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American College of Dentists - Journal of the - The Evidence for Ethics
Journal of the
                 American College
                 of Dentists

The Evidence
    for Ethics

  Winter 2020
   Volume 87
   Number 1
Journal of the
American College
of Dentists
A publication advancing                             Communication Policy
excellence, ethics, professionalism,
and leadership in dentistry
                                                    It is the communication policy of the American College of Dentists to identify and
The Journal of the American College of Dentists     place before the fellows, the profession, and other parties of interest those issues
(ISSN 0002-7979) is published quarterly by          that affect dentistry and oral health. The goal is to stimulate this community to
the American College of Dentists, Inc., 839J        remain informed, inquire actively, and participate in the formation of public policy
Quince Orchard Boulevard, Gaithersburg, MD          and personal leadership to advance the purpose and objectives of the college.
20878-1614. Periodicals postage paid at             The college is not a political organization and does not intentionally promote
Gaithersburg, MD, and additional mailing
                                                    specific views at the expense of others. The positions and opinions expressed in
offices. Copyright 2020 by the American
                                                    college publications do not necessarily represent those of the American College
College of Dentists.
                                                    of Dentists or its fellows.
Postmaster—Send address changes to:
Managing Editor
Journal of the American College of Dentists
839J Quince Orchard Boulevard                       Objectives of the American College of Dentists
Gaithersburg, MD 20878-1614
                                                    T HE A MERICAN C OLLEGE OF D ENTISTS , in order to promote the highest ideals in
The 2020 subscription rate for members of
                                                    health care, advance the standards and efficiency of dentistry, develop good
the American College of Dentists is $30 and
is included in the annual membership dues.
                                                    human relations and understanding, and extend the benefits of dental health to
The 2020 subscription rate for nonmembers           the greatest number, declares and adopts the following principles and ideals as
in the United States, Canada, and Mexico is         ways and means for the attainment of these goals.
$40. All other countries are $60. Foreign
optional airmail service is an additional $10.      A. To urge the extension and improvement of measures for the control and
Single-copy orders are $10.                            prevention of oral disorders;
                                                    B. To encourage qualified persons to consider a career in dentistry so that
All claims for undelivered/not received
issues must be made within 90 days.
                                                       dental health services will be available to all, and to urge broad preparation
If the claim is made after this time period,           for such a career at all educational levels;
it will not be honored.                             C. To encourage graduate studies and continuing educational efforts by dentists
                                                       and auxiliaries;
While every effort is made by the publishers
and the Editorial Board to see that no inaccurate
                                                    D. To encourage, stimulate, and promote research;
or misleading opinions or statements appear         E. To improve the public understanding and appreciation of oral health service
in the Journal, they wish to make it clear             and its importance to the optimum health of the patient;
that the opinions expressed in the articles,
                                                    F. To encourage the free exchange of ideas and experiences in the interest
correspondence, etc., herein are the
responsibility of the contributor. Accordingly,        of better service to the patient;
the publishers and the Editorial Board and          G. To cooperate with other groups for the advancement of interprofessional
their respective employees and officers accept         relationships in the interest of the public;
no liability whatsoever for the consequences
                                                    H. To make visible to professional persons the extent of their responsibilities
of any such inaccurate or misleading opinions
or statements.                                         to the community as well as to the field of health service and to urge the
                                                       acceptance of them;
For bibliographic references, the Journal           I.   To encourage individuals to further these objectives, and to recognize
is abbreviated J Am Col Dent and should                  meritorious achievements and the potential for contributions to dental science,
be followed by the year, volume, number,                 art, education, literature, human relations, or other areas which contribute to
and page. The reference for this issue is:
                                                         human welfare—by conferring Fellowship in the College on those persons
J Am Col Dent 2020; 87 (1): 1-68.
                                                         properly selected for such honor.
Editor
David W. Chambers, EdM, MBA, PhD
dchamber@pacific.edu

