedconsent, development of multiple chan-nels of communication with staff, andclear signaling that the dentist is willingto listen and discuss concerns on a personal basis. In this sense, the bestantidote to potential abuse of digitalcommunication is effective use of non-electronic communication in the office.

Once patients have signaled, publi-cally, that their sense of trust has beenviolated, the dentist has the options ofignoring the matter, denying the facts,offering excuses, promising reparations,apologizing, and taking or threateninglegal action. Efforts should be made toobtain a copy of the electronic complaint.Failing to respond, denial, and makingexcuses (including blaming the patient)generally have the effect of creating further distance and potential escalationin front of an audience. Even when theoriginal issue is ambiguous, a disgrun-tled patient is on very solid grounds incomplaining to anyone who will listenwhen the dentist refuses to engage in a conversation. That will become thedominant voiced concern. Courts andmalpractice carriers are sensitive to dueprocess matters. Promising reparationsis a decision about the costs of maintain-ing a patient or one’s reputation. Somemalpractice carriers still advise againstprofessionals apologizing, although the literature shows that this does notincrease and may actually decrease settlement costs in the event of legalaction. It does have a strong effect ondecreasing the likelihood of legal action.Apology includes a believable expressionof regret over the outcome and opennessto accept just responsibility. The apologyshould be extended in private andshould be understood as an invitation toseek a mutually satisfactory resolution.

The literature on service recovery(effective management of customer complaints) shows that satisfied cus-tomers tell three friends and dissatisfied

customers tell seven to ten. Digital mediamagnify these numbers but probably donot change the ratio. The goal of servicerecovery is to convert an unsatisfied cus-tomer into a satisfied one. An open effortto do this is often effective, and surpris-ingly, recovered customers are actuallymore loyal than originally neutral ones.It is something like remineralized enamel.

A third alternative is to engage inpositive reputation building through customers. Recently companies have veryopenly taken to “coaching” customersabout responding to satisfaction surveysand openly soliciting testimonials andpositive comments. It is not uncommonfor service companies to instruct per-sonnel to inform customers that they“expect a perfect 10 on the third-partysurvey you will be receiving.” This hasextended to language, often buried in consents and agreements that the customer can be used for promotionalpurposes at the discretion of the company.There are firms that will sell bulkFacebook “likes.” At the homemade level,small businesses encourage employees tomake positive comments on relationship-hosted sites and to recruit their familyand friends to do the same. This localballot box stuffing is sometimes so crude that it must be obvious. The ethics ofprofessionals soliciting favorable publicopinion is suspect.

The most reactive, and certainly the most damaging, response is for professionals to attempt suppression ofnegative opinions expressed in public.There are two forms this response takes.First is legal action under the head ofprosecution for libel. Libel is the publica-tion of defamatory remarks that tend toinjure another’s reputation. To prevail in a libel case the plaintiff must be ableto show that the claim was made by a

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The most reactive, and

certainly the most damaging,

response is for professionals

to attempt suppression

of negative opinions

expressed in public.

that exceed those of their patients.Ethically fair resolutions of disagreementsare based on adjustments that are proportional to what each party standsto lose by not coming to agreement. ■

ReferencesAshforth, B.E., & Gibbs, B. W. (1990). The double-edge of organizational legitimation.Organization Science, 1 (2), 177-194.Chambers, D.W. (2010). Dentistry from theperspective of the San Francisco phonebook. CDA Journal, 38 (11), 801-808.Chambers, D.W. (1989). Problems and problem-solving strategies during the first12 years of dental practice. Journal ofDental Practice Administration, 29-34.Chambers, D.W.C., & Eng, R. L., Jr. (1994).Tasks and stages of professional growth.CDA Journal, 12, 35-42.Davenport, T. H., & Beck, J. C. (2001). The attention economy: Understanding the new currency of business. Boston: Harvard Business School Press.Fisher, R., & Ury, W. (1991). Getting to yes:Negotiating agreement without giving in.New York: Penguin Books.Kim, P. H., Dirks, K.T., & Cooper C.D. (2009).The repair of trust: A dynamic bilateral perspective and multilevel conceptualiza-tion. Academy of Management Review, 34 (3), 401-422.Porter, M.E., & Teisberg, E.O. (2006).Redefining health care: Creating value-based competition on results. Cambridge,MA: Harvard Business Press.Smets, M., Morris, T., & Greenwood, R.(2012). From practice to field: A multilevelmodel of practice-driven institutionalchange. Academy of Management Journal,55 (4), 877-904.Tapscott, D., & Williams, A.D. (2008).Wikinomics: How mass collaborationchanges everything. New York: PortfolioPress.Rheingold, H. (2002). Smart Mobs: The next social revolution. New York: Basic Books.Zeithaml, V. A., Parasuraman, A., & Berry,L. L. (1990). Delivering quality service:Balancing customer perceptions andexpectations. New York: The Free Press.

person who knew or should haveknown that the damaging statementswere false. A patient’s opinion that he orshe was not treated as they expected tobe treated generally does not meet thiscriterion. A second strategy that someprofessionals have attempted to preventnegative postings to electronic systems isto require that patients sign a promisethat they will not criticize the provider.Courts have almost universally rejectedlibel cases brought by dentists againsttheir patients and have held that con-tracts precluding expression of opinionsfollowing treatment to be against “publicpolicy” and unenforcable.

Sites such as Yelp, Angie’s List,Healthgrades, Ratemds, Vitals, andDoctoroogle are commercial platformsthat serve the public by hosting the opinions of users of professional services.They are lay ratings of professional services—uninvited electronic scorecards.Presumably there is an equal potentialfor an uninformed patient or a familyfriend to give a practice an unrealisticallyhigh rating or for an equally uninformedor biased individual to give an unwar-ranted low rating. The fact that thirdparties can make a profit by hostingsuch ratings demonstrates that profes-sional reputations have value. Dentistsshould monitor these ratings and seek to diagnose opportunities to improvetheir reputations.

8. Dentists should be prepared to makemore accommodations to patientsthan patients do to dentists in resolvingmisunderstandings about treatment.

There is a perception of a doublestandard for professionals and the publicin terms of what can be said in publicabout their relationships and how fareach should go to resolve differences.That perception is accurate, and profes-sionals have to extend themselves morethan patients do.

This is the case for two reasons: oneethical and the other economic. There isan implied contract between the profes-sions and the public which includes,among other matters, an expectationthat the profession will have exclusivemarkets and a degree of self-policing inexchange to its agreeing to serve thepublic’s interests. This is different fromthe relationship between the public andcommercial operations such as car deal-erships or pest control. Professionals aregranted a very large measure of trustfrom the beginning of any relationshipthat strictly commercial relationshipsmust earn.

To the extent that dentistry is both aprofession and a business, there is a riskthat professional trust will be compro-mised when dentists signal an emphasison commercial values. There is certainlyample potential for confusion. It wouldbe inherently unethical for dentists toexpect the full benefits of professionaltrust at the same time they counted onfull access to the rewards of commercialenterprise. Digital communication, withits bringing previously private relation-ships between patients and dentists intopublic view and beginning to make aplace for third parties in those relation-ships has drawn attention to the ethicaldimension of this double standard.

The economic reason why dentistsmust extend themselves further to reconcile differences of perceptionbetween themselves and patients isbecause dentists are in a favored positionin the relationship. Finding the “fair”balance between parties of unequalpower is known as the Nash BargainingSolution. John Nash won the Nobel Prizein Economics in 1994 for, among otherthings, pointing out that society pullstoward a balancing of conflicts of inter-est based on how much each party hasto lose by not reaching accommodation.Generally dentists enjoy economic status,reputation, and positive standing in thecommunities where they live and work30


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AbstractThe rise of the social media phenomenonand its impact on dentistry are discussed in the paper. The relationship betweendentists and patients is growing wider and more indirect. Social media can beroughly characterized in five categories:social, reference, review, coupon, andinformation networks. Opportunities and threats posed by social media are explored.

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People Will Talk

Social Media

Dr. Chan is a pediatric dentistpracticing in Fremont, California,and a Regent of the college;[email protected]

What is word of mouth? It isthe human condition—toshare experiences. Social

media is changing the way people talk.It is changing how people talk to eachother or about each other. It is changingthe fundamental roles of dentist andpatient.

A three- year-old boy was referred toour pediatric dental office by a generaldentist. The child had multiple caries.The general dentist was unable to treatthe child. Due to the extensive treatmentrequired and the child’s immature cogni-tive ability, we recommended oralconscious sedation. Informed consentwas discussed and signed.

The treatment was completeduneventfully. The child did well for theprocedure. The parents were satisfiedwith the results. The parents elected toreturn to the general dentist for continu-ing care.

Two years later, the same child wasagain referred to us for additional newtreatment. While the child was older, hestill exhibited situational anxiety. Wereviewed the options with the father fortreating the child. We mutually concludedoral conscious sedation would be thebest option to treat the child. Due to theextent of the treatment needed, we splitthe treatment into two sessions. Afterthe first session, the child again didgreat. The procedure was uneventful.

The mother called a week later. “Iwant my child treated on Friday after-noon. I want to be with him in the room

when you work on him. I want you towaive any co-payment or I will post badreviews of you on ‘X’ site.”

The Social Media PhenomenonFacebook, the iconic social media com-pany, is credited by many with startingthe social networking phenomena. Itrecently opened its IPO—creating a company value of $137 billion. Whilethere is controversy on the valuation,social media has fundamentally shiftedhow we communicate.

Of the many social media sites,Facebook alone boasts of 1 billion users.Each user can broadcast a message within a group or node. But then themessage distribution can explode fromnode to node. The audience grows exponentially. The reach of the messageoccurs in seconds. Social media is funda-mentally changing where consumerssearch for services. Eight years ago, thelocal Yellow Pages was nearly four inchesthick. Today, the Yellow Pages or “busi-ness section” of the telephone book is lessthan a third of that size and seldom used.

Social media is changing the man-ner of seeking healthcare providers.Increasingly, consumers seek dentists on

the open market. Social media sites suchas Yelp tout that they can find “dentists,hair stylists, and mechanics,” and Angie’s List can help the consumer find“roofers, plumbers, house cleaners, anddentists.” In the eyes of the consumer,dentists are reduced to the comparablestation in society.

Social media creates an egalitarianenvironment within a community. Allparticipants are equal. Within a virtualcommunity, borders are blurred betweenthe formal professional conversationand the informal personal conversation.The once confidential conversation within the dental office is increasinglyconducted in cyberspace.

Patients search for health informationonline. Dentists’ opinions, presumablyknowledge-based, are increasingly beingquestioned. While informed health decision making by patients is desirable,the dentist as an authority figure isdiminished.

There is a growing cautionary moralin the interplay of social media, socialnetworking, and professional relation-ships. The challenge is to remain that ofbeing the dentist.

The Choice

In marketing, the conventional approachof a seller is to profess the attributes ofone’s products or services to the market-place. Your hope is that someone isattracted to what you have to offer.

From the frame of reference of theconsumer, he or she relies on cuesbeyond the seller’s words or images.When a consumer chooses products,physical attributes are used to judge

comparative features of products amongcompetitors. In computers, the discrimi-nating features may be the size of thememory. In restaurants, it may be themenu choices.

When a consumer chooses services,there are fewer tangible attributes withwhich the consumer can discriminateamong service providers. The consumeruses different cues to initially choose aprovider. Without a personal experiencewith the provider, consumers make theselection based on brand identification oraffiliation, reputation, and testimonials—or even price. The consumer does nothave the professional experience or skills to recognize technical merit. Theconsumer relies on indirect, informalcues of a service provider when making their choice.

The single most persuasive factor inthis decision making is the testimonial.The blind testimonial can be offered by a source unfamiliar to the consumer.The consumer does not know how sourcesform their opinions. Yet, the consumertakes the testimonial on face value.

From the frame of reference of thedentist, he or she believes the technicalfeatures, i.e., the margin, the occlusion,the shade, the anatomy of the restoration,should be the determinants of whether a patient will think highly of our work.Yet it has always been the nontechnical,informal cues, such as the courtesy ofthe staff, the attentiveness or empathy ofthe dentist, the décor or cleanliness, thetimeliness of the appointment that leadthe consumer to judge a “good service.”Price point is certainly a determinant.

Once consumers have first-handexperience, they have knowledge thatothers do not have. Consumers have a“power advantage” over those with whomthey are in contact. They are nowauthorities. The power differential is thedriver in the sharing of an experience.With social media, direct experience isno longer a precondition for having an

opinion. Any individual can rate a dentistonline in any city in America, whetherthey have been a patient or not. Any dentist can rate himself or herself as well.

Social media now takes the testi-monial and expands the range of thistestimonial to a much wider distribution.Social media becomes the conduit orweb between members within a socialcluster. Clusters grow. Each cluster thenbecomes a nidus to expand the messag-ing to new social clusters. The messagecan travel far from ground zero wherethe message originated.

The Target

Social media has become the darling of the marketing world. It is a low-cost,high-volume distribution vehicle to display your wares in the marketplace.Consumers increasingly do their shoppingfor products and service online. Respond-ing to these market forces, there aregrowing trends for businesses to shifttheir marketing resources from traditionalprint and electronic mass marketing tosocial media tools. Businesses look for areturn on investment of these resources.They seek a high conversion ratio ofresources expended to how many buyersare secured.

A business sells its service or productsto a range of different buyers. Buyers differ in their purchasing needs. Thereare buyers who are “price sensitive.”Companies offer promotional devices ordiscounts for these buyers to make purchases. This type of buyer tends tomove from attractant to attractant. Theytend to want to try the new “thing” inthe social environment.

Buyers who are “brand loyal” seekenhanced value-added propositions. InMalcolm Gladwell’s book, The TippingPoint, these buyers are identified as late adopters or laggards. They tend to

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need additional information about thefeatures of their purchase before makinga decision. Once they have made a decision, they are reluctant to change.They seek value for their purchases.

Sellers (of services or products) allocate resources to attract buyers.Marketing is the outreach of a business.The marketing must have a consistentmessaging to identify and differentiatethe seller from competitors. It must consider an overall strategy of costs, targeting, and monitoring to determinethe effectiveness of the resourcesexpended to attract buyers.

When using social media tools, fromthe seller’s viewpoint, the strategy is notnecessarily to secure a single point-of-contact purchase. The strategy is to reachinto an existing social cluster or pool ofpotential customers. The business con-cept is termed “customer acquisition.” A new entrant in the marketplace mustexpend resources to develop a customerbase or buy access into an existing pool.

The strategy is to enable multiplepoints of contact with the business forthose first-time purchasers. With socialnetworking, conventional wisdom says the wider the net, the greater thelikelihood of the catch.

The Market

Social media is the vehicle that carriesthe message within a community orbetween communities. For the purposeof this article, there are five major typesof social media:1. Social networking community

or blog2. Referral network3. Review network4. Coupon network5. Information hub or resource

The object of a social network orblog is to create a community. It enablesconnections. New entrants seek to establish a personality within that community. In social networks, people

talk. Sites such as Facebook, Twitter,LinkedIn, Yelp, and Google products(Google + and YouTube) typically havebeen Internet based. There is a lag timebetween the encounter and entering the message of the experience online.New variations emerge.

Mobile apps on smart phones andtablets are expanding exponentially.With each new product debut on themarket, there is a drive for more real-time entry of the encounters. Access toinformation is in the hands of many,many more people. This “word of mouth”behavior is no different from moms onthe baseball field sharing what dentiststhey take their kids to. The difference in the social network medium is that the participants in the network may be unfamiliar with the source of infor-mation. When a testimonial is shared,others in that network vicariously sharethe attributes.

The referral network is sponsored by a name-brand Web site company. Itcapitalizes on its name recognition inthe market as its authority to direct newbuyers to a market. In business, it offersa form of customer acquisition. It bringsa community of potential purchasersthat the seller would not likely have accessto or does not have the resources to cultivate. The Web site sponsored by thecomponent dental society is an example.

The review network shares similari-ties with the referral network. Thisnetwork gathers reviews from past purchasers. The testimonial source isoften unknown to the seeker. The reviewnetwork may either directly refer orimply referral to the seller. There is typically a multiplicity of testimonials.

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Social media is changing

the manner of seeking health

care providers. Increasingly,

consumers seek dentists

on the open market.

The coupon network is a crossoverfor the price-sensitive buyer and thebrand-loyal buyer. Depending on thestructure, a potential seller will subscribeto this network. The seller is also “pur-chasing” access to a customer base. The seller hopes to capitalize on a finiteaudience who seeks price-sensitiveincentives to purchase.

The information hub network presents itself as a consumer resource of information. It can be a companyexplaining its products or services. It can be institutional and provide genericinformation relative to their field ofexpertise. It can be proprietary and profess to be a self-described expert.

The Opportunity

The object of engaging in social media is twofold. It is an electronic “word ofmouth” media to introduce a practitionerto the market. It is also a virtual commu-nity to groom social capital to develop apresence and reputation.

Social media consumption is drivenby the market. Contemporary patientsget information, education, and newsfrom electronic media and print media.Social media is distinct from traditionalmedia, such as newspapers, television,and film. It is relatively inexpensive andaccessible to enable anyone to publish or access information. The attractive features for a small business to use socialmedia are low start-up, low maintenancecosts, and broad reach.

The Challenges

Dental conventions are excellent venuesto observe emerging trends in the profes-sion. Companies designing computersoftware have evolved to Web site developers. Web site developers haveexpanded into the burgeoning market of

social media marketing. In the currentdown economy and the hunt forpatients, practitioners desperately lookfor solutions. Social networking tools are positioned as salvation.

As social media infiltrates businessmarketing there is a shift from massmarketing to a faceless audience—to individuals, but in mass. As social mediainfiltrates the marketplace, there areemerging conflicts. As the health professions engage in a field out of theircontrol, there are new rules of engage-ment. Dentists and patients are creatingnew and nontraditional roles. Socialmedia brings rewards and risks.

The purpose of the following casehistories is to identify potential risks and consider actions to prevent or mitigate them.

Case Histories There are two sides to every story. On the surface, a company engages theuse of social media to broadcast itswares to a wider audience. The flip sideis if there is a disagreement between twoparties. The following cases illustrate howdisagreements can cascade far beyondan initial difference of opinion or even acommon view of what is happening.

Case 1: A Matter of Escalation

A pediatric dentist, Dr. W in Foster City,California, treated a four-year-old childwith nitrous oxide and performed anamalgam restoration. As the child waswalking back to the car, he vomited. The father, Mr. J, was angry and seeks asecond opinion.

Dentist #2 implied that Dr. W missedseven cavities and he placed composites.

Mr. J researched the Internet andconcluded that “the FDA had reversed itsposition with regard to the safety ofamalgam” and that nitrous oxide is “agas that causes general anesthesia.” He posted a review that he was misled by Dr. W.

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Within a virtual community, borders are blurred between the formal professionalconversation and theinformal personal conversation.

Decency Act of 1996. This Section holdsoperators of Web sites harmless for statements posted on their sites by thirdparties. Yelp argued that it did not generate the content.

The key issue in the case is whetherthe content of the review is libelous or ifa topic of public interest (i.e., amalgam)is being suppressed. Dr. W asserted thatthe parent libeled her and publicallydefamed her professional reputation.

The court found that there is “publicconcern, discussion, and controversyabout the use of silver amalgam becauseit contains mercury” and, therefore, theYelp review was protected under theanti-SLAPP law because it contributed tothe public discussion.

The parents’ attorney further asserted that the suit violated the client’sfreedom of speech.

In the Santa Clara Superior Court,Judge Kirwan ruled against Dr. W. The ruling stated that Dr. W must payattorney fees and costs incurred by thepatient’s parents and Yelp related to thelawsuit. Yelp and the parents said theyhad incurred legal bills of $113,620, butthe judge reduced the fee award to$80,714.

Analysis The practitioner had several options as a response to the actions by the parent:1. Ignore the posting on Yelp by the

parent.2. Attempt to persuade the parent to

remove the posting.3. Petition the site to remove the

posting.4. Negotiate with the parent to remove

the posting. This likely entails someconcession on the part of the dentistfor the parent to give up the action.

5. Issue a refund, take the loss, to minimize further loss of social capital in the marketplace.

6. Initiate a lawsuit against Yelp and the parents.

The unintended results are illustratedin the description of the case. What thedentist assumed as damaging to her professional reputation has becomemore complex. This precedent-settingcourt case identified protections to thedefendant that are not afforded to thedentist plaintiff. The courts upheld thefreedom of speech over the reputation of the dentist.

The drive for vindication was trans-lated into a higher economic cost beyondjust the client’s legal expenses. It is diffi-cult to quantify the risk or economic lossto business due to continuing height-ened media and social media publicity.