Managing Editor
Theresa S. Gonzales, DMD, MS, MSS

Editorial Board
Rick Asai, DMD
Phyllis Beemsterboer, EdM, MS
Greg Chadwick, DDS, MS
R. Bruce Donoff, MD, DMD
Nanette Elster, JD, MPH                              The Evidence for Ethics
Nancy Honeycutt, CAE
Robert Lamb, DDS
Philip Patterson, MA, PhD                             4 Focus Group Results
Carlos Quiñonez, DMD, MSc, PhD                           David W. Chambers, EdM, MBA, PhD, FACD
Ken Randall, DMD
Lindsey A. Robinson, DDS
Harriet F. Seldin, DDS                               18 The Dental Ethics Teaching Case
Robert Sherman, DDS                                      David W. Chambers, EdM, MBA, PhD, FACD
Ronald Tankersley, DDS

Design and Production                                26 Dentists’ Knowledge of ADA Code
Annette Krammer, Forty-two Pacific LLC                   David W. Chambers, EdM, MBA, PhD, FACD
Correspondence
Address correspondence relating to the Journal to:   35 Ethical Touchstones
Managing Editor
                                                         David W. Chambers, EdM, MBA, PhD, FACD
Journal of the American College of Dentists
839J Quince Orchard Boulevard
Gaithersburg, MD 20878-1614                          41 Practice Goals: Opportunities and Obligations
Letters from Readers                                     David W. Chambers, EdM, MBA, PhD, FACD
Comments concerning any material appearing in
this journal are welcome at dchamber@pacific.edu.    48 Survey of Dental Ethics Education: 2018
They should be no longer than 500 words and will         David W. Chambers, EdM, MBA, PhD, FACD
not be considered after other letters have already
been published on the same topic. The editor
reserves the right to refer submitted letters        59 Ethical Attribution Effect Hypothesis
to the Editorial Board for review.                       David W. Chambers, EdM, MBA, PhD, FACD
Business Office
Journal of the American College of Dentists
Tel. (301) 977-3223; Fax. (301) 977-3330

Officers
Stephen A. Ralls, President
Leo E. Rouse, President-elect                        Departments
Richard E. Jones, Vice President
Robert M. Lamb, Treasurer
Thomas J. Connolly, Past President                    2 From the Editor
Theresa S. Gonzales, Executive Director
David W. Chambers, Editor                                A Dead Letter?

Regents                                              66 Code of Conduct of the American College of Dentists
Paula K. Friedman, Regency 1
David A. Anderson, Regency 2
Carole M. Hanes, Regency 3
Terry L. Norris, Regency 4
Charles F. Squire, Regency 5
Robert M. Anderton, Regency 6
Gary S. Yonemoto, Regency 7
Lance M. Rucker, Regency 8
Teresa A. Dolan, At Large
Robert A. Faiella, At Large
Stephen M. Pachuta, At Large

Toni M. Roucka, ASDE Liaison
Michael C. Meru, SPEA Liaison
Erik C. Klintmalm, Regent Intern

                                                                Cover image Imagine you were on trial, accused of being ethical. Would there
                                                                be enough evidence to get a conviction?
                                                                © 2020 peshkov, istockphoto.com. All rights reserved.
Editorial

From the Editor

A Dead Letter?

                                                about topics that seem to be fuzzier        ethics. First I learned that the lead
    L    et’s consider what to do with this
         journal. For the first 13 years the
    college had none. Then for about half
                                                and faster moving than in simpler
                                                times. But the essential concern is that
                                                                                            material, the few paragraphs of news
                                                                                            written by Dr. Bicuspid staff, were
    a century it was the way the Board of       the ways dentists find information and      timely, informative, and balanced. The
    Regents informed the fellowship what        use it have evolved.                        responses were certainly not. Ethics is
    they were doing. There were minutes            Only a Rip van Winkle would be           not a hot topic. Only a handful of
    of meetings, announcements, letters,        surprised to learn that the computer        “regulars” seemed to have opinions,
    policy positions, committee reports,        has changed the way we communicate.         but they had opinions about nearly
    and some scientific articles. It was        What I have in mind is cost, speed,         everything. Most tellingly was the
    what held a national organization           number of folks who have something          chaining of the comments. The first
    together. This was followed by a shift      they have to say, diversity of opinions,    responder addressed “something” in
    to publishing refereed papers as the        shallowness of messages, absence of         the lead post; that was followed by a
    newsletter took over the task of            expert vetting, and ability on              reaction to “something” the first
    sharing timely and personal                 “readers’” part to find anything they       commenter had said. By the third or
    information. Since 1990 the journal         want and only that. Twenty-five years       fourth comment, it was impossible to
    has done theme issues, presenting           ago a troll was a fairy tale creature who   connect the comment to the original
    multiple responsible perspectives on        lived under bridges in Scandinavia,         story. Remember the game of
    emerging concerns in the profession.        conflict of interest disclaimers were       telephone? The only way to protect
    It is the only publication in dentistry     superfluous, and, as Tom Nichols said       your message would be to participate
    to be focused on discussions regarding      in The Death of Expertise, knowing          at multiple points in the channel.
    policy issues.                              what you are talking about was                 The high-value coin in the
        But it may be time to discontinue       praiseworthy instead of inviting            communication world today is timely
    the journal. This is certainly not          knowing sneers.                             pictures and very short messages. And
    because hosting discussions of policy          It is not so much a question of          these should be easy to find, flattering,
    matters has lost its significance. True,    whether the college should continue         and brief enough to present only the
    it is getting more difficult each year to   to speak usable truth to the profession     correct perspective. Message selection
    find the right people willing to write      as whether we should recognize that         matters more than message evaluation.
                                                the game has moved to a new field.             Several months ago I emailed the
                                                Should we not think about moving            young dentist I mentioned above and
                                                too? Even if our mission has not            asked whether she ever checked in
                                                changed, it may be time to                  with blogs such as Dr. Bicuspid. The
                                                communicate it differently.                 answer was that she “might have done
                                                   I wrote an editorial about blogs in      so once long ago.” I have a habit of
                                                2010 based on a conversation I              circling back on those who tout
                                                overheard between some senior               reports or articles in meetings. Most
                                                dentists and a junior member of the         cannot remember even having seen
                                                profession. The direct question of the
                                                millennial was, “Where do you get
                                                your information?” The answer was
                                                Dr. Bicuspid. So I monitored the site
                                                for a few months, focusing on dental

2                                                                                                     2020    Volume 87, Number 1
Editorial

what was once “really great.” The             first impressions, short, actionable
shadow of message awareness                   messages from multiple sources
increasingly stands in the place of           work best.
content evaluation.                               There are only three problems          It is not so much a question
    The point is not to belittle those we     with a serious quarterly journal:
                                                                                         of whether the college should
want to communicate with. It is to be         (a) it covers only a small segment of
realistic about who is listening, what        the communication market; (b) it is        continue to speak usable
they are listening for, and where they        expensive and may burn through the
                                                                                         truth to the profession as
are listening. If we do not know this or      limited resources of the college, and
choose to ignore it, the shame is on us.      perhaps most worrisome; (c) it             whether we should recognize
    Good communication involves               nourishes the illusion that we have
                                                                                         that the game has moved
listening as well as talking. The college     the most important aspects of
may well want to invest in systematic         communication covered.                     to a new field.
and wide listening campaigns to                   Dare we remain the only or one of
decide who should be part of the              a very few places dentists can go to
conversation and what should be on            find a balanced discussion of emerging
the agenda. One definition of news is         issues, knowing that this will be, of
what we get credit for knowing before         necessity, heavy lifting and almost
others do since it will be of little          certain to contain a few things some
importance tomorrow. The pace of              will find indigestible? Do we have
considered change in dentistry is             the gumption to listen as well as tell
beginning to creep up on the status of        others what we think? And do
news. Certainly yearly or quarterly           we have the skills and financial
cycles will be increasingly behind the        resources to undertake this? Would
times. The professionally appropriate         we be welcomed?
ways to practice dentistry are shifting           I would love to hear what you think.
more quickly than big reports can
manage. What matters to some does
not necessarily matter to all. Or at least
not in the same way. The number of
channels dentists are listening to is
multiple and each often only lasts
for a few months. Professors and
practitioners of marketing have long
known that deep, logical arguments
are attractive to those involved in
serious matters, but they seldom
change opinions. On the other hand,
for awareness and forming favorable

Journal of the American College of Dentists                                                                          3
The Evidence for Ethics