Case 2: Cascading Events

Following the extraction of a youngchild’s tooth, a California pediatric dentist was accused by an angry parent of mistreating his son. Mr. C claimed thatthe pediatric dentist extracted his five-year-old son’s tooth without anesthesia.He claimed his son vomited, screamed,and urinated on himself while beingheld down by several assistants duringthe procedure.

Angry, Mr. C createsd the “I Hate Dr.D of Bakersfield” Facebook page. In itsfirst 48 hours, the page attracted more

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Dr. W discovered the negative posting.She registered a complaint with Yelpabout the review being untrue. Yelpreferred her back to the author of theentry to resolve the dispute.

A Yelp.com representative offered tosell her advertising on the site. Advertisershave the option of promoting a favorablereview to the top position on the site,though they cannot delete or edit unfa-vorable ones.

Dr. W felt her reputation had alreadybeen damaged. She did not want to buyinto what she deemed a “protectionracket.” Dr. W filed a lawsuit againstYelp.com and both parents.

As the litigation progressed throughthe courts, the traditional media escalat-ed the profile of this case. The lawsuitencountered two barriers.

Mr. J asserted that Dr. W’s lawsuitwas trying to preventing him fromspeaking against her in a legal maneuverknown as SLAPP (Strategic LawsuitsAgainst Public Participation). He assertedthe lawsuit was intended to censor,intimidate, and silence his critic by burdening him with the cost of a legaldefense until the criticism was abandoned.

California and some other stateshave prohibited lawsuits aimed simply atharassing or intimidating people whowant to exercise legitimate free speech.California’s laws governing strategiclawsuits against public participation give judges the right to dismiss lawsuitsthat do not seem likely to prevail ontheir merits.

The California Court of Appeal forthe Sixth District issued an opinion sup-porting the right of consumers to postreviews of businesses on Web sites suchas Yelp.com and to have lawsuits basedon such reviews dismissed under theCalifornia anti-SLAPP law.

In the second hurdle, the court decided Yelp was protected underSection 230 of U.S. Communications

their existence. Companies such as Yelpbecome intermediaries. They have cultivated a body of potential customers.They create communication channels inthe market between potential buyers andpotential consumers.

The following excerpt comes fromthe Yelp Web site. It offers a view of whatYelp perceives they bring to the table forprospective clients:• Yelp was founded in 2004 to help

people find great local businesseslike dentists, hair stylists andmechanics.

• Yelp had an average of approximate-ly 71 million monthly unique visitorsin Q1 2012.

• Yelpers have written over 27 mil-lion local reviews.

Case 4: Trapped

San Francisco is a highly competitivemarket. Dr. R engaged Yelp, paying $200a month in 2004 and 2005 for onlineadvertising. She canceled because shewas unhappy with reviews she considereddefamatory and untrue. She assertedthat her Yelp reviews got even worseafter canceling. Positive reviews disap-peared from the site and negative onesbecame more prominent.

In 2011 she yielded to the solicitationfrom the site’s ad sales team. She waspaying $500 a month for the ads. Theprincipal advantage she gained was theright to choose a review that is displayedat the top of the results. Yelp says, otherthan selecting this one review, businessescannot influence the order of reviews orwhich ones disappear from the site, nomatter how much they pay.

Dr. R believed she was trapped and compelled to advertise on Yelp or

than 200 viewers posting negativereviews. The news of this case, promptedby the Facebook page, escalated. Localtelevision news picked up the story. It became a media event. Protesters picketed the office.

The situation escalated further. The parent posted disparaging attacksabout Dr. D on the state pediatric dentalsociety’s Facebook page and then on the national pediatric dental society’sFacebook page. The target audienceexpanded to a state and national audi-ence of Dr. D’s professional peers.

Still further escalation ensued with a national syndicated TV investigativenews program, “Inside Edition,” expanding the case to a national audi-ence. The case has now become morethan a case of a bad experience. Theissue has become an “exposé” on the useof restraints on children by dentists.

AnalysisFrom time to time, conflicts will arise inany practice where patient expectationsare not met. As with any activity requir-ing human performance, there areunanticipated events. Recognizing thereare failures in any human performanceis the start of conflict resolution.

Events in this case escalated the parent’s response to the incident. Theinitial tipping point was the dentist’sfirst response to the parent’s complaint.The second tipping point was the escala-tion in a public venue such as Facebook. The third tipping point was the publicresponse by apparently nonpatients ofDr. D to the TV and press media.

In typical disputes on treatmentwhere the issue cannot be resolved

between patient and dentist, a complaintcan be directed to either state associa-tion peer review or to the state dentallicensure and enforcement board. Incases of egregious harm, malpracticesuits ensue.

In this case, the parent expanded theissue to the “court of public opinion.”The dispute extends beyond the actualtreatment. The parent’s action now fits a description of “cyberbullying.”Cyberbullying is defined in legal glossariesas actions that use information and communication technologies to supportdeliberate, repeated, and hostile behaviorby an individual or group intended toharm others. Examples of what consti-tutes cyberbullying include communica-tions that seek to intimidate, control,manipulate, put down, falsely discredit,or humiliate the recipient.

Case 3: Online Ratings and Reviews

In highly competitive markets, companieslook for a distinctive edge. In urban markets, the concentration of dentists isa drive to compete in the same venues.We are being graded in the public arena,whether or not we choose to participate.

An extreme example of concentra-tion of dentists within a confined urbangeographic space is a building known as450 Sutter in San Francisco, California.This building has the single most con-centrated aggregate of medical anddental practices. One hundred sixty-two dental practices (across all dentalspecialties and includes multi-specialtypractices listed under fictitious names)are included in their directories.

Online listing sites have supplantedthe printed Yellow Pages as the firstplace a consumer looks for information.Yelp has developed a growing marketshare as that online listing site. SanFrancisco is the headquarters of Yelp.

In competitive markets, companiesmust expend resources to enable themarket (consumers) to be aware of

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negative reviews could rise to the surface,impacting her practice. There have beenlawsuits against the Internet review Web site Yelp.com alleging that it extortsbusinesses by posting more favorablereviews if they buy advertising.

The practice of “gaming” the site isdescribed when business owners solicitfavorable reviews or even hire people to write them. Ms. B accuses Dr. R ofposting “dummy” positive reviews of herown practice. Yelp is wary of this practice.

Users and business owners may contest entries by petitioning to Yelp toreport reviews that do not meet the site’sguidelines, such as reviews by peoplewith conflicts of interest or those whomake personal attacks.

From the dentist’s point of view, ifthe entry is untrue, incompletely true, orfabricated and not removed, the dentistscan opt to respond publicly in an attemptto set the record straight or may file alawsuit. This can be an arduous processto prove a negative or be handicapped by privacy laws to completely discloseone’s side of the story. Or the dentist canattempt to subordinate the negativeentry with positive ones.

U.S. District Judge Edward Chen, inOctober 2011, dismissed two class-actionsuits filed by businesses that alleged Yelpthreatened to degrade their ratings ifthey did not advertise on the site. Therewas insufficient evidence to prove thebusiness practice of manipulating posi-tions of reviews existed.

AnalysisThis case is an interesting examinationof power in the marketplace and howthe marketplace drives decision making.Among the definitions of power is thepossession of control, influence, or com-mand over others. It is further describedas the ability to make people (or things)do what they would not otherwise have done.

In the study of power, the followingalgorithms illustrate and are consistentwith the interplay of social media and apractice. • A has effects on B’s choices and

actions.• A has the capacity to move B’s

choices and actions in ways that A intends.

• A has the capacity to override opposition from B.

The relationship between A and Bdescribed by propositions 1, 2, and 3 ispart of a social structure and has a tendency to persist.

Case 5: False Protections

A class-action lawsuit filed November 29,2010 in the U.S. District Court for theSouthern District of New York claimedthat waivers Dr. M had patients signprior to treatment violate New York law, misuse federal copyright laws, andviolate dental ethics.

Mr. L of Huntingtown, Maryland,went to Dr. M’s office with a toothachein October 2010. Before treatment, Mr. Lwas asked to sign several forms, includ-ing a “Mutual Agreement to MaintainPrivacy” that claimed the HealthInsurance Portability and AccountabilityAct (HIPAA) contains “loopholes” thatallow dentists to use patient informationfor marketing purposes.

By signing the agreement, Dr. Mwould promise not to use any of Mr. L’sinformation for marketing purposes. In return, Mr. L would agree not to denigrate or disparage the dentist on the Internet or other broadcast media,according to the complaint.

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Social Media

As the health professions

engage in a field out of their

control, there are new rules

of engagement.

Even though Mr. L wondered why hewas being asked to sign such a form andwhether it was even legal, he complied.Mr. L claimed that he was in excruciat-ing pain for almost a week followingtreatment and did not have time to findanother dentist.

Mr. L was also told he would have topay Dr. M directly for his treatment andthat her office would send the treatmentplan to Delta Dental for reimbursement,according to the complaint. He wascharged $4,766 for two office visits,including a single filling. Dr. M’s officesubsequently submitted the claim, buttold him it was rejected. Mr. L contendsthe claim was purposely sent to thewrong company.

He then asked for his records so hecould submit the claim himself, but Dr.M referred him to a third party thatdemands 5% of the total bill for copyingthe records, according to the lawsuit.

As a result of his dealings with Dr. M,in August 2011 Mr. L posted negativecomments about her on several Web sites,including Yelp and DoctorBase. The nextday Dr. M sent Mr. L a letter warninghim that he had violated the agreementhe had signed prior to treatment andthreatening to sue him for breach ofcontract and copyright infringement.

The following month Dr. M sent letters to the two Web sites demandingthat Mr. L’s comments be removed. Theletters also disclosed Mr. L’s personalinformation, a HIPAA violation, the lawsuit claimed. The Web sites refused to remove the comments, saying theyregard purported copyright assignmentsas legally unenforceable.

Dr. M then began sending invoices to Mr. L. charging him $100 per day forcopyright infringement. She also sentanother letter threatening to sue him.

Mr. L engaged a public interestgroup, Public Citizen, to file a lawsuitagainst Dr. M. The lawsuit is the first todirectly address the issue of restrictingonline criticism. It sought an injunctionagainst imposing the agreement on Dr. M’s future patients and a declarationthat the agreement with Mr. L was nulland void. In addition, the lawsuit allegedthat requiring patients to sign the agree-ment violates dental ethics and is abreach of the dentist’s fiduciary duty.The suit asserted that being forced tosign these documents before care wasrendered placed her interests abovethose of her patients. It also misusedcopyright law to stifle public criticism.

AnalysisOn the surface, it may appear reasonablefrom the practitioner’s frame of referencethat a patient should agree to signwaivers before the dentist renders care.

A power dynamic emerges. Whenone party has something that a secondparty wants, the first party now haspower over the second. This is describedas a power differential. The dentist isseen as withholding care, coercing thepatient to agree to conditions underduress. By withholding care, the dentistexerts an unfair advantage over thepatient. In the extreme, this may consti-tute extortion. In addition, the legal system holds a higher value to protectrights guaranteed by the Constitution,particularly the Bill of Rights, whichincludes the First Amendment Right toFree Speech.

There is an unfair leverage of powerover a patient. The action creates an ethical challenge for the dentist. Anunanticipated effect emerges where the

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Social Media

Dentists and patients are creating new and nontraditional roles. Social media bringsrewards and risks.

• Does the rendering of an opinionconstitute a practice of dentistry outside of the licensure jurisdictionof the source?

Blogging or Answering PatientInquiries Online• How do you know who is the

recipient of the information on the other end?

• Can this be further transmittedagainst the consent of the patient?

• Given the information by the senderonline, is this a complete picturewith which you render an opinion.

• Can the statement be taken out of context?

Professional Criticism• Is there risk of negatively comment-

ing or implying about treatmentrendered without looking at it direct-ly or considering complete analysisof the variables when care is ren-dered?

• Is there is risk of providing unin-formed, unqualified opinions?

Secondary Risk Via Office StaffThe office staff’s use of social media canpose risks: • Offhand comments about patients

(disparaging or violating privacy)• Obtuse violations of confidentiality

statements• Lack of calibrated responses from

the office social media • Dispensing advice beyond the scope

of their duties■

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Social Media

court protects the patient’s rights overthe actions of the dentist as a protectionfrom litigation.

Emerging Opportunities andThreatsThe use of social media is opening new variations in how professionalsengage patients.

Information Web sitesBy providing health information online,Web sites gain social capital in the mar-ketplace. They position themselves to bethe authority on the information.

In our frame of reference, we valuepeer reviewed, professional association-based, even government institution-based resources. The consumer is lesslikely able to differentiate credible science from junk science. Consumerswith predisposed points of view willchoose a reference that favors their position. However:• For those consumers who are truly

trying to be informed, how can theydetermine legitimate sources fromthose with hidden agendas?

• If the link is sponsored, is there anunderlying message to sell some-thing? Advertising placement isplanted in customer pools most likely to consume their products. Is there risk of implied commercialinfluence?

• If a case history is used to illustrate a condition, can the patient be identified and therefore violate privacy or HIPAA regulations?

• When a previously unknown con-sumer solicits professional advicefrom a Web site, is there an implieddentist-patient relationship?

• Is there diagnosis and advice without a visual or hands0on examor insufficient info?

When a previously unknown

consumer solicits professional

advice from a website, is

there an implied doctor

patient relationship?

Michael Meru, DDS

AbstractThis overview of social media categories some of the typical types and uses of this form of communication and suggests common courtesies and effectivestrategies for participation in the social media culture.

40


Introduction to Social Media

Social Media

Whether by choice, coercion, orsheer necessity, each of youreading this has most likely,

in some form or fashion, participated insocial media and electronic communica-tion. To define social media, let’s look tothe wiki of wiki’s, Wikipedia, whichstates that social media is “media forsocial interaction, using highly accessibleand scalable communication techniques.Social media is the use of Web-based andmobile technologies to turn communica-tion into interactive dialogue.” To breakthat down further, social media wouldbe a Web site or Web portal that does notjust provide information but createsinteraction and user generated contentwhile giving you that information. Thus regular media would be one-waycommunication while social mediawould be two-way communication.

With the millennial generation nip-ping at our bootstraps and seeing that22% of time spent online is on socialmedia sites (http://thesocialskinny.com/99-new-social-media-stats-for-2012/),and with 65% of adults now interactingvia social media, it is essential that webecome familiar with this phenomenon.In 2010 Kaplan and Haenlein categorizedsocial media into six types: collaborativeprojects, blogs, content communities,social networking sites, virtual gameworlds, and virtual social worlds (Usersof the world, unite! The challenges andopportunities of social media. BusinessHorizons, 53, 59-68). These sites andportals come in various forms that thelayperson is more familiar with includ-

ing: social networks, Internet forums,wikis, blogs, video-sharing, photo-sharing,microblogs, podcasts and videocasts, andconsumer rating sites, among others.

So why do 62% of the worlds popula-tion connect through social media and85% through email (www.huffingtonpost.com/2012/03/27/email-connects-the-world_n_1381854.html)? How didthe social media epidemic take hold ofthat many in just a decade? While theanswer to this inquiry is complex, thereare three main reasons for why ourworld uses social media: connectedness,ease of communication, and the gossipfactor. While use of social media hasincreased the ability to stay connected toa larger number of people than everbefore and has made communication aseasy as 140 characters in a message, thegossip factor is what draws in many people. The cliques at the country club nolonger have to gather to get the skinnyon who is thinking of running for stateoffice or to find out which supplier isoffering bargains. Now all they have todo is pull their sleek phones out of theirpockets and log into their favorite socialmedia site. And to look sophisticateddoing so. It is human nature to want togossip and social media plays right tothat attribute. While it is only the minor-ity of users who regularly post, themajority of social media users are

Dr. Meru practices orthodon-tics in West Jordan, Utah, and is the immediate past Regent Intern for the AmericanCollege of Dentists; [email protected].

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Social Media

voyeurs who sit back and watch the egosand drama that occur online. In timespast you had to be a part of the clique to be in the know, now all you have todo is log in.

With more than 200 well-knownsocial networking Web sites in existence—and that only covering one of six cate-gories—it would be difficult to describeeach here. With that said, the followingsites are some of the most popular within the dental profession:• Facebook is the most widely used

social networking website in theworld that was created to connectfriends, family, and business associates. As of the day this articlewas written, Facebook had960,930,020 users.

• Twitter is a microblogging and social media site that allows users tosend and read text-based messages(tweets) of up to 140 characters tothose who choose to follow them orthat they choose to follow. There arecurrently over 500 million active users.

• Wikipedia is an online, user-generat-ed encyclopedia that anyone can add to or edit. A wiki is any Web site that allows users to create and editcontent online.

• Instagram is a social networking site for posting and sharing photosthat can then be linked into usersFacebook, Twitter, and Tumblr pages.

• Pinterest is a virtual pinboard where users can share photos foundon the Internet that interest them.With this site users can also followother users whose content they find interesting.

• Yelp is an online city guide that helps people find places to eat, shop,play, go to the dentist, physician, etc. The guide is completely user generated, and reviews are completedby those who have been to the placeof business (it is hoped).

• LinkedIn is a business orientedsocial networking site where its 175million members can build relation-ships and find information aboutprospective employment. Memberscan search for jobs, research compa-nies, network with businesscolleagues, and share resumes.

• FourSquare is a location-based social network where users check in at locations via GPS on a mobiledevice and share it with friends. This encourages users to frequentlocations that receive a high volumeof check-ins, thus indicating its valueor trendiness.

• Google+ is what some call Google’sanswer to Facebook, though thatonly scratches the surface. Google+ iscore to Google’s mission “to organizethe world’s information.” This infor-mation network has photo sharing,video-sharing, videoconferencing,video broadcasting, a social network,games, and a local Yelp-type site,among others.

• E-mail. While the experts are spliton whether e-mail truly is socialmedia, it is a modern form of com-munication that is ubiquitous in our

While it is only the minority

of users who regularly post,

the majority of social media

users are voyeurs who sit

back and watch the egos

and drama that occur online.

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Social Media

world. It can be as simple as a one-way broadcast advertisement or anin-depth conversation to as manypeople as we can CC.

While there are so many others thatcould have made this list, it is hoped thepoint has been made that using socialmedia is the way the world communi-cates today.

As with any form of communication,ethics, professionalism, and proper etiquette still apply, though they may bemuch easier to forget or breach due tothe speed of the communication andlack of intimacy in the contact.

Social Media has changed the waywe hear each other. The tone hasbecome less personal, more intrusive,and even ruder. There is something likea civility blanket that has made e-mailsless personal than face-to-face communi-cation. It is a wise rule of thumb toassume that those reading your mes-sages will not have the nonverbal cuesthat normally aid communication andthe filter will work selectively in the negative direction. Assume that anythingthat can be misunderstood will be. Humoris difficult, and sarcasm and irony areinvariably DOA. Extremely abrasiveremarks that are assumed to be protectedbehind the anonymity of the electronicfirewall are called “flaming.” Don’t flame.

When the typical person today wakesup to a smart phone alarm clock, checkse-mail while laying in bed, heads to theoffice to spend a good portion of the dayin front of a computer, plays with aniPad at lunch, heads home with smartphone in hand, and finishes the nightwatching a movie that is streamed to a

smart TV, we must ask ourselves, what isthe limit of the social media viewers’attention? The sheer volume of electron-ic communication has diminishedattention span. Like it or not, we are allcompeting for the eyeballs and interestsof our friends with a hoard of slick pro-pagandists armed with batteries ofelectronic weapons. When our friendsthrow out the dirty bathwater of com-mercial racket, we are in danger of beingthe baby that goes out as well. Further,we may compose our messages on full-sized screens in the comfort of ouroffices only to have them read on hand-held devices with tiny screens on shortelevator rides. This is not a counsel tostop saying things that are important orto trivialize complex topics, but helpmust be given to those who receive ourmessages. It is a good idea to announcethe topic in the first sentence. If there ismore than one subject to be mentioned,number them. If action is requested, sayso and underline it. These techniqueswere articulated by Winston Churchill inone of the first (dictated and typed)memos he issued as prime minister atthe beginning of the Second World War.

Social media triage is now a requiredskill. As soon as the message is received,do one of the following: (a) delete it—justgossip; (b) block the sender—preventsfurther solicitations from unwantedsources; (c) respond or forward anddelete—if no research is needed to answer,do so quickly; (d) acknowledge—saywhen the request will be answered. The worst thing you can do is let themessages pile up, usually leading toembarrassment. If the techniques aboveare used, you have converted your e-mailsystem into a “to-do” list. If someoneresponds to a request you have made,thank them.

With the constant exchange of information that occurs in social media,who should be the ones to receive our

messages? The average user on Facebookhas 229 friends (12 http://pewinternet.tumblr.com/post/23177613721/facebook-a-profile-of-its-friends-in-light-of), andeach time a user posts, each of those 229friends will see that message. E-mail hasslightly more control, but there always isa danger that e-mail messages may get topeople for whom they are not intended.It is all too easy for a friend to tap the“forward” or “reply all” button and sendyour note to someone you would havepreferred not get the message. The bestprotection in such cases is not to saycontroversial and negative things in thefirst place. If that advice cannot alwaysbe followed, limit the number of peoplewho get the message and be clear aboutthe sensitivity of the material.

For e-mail, use the “bcc” field in the address function to control chatteramong recipients of your messages.There may be no reason why all thosegetting your note need to have the e-mailaddresses of everyone else (they mighteven value their privacy), so considerbroadcast messages addressed only to“bcc” lists. If various individuals have different roles to play in a shared activity,send the base message and backgroundattachments to everyone and short cus-tomized separate messages to individuals.

The aforementioned courtesies andbest practices differ slightly for eachsocial media application, though in abroad sense they apply to them all. Thisissue of the Journal will delve furtherinto social media and provide a WhitePaper on the ethical implications of itsuse within our profession as well as a list of best practices to guide you in youruse of social media. ■

Carl L. Sebelius, Jr., DDS, FACD

AbstractMost professional organizations havedeveloped policy for use of social media by their members and several have developed Web sites to help members withethical media use. It is commmon amongbusinesses, nonprofit organizations, andgovernment agencies to have policies governing use of media by employeeswhen communicating with the public andprovide employee training. This articlesamples some of the best practices insocial media policy. Development of suchpolicy represents an attractive opportunityfor dentistry.

Dentists’ reputations have cashvalue. Recently a small army ofenterprising people has emerged

to help manage this resource—for theirown good, of course. The low cost ofusing electronic media and the ability ofthose with little training in the scienceof marketing has fueled something likean epidemic. It is called, in the jargon,“going viral.” There are two dangers towatch for and avoid. On one hand, den-tists can use social media as a substitutefor good dental care or even, in rarecases, compromising it. Second, otherscan use social media to diminish the rep-utations of dentists who are providingexcellent oral health.

American industry, the nonprofitcommunity, and professional organiza-tions have recognized the need forguidelines and standards to promoteappropriate use of social media. Some of these standards are presented here.

Policies in Other ProfessionsThe American Medical Association (AMA)policy statement, Professionalism inthe Use of Social Media, is an excellentguide (ama-assn.org/ama/pub/meeting/professionalism-social-media.shtml). Itplaces “outgoing” communication byphysicians in the context of professional-ism. The AMA’s standards specificallyreferences to the professional-patientrelationship and notes that “physiciansmust maintain appropriate boundariesof the patient-physician relationship inaccordance with professional ethicalguidelines just as they would in any

other context.” Patient privacy and confi-dentiality are cited as requirements. It isurged that physicians establish separatesystems for personal and professionalcommunication and use available privacysettings. Because privacy protection isnot always adequate, physicians areurged to monitor their own sites.

Point (e) in the AMA policy is worthquoting at length and verbatim. “Whenphysicians see content posted by col-leagues that appears unprofessional theyhave a responsibility to bring that con-tent to the attention of the individual, sothat he or she can remove it and/or takeother appropriate action. If the behaviorsignificantly violates professional normsand the individual does not take appro-priate action to resolve the situation, thephysician should report the matter toappropriate authorities.” This policy isgrounded in an additional policy pointthat the postings of any physician affectthe reputation of all physicians.

The American Bar Association(americanbar.org/groups/bar_services/resources/socialmedia.html), theAmerican Nurses Association (nursing-world.org/socialmedia), the AmericanInstitute of Architects (aia.org/about/

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Social Media Policy in Other Organizations

Social Media

Dr. Sebelius is a Regent ofthe College and a retired oraland maxillofacial surgeon living in Memphis, Tennessee;[email protected]

aiab083034), and many other profes-sional organizations have similar policies.In some cases, these organizations haveonline resources that help professionalsparticipate ethically in social media. TheCanadian Dental Hygiene Associationhas an excellent site with a moderatordesigned to assist hygienists. The site is hosted by the Canadian DentalAssociation (blog.cdha.ca/?p=404). Thethrust of professional organizationsinvolvement in social media appears to be to offer assistance in responsibleuse by professionals.

Policies to Protect OrganizationsVirtually every large organization has a social media policy. The policies areintended to recognize the free-speechrights of employees to express their opinions while simultaneously protectingthe interests of the organization.

Some companies encourage employeesto blog and carry on professional communication (content.dell.com/us/en/corp-comm/social-media-policy.aspx;hp.com/hpinfo/blogs/codeofconduct.html; forums.com/t5/welcome-news/best-buy-social-media-policy/td-p/20492)

Social media policy in corporationsis intended to guide the behavior ofemployees and customers alike—but indifferent ways. Corporate policy foremployees establishes guidelines forblogging, responding to customer com-munications, and general e-mail use.The most common themes across thesepolicies include: • Be civil, thoughtful, and professional• Be transparent, always disclose who

you are, what your capacity in theorganization is, and why you arecommunicating

• Do not break the law by defaming or slandering; revealing corporate,copyrighted, or other protected information; or misrepresentingproducts or services

• Where corporate policy regardingelectronic communication from customers exists, it is for the sake ofestablishing expectations regardingparticipation in media conversationshosted by the company (corporate.walmart.com/social-media-guide-lines; blogs.cisco.com/news/ciscos_internet_postings_policy). Corporatepolicies for customers who want touse company media platforms,including responses to companybloggers, typically mention:— No foul or offensive language— No advertisements or self-

promotional material— No product support, refunds, or

other business transactions(these are handled through otherchannels)

— No illegal activity, including comments that defame others

— No spam or repeated postings ofthe same message

— No anonymous postings or post-ings attributed to those otherthan the writer

Generally, companies that host sitesreserve the right to review and declinepublication of outside comments. TheMayo Clinic has a very strongly wordedcomment policy (mayoclinic.org/blogs/comment.html), and the American RedCross has a liberal one (docs.google.com/document/pub?id=1peevqnjjvknybdlhx4).

There are a number of not-for-profitorganizations that offer suggestions andservices to others, especially individualsand nonprofits, to help write socialmedia policy (socialfish.org/2009/10/drafting-socmed-guidelines.html;socialvoice.liveworld.com/blog-entry/bryan-persons-blog/creating-socialmedia). One excellent example is ShiftCommunications (www.shiftcomm.com), which invites imitation of its

ten-point template, as follows:1. Be transparent about who you are

and who you represent.2. Never misrepresent anything about

the company.3. Stay on topic and be meaningful.4. Use common sense and check with

others if in doubt.5. Do not speak beyond your area

of expertise.6. When disagreeing, be polite.7. Be very careful, diplomatic, and

factual when writing about others.8. Avoid legally protected topics.9. Never comment online about a

crises or emergency situation.10. Always bear in mind that electronic

communication can be discovered by almost anyone, not just the person you have in mind when communicating.

There are also organizations thattake a very liberal stance on free speech.This ranges from the Associated Press(ap.org/images/social-media-guide-lines_tcm28-9832.pdf), which hasdeveloped a useful set of standards, with concrete examples, for journaliststo the Electronic Frontier Foundation(eff.org/wp/blog-safely) that offers on-line advice on establishing anonymousblogs for employees who want to criticize or bring legal action againstcompanies. The Media Law ResourceCenter (mlrcblogsuits.blogspot.com)maintains a Web page listing the status of current law suits involving challengesto online speech.

I have not been able to locate a corporate policy that attempts to dictateor curtail what customers can say onthird-party sites. Recent court cases suggest that that would be a violation of freedom of speech.

Policies in DentistryA letter was sent from the Office of theAmerican College of Dentists over my

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Social Media

name to all (46) executive directors ofstate dental associations. The letter tookthe following form:

What has the [name of the state]Dental Association done to addressactual or potential problems relatedto the use of social media by dentists,dental staff, and patients? We areespecially interested to learn whatpolicy statements or training oppor-tunities you have planned orundertaken designed to promoteappropriate ethical behavior on thepart of dentists in this challengingnew world.

Responses were received for 17 of the 46 associations (37%). It is very likelythat the non-responding associations donot have formal social media policies. Of

those that did respond, three said theyhave a policy, and two of these have published their policy. Nine state associa-tions reported providing some form ofsocial media training, including articlesin their journals or other publications.Among the activities states have pursuedin this area are the two policy statementsthat appear in the sidebars, continuingeducation courses in four states, journalor newsletter articles in three, changesto judicial or ethical committess in two,publication of an “employee handbook”and Web comments. Five states have recognized the ADA Council on EthicsBylaws and Judicial Affairs advisoryopinion on Groupon/fee -splitting. Itshould be noted that the two policiesprovided apply only to staff and officers

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Social Media

in their capacities as representative ofthe state associations. They are notintended as policy for dentists practicingin the states.

While the response rate was low, this is probably a fairly representativenational picture in dentistry. It appearsthat the use of social media is becominga more widely recognized situation,which has been affecting the public ingeneral, and no less the dental profes-sion. In view of the fact that no stateassociations have developed policies forpractitioners, there is potential concernthat discussion leading to profession-wide standards for the use of socialmedia would be helpful. ■

The following applies to Staff, Officers,and Dental Volunteers who create or contribute to social media, including butnot limited to: blogs, social networks,wikis, and online forums,

A social media changes the way we socialize and conduct business, it is impor-tant to remember that what you do onlineis ultimately linked to your personal andprofessional views, and that your “virtualfootprint” can be tracked and traced.

The NDA respects Staff, Officers, andDental volunteers’ right to participate inonline forums for personal reason duringnon-work hours.

All NDA Staff, Officers, and DentalVolunteers participating in social mediaand online commentary are expected touse their professional judgment prior toposting anything online and to adhere to all NDA policies as detailed in theEmployee Handbook.

Content posted on blogs, social networks,wikies, and other online forums shouldcomply with the association’s confidentialityand employee ethics policies. Any work-related comments should be respectful and

relevant in a way that protects the associa-tion’s brand and reputation and follows theletter and spirit of the law. Written consentis required to use a NDA logo.

Your online presence reflects upon theNDA and its brand. Be aware that youractions captured via images, posts, or com-ments can reflect that of the association,regardless of whether it occurs duringwork hours. Tips for maintaining your andthe NDA’s professional image online:

1. Keep your personal and professionallives separate to help protect your ownprivacy. However, if you use professionalnetworking sites like LinkedIn, pleasedo promote your role in the NDA in apositive way.

2. Remember that even anonymous comments can be traced back to your IP address, so use NDA internet accessfor work-related purposes only per theEmployee Handbook. Do not use youNVDA.org e-mail address as theaddress associated with any personalsocial networking sites.

3. Post meaningful, respectful commentsthat positively promote your role as

a NDA employee and reflect on your co-workers/ colleagues, departmentand organization.

4. Respect Health Insurance Portabilityand Accountability Act (HIPAA) privacyrequirements.

5. Be transparent. Do not misrepresentyourself.

6. Respect copyright laws and referenceor cite sources appropriately.

7. When disagreeing with others’ opinions,keep it appropriate and polite. If youfind yourself in a situation online thatlooks as if it’s becoming antagonistic,disengage from the dialogues in apolite manner.

8. Never participate in social media whenthe topic being discussed might be considers a crisis situation.

When in doubt about posting a comment orimage, don’t! Protect yourself, your privacy,and the NDA’s confidential information andits reputation. What you publish is widelyaccessible and will be around for a longtime, so consider the content carefully.Google has a long memory.

Nevada Dental Associaion Social Media Policy

BackgroundAsocial networking has become a popularmeans of networking and quick communi-cation. Because of its intense popularity,the ODA has been compelled to enter intonew territory in order to more effectivelycommunicate with member’s dentists,staff, committee, boards, and councils.

Online communicates and commutationmediums have helped people connect inmany positive ways. Through these onlinemediums, ODA members, staff, and otheraffiliations with the ODA now have theability to create relationships of those withsimilar interests, formed groups to exploreand learn about the profession, and trans-formed the ways that we communicatewith each other in formal and non-formalmeans. The Association realizes the impactthese mediums may have on its members,staff, board members, and affiliations.

There are multiple social networking mediums and as the market continues to change, the intent of this policy is to protect the Association and its membersand staff equally. Examples of current key social networking sites are:

• Facebook• Twitter• LinkedIn• MySpace

Policy Scope1. The requirements of this policy do not

apply to the use of personal profilesunless used in the capacity of officialAssociation business. This applies toany individuals serving on councils,commissions, consultants, or any position that directly works with theoperations and presentation of theOklahoma Dental Association. If you are utilizing Association Services asallowed to manage your personal profile the policy is applicable.

2. This policy applies to the sue of anysocial networking medium intended for consumption by members, and to the use of social networking mediaon behalf of the Association for any purpose.

3. This policy applies to any interaction withany social; networking site whereby“Association Services” (defined below)are utilized in the viewing, posting orany other interaction with any suchsocial networking site. For the purposesof this policy, “association Services”means any services performed by ODApersonnel, any services performed onODA personal property, and any servicesperformed on behalf of or at the requestof the ODA.

Oklahoma Dental AssociationProtectionSocial networking sites are a useful andeffective tool in communicating with theOklahoma Dental Association member andgeneral public. Thus, certain sites havebeen identified as a means for theOklahoma Dental Association’s marketingand technology efforts, and communicationefforts for committess, ouncils, and boardoperations. When a group, page, event,profile and the like are created with repre-sentative Oklahoma Dental Association, itbecomes a direct representation of theODA to the members and participants ofthese social networking sites, and can beperceived with as much credibility as anews article or Association position oradvertisement, in the best interest of theAssociation, this communication may bemonitored in conjunction with an adminis-trative awareness of all forms of outreachon such sites, As a public operation, ODAis held to the highest ethical standards andis accountable for the way it is representedto all internal and external audiences.Staff, committee, council, consultant, andboard members of the Oklahoma DentalAssociation are seen as role and represen-tative models in the dental community andprofession. As staff representative of ourmembers, employees directly representingthe Association have the responsibility to portray the Association and themselvesin a positive and respectable manner at all times.

Recognizing both the effectiveness ofsocial networking sites and the need for a form of official management to protectthe interests of the Oklahoma DentalAssociation and professional relations

this policy is to manage and outline thepolicy involving the Oklahoma DentalAssociation’s social networking accounts.

Social networking at/through the OklahomaDental Association is encouraged, but mustbe managed through the CommunicationsAdvisory Board and reported to the Execu-tive Director and Board of Trustees of the Oklahoma Dental Association to ensure the integrity of the account and any information communicated on behalf of the Association.

Purpose The purpose of a social networking policyis to ensure that all appropriate Associationpolicies are followed while working withinor outside of the confines of the OklahomaDental Association network and media.

Definition of OfficialOfficial ODA social media sites are sitesthat were started with the directive andpermission of the ODA Executive Directorand the Communications Advisory Board.These sites are managed by ODA staff or volunteers under the supervision of the ODA Executive Director and theCommunications Advisory Board.

Requirements for Using SocialNetworking sites for OfficialAssociation Business1. In your capacity as an employee,

volunteer, council or committee member, board members of consultant,or when posting on ODA social mediaor on behalf of the Association, theintellectual property that you create and publish to social networking sites(postings, messages, etc.) can and will be considered the property of theOklahoma Dental Association.

2. The direct operation and format ofsocial networking sites, or any third-party application service providers, isnot under the control of the ODA, andtherefore the ODA will only seek tomaintain that content over which it has reasonable control.

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Social Media

Oklahoma Dental Association Networking Draft Policy

47


Social Media

The policies are intended

to recognize the free-

speech right of employees

to express their opinions

while simultaneously

protecting the interests

of the organization.

3. All Association or department levelsocial networking accounts must bemanaged by an approved, general e-mail account so dual role or responsi-bility is shared. No single individual is responsible for a social networkingaccount outside of the ODA networksystem.

4. All profile, group, and fan page origina-tors that communicate and establishrelationships on behalf of and for theAssociation will sign an agreementgranting ODA ownership of the profiles,group, and fan page. Should the origi-nator’s relationship with the ODAchange or terminate, the ODA willretain ownership of the profile, group,fan page, and established relationships.

5. All official ODA social networkingaccounts created/and or/ maintainedmust be reported to the ExecutiveDirector of the ODA and the Communica-tions Advisory Board of the ODA bysending the following information via e-mail to: [email protected] general,ODA e-mail address, the names of allmembers and their departments, titles,ODA e-mails, and ODA phone informa-tion. Requests for general ODA e-mailaddress (aliases and/or domain e-mail)may be sent to Information@ okda.org.

6a. If social networking gathering sitessuch as “groups” or “pages” must provide appropriate language for ODA’slegal and policy information:

Visitors: You are hereby on notice thatthe ODA does not control all aspects of this Web site. While employees, volunteers, members, consuls, and committees, and consultants of theOklahoma Dental Association communitypost to this public third party site, theODA is not responsible for the views,opinions, and postings by others foundon this site. The legal policies and procedures, for members, by which the ODA operates, are posted atwww.okda.org.

7a. All paid placement marking advertise-ments place on social networking sites must be developed and approvedby the ODA Executive Director and theCommunications Advisory Board prior to implementation.

8. Content must be current, reliable, accurate, and grammatically correct,but may utilize Web 2.0 language such as “@username,” and other generally recognized methods of onlinecommunication.

9. When determining the appropriatenessof personal online public material, consider whether it upholds and posi-tively reflects personal values andethics as well as the Oklahoma DentalAssociation’s Professional Communityand the value to the General Public.Remember, always present a positiveimage and do not do anything to embarrass yourself, your family, or the Association.

10.Personal pages should adhere to the policy when discussing official ODA business. Users should not have a reasonable expectation of privacy on any content posted on a social networking site.


AbstractWhat is at stake for dentists in the worldof social media? Because it is unrealistic to completely avoid the new network, dentists should master some of theseskills: risk management, crises manage-ment, and reputation management, as wellas understanding that the playing field isnot even. Guidelines for professional useof media are presented, along with somesuggestions for effective participation.

Our editor shared this story withme. An Austrian philosopher,Ludwig Wittgenstein, had been

pestering the economist John MaynardKeynes about getting a teaching positionat Cambridge. In a particularly pushy letter in 1929, Wittgenstein wrote:“Please don’t answer this letter unlessyou can write a short and kind answer…So if you can’t give me a kind answer inthree lines, no answer will please mebest.” Social media is a powerful weapon,but we cannot make it only cut the waywe want.

Managing Digital CommunicationSince it is unreasonable to expect thatdentists will be able to completely sidestepthe effects of social media, they shouldbe prepared to actively engage in manag-ing risk, crises, and their reputations.

Risk Management

The object of risk management is toanticipate harmful behaviors and unantic-ipated consequences of business processes.The purpose of risk management is toinstitute practices to avoid and mitigatecomplaints that impair reputation in themarketplace, complaints to regulatoryagencies, or disputes leading to litigation.

Risk management principles aregathered from case history experiences.As risk managers gather a portfolio ofexperiences, they see patterns of humanbehavior. Some observers believe thatexperiences in social media that nega-tively impact a dentist are only earlymanifestations in the life cycle. There are

too few cases at this time to see patterns.One must gain a retrospective experiencewith large enough samplings in order toidentify patterns for risk managementinvolving social media.

One of the sidebars at the end of thisarticle outlines some of the principles ofgood risk management.

In human behavior where anger isaroused, there is an excitation or agitationphase characterized by a strong desire to express the experience. Then there isthe infectious phase or the need to sharethe experience with others. Eventually,there is fatigue and finally the behavioris extinguished. The incident is then forgotten and we go on with our lives.

Entries on the Internet, however,never go away. The risk of social media is the reemergence of the entry,thereby agitating and inflaming oldwounds and renewing angst.

Defamation, Libel, and Slander

Generally speaking, defamation is theissuance of a false statement aboutanother person that causes that personto suffer harm. Legal definitions vary in statute from state to state. For example, in California, slander includes“imputations that a person is generallyunqualified to perform his or her job ortending to lessen the profits of someone’sprofession, trade, or business.

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Being Professional in the Social Media World

Social Media

Dr. Chan is a pediatric dentistpracticing in Fremont, California,and a Regent of the College;[email protected]

Slander is defined as oral defamation,in which someone tells one or more per-sons an untruth about another, whichuntruth will harm the reputation of theperson defamed. Slander is a civil wrong(tort) and can be the basis for a lawsuit.

Libel involves the making of defamatory statements in a printed orfixed medium, such as a magazine ornewspaper.

Damages are typically to the reputation of the plaintiff, but depending upon the laws of the jurisdiction, it maybe enough to establish mental anguish.Damages for slander may be limited toactual (special) damages unless there is malicious intent, since such damagesare usually difficult to specify and harderto prove.