Focus Group Results

    David W. Chambers, EdM, MBA,
    PhD, FACD                                      T   here is value in listening to what
                                                       patients and dentists say about
                                                   ethics in dentistry. If anyone knows
                                                                                              themselves as American Dental
                                                                                              Association (ADA) members. These
                                                                                              sessions were conducted by Dr.
                                                   how ethics “feels” rather than what it     Chambers. He also conducted four
    Abstract                                       “should” be, they would be the first       focus groups with leaders in the
    One hundred eighty-two dentists and            ones to say. A reasonably large sample     profession. These included nine
    patients participated in 18 focus groups       should give a true picture, one richer     officers of the California Dental
    across the United States in approximately      than theory or statistics.                 Association (CDA), 13 members of
    one-hour discussions of the perception of                                                 the CDA Judicial Council, 20 “young
    ethical issues facing the dental profession.   The Sample                                 dental leaders” identified by the Ohio
    Additionally, 237 dentists completed an        Small groups of dentists, leaders in the   Dental Association, and 17 officers in
    open-ended survey on dental ethics.            profession, patients, and those involved   the Oklahoma Dental Association.
    All data gathering was unguided. Written       in healthcare policy contributed their     All of these participants were assumed
    and oral comments were recorded.               opinions. Eight focus groups were          to be members of the ADA.
    Results of this “listening” are reported       conducted among 86 patients in the            The CAC conducted a session for
    here, grouped by type of respondent. The       states of California, North Carolina,      healthcare policy experts in
    findings are reported as frequency of          Ohio, and Oklahoma. Six of the focus       Washington, DC. Those participating
    common responses and verbatim remarks.         groups were organized and conducted        on this panel included former staffers
    No attempt has been made to interpret          by the Citizen Advocacy Center (CAC),      of AARP, a representative of a state
    these comments or to connect them to           a Washington, DC, nonprofit that           dental board, and policy analysts and
    positions or opinions regarding approaches     represents members who serve on            lobbyists. There were nine participants
    to addressing ethical concerns.                state health boards. Two groups were       as well as three representatives from
                                                   conducted by Dr. David W. Chambers.        the CAC and Dr. Chambers present.
                                                   Patient groups were recruited by              The final such viva voce source was
                                                   professional polling agencies or from      an anonymous survey completed by
                                                   church groups in an effort to sample       237 graduates of one dental school as
                                                   the range of the public. All sessions      part of the school’s annual survey of
                                                   were recorded, and written summaries       graduates. Written comments
                                                   were made immediately following            regarding ethical issues in dentistry
                                                   the sessions. Dr. Chambers reviewed        were provided in response to open-
    Dr. Chambers is editor of                      all tapes and was present at four of       ended questions.
    the college. This report is part
    of the empirical study of
                                                   the panels.
    ethics in the profession                           Thirty-seven dentists in the           The Stimulus
    requested by the regents of                    practitioner cohort participated in        For all cases, respondents were invited
    the college and known as the
    ACD Gies Ethics Project.                       four groups, two each in Maryland          to address questions regarding ethics
    Photo by Dr. Herb Borsuk                       and North Carolina. By show of             based on their personal experience.
                                                   hands, approximately two-thirds of         Most groups answered three
                                                   those participating identified             questions: “What is the greatest
                                                                                              current ethical issue regarding the
                                                                                              relationship among dentists?” “What
                                                                                              is the greatest ethical issue regarding

4                                                                                                       2020   Volume 87, Number 1
The Evidence for Ethics