Some statements such as an untrueaccusation of having committed a crime, having a loathsome disease, orbeing unable to perform one’s occupa-tion are treated as slander per se, sincethe harm and malice are obvious andtherefore usually result in general and even punitive damage recovery bythe person harmed.

Crisis Management

Where risk management attempts toanticipate events, crisis managementinstitutes measures for damage control.The characteristics of a crisis are: surprise,insufficient information, intense escalat-ing flow of events, loss of control, scrutinyfrom the outside, siege mentality, panic,and short-term focus. Key principles inhandling crisis:

• Control information• Isolate a crisis team from daily

business• Define the real problem short-term

and long-term• Recognize the value of a short-term

sacrifice• Resist the combative instinct

Managing One’s ProfessionalReputation

The Importance of Reputation

Benjamin Franklin reminds us that “Ittakes many good deeds to build a goodreputation, and only one bad one to lose it.”

In building one’s career as a dentist,there are many things we hope to achieve.We work at performing our craft well.We work at making a living from ourcraft. We work to build our reputationfrom our craft. What is reputation?

For many, building a reputationmeans accruing a favorable array ofattributes and experiences among members in a community. The driversare egoistic and economic. Reputation isconsidered a component of identity orimage. It is a series of beliefs about a person or entity based on the opinionsof others. To be more precise, reputationtransmission is a communication of anevaluation without knowledge of thespecifications of the evaluator.

In developing a reputation, there is a life cycle. As any new entrant to a

49


Social Media

It is probably an illusion to

believe that one might opt out

of the social media world.

Under the circumstances,

it is prudent for professionals

to assume that they must act

professionally at all time.

community, one is unknown to themembers of that community. The title of “Doctor” may bring some immediacyof respect due to the elevated statusafforded in society. However, as anunknown to that community, you nowhave to prove yourself.

At first, reputation begins with a declaration to the marketplace of animage. It is a self-description of how onewishes to be identified to the consumer.In the early stages, the image is mostlikely transmitted via traditional advertis-ing vehicles such as ads in various printand electronic media. In these earlystages, there are few experiences amongmembers of a target community thathave personal experience with the practitioner.

One’s reputation is also revealed bybehavior. Does one’s actions support itsclaims? Does one own up to an imperfec-tion or flaw in the product or service? Areputation is revealed by action in theface of adverse events. When Johnsonand Johnson was faced with the crisis ofcyanide laced Tylenol in 1982 and 1986,it immediately chose to pull all productoff the shelf. Thirty-one million bottleswere removed at an estimated value of$100 million. Tylenol was a core productfor Johnson & Johnson. The crisis enabledthe company to reposition its imagewhen it introduced tamper-resistantpackaging to the market place.

As a community’s experience withthe practitioner matures, the transmis-sion of one’s image expands fromtestimonials. Eighty-seven percent of U.S.consumers consulted friends or familiesand professional or online reviews whenresearching a product or service.

Media Threats to Reputation

The greatest reputation threat online tocompanies is negative media coverage(84% of surveyed Americans say so).The next two greatest threats are

customer complaints in the media orgrievance sites online (71%) and negative word of mouth (54%). Thisnegative word of mouth could be notonly from dissatisfied customers butfrom employees as well.

Historically, disputes between dentistsand patients have involved only thosetwo parties. Social media is changingthis interaction. Social media brings anaudience to a broader conversation.

There are emerging hazards of practitioners engaging social media. At the core of the dark side, social net-work exposes the vulnerability andfragility of reputation. It is the fear ofdamaging or impairing one’s reputationin the market place.

The social phenomena of “word of mouth” or informal transmission of a person’s experience with a serviceprovider to others is not a new concept.The conveyor of information is describedin sociological terms as a “vector”—transmitting information from one socialcluster to another. Social media broad-casts the transmission far beyond thesocial cluster of origin. Social mediapropagates both positive as well as negative messages of a professional rep-utation. Social media now brings a newaudience unfamiliar to the original source.

In a well-known experiment, as messages are passed from person to person, the initial message becomesaltered, embellished, and exaggeratedwith each recitation of the message. Thedownstream message becomes much different than the original incident.

When the exchange in social mediabecomes adversarial, another disadvan-tage is the anonymity of the attacker.Attackers do not have to identify them-selves. They can adopt fictitious namesand personas. It takes time for the recipient of the attack to sift through the entries to determine if the attackersare patients. Then recipients must peti-tion to the site to remove the attack.Meanwhile, the attack has been made,50


Social Media

The practitioner mustdefend a negative in the court of public opinion but is gagged bypatient privacy concernswhen doing so.

the damage is done, and no retraction ofthe falsehood is entered.

The economic damage to a practiceis difficult to quantify. Each point of contact with that knowledge now potentially translates to patients decidingnot to choose the dentist to service thepatient’s needs. The net result is “incomenot realized” due to an unverified rumor.

Ego is a significant factor affecting aprofessional’s decision to defend thatreputation in the market. In defendingone’s good name in the marketplace, ego can affect how far one commits personal economic resources. Recoverymay take time and therefore the practi-tioner may have income not realizedfrom the damage. “It takes 20 years tobuild a reputation and five minutes toruin it. If you think about that, you’ll dothings differently.” That is the advicefrom Warren Buffett.

The Playing Field

There is an uneven playing field fromthe perspective of the practitioner. In disputes referred to local peer reviewcommittees, a panel of uninvolved,impartial dentists objectively reviews thefacts of the case. They render an opinionbased on those facts regarding whetherthe performance meets the “standard of care.”

Complaints to a state dental boardare sent to consultant dentists to reviewthe records. Typically, the investigationlooks for egregious outcomes and grossnegligence. While there are state-to-statedifferences in adjudicating claims, thesereviews typically undergo a series ofadministrative processes before deter-mining an outcome. Only if the findingsare decided against the dentist do theoutcomes become public.

In complaints to third-party carriers,review is performed by consultant den-tists. Typically, review of the records and

clinical review will lead the insurancecompany to decide whether the treatmentis consistent with a standard of care. Theoutcomes are shared with the patient,the dentist, and the third-party carrier.Typically, there is not a public disclosure.

In social media, a patient can makeclaims, perhaps unsubstantiated, unveri-fied, and not technically reviewed. Thepractitioner is enjoined from the conver-sation largely due to the specter ofviolating patient privacy. The practitionermust defend a negative in the court of pub-lic opinion but is gagged when doing so.

A difficult dilemma for the profes-sional is the norm of granting primafacie credibility to patients’ personalremarks while grounding professionalresponses in objective evidence.

Professional Conduct Historically, professional conduct wasmonitored wholly by the individual pro-fessional bodies. The codes establishedby the professions were sufficient. Theseare self-imposed. In order to join, thecandidate agreed to abide by the samestandards that hold for all colleagues.

A code of ethics marks the moralboundaries within which professionals inthat body agree to be ethically bound. Incertain areas, where the public interestis considered to be heavily engaged, legislation is imposed on the professionalbody. Either legislation replaces profes-sional self-regulation with statutorylegislation or a statutory body is givenauthority to supervise the professionalassociation.

Many principles from the ADA Codeof Conduct can be implied but are notspecifically cited in the context of socialmedia. In the current ADA Code ofEthics, there is no language pertainingspecifically to the overall subject of social media, as there is in the code ofthe American Medical Association.

Social media is challenging traditionalparadigms of dentist-patient relationships.Traditionally, dentist-patient communi-

cation has been a private conversation.Social media now inserts an audienceinto those conversations.

Social media is creating conflict intraditional dentist-patient communica-tions. Social scientists study the positionand role of the professional in thedynamics of that conversation. In thisparadigm, there is a “social distance” or separation from the professional tothe patient. Social media encourages aleveling of the status among members of virtual communities.

Sharing a bad outcome throughword of mouth has always existed. Itwas often self-limiting through fatigueor merely limited to the contact of theoffended party. In social media, partiesunknown to the offended party and thedentist now share this complaint. The“posted” complaint never goes away. Ifthere is a resolution between parties, ittakes a conscious effort to remove thecomplaint or publicize the resolution.

Guides to Professional Conduct

The following are references to existingstandards that serve as useful guides toprofessional conduct under the height-ened scrutiny of social media.

Federal Regulatory Overlay The HIPAA Privacy Rule establishesnational standards to protect individuals’medical records and other personalhealth information. It applies to healthplans, health care clearinghouses, and those health care providers that conduct certain healthcare transactionselectronically.

The rule requires appropriate safe-guards to protect the privacy of personalhealth information and sets limits andconditions on the uses and disclosuresthat may be made of such informationwithout patient authorization. The rulealso gives patients’ rights over theirhealth information, including rights to

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Social Media

examine and obtain a copy of theirhealth records, and to request corrections.

The Privacy Rule is located in 45CFR Part 160 and Subparts A and E ofPart 164.

State Regulatory Overlay Business and professions regulatorystatutes governing and protecting privacyof patients and clients vary from state to state in language and content.

California Rules of ProfessionalConduct (CRPC) 3-100: “A member shall not reveal information protectedfrom disclosure by Business and Profes-sions Code section 6068, subdivision(e)(1) without the informed consent of the client.”

American College—Ethical HandbookThe American College of Dentist’sEthical Handbook contains standardson advertising, confidentiality, disclo-sure and misrepresentation. Thesecontinue to be applicable as guidingprinciples for professional conduct insocial media. [See sidebar.]

On the Edge

It is probably an illusion to believe thatone might opt out of the social mediaworld. Under the circumstances, it isprudent for professionals to assume thatthey must act professionally at all times.

The important questions thenbecome those of being a professionalparticipant. A few useful standards forall online communication include:• Avoidance of overtly or obtusely

self-promoting material• Objective explanations and advice to

minimize selective addition or omis-sions of facts leading the reader tobiased conclusions

• Suppression of personal opinions orcriticisms of treatment by others

• Full disclosure of risk• Grounding remarks in evidence

Clean MarketingAny marketing strategy should be wellconstructed. Variables such as start-upcosts, return on investment, mainte-nance costs including personnel andpersonal time to monitor should be considered. Social media is only one toolin that strategy.

Marketing strategy identifies aknown target audience and tailors themessage which differentiates the prac-tice. Particular attention should definethe image you wish to portray to themarket.

If engaging a vendor to develop this campaign, there should be a frankdiscussion of risks and benefits. A “what-if” scenario of an eventual negative review should be a part of this tactical discussion. Here are someideas to think about:• Flood your site with good reviews. • Ask your patients to write good expe-

riences. The object is to dilute orsubordinate posted negative reviews.

• Avoid fake user reviews. In somejurisdictions, fake reviews, whetherwritten by the dentist, a staff mem-ber, or a third-party marketer, canlead to possible fines, jail time, andloss of license

• The Federal Trade Commission monitors truth-in-advertising, including online review sites. Section16 CRF Part 255 defines “Guides concerning the use of Endorsementsand Testimonials in Advertising.” The social networks are governed byfederal interstate commerce laws.

• Sites such as Yelp have algorithmsthat identify artificial entries of posi-tive reviews. They are alert to ploysthat “game the system.”

• False and misleading dental advertis-

ing is under the jurisdiction of statedental boards.

• Flood your site with communitynews of what you did. Develop virtu-al social capital by counteracting negative images with good thingsyou do in a community.

• Go to the host site and inquire about the process to remove falsestatements.

• Deflect an accusation with a positivespin. From “Dr. X does horriblework” to “Dr. X gives advice on howto recognize substandard work.”

• Hire services of Internet reputationcompanies such as Reputation.comor Demand Force, which propose tomanage reputations online.

The Groupon GambitThis variation of a social media network-ing site does not fit the model of abuseseen in the prior case histories. The busi-ness model of a social coupon network isbased on the seller offering a discount orother incentive to purchase their wares.The network collects a fee from the sellerto gain access to the pool. For every “hit”from the network, the dentist remits apercentage of that fee to the network.

The Groupon business model bringsseveral principles for the marketingpractice. The social couponing companybrings customer acquisition. When anew business enters a market, it mustexpend resources to capture consumers.The social coupon company brings apool of customers.

The social couponing companybrings communication channels. It deliv-ers messaging to the pool of customersthat a subscriber company would haveto expend resources to continuously connect with those new customers.

The object of marketing is to attractconsumers to a product or serviceoffered by a company. Consumers vary

52


Social Media

in needs and what attracts them to aproduct or service. A company shoulddesign its marketing to the profile ofconsumer it wishes to attract.

Groupon consumers are consideredto be “price sensitive.” They are morelikely driven to seek and consumeepisodically. They tend to shop fromplace to place—looking for the next bar-gain. In Malcolm Gladwell’s The TippingPoint, the profile is the innovator. Theinnovator wants to be the first to try thenew thing within the social system.Their drive is to be the first to share theexperience with others.

The resources used to attract thisprofile of patients have to be continuous-ly renewed. This consumer is less likelyto be sustainable. The hypothesis—thatonce the vendor’s wares are sampled,the consumer is likely to be a repeat cus-tomer—has not been demonstrated. Therisk of engaging this profile of customeris the episodic behavior.

Contrast the “brand loyal” consumerswho tend to stick with that vendor orproduct once they make a decision toconsume a service (or product). Theyare more likely to continuously reaffirmthe brand to others in the marketplace.

The ADA Council on Ethics, Bylawsand Judicial Affairs believes that thisbusiness model is fee-splitting and there-fore an unethical practice. It issued anAdvisory Opinion at its March 2012meeting (See sidebar).

This same ethical concern isexpressed in associations such as theAmerican Medical Association and theAmerican Bar Association.

EpiloguePerhaps we are experiencing social mediain just one phase of its life cycle. It is muchlike every other social phenomenon.

All social phenomena undergo lifecycles. Social phenomenon experiencesthe following stages in a life cycle: dis-covery, curiosity, novelty, experiment,excitation, infection, expansion, adop- 53


Social Media

A difficult dilemma for the

professional is the norm

of granting prima facie

credibility to patients’

personal remarks while

grounding professional

responses in objective

evidence.

tion saturation, fatigue, and then theybecome extinguished.

The growth in the adoption of asocial phenomenon is typically seen asan “S” curve. When a social phenomenonis introduced to society, there is a lowrate of adoption in the novelty phase. Inthe growth or exponential phase, thereis an explosive rate of adoption. Finallythe adoption rate plateaus then declinesprecipitously. There is a belief that weare experiencing the exponential phaseof the social media phenomenon.

While we are in this phase of the life cycle, we do not have the benefit ofseeing if the challenges are transient or an integral fabric of the phenomenon.If we adopt media, we should consciouslyacknowledge both the benefits andtradeoffs of the phenomenon.

Some evidence of the evolving natureof social media is the pushback seen inthe marketplace against wholesale,unqualified adoption.

There have been class action lawsuitschallenging alleged unfair business practices of online review companies.While the suits have not prevailed, andchallenges have favored the online companies under the CommunicationsDecency Act, online companies haveadjusted their policies responding toresistance in the market.

In general, as social phenomenabecome adopted by the greater whole ofa population, the phenomenon adjuststo market forces. It undergoes correc-tions to accommodate that greater partof the market.

Meanwhile, from the current van-tage point in the life cycle, one can onlysee the immediate threats—the negative

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Social Media

reviews, the attacks. One does not yethave the benefit of perspective. As withmany social phenomena, the manifesta-tions vacillate to extremes. All socialphenomena are best seen with clarity in hindsight. There are times to take adeep breath and be patient.

SummaryIn the face of some emerging adversarialelements of social media, a dentist is still held to a higher level of conduct by society. He or she should be a profes-sional. There is an unwritten code thatthe dentist should be unemotionallyattached in delivering or receiving the message.

However, a dentist does not operatein society in isolation. In today’s market-place, he or she could choose to:• Be optimistic. The marketplace will

self correct.• Adapt as the phenomena changes.• Be patient. Wait to see what early

adopters do. Observe the mistakes,successes and failures, and what survives in the marketplace.

• Not participate. Recognize that the niche you wish to serve does not use social media as its decision-making determinant.

Social media is a social phenome-non. It is continuously evolving. Social scientists and business scholars whostudy it are still gathering experiences.New legal challenges and new prece-dents emerge. The phenomenon isorganic. It continuously adapts to mar-ket forces. The research presented inthis article reflects only a snapshot intime. ■

AdvertisingWhile the practice of advertising is considered acceptable by most professionalorganizations, advertising, if used, mustnever be false or misleading. When properlydone, advertising may help people betterunderstand the dental care available tothem and how to obtain that care.

Advertising by a dentist must not:

• Misrepresent fact;

• Mislead or deceive by partial disclosure of relative facts;

• Create false or unjustified expectationsof favorable results;

• Imply unusual circumstances;

• Misrepresent fees;

• Imply or guarantee atypical results;

• Represent or imply a unique or generalsuperiority over other practitionersregarding the quality of dental serviceswhen the public does not have theability to reasonably verify such claims.

Dentists should seek guidance on advertising from their professional organi-zations. The best advertising is alwaysword-of-mouth recommendations by satisfied patients.

ConfidentialityThe accepted standard is that every factrevealed to the dentist by a patient is, in principle, subject to the requirement ofconfidentiality, so that nothing may berevealed to anyone else without thepatient’s permission.

This standard has several accepted exceptions. It is assumed that other healthprofessionals may be told the facts theyneed to know about a patient to provideeffective care. It is also assumed that relevant ancillary personnel, such as record keepers, will need to know some of the facts revealed to them by the dentistto perform their job.

Further, relevant facts may be communicatedto students and other appropriate healthcare professionals for educational purposes.If maintaining confidentiality places othersat risk, then the obligation to breach confidentiality increases according to theseverity of the risk and the probability ofits occurrence.

Disclosure and misrepresentationDentists should accurately represent them-selves to the public and their peers. Thedentist has an obligation to represent pro-fessional qualifications accurately withoutoverstatement of fact or implying creden-tials that do not exist. A dentist has anobligation to avoid shaping the conclusions

4.E.1. Split Fees in Advertising and Marketing Services. The prohibition against a dentist’saccepting or tendering rebates or split fees applies to business dealings between dentistsand any third party, not just other dentists. Thus, a dentist who pays for advertising or mar-keting services by sharing a specified portion of the professional fees collected fromprospective or actual patients with the vendor providing the advertising or marketing servic-es is engaged in fee splitting.

The prohibition against fee splitting is also applicable to the marketing of dental treatmentsor procedures via “social coupons” if the business arrangement between the dentist andthe concern providing the marketing services for that treatment or those procedures allowsthe issuing company to collect the fee from the prospective patient, retain a defined per-centage or portion of the revenue collected as payment for the coupon marketing serviceprovided to the dentist and remit to the dentist the remainder of the amount collected.

ADA Advisory Opinion on Social Couponing

American College of Dentists Ethics Handbook

55


Social Media

Social media is a social

phenomenon. It is

continuously evolving.

or perceptions of patients or other professionals by withholding or alteringinformation that is needed for accurateassessment.

The dentist has an obligation to disclosecommercial relationships with companieswhen recommending products of thosecompanies. The dentist has an obligationto disclose commercial relationships inprofessional presentations or publicationswhere the dentist promotes or featuresproducts of those companies. The dentistmay ethically have ties to commercialentities, but the dentist should fully dis-close such relationships to patients andprofessional colleagues when nondisclo-sure would lead to differing conclusions,perceptions, or misrepresentation.

Incomplete disclosure and misrepresenta-tion may also adversely affect dentalresearch and journalism. In the course ofevaluating research and dental literature,dentists are cautioned that such problemsmay exist and can lead to incorrectassumptions and conclusions. If suchincorrect assumptions and conclusionsare adopted, less than proper care mayresult. It is important that dentists criti-cally evaluate dental research, literature,and advertising claims.

Principles of Risk Management• Identify, characterize, and assess

threats.

• Assess the vulnerability of criticalassets to specific threats.

• Determine the risk (i.e., the expectedlikelihood and consequences of specific types of attacks on specific assets).

• Identify ways to reduce those risks.

• Prioritize risk reduction measuresbased on a strategy.

Immediate steps:

• Respond to all negative reviews promptly.

• Don’t be defensive.

• Take the discussion offline.

• Give them back their money.

• Negotiate to remove the review. Go to the host site to inquire how to remove a false statement. It willlikely take time. Meanwhile, thereview stays in full view of a continuously renewing audience.

• Apologize if necessary (“I’m sorry you had a bad experience”).

• Turn a positive into a negative.

• Potential new consumers will seehow you solve a dispute.

• Be a real person, empathize, don’t be contrived, don’t be high-handed,authoritarian.

• Risk prevention.

• Monitor via Google alerts: Go towww.google.com/alerts, and fill inyour name and a new alert with yourpractice name. This will give youquick notice, via e-mail, so you canvisit the offending review and decidewhat to do about it.

• Ask patients to create real, positive reviews.

• Ask patients to go on Yelp or Facebookand write a positive review aboutyou. A case study. A testimonial.

• Be careful of contriving positivereviews or “gaming the system.”These sites have algorithms that identify changes in volume,velocity (or increased rate), contemporary entries.

• Establish an office policy on staffengagement on social media and confidentiality agreements on the subject.

Bruce Peltier, PhD, MBA, FACDAnthony Vernillo, DDS, PhD, MBELola Giusti, DDSLarry E. Jenson, DDS, MA

AbstractIn this case a young dentist has signedonto a managed care plan that has severalattractive features. Eventually, however, he notices that he makes little or no netrevenue for some of the work that he does.A colleague recommends that he use different labs for different patients, withlabs matched to each patient’s dental planand coverage. Offshore labs are used formanaged care patients. Three knowledge-able experts comment on the case, twowith many years of private practice experience, two who are dental educatorsholding master’s degrees in philosophy and bioethics.

Different LabsIssues in DentalEthicsAmerican Society for Dental Ethics

Associate EditorsJames T. Rule, DDS, MSBruce Peltier, PhD, MBA

Editorial BoardMuriel J. Bebeau, PhDPhyllis L. Beemsterboer, RDH, EdDLarry Jenson, DDSAnne Koerber, DDS, PhDDavid T. Ozar, PhD (editor emeritus)Donald E. Patthoff, Jr., DDSJos V. M. Welie, MMedS, JD, PhDGary H. Westerman, DDS, MSGerald R. Winslow, PhDPamela Zarkowski, RDH, JD

Correspondence relating to the Issues in Dental Ethics section of theJournal of the American College ofDentists should be addressed to: James Rule8842 High Banks DriveEaston, MD [email protected]

The Case

After dental school you sign onwith a managed care organiza-tion because they offer to help

pay your student loans. The plan sendsplenty of new patients your way.

You begin to notice that you feel“ripped off” with patients who have this plan because your fixed costs areconstant, yet the payment you get fortaking care of these patients is low, nearly the same as your overhead for theprocedure and sometimes actually lower!This means that all of the discountcomes out of your “labor,” leaving youwith significantly less to take home.

You have lunch with an old dentalschool friend who has also signed onwith a managed care firm and she says,“That was a problem for me at first too,but I figured out a solution. I use two different labs; one for the managed carepatients and one for cash-paying orindemnity plan patients. The lab I usefor managed care is offshore. It isn’tquite as good, but they are much cheaper.It evens things out, and it’s fairer to me.I’m not working for free anymore.”

Introduction This case has important current implications as the American economystruggles and dental plans continue toevolve in more and more complex ways.The price of dental education is high,and the costs associated with establish-ment of a new dental practice increaseeach year. At the same time, the qualityand convenience of “offshore” labs continue to improve.

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Issues in Dental Ethics

Dr. Peltier is Professor ofPsychology and Ethics at theDugoni School of Dentistry,University of the Pacific in San Francisco; Dr. Vernillo isa faculty member at the NewYork University College ofDentistry; Dr. Giusti is a facultymember at the Dugoni Schoolof Dentistry; and Dr. Jensonpractices general dentistry inUkiah, California, lectures indental ethics at UCSF and is aboard member of the AmericanSociety for Dental Ethics;[email protected].

Three experienced practitioners and educators respond to the ethical andpractical dimensions of this case.

Dr. Vernillo’s ResponseA dentist meets with a colleague whoacknowledges the problem of inadequatefinancial reimbursement from a man-aged care organization. To stanch thefinancial hemorrhage, however, the dentist’s colleague decides to use two different labs. The dentist admits thatthe quality of the work from one lab isnot quite as good but reserves it for hermanaged care patients. The first dentallab is more costly but offers higher quality work. This dentist reasons thatshe can thus charge a higher fee for herservices by passing that increased coston to her cash-paying patients. She fur-ther argues that such a solution is fairerin terms of economic outcome for thepractice. It is not necessarily unethicalfor that dentist to charge a higher fee forbetter quality lab work if a cash-payingpopulation is willing to pay for betterquality, preferred treatment. Yet it is not more equitable for the managed carepatients who will likely receive a lesserquality of treatment. Whose well-being is most important?

A financial conflict of interest existswhen a clinician entrusted with theinterests of a patient tends to be undulyinfluenced by a secondary interest(Emanuel & Thompson, 2008). Thepatient’s health must be the dentist’s primary interest and should take prece-dence over financial self-interest or

the interests of a third party such as amanaged care insurance plan. No onebegrudges the dentist a comfortableincome, and loan repayment from professional school represents a majorfinancial burden. However, managedcare systems might provide incentives to decrease the quality of healthcareservices or even withhold beneficial care(Kassirer, 1998). In vulnerable popula-tions or those from lower socioeconomicgroups, extracting a tooth as a treatmentof choice rather than endodontic treat-ment with fixed prosthetics mayexemplify its greatest negative physicaland psychological impact.

To determine whether dentists areacting in the patient’s best interest, dentists might ask what they would rec-ommend if they were working under theopposite reimbursement system. Dentistsin managed care might ask whetherthey would recommend the interventionunder fee-for-service. Similarly, fee-for-service dentists might ask what theywould recommend if they would losemoney performing that procedure.Economics do matter, but financial considerations should not distort a clini-cian’s reasoning. When dentists face aconflict of interest, the dentist must reaffirm that the patient’s interests areparamount, disclose conflicts of interest,and manage the situation to protectpatients (Lo, 2009). Individual dentistsand the dental profession need to reaf-firm their fiduciary responsibility.

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When dentists face a

conflict of interest, the

dentist must reaffirm that

the patient’s interests

are paramount, disclose

conflicts of interest, and

manage the situation

to protect patients.

Several ethical concerns may arisewhen clinicians contract with managedcare organizations (Lo, 2009). First,high-quality care might not be providedto all patients. Patients who are moresocially privileged or persistent indemanding services are more likely toobtain the desired procedures. Second,the fiduciary role of dentists might beundermined. Dentists are entrusted tolook after patient interests as well astheir own. Third, a dentist may even usedeception to obtain insurance coverage.Such deception may be more commonwhen dentists believe that it is unfairwhen a plan fails to cover a more expen-sive procedure that they perceive to benecessary. However, deception under-mines social trust. Within the constraintsof managed dental health care, dentistsshould act as advocates when a patientcould receive significant clinical benefitfrom a procedure that the plan disallowsfor that patient.

Dentists should disclose all treatmentoptions to patients along with paymentimplications, allowing patients to exercisetheir autonomy to make decisions intheir own best interests. Imagine a physi-cian who fails to disclose all treatmentoptions to a patient with disseminatedcancer. If that patient knew that othertreatments existed, then that patientmight choose another option (regardlessof greater cost) if it could be reasonablyexpected to prolong the patient’s qualityof life. Failure to disclose such informa-tion would undermine that patient’sautonomy and capacity to choose morebeneficial treatment.

If the dentist is to get involved in abalancing act between who can and cannot afford certain types of treatment,

then the fairest way to negotiate that situation at minimum is to disclose alloptions to each patient. Perhaps dentalpatients in a managed care plan maythen be able to obtain additional finan-cial support from another source (suchas family members or a loan) to electmore beneficial and desirable treatment.If the cash-paying patients pay more,then they likely permit the dentist toremain in practice for managed carepatients who would perhaps not receiveany treatment at all. However, it is ethi-cally (and perhaps, legally) problematicto assert that some treatment, even oflesser quality, is better than none.

Dr. Giusti’s ResponseControlling overhead expenses can be challenging for the new dentist.Inexperience in management of thefinances of a private practice combinedwith the very real burden of debt servicefor educational and practice loans cansend a young practitioner into full-tiltmode. It has been observed that, over thepast 13 years, mean office overhead hasincreased every year while compensationfrom capitation plans has decreased dramatically (Rhodes, 2010). Unsurpris-ingly, solo practitioners with averageoverhead may perceive that capitationrates constitute compensation that isincompatible with dentists’ incomeobjectives and therefore unfair.

Recent increases in the cost of goldas well as lab components such as thoseused in implant restoration have moti-vated many private practitioners to turnto overseas laboratories. Laboratoryoverhead costs have dropped from 10-12% of production to 8-10% in a managedcare office (Jones, 1998). The local dentallab is now competing with facilities inChina, Korea, the Philippines, CostaRica, and Mexico, where low labor andproduction costs enable these “offshore”operations to flourish. These labs do nothave to concern themselves with FDA orADA compliance rules requiring the use

of approved materials. American labsstruggle with the high cost of setting uplabs, with an average minimal capitalinvestment of $200,000 (Napier, 2011).There are no states in the United Stateswhere technicians are required to belicensed, and the number of graduatesfrom certified technician training pro-grams in America now number only 300annually (Napier, 2011). The difficulty inattracting a trained technician combinedwith the steep cost of equipment drivesmany local dental labs to respond toInternet advertisements for low-cost labwork done in other countries. These labs can promise a seven-day turn-around for work sent via UPS or FedExto Hong Kong or Zhuhai City. This canturn a local lab into a broker as well as a producer.

The American dental lab market ishuge, and to offshore entrepreneurs itmay look like low-hanging fruit. In 2010$1.32 billion in overseas dental laboratoryfees were generated by American dentaloffices. This represents 20% of U.S. salesand nearly 40% of actual restorations(Napier, 2011).

So what’s wrong with this picture?As it turns out: plenty.

Practitioners in Sweden have foundoverseas labs to be eager to serve them.A study by Ekblom, Smedberg, andMoberg published in the Swedish DentalJournal in 2011 compared single crownsand fixed bridges done in Swedish labswith those done by Chinese technicians.While Chinese fixed partial dentures costless than half the price of those done inSweden, there were problems. Theauthors found that the general quality of the bridges made in China was comparable, but the dimension in somecases was too weak. The gold alloy that the dentists ordered was often notthe alloy used in fabrication, and the

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chromium-cobalt alloy contained small amounts of nickel.

The seal attached to a restoration isan Identalloy certification of the metalcontent that was used, and it is designedfor inclusion in a patient’s chart.Research has confirmed that this may ormay not be the actual metal used by anoverseas lab (Ekblom et al., 2011). Thepractitioner, however, must uphold thisstandard, managed care or not. Patientsdepend on us. They have no idea wherethe materials come from, and they willbe living with them in their mouths fordecades, perhaps the rest of their lives.

While offshore labs may seem attrac-tive, there are downsides in addition tothe ones noted by the Swedes. Difficultrestorations which require multiple fittings may be more conveniently fabricated by a local laboratory so thatshade or contour adjustments can beperformed expediently. Whose responsi-bility is it when an undersized bridgeframework fractures? (The dentist’s).Will a foreign lab make good on a failuresuch as this? Remakes dramaticallyimpact the bottom line in all practices,more painfully in a managed care officewhere reimbursement is less. If a patienthas an allergic reaction to a non-pre-cious metal such as nickel and a crownneeds to be replaced, the dentist muststand behind that restoration and get itremade. It has been estimated that one denture remake negates the profitcompletely, as lab expenses constitute as much as half of the dentist’s fee. Aredistant labs willing and able to satisfythe functional and esthetic requirementsof an American dentist or patient?Private practitioners who participate inmanaged care plans continue to have afiduciary relationship with their patients,identical to that which they uphold forall of their other patients. If the dentistchooses to maintain his or her profitmargin by decreasing lab expenses, boththe dentist and the patient could pay aheavy price for the use of an overseas lab.

There is an educational “cost”involved, as well. A relatively new practi-tioner profits in many ways by workingwith a seasoned dental technician. Forexample, an experienced lab tech canquickly recognize weaknesses in the den-tist’s techniques and “mentor” the youngdentist by troubleshooting impression-making techniques, for example. Thistype of relationship allows the dentist toascend the learning curve much morequickly and avoid costly mistakes earlyon. Repairs to fixed or removable pros-theses can be done expediently whenworking closely with a local lab. A solidrelationship with a lab benefits the dentist who can provide rapid service to patients who may require a quickesthetic remedy such as a stayplate. Bycollaborating on an ongoing basis withthe same laboratory it becomes easierfor the lab to “rush,” and the extra timejust becomes part of managing thataccount. Custom shade matching is easily done by a local lab, but how doyou make small adjustments when thelab is 8,000 miles away? There will be nonoontime visit by the dentist to consultwith the lab technician on a demandingcase when the work is done in HongKong or Mexico.

What about the ethics involved inthis dentist-technician relationship? Is the dentist required to inform thepatient that the lab work involved in acase is done overseas? Can the dentistreasonably assert to the patient that heor she is overseeing the fabrication of along-span bridge or complex veneer casewhen it is actually being completed inAsia? Would patients care?

It is well-known in the lab industrythat laboratories used by managed careoffices are likely to use non-preciousalloys for work done on behalf of theirpatients due to the lower cost of the

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Difficult restorations which

require multiple fittings

may be more conveniently

fabricated by a local

laboratory so that shade

or contour adjustments can

be performed expediently.

alloy. These non-precious alloys have different casting properties and porcelain-bonding abilities than their moreexpensive counterparts. Is it fair to use ahigher quality alloy for a private patientwhose fee is also higher? Does the patientwith the “better” job whose dental planreimbursement rates are “better” also geta “better” crown? I would assert that thedentist treating two patient populationswill more willingly go the extra milewhen reimbursed at the higher fee. It ishuman nature. A careful and conscien-tious practitioner may have to dig deepto take the energy and chair timerequired to remake an impression for amanaged care patient when such anexpense cuts into an already narrow

profit margin. If patients with the full feeprofile are used to “underwrite” the workdone on patients with lower reimburse-ments we face another moral conundrum.

If the dental practice is a microcosmof the society in the area, redistributingmoney to benefit those less “able” might be a way to approach resources,but it is really not fair to raise the fee ofthe full-fare patient to accomplish thisgoal. Nonetheless, a dentist might decide to use the same lab and materialsfor every patient and average out theprofit over both populations as an alter-native resolution.

Finally, while dentists are not directlyresponsible, the local economy and perhaps the quality of life in local com-munities are impacted by the use of offshore labs as jobs move overseas.

There are probably better ways forthis young dentist to solve his problem,but they require that he take the “longview.” Another way to protect the bottomline in a new practitioner’s office is to“grow” the practice by taking really goodcare of existing patients and encouragingthose patients to refer their family members and friends. This method takes time, but it is the soundest way fora practice to enlarge its base. I wouldencourage new dentists to take the old-fashioned route to a successful career.Excellent care and high quality serviceare practical in the long run. Analyses ofrevenues from capitated and managedcare plans may demonstrate thatincreasing the number of those patientswill never help the bottom line, and participation in those plans createsinevitable quandaries, as we have seen.New dentists can also team up with eachother (I think this is an especially goodway for young women with families) to provide the best possible coverage,

energy, and overhead expense contain-ment for an office. A private practitionercould also hire a marketing consultantto analyze the demographics of the areain which the practice is located to betterunderstand whom the practice serves,and decide if the mission of the practiceis in alignment with the patient base.Adoption of any or all of these strategiesinstead of using a foreign lab is a better choice in the long run for theyoung dentist.

Dr. Jenson’s ResponseCrowns are not restorations. Thoughthese terms are commonly interchangedthey are not the same thing. A crown is amanufactured object, whether it is madeof acrylic, stainless steel, non-preciousmetal, gold alloy, or ceramic material. Arestoration is something that the dentistdoes with a tooth. A restoration is the act and result of returning a tooth to itsoriginal (or sometimes an improved)form and function. The quality of therestoration depends upon the skill andconscientiousness of the dentist. It is thedentist that makes the decision to restorea tooth with a crown, what type ofcrown to use, and the ultimate accept-ability of the restoration. Thus theethical considerations of restorationsinvolve the care and judgment of thedentist and not the laboratory, CAD-CAMmachine, or box from which the crownwas produced.

For example, in the scenario presented, the dentist has a source ofmanufactured crowns that she deemsinferior to another more expensive laboratory. This may or may not play arole in the final restoration of a tooth. If the dentist is able to use the crown toachieve acceptable margins, contacts,contours, and esthetics, she can fulfillthe ethical obligations involved in restor-ing teeth. This, of course, may requireconsiderable additional work by the dentist; however, it is still possible.Again, it is the resultant restoration that

is the dentist’s responsibility. To makethis more obvious, we would not saythat a near perfect crown (object) is anadequate restoration if the crown werecemented onto the tooth improperly, creating an open margin and a highocclusion. In that case, the restoration isa failure regardless of the attributes ofthe crown.

With this in mind, let’s take a look at the ethical issues in the scenario presented. It is clear that the “old dentalschool friend” is trying to save money by purchasing crowns that are in someway “inferior” to those from her usuallaboratory. Is there an ethical problemwith finding ways to reduce costs? Quite the contrary. In Dental Ethics atChairside, Ozar and Sokol (1994) pointout that dentists have an ethical respon-sibility to use dental resources in anefficient manner. Finding a cheaper laboratory is fine as long as the dentistaccepts the responsibility for the finalrestoration as discussed above. However,whenever cost-cutting tactics reduce thequality of care provided, a higher ethicalvalue, the patient’s oral health, has beencompromised and the tactics are thusunethical. As stated above, if the finalrestoration meets the standard of care,its price is not an issue.

Another consideration is the actualmaterials used in fabricating the crown.If a lower crown price has been achievedby using cheaper materials that may nothave the longevity of the higher-pricedcrown or are possibly toxic in nature,this does present an ethical problem.Every dentist is ethically required toknow the content of the materials usedin any restorative procedure. Thisrequires him or her to work with labora-tories that can reliably report the exactcontent of metal alloys and ceramicsused in the manufacture of the crown. Ifthe dentist cannot get this information

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from the laboratory or does not trust thelaboratory’s reporting of the materialsthat they use, he or she must find a labo-ratory that can be trusted. Patients havelittle expertise in evaluating crown con-tent and structure and must rely uponand trust the dentist to determine thesethings for them. Misrepresenting thequality of the crown to the patient vio-lates this trust and violates the autonomyof the patient to make an informedchoice. In this scenario, are the patientsin the managed care program informedthat the crowns being placed in theirmouth are in some way inferior? Is theinsurance company that pays for thecrown being informed that the crownsare inferior? If not, the dentist is misrep-resenting the work and is thereforebeing unethical. In the case of the insurance company, it may actuallyamount to fraud.

These principles apply to any crownsource. We often see advertisements for “crowns-while you-wait” these daysin offices that use the new CAD-CAMtechnologies. Are patients being fullyinformed about the nature of thesecrowns? Are these crowns really as goodas the gold or porcelain fused-to-metalstandard of the industry? Do they breakmore frequently? Will they last as long?Do patients realize that more toothstructure must be removed in order tomake these crowns work? To a patient, acrown is a crown is a crown. It is theresponsibility of the dentist to discussthe limitations of any restorative materi-al or procedure. To represent these newtypes of crowns as an equivalent to thetraditional gold or porcelain fused-to-gold crown without the supportingscience is ethically questionable at best.

To continue with the scenario, isfully informing the patient as to thequality of the crown enough? One mightask if it is ever acceptable for a dentist tocreate a restoration that does not reachthe level of quality of his or her bestwork? Might a patient of limited finan-

cial resources request a lower qualityrestoration in order to achieve sometherapeutic benefit? I think we can allagree that this is an accepted practice indentistry. It is certainly clear that there isa broad range of restorative choices thatare offered in the typical dental office.Let’s take the example of a stainless steelcrown. Dentists have provided stainlesssteel crowns to patients for many yearsas a compromise treatment. Most den-tists would agree that a stainless steelcrown meets many of the requirementsof tooth restoration but the margins,contours, and contacts are, generallyspeaking, far less than ideal. And yet inmany cases, this type of crown is betterthan doing nothing at all; there is sometherapeutic benefit to be obtained bydoing these types of crowns.

There is no question that dentistsand patients often work within an eco-nomic structure that constrains what ismeant by the phrase “best possible treat-ment.” Every day in practice, patientsand dentists engage in discussions thattry to balance treatment goals with the economic resources of the patient.For many patients, the “best possibletreatment” is simply not possible due tofinancial reasons, and dentists are fre-quently compelled to find a compromisetreatment plan that maximizes theresources of the patient and yet still pro-vides an enhancement to the patient’soral health. This is an ethically acceptedpractice under the following circum-stances: (a) The specific proceduresdone by the dentist do no harm to theoral health of the patient and achievesome benefit for the patient. (b) The specific procedures are done to a level ofquality commensurate with the dentist’sbest efforts. For example, if one choosesto do a stainless steel crown, one isrequired to make the best stainless steel

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A relatively new practitioner

profits in many ways by

working with a seasoned

dental technician.

crown one is capable of making. (c) The patient is fully informed and under-stands the risks involved with anytreatment compromise.