the relationship between dentists and         analysis, data was aggregated (but not
patients?” and “What is the greatest          modified) for each of the types of
ethical issue regarding the relationship      panels: practitioners, leaders, patients,      For all cases, respondents
between dentists and organizations?”          policy experts, and alumni. The final
Respondents usually answered these            level of analysis involved highlighting,       were invited to address
questions by writing short phrases on         but not further synthesizing, trends           questions regarding ethics
personal but anonymous response               for each of the five respondent groups.
forms, followed by public discussion.         This final level was called the “story         based on their personal
Both written remarks and group                according to…”                                 experience.
contributions were recorded verbatim             This article reports the summary
and counted in common categories.             data at the third level: combined
The discussion sessions were mature           summaries for each of the five
and candid, with no steering by the           data sources.                                  “When I see something that should
facilitators. Usually no comment was                                                      not have happened in a patient’s
made by the facilitators other than to        Results                                     mouth I am angry with my colleague.
ask the major questions. Participants         Practitioner Focus Groups                   But I don’t know what to say to him or
did not make frivolous remarks since                                                      what to say to the patient.”
                                              Fifteen practitioners in two sessions in
they were commenting in public in                                                            “Dentists just don’t talk much with
                                              North Carolina; 22 in two sessions in
front of their peers.                                                                     each other about what they have in
                                              Maryland. Approximately 66% ADA
                                                                                          common, except for common
                                              members. Written notes were
Summarizing the Data                                                                      ‘enemies’ such as insurance, under-
                                              completed by participants prior to
Conventional standards were followed                                                      stood in the sense of common excuses.”
                                              open discussion.
in analyzing such qualitative data                                                           “ADA Code requirement to
(Charmaz, 2006; Corbin & Strauss,                                                         report improper behavior is generally
                                              Dentist-to-Dentist Ethical Issues
2008; Denzin & Lincoln, 2003).                                                            ignored.”
                                              [N = 18] Differences of opinion                “Everybody knows we have
Recordings and written records were
                                              among dentists is an ethical issue.         problems and challenges, but we are
preserved. These were summarized
                                                 “There’s a dentist in our area who       afraid to talk about it. There is no
separately for each panel or set of
                                              pays people a ‘finder’s fee’ to get         forum for communication and there
related panels. Naturally occurring
                                              referrals. I don’t know what to do          seems to be a tacit understanding that
clusters of comments were identified
                                              about that. There’s no point in going       even talking about differences is an
in each group independently of what
                                              to the board.”                              insult to professional integrity.”
other focus groups reported. The
                                                 “Afraid of conflict; must go on             “Most differences of opinion
number of mentions of each topic was
                                              tip-toes when discussing values in          among dentists are about very small
recorded, and illustrative verbatim
                                              dentistry.”                                 differences; often just preferred habits.”
comments were recorded [shown
                                                 “Mostly when there is bad dentistry         “The best way to manage patients’
below in square brackets]. These
                                              that comes to my attention I try to         problems caused by other dentists is to
numbers may be interpreted as
                                              smooth it over. But if it is serious I
reflecting the extent of concern over
                                              suggest that the patient contact the
various themes. At the third level of
                                              state board—it is ultimately the
                                              patient’s problem.”

Journal of the American College of Dentists                                                                                            5
The Evidence for Ethics

    keep the discussion at the descriptive      [N = 9] General practitioners (GPs)         [N = 2] Quota dentistry displacing
    and technical level. Stick to the facts.”   and specialists competing for patients      quality dentistry in schools and in
       “Most problems about the poor               “Fewer referrals. More GPs trying        corporate model
    work colleagues have done is really         to do all the work to avoid losing the         “If parts of the profession are
    about money—who is going to pay             patient.”                                   moving to judging success as
    to make it right. And the insurance            “Specialists are now doing general       production, the rest of the profession
    companies keep out of these things,         dentistry.”                                 has an excuse to follow.”
    saying they have ‘already paid for the         “Sometimes specialists cherry pick
    treatment.’”                                care provided.”                             Dentist-to-Patient Ethical Issues
       “I just do not know what to say to          “Turf or scope of practice conflicts     [N = 20] Overtreatment: Profit-driven
    my colleagues, especially those who         in dentistry: specialists want              treatment planning
    have a different idea about dentistry.”     regulations that favor them; generalists       “In the competition between ethics
       “Problem patients are passed from        want to do traditional specialty            and business, business usually wins.”
    one dentist to another.”                    treatment.”                                    “Treatment options given or
                                                   “The whole business of the               preferred may be ones with highest
    [N = 13] Each has his or her own            relationship between GPs and                profit margin.”
    standard; dentists mistrust each other;     specialists is murky; it goes differently      “Patient selection by ability to pay.”
    cannot communicate                          in different situations.”                      “Here patients are written up for
       “There is diversity of opinion                                                       the most expensive treatment options
    regarding standards in the profession.”     [N = 4] Misleading advertising              plausible on the grounds that it is
       “‘Standard of care’ is a term with          “Marketing has gotten out of hand.       easier to forgive planned treatment
    unclear and often private or expedient      The claims dentists are making to           than to break the news that more is
    meaning.”                                   patients have nothing to do with            needed.”
       “We are a profession of self-            dentistry. They are about price and
    appointed experts.”                         convenience and smiles.”                    [N = 17] Inadequate informed
       “Differences in professional                “Some make promises about                consent, “steering” patients; breaches
    opinions are about ego and money.”          treatment outcomes that are                 of confidentiality
       “Dentists do not always share            impossible without seeing the patient.”        “Who should decide when there
    information about their patients.”             “Internet marketing is not about         are alternative treatment options?”
                                                quality of dental care.”                       “Dentists just tell patients enough
    [N = 10] Competition among dentists            “Voluntary restraint on advertising      to get them to go along with what the
       “Criticize others’ work in effort to     only penalizes the good dentist.”           dentist wants to do.”
    steal patients.”
       “Not commenting on the consistent        [N = 4] Questionable business               [N = 7] Piecemeal treatment, not
    bad work of colleagues creates an           practices, kickbacks, pay for referrals     comprehensive care
    environment where standards other              “Unethical business practices are
    than quality of treatment are               becoming the norm: ‘everybody is            [N = 5] Eroded trust; conflicting
    acceptable or even come to define the       doing it’ becomes the justification.”       opinions
    profession.”                                   “I know a dentist who has for years         “Dentistry is no longer about the
       “Sense of professionalism seems to       kept two sets of books.”                    dentist and the patient and oral health
    be declining. Dentists are withdrawing                                                  needs; it is about money and outside
    into their own offices.”                    [N = 2] Fear of having own work             interests. The patient is the one who is
       “Dentists competing for insurance        evaluated [not mentioned in the             being used.”
    contracts drives down the                   general discussion]                            “Patients hear different stories from
    reimbursement rates for everyone.”                                                      different dentists and so they lose faith
       “There are too many dentists.”           [N = 2] Pseudo credentials and              in the profession as a whole.”
       “Dentistry is becoming a job rather      specialties                                    “The Readers’ Digest story was fully
    than a profession.”                                                                     to be expected: each of the alternative
                                                                                            treatments could be justified.”