The ethical piece missing in this scenario is an open and honest discus-sion with the patient regarding material,structure, and long-term expectations of the intended restorative procedure.Hiding important information from thepatient in order to obtain a financialgain should be seen as unethical—whether it is a lower laboratory fee or, as in the case of a CAD-CAM crown, a competitive edge.

Summary and ConclusionsThree accomplished dental practitioner-educators have presented thoughtfulcommentary on this intriguing case, onethat has timely practical implications.“Offshore” dental laboratories representa resource that every practitioner must

consider. The majority of dental practicesin the United States treat patients with avariety of payment configurations, some“better” than others. During a recession-ary economic period, dentists andpatients alike will reasonably search forefficiencies and other ways to cut costs.

The commentators aptly describe thenumerous difficulties and pitfalls associ-ated with the variable use of local andoffshore labs, and all three come to theconclusion that no matter what labs putout, the final restorative result is a den-tist’s fiduciary responsibility. They pointout that this responsibility is effectivelyand properly discharged when patientsfully understand and consent to theirspecific treatment and when the resultmeets the standard of care. Dr. Jensonwrites that “To a patient, a crown is acrown is a crown.” I would go furtherand note that to most patients a crown isactually a “cap.”

Four scenarios seem possible:First of all, there is a materials issue.

The dentist has a responsibility to discern the content of any crown that heor she places in someone’s mouth. It ispotentially disastrous for a lab to usetoxic materials, and it is the dentist’s jobto figure this out. We cannot rely solelyon advertisements or the informal“word” of representatives of a laboratoryon this question. There is a due diligenceresponsibility when a dentist uses anylab, offshore or not. If a dentist discoversthat a lab uses dangerous or suspectmaterials, he or she must avoid the use of this lab. Patients rely on dentiststo do this.

The second scenario is when thematerials or crowns or bridges producedby the offshore lab are safe but inferiorin some way. If this poorer quality is

likely to result in a restoration that isunlikely to last as long as one that usedmore expensive lab products, this mustbe discussed with patients. As Dr. Jensonpoints out, trade-offs are not categoricallyunethical as long as patients understandthe implications of the arrangement. Dr. Vernillo worries that the reimburse-ment structure of managed care plansirresistibly causes better care for somepeople and worse care for others. Heagrees with Dr. Jenson about full andhonest disclosure to patients. It is clearlyunethical to make clinical trade-offsbehind a patient’s back. If trade-offs inquality are to be made, patients shouldbe invited to participate in the decisionmaking, and Dr. Vernillo points out thatsome patients will find additionalresources when they know what is atstake. Many dentists articulate a reluc-tance to do anything that does notrepresent their “finest” work, but thisposition seems rigid, impractical in thereal world, and perhaps elitist. That said,it is hard to defend dental care in courtwhen it is not a dentist’s best, especiallywhen the dentist knows it is not his orher best work. Dr. Jenson resolves thisissue by asserting that no matter whatlab product a dentist uses, he or she canstill do their “best” technical and clinicalwork when using that crown or bridge.Some patients at some points in theirlives prefer a less expensive solution thattheir dentist might not favor. That said,the final clinical outcome obviouslymust fall within the standard of care forcrowns in general. The matter becomesa bit more complicated when weacknowledge that patients’ standards donot always match the standard of theirdentist. Sometimes patients would behappy with an outcome that is less thanthe one envisioned by the dentist andsometimes a patient seeks a standard ofperfection that the dentist knows isunachievable. The use of a less expensivelab seems more acceptable when bothpatient and doctor agree about the results.

The third scenario is a variation onthe second one. The young dentist mightfind that when he uses the less expen-sive lab he ends up using more time tomake the crown or bridge fit properly(which is his duty, independent of thequality of the lab work), thus burningthrough any financial advantage hethought to gain by using that lab. To usea cheaper lab and leave margins open isdifficult or (more likely) impossible tojustify. Dr. Giusti points out the problemof actual lab work failures. The dentist is on the hook when a cheap bridge fractures prematurely. Time and moneyare both at stake when that happens.You do often get what you pay for.

The fourth scenario occurs when the less expensive offshore lab produceswork of adequate quality or better. Thismay turn out to be a realistic future scenario. As an example, many Chineseproducts continue to improve in quality,and it was not that long ago thatAmericans snickered at the phrase“Made in Japan.” No one snickers at aJapanese automobile any more. Thebiggest problem with this scenario, asDr. Giusti notes, is that the dentist losesan important personal relationship withthe lab and its people. This is a seriousmatter, as close coordination can resultin a much better outcome for presentand future patients, as well as a quickerturnaround time. Difficulties related toworking with a lab that is 11 time zonesaway are lessening, but will never com-pletely resolve.

There are complicated issues of fairness in this case, some real and somerationalized. The normative ethical principle of justice is clearly in play. First, is it fair to patients who receive labwork that is not as good? Obviously notwhen materials are toxic or dangerous.But when the lab product is safe and

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adequate, commentators insist that it isthe dentist’s responsibility to ensure thatthe final restorative outcome is soundand meets the standard of care. Readersmust decide whether it is okay for dentists to provide “better” care to somepatients based on financial wherewithal.It is difficult to imagine a world wherethat would not, in actual practice, be thecase. The fairness matter turns on thequestion of whether or not the conceptof “you get what you pay for” applies tohealth care, and many dentists (andpatients) are uncomfortable with thatidea. If health care and treatment of dis-ease and the human body are a specialcircumstance that should not be treatedin a commercial way, then it seemsunfair to provide multiple levels of clini-cal care. But if that is the case, someonehas to pay, and therein lies the rub. Inthe United States, from a practical, cultural, and political point of view,there seems insufficient enthusiasm forthe notion that we should all chip in toensure that everyone receives a premi-um level of health care. One could evennote that dentists have priced themselvesout of the mainstream market by evolv-ing treatments that are better than theeconomy can support. Multiple implantsand truly beautiful cosmetic solutionsare out of reach for most cash-paying,middle-class Americans, and employerswould obviously prefer to keep the costof dental benefits as low as possible.

It seems appropriate that bothgroups of patients be informed of all thereasonable treatment options. Perhaps ahigh-end patient might prefer a lower-cost restoration for some reason and, asDr. Jenson notes, some patients lackingexcellent dental coverage might find away to pay for the use of a better lab ifthey understood the implications. Thatsaid, it must be noted that many patientshave zero interest in this kind of infor-mation and decision. They prefer toleave such matters to the discretion of

their dentist, and trust him or her to dothe right thing.

The question of whether or not thereimbursement structure of a managedcare program is fair to a dentist is another matter entirely. To assert thatthose arrangements are unfair is arationalization. Dental plans have noobligation to ensure that a dentist’sfinancial goals are met. There are hundreds of plans out there, and it is adentist’s duty to evaluate them and sign binding contracts only after duediligence has been done. To somehowassert that one “has to” participate inone of these plans is pure rationaliza-tion. If a plan is that bad no dentists willenroll or participate, and the plan wouldbe forced to change or go out of business.On the other hand, to participate in aless than attractive plan in order to serve patients who would otherwise notreceive care is noble indeed. But then,whining is not allowed. It is truly great to choose to make a professionalcontribution to the community, andthere is a price to be paid. That is why itis called a contribution.

Dr. Giusti recommends that youngdentists take the long view and developtheir practices the old-fashioned way, by providing excellent care so that word-of-mouth reputation is your marketer.

I also recommend a discussionbetween the young dentist and his lab.Do lab owners have any practical suggestions about how to deal with themanaged care dilemma? In order tomaintain a lasting and productive rela-tionship with this young dentist, the labmay be willing to create some sort ofwin-win that has not occurred to thedentist. Local labs, you can be sure, arewell-aware of the threat from across the ocean. ■

ReferencesEkblom K., Smedberg J.I., & Moberg, L.E.(2011). Clinical evaluation of fixed partialdentures made in Sweden and China.Swedish Dental Journal, 35 (3), 111-121.Emanuel, E. J., & Thompson, D. F. (2008).The concept of conflicts of interest. In E. J.Emanuel, C. Grady, & R. A. Crouch (Eds.),The Oxford Textbook of Clinical ResearchEthics. New York: Oxford University Press,pp. 758-766. Jones, D. G. (1998). Evolving business:Keeping up with the profession is the chal-lenge. Journal of the California DentalAssociation, 34 (1), 29-36. Kassirer, J. P. (1998). Managing care—Should we adopt a new ethic? NewEngland Journal of Medicine, 339 (5), 397-398. Lo, B. (2009). Resolving ethical dilemmas:A guide for clinicians. New York: LippincottWilliams & Williams, Wolters KluwerHealth. Napier, B. (2011). The relationship betweendentists and dental laboratories —Predictions for the future. Journal of theCalifornia Dental Association, 39 (8), 569-571.Ozar, D. T., & Sokol, D. J. (1994). Dentalethics at chairside: Professional principlesand practical applications. St. Louis:Mosby-Year Book.Rhodes, S. K. (2010). Dental capitationinsurance provider compensation: A fairdeal? American Journal of Managed Care,16 (11), 276-280.

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Eric K. Curtis, DDS, MA, FACD

AbstractThe rhetoric concerning mid-level providersand their impact on general dental practiceis building in intensity. This is a complexissue and there is no clear picture of eitherthe benefits or dangers to the public ofsuch a delivery model, whether such plansare economically sustainable, or the role of general dentists in the configuration of future practices. The opinions of a representative sample of thinkers from various perspectives are sampled.

An internist friend of mine is predicting the demise of his profession. “Primary care

medicine,” he says, “will be dead in fiveyears.” The reasons involve a complex,long-simmering stew of governmentmachinations and shrinking third-partyreimbursements, which threaten tosqueeze the already-dwindling supply of American general internists, pediatri-cians, and family practitioners out of ajob. The internist acknowledges thatthere will be mid-level providers to takehis place. “I’m not going to be able toafford to practice,” he says. “My job willbe to watch over six physician assistants[PAs] and make sure they each see 40patients a day.” He foresees an increas-ingly scrambled healthcare structure inwhich nurses and PAs refer patientsdirectly to secondary- and tertiary-careproviders. “The system is upside-downfor primary care doctors,” he says, someof whom now make less than some PAs.But he believes that the biggest losers in this brave new medical world are thepatients, who face increasing costs andfragmented, overall lower quality care. “I look forward to the day,” he says, “that a nurse practitioner operates onPresident Obama.”

My friend is not alone in his worry: A 2006 position paper by the AmericanCollege of Physicians, “The ImpendingCollapse of Primary Care Medicine andIts Implications for the State of theNation’s Health Care,” begins by pro-claiming, “Primary care, the backboneof the nation’s health care system, is at

grave risk of collapse due to a dysfunc-tional financing and delivery system.”The potential failure of general medicineis an alarming development. But there is another one that might make yousquirm even more: General dentistrycould be next.

The Death of Dentistry ForetoldIs general dentistry a dead professionwalking? Many fear that dentistry, thefirst specialty of medicine but also its historical outcast, is finally going theway of primary care medicine, poised tosink with a sigh into a mire of competingproviders. If the public’s next physicianwill be a nurse or a PA, then its next dentist may well be a dental hygienist, adental health therapist (DHT), or even adesperate internist. “The train has leftthe station,” writes dental coach Marc B.Cooper, DDS, president and CEO of TheMastery Company in Ashland, Oregon,in the online article “Mid-level DentalProviders and You.” The arrival of non-dentists to perform extractions andfillings, he declares, is no longer anexperiment, but a fait accompli: “Mostprivate practitioners will perceive it as athreat to their survival. It won’t matter.It’s going to happen.”

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Is General Dentistry Dead?

How Mid-level Dental Providers Will Affect the Profession

Manuscript

Dr. Curtis practices generaldentistry in Safford, Arizona; [email protected]

This paper won the AmericanCollege of Dentists /AmericanAssocaiton of Dental EditorsJournalism Prize in 2011. Itoriginally appeared in AGDImpact in 2010.

Bryan C. Edgar, DDS, of Federal Way,Washington, chair of the AmericanDental Association Commission onDental Accreditation, likewise warns thatthe future has arrived. “The idea of acompeting provider of dental services isvery alarming to most of the profession,”he says. “I am from a state where weview the reality of an independent mid-level as something that will happen,whether we like it or not.”

Some believe that dentistry as nowpracticed will indeed soon be gone. Publicattitudes are primed and grievancesloaded. In the popular imagination, it issaid that general dentists, whose averageincome approaches that of primary carephysicians, make too much money.Dentists charge too much, a situationrendered all the more visible by the factthat most third-party plans pay only aportion of the total fees. Dentists also areperceived as standoffish, even selfish,rarely playing ball with Medicaid and itsstate analogs, and never with Medicare.They do not work on Fridays and avoidpracticing where people really needthem, such as in community clinics andsmall towns. What is more, their work,although technical, is essentially easy. Atleast one university president has sug-gested that dentists ought to be trainedin community colleges. So, the thinkinggoes, let someone who can deliver thecare more easily and cheaply—and, toscratch below the surface, more sympa-thetically—go ahead. The specialists willstill be there to do the hard stuff.

General dentistry certainly will not die immediately among mid-level

providers, but its traditional activities—and identity—may well be altered.Richard W. Dycus, DDS, Cookeville,Tennessee, chair of the Academy ofGeneral Dentistry Dental PracticeCouncil’s Workforce Subcommittee,describes the resulting shift in focus thatmy internist friend dreads. “When thefederal government is involved,” he says,“70% of a practitioner’s time will bespent on administrative tasks.”

Dr. Cooper tells his dentist clients to embrace the inevitable change bypreparing to become practice adminis-trators rather than constantly bendingover the chair themselves. Educatorssuggest that dentists may need to incor-porate some part of the business modelinto their professional training. RichardJ. Simonsen, DDS, MS, founding dean ofMidwestern University College of DentalMedicine–Arizona, identifies anotherchange in emphasis: “Dentists will spendmore time in diagnosis.”

Conflicting Perceptions of Accessto CareA February 2010 paper published by the Pew Center on the States (“The Costof Delay: State Dental Policies Fail One in Five Children”) declares, “A ‘simplecavity’ can snowball into a lifetime ofchallenges.” But the Pew Center estimatesthat more than 10% of the nation’s pop-ulation “has no reasonable expectationof being able to find a dentist.” (In some

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General dentistry certainly

will not die immediately

among mid-level providers,

but its traditional activities

—and identity—may well

be altered.

states, it says, that figure rises to one-third of the general population.)Concentrating its interest on children,the Pew Center identifies three causativefactors in “the national crisis of poordental health and lack of access to care”:lack of widespread sealants and fluorida-tion; lack of dentists willing to treatMedicaid-enrolled children; and its ownconclusion that “in some communities,there are simply not enough dentists toprovide care.” The Pew Center’s fourfoldsolution includes two preventive measures—more widespread school-based sealantprograms and community water fluori-dation—and two proposals to increasetreatment: Medicaid improvements thatwould enable and motivate more den-tists to treat low-income children, and“innovative workforce models thatexpand the number of qualified dentalproviders, including medical personnel,hygienists, and new primary care dentalprofessionals, who can provide carewhen dentists are unavailable.”

Such calls for mid-level dentalproviders clearly mark a response tosocial demand. “Society has gotten theword out,” says Kenneth L. Kalkwarf,DDS, MS, dean of the University of TexasHealth Science Center at San AntonioDental School. “People would likeimproved access to oral health care, andthey would like the cost of care to bemore reasonable.”

Dr. Dycus agrees. “Healthcare reformof all kinds,” he says, “is happeningbecause the public could not get the careit wanted at the price it wanted.” Theperfect price point, of course, is none atall. “The American public believes healthcare should be free,” Dr. Dycus says,explaining that external payment mech-anisms during the past decades havelulled and confused policyholders. Forexample, 1970s-era laws allowing third-

party payer checks to be assigned directlyto dentists yielded an important unin-tended consequence: Patients nowadaysdo not understand the costs of care.

Some argue that the push for mid-level providers reflects not just dentistry’sfailings but its faults. Dentists havefocused on individual practice growththrough more expensive services, virtu-ally ignoring the public health problemsof restricted wider access to dental care.In a newsletter article, “Can’t Get Therefrom Here: The Futile Attempt to Resolvethe Access Issue” (available at www.mas-teryofpractice.com), Dr. Cooper observesthat within the context of private prac-tice dentistry, dentists are acculturated to“doing highly technical work to restorehealth and beauty to patients who canpay for it.” In this world, access really isnot an issue. Because the perfectionist,one-on-one culture of private practice is so single-minded, dentists consideralternative providers—from denturists toindependent registered dental assistantsto foreign-trained dentists—to be not just competitors, but hacks. At the same time, dentists fail to recognize theinadequacies of volunteerism, effortsakin to pouring individual buckets ofwater into a burning building.

Dr. Dycus counters that dentistry’sfocus is not narrow, but realistic.Regardless of their proponents’ goodintentions, care-stretching medical modelssuch as mid-level providers simply willnot work for dentistry—which is, for themost part, surgery rather than medicine.“Legislators think dental mid-levelproviders will be like nurses,” he says,“but dental practice is much more com-plicated than writing a prescription.”Mid-level providers also may contributeto tiered treatment inequities, with themid-level provider seeing patients fromcut-rate plans, while the dentist sees the“good” patients. What is more, mid-levelproviders do not provide a “dental home.”“They are pain- and urgent care-focused,”Dr. Dycus says, “not prevention-focused.66


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Because the perfectionist,one-on-one culture of private practice is so single-minded, dentistsconsider alternativeproviders—from denturists to independentregistered dental assistants to foreign-trained dentists—to be not just competitors,but hacks.

That’s why the ADA is experimentingwith an alternative community dentalhealth coordinator [CDHC] model.Prevention is the key to controllingcaries and periodontal disease.”

Dr. Dycus contends, in fact, that mid-level providers do not even benefitmedicine, where efficiency has declinedas a result in two key respects. The firstis timeliness of care: “When people go to PAs and nurse practitioners first,” hesays, “diseases do not get treated assoon.” The second is cost control: “MDsmake less and mid-levels make more,and costs just rise and rise.”

All this, Dr. Dycus contends, sidestepsthe underlying reality: mid-level providersare simply not needed. First, they are toolimited in scope to solve the access issue.No mid-level will be able to providedefinitive, final care. Second, in most circumstances, the problem is not thatdentistry is unavailable but that it isunderutilized. Because dentists havebecome much more efficient than olddelivery models recognize, the traditionaldentist-patient ratios are inaccurate.“The dental office capacity we have nowis sufficient,” Dr. Dycus says, “and exist-ing capacity, including better use ofexpanded-function dental assistants,could be expanded more inexpensively,safely, and efficiently than creating anew position.” Increased utilization ofdental services, he says, is a function ofnot only population growth, but of oralhealth literacy, financial incentives, andmandated care. In any case, the existingworkforce is sufficiently elastic: “We can give care at a lower fee as long asthe fee covers overhead.”

The Players: Who Stands to Gainfrom Mid-level Providers?Regardless of dentists’ existing capacity,other parties see opportunities—andprofits—in developing mid-level providers.

Large group clinics and HMO-centeredpractices may employ mid-level providersto leverage their facilities. State dentalpractice acts typically allow physicians to practice dentistry, so primary careMDs and DOs—even emergency roomsand urgent care centers—could hire dental mid-level providers to supplementincome. Insurance companies also mayanticipate a possible profit center as thepresence of more providers encouragesmore potential plan enrollees. Hygienistgroups hope to use the mid-level positionas a springboard to expand their scopeof practice or move toward independ-ent practice.

Dental educators also may have avested interest in training mid-levelproviders. The University of Minnesota,for example, educates non-dentist dentaltherapists alongside dental students,while the University of California, LosAngeles—consistent with recent changesin California law—trains expanded-function registered dental assistants toplace restorations. Yet, understandingthat a non-dental school-based alternativeexists for each of these mid-level directionsas well—Metropolitan State University inMinnesota and Sacramento City Collegein California—could turn even doubtingdentists into philosophers. “Isn’t dentaleducation best accomplished in a dentalschool?” asks Midwestern’s Dr. Simonsen.Midwestern University investigated thedevelopment of a mid-level training program but chose not to pursue it.

Dental education is again a growthindustry, albeit one with results moremodest than practicing dentists mightexpect. According to a 2009 article in the Journal of Dental Education, “TheImpact of New Dental Schools on theDental Workforce Through 2022,”authors David Guthrie, Richard W.Valachovic, DMD, MPH, and L. JacksonBrown, DDS, PhD, describe how, follow-ing a spate of dental school closuresbetween 1986 and 2001, three new dental schools opened between 1997

and 2003, and eight more are in variousstages of development over the nextdecade. By 2022, 8,233 new dental graduates will have joined the U.S. work-force, adding about three dentists per100,000 people. The authors concludethat this jump in new dentists likely willresult in a stable dentist-to-populationratio, but not one that by itself willnoticeably increase access to care forlow-income or rural populations.

While some interested entities aresimply opportunists looking to cash inon a trend, the direct catalysts for thecreation of mid-level providers are insti-tutions further removed from dentistry.“What makes this a very complex issue,”says Dr. Edgar, “are the dynamics of various groups outside our professionwishing to push their ‘solution’ toaccess.” He identifies two such groups in particular—state legislatures and nonprofit charitable foundations. “We all know that the economics of dentistrywill not allow an independent mid-levelprovider to solve the access problemwithout some meaningful funding, suchas increases in Medicaid rates or taxincentives,” he says. Any increase inaccess to care requires funding, and lawmakers nowadays are suspicious ofhanding over the cash to dentists. “Thelegislatures are beginning to view ourscope issues as turf protection ratherthan public protection,” Dr. Edgar says.Certain foundations, for their part, areflexing their money muscles as changeagents. The Pew Center’s February 2010paper calling for the development ofmid-level providers identifies three phi-lanthropies networked in that intent: thePew Center, the DentaQuest Foundation,and the W.K. Kellogg Foundation.

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Threat or Opportunity?Responding to Mid-level ProvidersDentists, deeply conflicted about theexistence and role of mid-level providers,also are divided in their response. Dr.Dycus says, “One camp wants to draw aline in the sand, dig deeper moats, andbuild higher walls. The other side, citingthe argument that you are either at thetable or on the menu, says that we haveto be on board with the concept, or thegovernment will impose something onus without our input.” What dentists oneither side cannot afford to do is ignorethe situation. “If we do not stand up, no one will,” Dr. Dycus says. “The AGDneeds to be clear that demand can bemet using the existing structure of auxiliaries more efficiently. Expandedfunction dental assistants could performreversible procedures, such as placingrestorations.”

“A lot of people can do certain dentalprocedures cheaper than dentists,” Dr.Kalkwarf says, “including dental assis-tants, hygienists, denturists, and dentalstudents. It is a matter of who is in control.” Dr. Edgar agrees that dentistcontrol is crucial. “We need to push ashard as we can to retain supervisionover these new providers and makethem truly ‘team members,’” he says.“We need to maintain a credible peer-to-peer accreditation process of any educational system that trains these individuals.” Dr. Simonsen sees theMinnesota programs as accomplishingthat aim: “They are putting the mid-levelunder the license of the dentist, whichleaves the dentist in total control.”

Mark I. Malterud, DDS, of St. Paul,Minnesota, past president of the Minne-sota AGD, says that once a mid-level lawwas passed in his state, dentists wereobligated to support it. He says, “Even

though we do not believe that there is aneed for a dental therapist and that theimpact will remain minimal for quitesome time, we wanted to be sure thatthe training and testing of these para-professionals would be adequate and thatthey also would be able to join into ateam concept so that the patients receivethe quality of care that they deserve.”

The first question for any proposedchange in dentistry is how the publicwill fare. “A self-interested point of viewhas no place in determining what is best for the public,” says Dr. Simonsen.The priorities, Dr. Kalkwarf says, mustproceed in this order: “What is good forsociety comes first, then what is good forpatients, and finally, what is good for self.”

Dr. Malterud sees potential advan-tages to society in a mid-level provider.“There are situations,” he says, “whererural access clinics with a heavy load ofpatients may benefit from this, too, aslong as it is within a team concept.” Buthe also worries about the risks. “In anon-team environment,” he says, “I seethe potential for the general public toactually be open to injury. There are somany interoperational diagnostic situa-tions that come up that move a ‘simple’procedure to another category outsidethe mid-level’s scope of practice. If a mid-level provider is functioning outside thedental team, resolution of such situationscannot be completed safely.”

In “The Disappearing Dentist,” a segment of Slate magazine’s 2009 five-part analysis, “The American Way ofDentistry,” author June Thomas calls not just for more dentists, but for moregeneral dentists, to improve access tocare. “Just as in medicine,” she writes,“there are too many specialists and toofew general practitioners.” Ms. Thomasreports that in the 1980s, about 20% ofdental graduates pursued specialty pro-grams; by the turn of the 21st century,the figure was closer to one-third.

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Any increase in access to care requires funding,and lawmakers nowadaysare suspicious of handingover the cash to dentists.

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1. Extend the period over which student loans are forgiven to tenyears without tax liabilities for the amount forgiven in any year;

2. Provide tax credits for establishing and operating a dental practice in an underserved area;

3. Offer scholarships to dental students in exchange for committing to serve in an underserved area;

4. Increase funding of and statutory support for expanded loanrepay ment programs (LRPs);

5. Provide federal loan guarantees and/or grants for the purchaseof dental equipment and materials;

6. Increase appropriations for funding an increase in the numberof dentists serving in the National Health Service Corps andother federal programs, such as the Indian Health Service (IHS), programs serving other disadvantaged populations andU.S. Department of Health and Human Services (HHS)-wideloan repayment authorities;

7. Actively recruit applicants for dental schools from underserved areas;

8. Assure funding for Title VII general practice residency (GPR)and pediatric dentistry residencies;

9. Take steps to facilitate effective compliance with government-fund ed dental care programs to achieve optimum oral healthoutcomes for indigent populations:

a. Raise Medicaid fees to at least the 75th percentile of dentists’ actual fees

b. Eliminate extraneous paperwork

c. Facilitate e-filing

d. Simplify Medicaid rules

e. Mandate prompt reimbursement

f. Educate Medicaid officials regarding the unique nature of dentistry

g. Provide block federal grants to states for innovative programs

h. Require mandatory annual dental examinations for children entering school (analogous to immunizations) to determine their oral health status

i. Encourage culturally competent education of patients in proper oral hygiene and in the importance of keeping sched uled appointments

j. Utilize case management to ensure that the patients are brought to the dental office

k. Increase general dentists’ understanding of the benefits of treating indigent populations;

10. Establish alternative oral health care delivery service units:

a. Provide exams for 1-year-old children as part of the recommenda tions for new mothers to facilitate early screening

b. Provide oral health care, education, and preventive programs in schools

c. Arrange for transportation to and from care centers

d. Solicit volunteer participation from the private sector to staff the centers;

11. Encourage private organizations, such as Donated DentalServices (DDS), fraternal organizations, and religious groups, to establish and provide service;

12. Provide mobile and portable dental units to service the underserved and indigent of all age groups;

13. Identify educational resources for dentists on how to providecare to pediatric and special needs patients and increase AGDdentist participation;

14. Provide information to dentists and their staffs on culturaldiversity issues which will help them reduce or eliminate barriers to clear communication and enhance understanding of treatment and treat ment options;

15. Pursue development of a comprehensive oral health educationcomponent for public schools’ health curricula in addition toprovid ing editorial and consultative services to primary and secondary school textbook publishers;

16. Increase the supply of dental assistants and dental hygieniststo engage in prevention efforts within the dental team;

17. Expand the role of auxiliaries within the dental team thatincludes a dentist or is under the direct supervision of a dentist;

18. Eliminate barriers and expand the role that retired dentists canplay in providing service to indigent populations;

19. Strengthen alliances with the American Dental EducationAssocia tion (ADEA) and other professional organizations suchas the Asso ciation of State and Territorial Health Officials(ASTHO), the Associa tion of State and Territorial DentalDirectors (ASTDD), the National Association of Local Boards ofHealth (NALBOH) and the National Association of County &City Health Officials (NACCHO);

20. Lobby for and support efforts at building the public health infra structure by using and leveraging funds that are availablefor uses other than oral health; and

21. Increase funding for fluoride monitoring and surveillance programs, as well as for the development and promotion of anew fluoride infrastructure.

Proposals for Increasing Access to Dental Care without a Mid-Level Provider

Source: AGD White Paper on Increasing Access to and Utilization of Oral Health Care Services, 2009

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Mid-level providers aresimply not needed. First,they are too limited inscope to solve the accessissue. No mid-level will beable to provide definitive,final care.

Dr. Malterud thinks that help from afew mid-level associates might free upthose general dentists to perform moreeffectively. “Working in a team conceptcan facilitate delegation of duties thatwould allow the lead dentist to providehigher levels of care and accomplishmore difficult procedures,” he says. “This can open up avenues of educationfor the general dentist to get advancedtraining to help more patients withmore complex cases.”

Dr. Edgar also thinks mid-levelproviders could provide an unexpectedboon to general dentistry. “In someother countries that have dental thera-pists, dental education programs havebeen expanded to train dentists in morecomplex patient care,” he says. “Thesame could happen here.”

The Future of Dentistry: WhereWill We Be in Ten Years?Neither planners nor pundits can predictto what extent the public’s unmet dental care needs actually translate intodemand. “Access to care is a multifacetedproblem that needs to be addressed onmany fronts and on several levels,” saysDr. Simonsen, noting that mid-levelproviders represent only one of manyapproaches. Dr. Kalkwarf suggests thatthe survival of mid-level dental practi-tioners, much less their widespreadentrenchment, is not assured. “There area lot of pieces in play,” he says. “Becausemid-levels are trained less, they may beable to provide care less expensively. Itsounds good in theory, but the market-place may direct something else.”

The mid-level concept is amorphous.Potential mid-level providers include acumbersome assortment of healthcarefigures encompassing a broad range oftraining, from dental assistants to super-vised or independent dental hygienists,to dental therapists of either undergrad-uate or graduate status, to nurses, toprimary care physicians. It is largelyuntested. And it is fragmented. “This is afifty-state issue,” Dr. Dycus says, “onethat will be fought state by state. Mid-level dental care is not a national issueper se, because dental practice acts andinsurance rules are different in eachstate.” What’s more, there is no guaran-tee that mid-level providers will end upworking with the underserved popula-tions any more than dentists will, aslegislatures and foundations envision.

While Dr. Simonsen characterizesthe acceptance of mid-level providers as potentially “painful” to dentists, Dr.Edgar minimizes the threat. “I do notbelieve that dental therapists as they currently exist will kill general practice,”he says. “Mid-levels are constrained byboth the narrow scope of treatment procedures allowed and the limited populations that they are able to treat.Dentists will remain the leader of the team.”

Dr. Kalkwarf also believes thatreports of the death of dentistry havebeen greatly exaggerated. He describes astudy in the 1970s that predicted therewould be no future need for endodon-tists or pediatric dentists. Instead, hesays, “Those specialties evolved, broad-ened their scope, and they havecontinued to be successful.”

General dentistry itself has beenwritten off before. In 1984, Forbes mag-azine published an article, “What’s Goodfor America Isn’t Necessarily Good forthe Dentists,” which announced the endof the profession. As fluoride cut the

super-generalists already by achievingtheir Mastership in the AGD.” Regardlessof the future of mid-level providers, Dr.Malterud contends, AGD super-generalistsare poised to flourish. Dr. Edgar agrees:“I see comprehensive general dentistryin ten years thriving beyond our currentexpectations.”

The mid-level challenge places dentistry at a crossroad. “We can eitherget in control of our profession and find models to provide greater access tocare,” Dr. Kalkwarf says, “or we can keep doing what we have been doingand see the erosion of the profession.”The profession’s movement as itapproaches the puzzle of mid-levelproviders feels something like that of the International Space Station circlingearth. Some worry that dentistry isplummeting, while others have faith itcan remain aloft, safely, usefully, andindefinitely. It is important to realizethat a freefall and an orbit are the same thing. In orbit, however, the craftis also moving forward. The difference is control. ■

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The priorities, Dr. Kalkwarf

says, must proceed in this

order: “What is good for

society comes first, then

what is good for patients, and

finally, what is good for self.”

decay rate in half—cavities, Forbesdeclared, “are going the way of polio and smallpox”—and dental schoolspumped out too many graduates, feesand incomes would fall. Dentists wouldwork on salary, and the professionwould dramatically contract, attractingless qualified students who would loweroverall standards of care.

Obviously, dentistry did not die. It did not even contract. In 1999, DavidPlotz wrote a Slate essay, “DefiningDecay Down: Why Dentists Still Exist,”concluding that dentists prospered in theface of predicted extinction because theyevolved. They made dental visits morepleasant, advanced their skills in estheticsand implants, and changed patient attitudes. “Americans under age 60believe keeping all their teeth is an entitlement,” Mr. Plotz observed. “Thetransformation of American dentistry…is…a case study in how a profession canwork itself out of a job and still prosper.”

Many observers believe general dentists will again figure out a way tothrive in the face of mid-level challenges.“While the details may evolve and maynot be all chairside, smart dentists candevelop a quite satisfying career forthemselves,” Dr. Kalkwarf says. Dr. Edgarsees dentistry’s future adaptability asbeing based firmly in education. “What I do in practice is very different frommany of my colleagues because of theeducational opportunities that the AGDhas offered me,” he says.

“When I was in dental school 30years ago,” says Dr. Malterud, “a lectureron the future of dentistry predicted therise of a new level of practitioner that hetermed a ‘super-generalist.’ I have keptthat in mind and used it as a target formy education. I believe that many of ourAGD members are positioned to become

Matthew Kramer, DDS

AbstractAccess to oral health care is an issue thathas received attention at the local, state,regional, and national levels. This studyfocuses on how dentists in private practicesettings attempt to address problemsregarding access to care through personalinitiatives. These dentists donate or discount services in their own offices toindividuals who face access barriers. These donated or discounted services maygo unreported and unnoticed. The researchquestion addressed in this study is: What was the amount and type of free and reduced-fee care that dentists in thecommunity of Brookline, Massachusetts,provided during the 2008 calendar year.

Individual capacity for obtaining neededdental care may be reduced for a num-ber of reasons: loss of private dental

insurance benefits due to retirement orloss of employment; retirees living onfixed incomes; a challenging economymay also contribute to complex accessissues. With the exception of trauma ororal cancer, Medicare does not providedental coverage, making elders one ofthe largest demographic groups lackinginsurance for needed dental care(Special Commission on Oral Health,2000). Elders face unique barriers tocare. In 2007, of adults 65 years andolder, among those with private dentalinsurance, 51% had contact with a den-tist within six months as compared toonly 32% of those over 65 who only hadMedicare health care coverage whichprovides no dental benefits (Pleis &Lucas, 2009). From 2006 through 2008,the percentage of adults age 18 to 64 inMassachusetts who had a dental visitwithin twelve months increased from67.8% to 75.5% (Long & Masi, 2009).

Due to the access challenges that segments of the population face andtheir lack of oral health care, some dentists have been accused of being self-serving by outside groups, when in fact,many dentists do pro bono work and areinvolved in their own special projects forwhich they have never charged patients.The aim of this study was to investigatethe amount and type of free and reduced-fee care that dentists in Brookline,Massachusetts, provide to patients duringcalendar 2008. The survey assessed theextent and type of care provided without

fee and the characteristics of the dentistswho provided such care.

Before conducting the study, severalhypotheses were formulated: • Older dentists would donate more

care than dentists who graduated from dental school more recently.The expectation is that younger den-tists still have a great amount ofdental school debt; therefore theymay be less likely to donate carethan established dentists who havepaid off their loans and dental schoolexpenses.

• Dentists who graduated from a private dental school would be inmore debt than those who attendeda public dental school and thereforemay be less likely to donate care.

• Dentists who own their practiceswould donate more than associatesof a practice because owners havethe decision-making ability andauthority to donate care, whereasassociates may not have the optionto donate care.

• Dentists would be more willing togive free care to patients referred tothem by a religious organization orcolleague than from a professionalorganization or local schools.

• Dentists would be more willing todonate care to children than to adults.

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Dentists Demonstrating Professionalism

Dentists in Private Practice Settings Provide Free or Reduced-fee Care

Manuscript

Dr. Kramer is a faculty member at the BostonUniversity School of Dentistry; [email protected].

• Dentists who have practiced inBrookline for a longer period of timewould be more likely to donate care.This assumption is predicated on a community-based, “giving-back” culture in the town of Brookline.

MethodsThe research protocol, including the survey created for this study, was sub-mitted to the Boston University MedicalCenter Institutional Review Board (IRB);it was determined to have exempt status.A survey was created to explore theamount of free and reduced-fee care thatdentists in the Brookline, Massachusetts,community provided. The survey con-tained a table in which dentists wouldestimate the number of patients to whomthey donated free care and the numberof patients for whom they provided care at a reduced-fee during the 2008calendar year.

The survey was divided into threesections. The first section focused on theage of patients and the amount and typesof free or reduced-fee care provided. Thepatients were categorized by age groupsinto children (under 18 years of age)and adults over 18, including senior citizens. To distinguish between routineand emergency care, dentists were alsoasked to specify the number of free andreduced-fee emergency procedures (trauma, pain, etc.) and the number offree and reduced-fee routine proceduresfor children and for adults and seniors.Finally, dentists were asked to estimatethe total monetary value of free andreduced-fee care for children and adults.

The survey included a question regardingthe sources of patient referral for free or reduced-fee care. The second sectionon the survey addressed demographiccharacteristics of the practice. Questionsincluded the amount of clinical hoursworked per week, the number of totalpatients seen in a week, and the type ofpractice (general/specialty; solo/group).The third section of the survey containedquestions regarding demographics aboutthe dentist, including sex, ethnicity, yeargraduated from dental school, type ofdental school attended (public/private),specialty, and number of years practicingin Brookline.

Initially, postcards were sent to the186 dentists with a Brookline mailingaddress alerting them that a surveywould be mailed to them within the next seven days and requesting theirparticipation. The names and addressesof all dentists with mailing addresses inBrookline were obtained from the Board ofRegistration in Dentistry in Massachusetts.Assurances were provided that allresponses would be anonymous and that results would be reported in theaggregate only. Three days after thepostcards were sent, the surveys weremailed to the population of dentists. The surveys were numerically coded todetermine non-respondents and placedin envelopes along with a self-addressedenvelope for the dentists to return thesurvey. Non-respondents were deter-

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While critics state that

pro bono care is not a

healthcare system, this study

suggests that many dentists

take it upon themselves to

address access to care and

to serving the underserved

in our society.

mined using the numerical codes on the survey. Two weeks after the initialmailing, a second request was sent tonon-respondents. Coding sheets weredestroyed immediately after the secondmailing and before any data wererecorded or analyzed. After the additionalresponses were received from the second wave, the data was tabulated and analyzed.

Results Forty surveys were received for a 21.5%response rate, however, one respondentwrote “retired dentist” at the top of thesurvey and another stated “full-time aca-demics.” Neither of these respondentscompleted the survey. Therefore, theanalysis is based on 38 valid responses.Table 1 shows the number of respon-dents who provide free or reduced-feedental care according to demographiccategories. There were no significantfindings that show these demographicsas predictors for donating care.

Of the surveys returned, the meanpercent of children treated in the prac-tices was 18%. The average number ofpatients seen per week by the respondentswas 82 and the average number of hours worked per week was 37. Of theserespondents, the range of patients seenwas 3 to 400 patients per week. Thehours worked per week ranged from 3 to 110.

As shown in Table 2, among respondents who did not provide free orreduced-fee care, those dentists reportedon average that children represented16% of their practice. The average num-ber of patients treated per week by thosewho did not provide free or reduced-feecare was 63 patients, and they workedan average of 29 hours per week.

For those who indicated that theydid provide free or reduced-fee care, themean percent of children they treatedwas 21%. These respondents estimatedthat they saw an average of 104 patientsper week and worked an average of 46hours per week.

I queried dentists about the referralsources of patients who receive donatedcare. Respondents were asked to checkall categories that applied. Since manyrespondents treated patients from multi-ple referral sources, the total percentagesexceeded 100%. The largest source ofrecipients of donated services was cur-rent patients of the practice. Of the 17dentists who indicated they provided freeor reduced-fee care, 13 (76%) indicatedthat the individuals they treated werecurrent patients. Five (29%) indicated areligious organization as a source, five(29%) stated professional organizationsas a source of patients, four (24%) citeda social service agency, and four (24%)indicated a colleague as a source ofpatients receiving donated care. Onlyone (6%) cited schools as a referralsource of patients.

The amount of free or reduced-feecare provided to children and adults varied substantially. For children, free carevalues ranged from $0 to $5,000 with amean of $1,500 and a standard deviationof $1,856; reduced-fee values ranged from$0 to $4,000 with a mean of $1,378 anda standard deviation of $1,352. Foradults, free care values ranged from $0to $60,000 with a mean of $14,000 anda standard deviation of $19,289; reduced-fee care ranged from $500 to $95,000with a mean of $19,225 and a standarddeviation of $31,358. Figure 2 shows the variation in the number of patientswho receive free and reduced-fee care for routine and emergency procedures.