6                                                                                                     2020    Volume 87, Number 1
The Evidence for Ethics

   “Patients just go from one dentist         [N = 8] Organized dentistry no longer          “The ADA is too far away and
to another until they find one they           represents the profession, controlled       seems to want to relate in terms of
can trust.”                                   by the few, lost trust                      money and advertising. Real
                                                 “The ADA gives too much                  participation is at the local level.”
[N = 4] Misleading advertising                attention to specialties.”                     “The ADA’s primary objective is to
  “Advertising is creating unrealistic                                                    stay in business.”
expectations.”                                [N = 6] Insurance
                                                 “PPOs [preferred provider                [N = 4] Corporate entities are taking
[N = 4] Use of unproven technology,           organizations] and managed care are         advantage of student debt to intrude
bad science                                   taking control away from the                commercial values in place of
   “New technologies seem to be               practitioner.”                              professional ones
profit driven and are often untested.”           “Insurance is intruding on
   “EBD [evidence-based dentistry]            diagnosis, treatment planning, and          [N = 4] Dentists cheat on insurance
does not help in this area because tech-      dentist-patient relationship.”                “Waiving copays is common
niques are evaluated in isolation and            “Insurance limits treatment              because patients ask for it.”
because there is so little actual data.”      options. Patients perceive that
                                              insurance undermines patient                [N = 4] Live patients on initial
[N = 2] Faulty or improper care               confidence in the dentist.”                 licensure exams
                                                 “It is impossible to standardize the        “Such tests are out of context and
[N = 2] Patient self-determination            correct reimbursement for any               invalid because they do not measure
   “Don’t try to stand in the way of          procedures because of differences in        comprehensive care.”
patient who wants a second opinion.”          clinicians’ skills, lab costs, front desk      “Would like to see nationally
   “Patients want to be heard; to know        and other practice characteristics.”        standardized licensure.”
that the dentist has their best interests        “Insurance industry has failed in
in mind.”                                     the role of standardizing and raising       [N = 3] Intrusions into treatment and
                                              level of care: only concerned with its      dentist-patient relationship from
[N = 2] Not current on CE                     own bottom line.”                           various sources
                                                 “Dentistry needs to involve the             “Beginning practitioners cannot
Dentist-to-Organization                       employer and government and those           start their own practices so they have
Ethical Issues                                who ultimately pay for dental health,       to start as associates or employees and
[N = 8] Organized dentistry less              not just the insurance companies.”          pick up the business habits of their
valuable, declining membership and               “Insurance companies are profiling       profit-oriented bosses.”
participation                                 dentists’ claims, ostensibly to detect         “Younger members aren’t joining
   “Does anybody know why the                 abusers, but perhaps to lower benefits      organized dentistry.” [Fact: They are
membership in the ADA is declining?”          generally.”                                 overrepresented compared to general
   “The ADA is ‘toothless.’”                     “Capitation doesn’t work for             dentists in their mature years.]
   “The way it is now, a smaller and          dentists because each office is like a
smaller number of dentists is carrying        private hospital and we do surgery, not     [N = 3] Tech companies, suppliers
the water for a larger and larger             comprehensive and long-range care.”         influencing treatment decisions
number of those who are getting a free                                                       “Massive advertising in
ride. Not sustainable.”                       [N = 6] Lack of transparency                professional journals, at trade shows,
   “Organized dentistry’s voice is               “Corporate hides what is really          and in ‘throw-aways’ distort true
getting weaker while Kellogg and              going on behind nondisclosure.”             professional values.”
Macy and others is getting stronger.”            “There is no forum for discussing           “Gurus hype major productivity;
   “The ADA does not even seem to             our concerns.”                              what’s in it for them?”
be aware of what EBD is or whether it
matters.”                                     [N = 5] Organized dentistry is too
                                              focused on political action committees
                                              and lobbyists, own structure, and
                                              survival