DiscussionFrom these results it is noticeable thatdonations of both free and reduced-feecare is not uniform across the profession

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Table 1. Percentage of respondents who provided free or reduced-fee care by demographic categories of practitioners.

Provide free Categories of or Reduced- Respondents fee care

Male 52%

Female 22

Attended Private School 49

Attended Public School 0

Work in a Solo Practice 55

Work in a Group Practice 47

Work in General Practice 48

Work in Specialty Practice 42

MassHealth Providers 60

NOT a MassHealth Provider 45

In Brookline > 10 years 54

In Brookline 6-10 years 50

In Brookline < 5 years 25

Caucasian 45

Other than Caucasian 33

Graduated > 20 years ago 52

Graduated < 20 years ago 22

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Table 2. Percentage of child and adult patients, hours worked per week, and number of patientsseen per week by practitioners who do and who do not provide free or reducted-fee care.

Child patient Adult patient Hours worked/ Patients seen/% % week week

Total Respondents 18% 82% 37 82

Free, reduced-fee care 21% 79% 46 104

No free, reduced-fee care 16% 84% 29 63

of dentistry. This can be seen in the standard deviations of those donating,especially donations to adults. Whilethere are dentists who donate large values in free and reduced-fee care, others do not donate nearly as much.Some of the respondents did not donateat all. Of the dentists who did notrespond, it would be easy to imaginethat the number of non-contributors islarger than in those who responded. Ihave no way of describing the practicesor philanthropy of non-responders.

As seen in Figure 1, the majority offree and reduced-fee donations went toadults. This was an interesting findingbecause it can be often assumed thatcharity from dentists goes mainly to chil-dren. It is also seen in Figure 2 that themajority of care provided by respondentswas reduced-fee and routine care. It istrue that adults were the preponderanceof patients in the participating practices,and it is also true that there are manyfinancial resources for children’s dentalcare, including Medicaid (there is noadult oral healthcare coverage inMassachusetts) and S-CHIP programsthat are not available to adults.

A statistically significant finding inthis survey was that dentists who worklonger hours per week were more likelyto provide free or reduced-fee care

Figure 1. Number of dentists who reported donating dollar amountsof free and reduced-fee care to children and adults.

Figure 2. Average number of children and adults receiving free andreduced-fee care for routine and emergency procedures.

school more than 20 years previously, 14 of 27 indicated that they had donatedcare. This result could be due to youngerdentists not having the financialresources available to them to donatecare. They may still be in the process ofpaying off loans for dental school andthe need to make and save money mayresult. These younger dentists also maybe less likely to own their own practiceand may not have the authority to offerfree or reduced care to patients. Of thenine dentists graduating from dentalschool 20 or fewer years previously, six indicated they worked in a grouppractice or as an associate.

In terms of gender, 15 of 29 (52%)male respondents said that they donatedcare, while two of nine (22%) of femalerespondents donated care. This is aninteresting result because people maypredict females to be more giving andtherefore to donate more care thanmales or to expect no difference at all.Another question is whether female dentists worked part-time as opposed tofull-time, and were employed in versusowners of practices. Our study did notaddress those questions.

For dentists practicing in Brooklinefor more than ten years, 15 of 28 (54%)donated care; two of four (50%) owhopracticed in Brookline for six to tenyears donated care; and one of four(25%) who practiced five or fewer yearsin Brookline donated care. This resultsupported the hypothesis that those whopracticed in Brookline longer would bemore likely to donate care due to the“giving-back” philosophy of the town.These results may also reflect that thelonger one is in practice, the more likelyit may be that services are donated freeor provided at reduced-fee.

Of the three respondents that gradu-ated from public dental schools, nonedonated care. Even though there werefew public school respondents, it wasthought that graduates of public schools

(ANOVA, F=5.174, p<.03). The resultsshow that among respondents, thosewho donated care worked an average of46 hours per week, while those who didnot donate care worked 29 hours perweek. One possible explanation for thisfinding could be that those who worklonger hours might have the financialresources from working longer hours todonate care to those in need. Anotherpossibility may be that by being in theoffice for a greater period of time in theweek, they may be more likely to fitpatients who need donated care intotheir schedule with more ease thansomeone who is not at their office aslong. In addition, those who workedfewer hours per week may have beenpart-time associates or newer in practiceand not in a decision-making position todonate services. Of the respondents whoworked fewer than 30 hours per week,three of ten graduated from dentalschool less than 20 years previously.Two of the three worked in specialtypractice and two of the three worked ingroup practice. Also, of the respondentsworking fewer than 30 hours per week,four of ten graduated from dental schoolmore than 35 years previously. Thesenumbers show seven of ten respondentsworking 30 hours or fewer per weekbeing either a recent graduate of dentalschool or a dentist who may be towardthe end of his or her career. Other possi-bilities include that the dentist wassemi-retired or worked in more than onepractice site, part-time in a hospital orteaching facility.

Of the dentists who had graduatedfrom dental school 20 or fewer yearspreviously, only two of nine indicatedthat they had donated care, while forthose who had graduated from dental

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In future studies of donated and reduced-feeservices, follow-up questions may be helpfulin gaining more insight into the pro bono care that dentists provide.

would be more likely to donate caresince they may have less debt from dental school. In contrast, 17 of 35(49%) graduates from private dentalschools donated care. This may showthat many dentists still find it importantto donate care to those in need eventhough they may have large educationaldebts to pay off from dental school. Itmay also reflect a community-based“serving the underserved” philosophy of private academic dental institutions. I wondered whether public school grad-uates were recent graduates of dentalschool and therefore limited in theirability to donate care. This was not thecase. Two of the three public schoolgraduates had graduated more than 30years ago, in 1977 and in 1968. Due tothe small number of respondents in this category, I was unable to draw anyinferences about public versus privateschool graduates.

Three of five (60%) MassHealth(Medicaid) dentists provided free orreduced-fee care to patients along withtheir participation in MassHealth. Thismay show that dentists who areMassHealth providers have a propensityto treat individuals based on need.

Fifteen of 33 (45%) dentists who arenot MassHealth providers donated careto individuals in need. These resultsshow that dentists do find a way to serve the community and help needyindividuals, even if they do not partici-pate in the MassHealth program. This isa very important finding because thelack of participation by dentists inMassHealth may be recognized, yet thedonated services that many of these dentists provide to their patients are notalways acknowledged.

The dollar value of care that adultsreceived was higher than that provided

to children. This may be reflective ofhigher fees related to adult dental services.Other possible explanations for this finding may include a low caries rateamong child patients in Brookline practices, or that services for childrentreated in these practices are coveredunder Medicaid/MassHealth. The totalvalue of donated services in this popula-tion was $177,500, and the total ofreduced-fee services was $250,600.

Although the response rate (21.5%)was low and the generalizability ofresults is limited, it is believed that if thestudy were replicated, the trend of givingand professionalism would be reflectedthroughout private practitioners in theUnited States. Another limitation of thestudy was that the survey instrument wasnot pre-tested for validity or reliability.Also, it was not possible to determinewhether the mailing addresses receivedfrom the Massachusetts Board of Regis-tration in Dentistry (BORID) were homeor office addresses. BORID confirmedthrough personal communication thatthe addresses they are given may beeither a dentist’s home address or officeaddress. Therefore, it is possible that thesurvey includes data for services providedin other communities.

Other limitations include the follow-ing: All data were self-reported; there wasno attempt to validate the accuracy ofthe amount or type of donated services.The population was small (n=186) andthe response rate was limited. I had noway to compare the results of respondentswith non-respondents. I have no datathat enables me to compare the respon-dents to all dentists in Brookline. Dentistsin Brookline may not be representativeof dentists in all communities in theUnited States, although I have no reasonto believe that they differ substantiallyfrom other practicing dentists in termsof giving back to the communities inwhich they practice.

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Manuscript

ConclusionsThe results of this study indicate theextent of pro bono or reduced-fee dentalcare that dentists provide. While criticsstate that pro bono care is not a health-care system, this study suggests thatmany dentists take it upon themselves to address access to care and to servingthe underserved in our society.

In future studies of donated andreduced-fee services, follow-up questionsmay be helpful in gaining more insightinto the pro bono care that dentists provide. Possible questions may includethe following: Why do you provide probono or reduced-fee care? How do youdetermine which patients in your prac-tice will receive free or reduced-fee care?How do you determine from whichsources you will accept referrals? How do you determine when you will acceptreferrals? How do you determine howmany referrals will you accept? How doyou determine how much free andreduced-fee care you will provide?Answers to these questions will provide a greater understanding of how individ-ual dentists contribute in helping toovercome barriers in access to dentalcare in the United States. ■

ReferencesLong S. K., & Masi, P. B. (2009). Access and affordability: An update on healthreform in Massachusetts, fall 2008. Health Affairs, w578-w587.Pleis, J. R., & Lucas, J.W. (2009). Summaryhealth statistics for U.S. adults: NationalHealth Interview Survey, 2007. NationalCenter for Health Statistics. Vital HealthStat,10 (240).Special Commission on Oral Health (2000).The oral health crisis in Massachusetts:Report of the special legislative commissionon oral health. Boston: The Commission.

Nine unsolicited manuscriptswere received for possible publication in the Journal of

the American College of Dentists during2012. Three were sent for peer review.Two manuscripts were accepted for publication following extensive modifi-cations suggested by peer review; one isawaiting further modifications before adecision can be made. Thirteen reviewswere received for these manuscripts, an average of 4.33 per manuscript.Consistency of reviews was determinedusing the phi coefficient, a measure ofassociation between review recommen-dations and the ultimate publicationdecision. The phi was .365, where 0.00represents chance agreement and 1.00represents perfect agreement. The Collegefeels that authors are entitled to knowthe consistency of the review process.The Editor also follows the practice ofsharing all reviews among the reviewersas a means of improving calibration.

Instructions for authors and instruc-tions for reviewers can be found on theWeb site of the College. Journal reviewersare encouraged to use a sequential set ofstandards in evaluating manuscripts.The first concern is that the manuscriptpresents a topic of significant interest to our readers. Those that meet this criterion are evaluated for absence ofbias in the presentation. The third stan-dard is clarity of presentation.

The Editor is aware of five requeststo republish articles appearing in thejournal and seven requests to copy articles for educational use received and

granted during the year. There was onerequest for summaries of recommendedreading associated with Leadership Essays.

In collaboration with the AmericanAssociation of Dental Editors, the Collegesponsors a prize for a publication in anyformat presented in an AADE journalthat promotes ethics, excellence, profes-sionalism, and leadership in dentistry.Eleven manuscripts were nominated forconsideration. The winner was LisaDeem’s article, “College Students PracticeDentistry in Third World Countries,”which appeared in the May/June 2011issue of the Pennsylvania DentalJournal. Eighteen judges participated inthe review process. Their names are listedamong the Journal reviewers below. TheCronbach alpha for consistency amongthe judges was .938.

The College thanks the followingprofessionals for their contributions,sometimes multiple efforts, to the dentalliterature as reviewers for the Journal of the American College of Dentistsduring 2012.

Daniel Bender, PhDSan Francisco, CA

Laura Bishop, PhD, FACDWashington, DC

Susan Bishop, DMD, FACDPeoria, IL

Herb Borsuk DDS, FACDMontreal, QC

Marcia Boyd, DDS, FACDVancouver, BC

R. Bruce Donoff, DMD, MD, FACDBoston, MA

Geraldine Ferris, DDS, FACDWinter Park, FL

Allan J. Formicola, DDS, MS, FACDMadison, NJ

Shelly Fritz, DDS, FACDAlbuquerque, NM

Richard J. Galeone, DDSLansdale, PA

Larry Jenson, DDSWillits, CA

William G. Leffler, DDS, JD, FACDMassillon, OH

Peter Meyerhof, PhD, DDS, FACDSonoma, CA

Daniel L. Orr II, DDS, MS, PhD, MD, JDLas Vegas, NV

Martha PhillipsAtlanta, GA

Stephen A. Ralls, DDS, EdD, MSDGaithersburg, MD

Alvin B. Rosenblum, DDS, FACDLos Angeles, CA

H. Clifton Simmons III, DDSMemphis, TN

Philip E. Smith, DMD, FACDLexington, SC

Richard C. Vinci, DDSWinter Springs, FL

James Willey, DDS, FACDChicago, IL

Steven Young, DDS, FACDOklahoma City, OK

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2012 Manuscript Review Process

2012 Manuscript Review Process

79


Submitting Manuscripts

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 substantial portions 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 recently volumes of JACD.These can be found on the ACD Web siteunder “publications.” In conducting thisreview, authors should pay particularattention to the type of paper we focuson. For example, we normally do not

publish clinical case reports or articlesthat describe dental techniques. Thecommunication policy of the College isto “identify and place before the Fellows,the profession, and other parties of interest those issues that affect dentistryand oral health. The goal is to stimulatethis community to remain informed,inquire actively, and participate in theformation of public policy and personalleadership to advance the purpose andobjectives of the College.”

There is no style sheet for theJournal of the American College ofDentists. Authors are expected to befamiliar with previously published mate-rial and to model the style of formerpublications as nearly as possible.

A “desk review” is normally provided within one week of receiving a manuscript to determine whether itsuites the general content and qualitycriteria for publication. Papers that hold potential are often sent directly for peer review. Usually there are sixanonymous reviewers, representing subject matter experts, boards of theCollege, and typical readers. In certaincases, a manuscript will be returned to the authors with suggestions forimprovements and directions about conformity with the style of work pub-lished in this journal. The peer reviewprocess typically takes four to five weeks.

Authors whose submissions are peerreviewed receive feedback from thisprocess. A copy of the guidelines used by reviewers is found on this site and islabeled “How to Review a Manuscript for the Journal of the American Collegeof Dentists.” An annual report of thepeer review process for JACD is printedin the fourth issue of each volume.Typically, this journal accepts about aquarter of the manuscripts reviewed and the consistency of the reviewers isin the phi -.60 to .80 range.

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

Submitting Manuscripts for Potential Publication in JACD

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2012 Article Index

2012 Article Index

Journal of the American College of Dentists, 2012, Volume 79

EditorialsLessons in Shifting the Burden: #3. The Critical Moment for Dental Ethics........................................................Number 4, page 2

David W. Chambers

Professional Service Organizations............................................................................................................................Number 1, page 2David W. Chambers

Sorry, I Should Have Asked More of You ...................................................................................................................Number 3, page 2David W. Chambers

William J. Gies: A Man of His Word ............................................................................................................................Number 2, page 2 David W. Chambers

Letters to the EditorArthur A. Dugoni ..........................................................................................................................................................Number 1, page 5

Allan J Formicola ..........................................................................................................................................................Number 1, page 7

Howard R. Gamble........................................................................................................................................................Number 3, page 4

Sean Gardner ................................................................................................................................................................Number 1, page 6

Robert J. Gherardi.........................................................................................................................................................Number 1, page 5

Dan B. Henry.................................................................................................................................................................Number 1, page 8

Bert W. Oettmeier, Jr.....................................................................................................................................................Number 3, page 4

Arthur Schultz...............................................................................................................................................................Number 1, page 6

Jack C. Wesch ................................................................................................................................................................Number 1, page 4

College MattersSomeone Guided Your Professional Growth: Do the Same [President-elect’s Address] .....................................Number 4, page 4

W. Scott Waugh

You Will Look Good Treating Others with Respect— I Guarantee It [Convocation Address].............................Number 4, page 8George Zimmer

2012 ACD Awards..........................................................................................................................................................Number 4, page 10

2012 Fellowship Class ..................................................................................................................................................Number 4, page 15

2012 Manuscript Review Process ...............................................................................................................................Number 4, page 78

Submitting Manuscripts for Potential Publication in JACD ....................................................................................Number 4, page 79

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2012 Article Index

Theme PapersThe Alaska Native Tribal Health System Dental Health Aide Therapist as a Dental-centric Model...................Number 1, page 24

Mary Williard

Being Professional in the Social Media World ..........................................................................................................Number 4, page 48Steven D. Chan

Continued Competency Assessment: Does It Have a Necessary Role in Dentistry? .............................................Number 3, page 13James R. Cole II, John S. Findley, Max M. Martin, Jr., William W. Dodge, Ronald L. Winder, Stephen K. Young, Joel F. Glover, Kenneth L. Kalkwarf

Continued Competency Assessment: Its History and Role in the Health Professions .........................................Number 3, page 5William W. Dodge, Ronald L. Winder, Stephen K Young, James R. Cole II, John S. Findley,Max M. Martin, Jr., James S. Cole, Joel F. Glover, Kenneth L. Kalkwarf

Continued Competency: The American Association of Dental Boards’ Perspective............................................Number 3, page 20White S. Graves III

Continued Competency: Dentistry’s “Road Not Taken”...........................................................................................Number 3, page 24David S. Gesko

Continued Competency in the Specialties and Academics......................................................................................Number 3, page 28Kent Palcanis and Marilyn Lantz

Dental Autonomy: A Policy of Isolation.....................................................................................................................Number 2, page 66William J. Gies

Dental Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching

Introduction .........................................................................................................................................................Number 2, page 32

Contents................................................................................................................................................................Number 2, page 42

Statutory Definition and Regulation of the Practice of Dentistry .................................................................Number 2, page 50

General View and Conclusions ..........................................................................................................................Number 2, page 55

William J. Gies

A Dental School on University Lines..........................................................................................................................Number 2, page 12William J. Gies

Development and Implementation of a Dental Office Assessment Program.......................................................Number 3, page 33James J, Crall, Karen L. Spritzer, and Ron D. Hays

The Human Capital Crisis in Orthodontics...............................................................................................................Number 1, page 21Marc Bernard Ackerman

Increasing Productivity in Dental Practice: The Role of Ancillary Personnel ......................................................Number 1, page 11Albert H. Guay and Vickie Lazar

Independent Journalism versus Trade Journalism in Dentistry: An Irrepressible Conflict................................Number 2, page 15William J. Gies

Introduction to Social Media.......................................................................................................................................Number 4, page 40Michael Meru

The Journal of Dental Research [first editorial] ......................................................................................................Number 2, page 28William J. Gies

Letters of William J. Gies..............................................................................................................................................Number 2, page 71William J. Gies

Looking at the Past to See the Future: The Role of the Dental Hygienist in Collaborating withDentists to Expand and Improve Oral Health Care ..................................................................................................Number 1, page 29

Ann Battrell

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2012 Article Index

Theme Papers (Continued)Mouth Bacteria: An Essay Presented to the Canadian Oral Prophylactic Association ........................................Number 2, page 5

William J. Gies

People Will Talk. ...........................................................................................................................................................Number 4, page 31Steven D. Chan

Position Paper on Digital Communication in Dentistry .........................................................................................Number 4, page 19Officers and Regents of the American College of Dentists, Prepared by David W. Chambers

Readiness Requires a Team .........................................................................................................................................Number 1, page 18David Hartzell

Social Media Policy in Other Organizations .............................................................................................................Number 4, page 43Carl L. Sebelius, Jr.

Response to Tribute......................................................................................................................................................Number 2, page 60William J. Gies

ManuscriptsDentists Demonstrating Professionalism: Dentists in Private Practice Settings Provide Free or Reduced-fee Care .................................................................................................Number 4, page 72

Matthew Kramer

Is General Dentistry Dead? How Mid-level Dental Providers Will Affect the Profession .....................................Number 4, page 64Eric K. Curtis

Issues in Dental EthicsDifferent Labs................................................................................................................................................................Number 4, page 56

Bruce Peltier, Anthony Vernillo, Lola Giusti, and Larry E. Jenson

The Person Who Wears the White Coat ....................................................................................................................Number 1, page 33David W. Chambers

Schadenfreude: An All Too Common Affliction .......................................................................................................Number 1, page 37Charles Solomon

Treating a Patient with a Terminal Prognosis: A Systematic FormatFormat for Resolving Ethical Issues in Clinical Periodontics .................................................................................Number 3, page 42

Alexander J. Schloss

Leadership EssayEnergy ............................................................................................................................................................................Number 1, page 40

David W. Chambers

Making Sense of Things ..............................................................................................................................................Number 3, page 48David W. Chambers

Journal of the


2012 Statement of Ownership and CirculationThe Journal of the American College of Dentists is published quarterly by the American College of Dentists, 839J Quince Orchard Boulevard,Gaithersburg, Maryland 20878-1614.Editor: David W. Chambers, EdM, MBA, PhD.

The American College of Dentists is anonprofit organization with no capitalstock and no known bondholders,mortgages, or other security holders.The average number of readers of eachissue produced during the past twelvemonths was 5,186, none sold throughdealers or carriers, street venders, orcounter sales; 5,314 copies distributedthrough mail subscriptions; 5,139 totalpaid circulation; 175 distributed ascomplimentary copies. Statementsfiled with the U.S. Postal Service,September 5, 2012.

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