Journal of the American College of Dentists                                                                                         7
The Evidence for Ethics

                                                 “Boards are not taking on the           Dental Leader Focus Groups
                                              known offenders; afraid of counter-
                                                                                         Seventeen leaders in the Oklahoma
                                              suits, underfunded.”
                                                                                         Dental Association; 9 officers of the
                                                 “Boards are overdoing the idea of
                                                                                         California Dental Association (only
                                              recovery or reclaiming previous
                                                                                         addressed issues relating to dentists
                                              offenders and letting bad actors back
                                                                                         and organizations); 13 CDA Judicial
                                              into the profession when they have
                                                                                         Council members; 20 Ohio “Young
“The ethics of the emerging                   not changed.”
                                                                                         dental leaders”
graduates is the ethics of the                [N = 2] Government: regulations and
                                                                                         Dentist-to-Dentist Ethical Issues
future of the profession.”                    low reimbursement rates
                                                 “FTC’s [Federal Trade                   [N = 40] Practicing in isolation
                                              Commission’s] preoccupation with              “We can still afford to live in our
                                              driving down cost is destroying quality    own worlds; no need to collaborate.”
                                              of care is an issue that is having            “Little real opportunity to
      “Product endorsements are                                                          communicate or cooperate on
                                              unintended consequences.”
    becoming more common.”                                                               treatment standards.”
                                                 “Legislators always respond to
                                              appeals for ‘free trade’ and ‘patient         “Practice is in silos.”
    [N = 3] Organizations are “fronts”                                                      “Patients are confused, and
                                              safety.’”
    for self-interest of members.                                                        consequently trust in the profession is
       “Factionalism.”                                                                   eroded.”
                                              [N = 2] Dental school environment
       “Multiple professional                                                               “Neither patients nor colleagues
                                              fosters competition.
    organizations are competing for                                                      have a voice in quality or type of care
                                                 “Dental schools are falling behind in
    membership, causing a narrowing of                                                   provided.”
                                              what they are teaching about ethics.”
    focus and appeal to self-interests.”                                                    “Dentists can collaborate as much
                                                 “The ethics of the emerging
       “Some organizations exist to                                                      or as little as they want to.”
                                              graduates is the ethics of the future of
    promote a business model, e.g., sleep                                                   “Lack of clear and consistent
                                              the profession.”
    dentistry.”                                                                          standards for what constitutes good
                                                 “Schools may not be able to do
       “ASDA [American Society for                                                       dental care.”
                                              anything about the ethics of young
    Dental Ethics] and the ADA need to                                                      “Every dentist can do whatever he
                                              people (already formed in youth), but
    grow up on this issue of patients on                                                 wants as long as he can talk enough
                                              they should be more selective in
    licensure exams.”                                                                    patients into it.”
                                              admissions.”
       “Different organizations are                                                         “Egos.”
                                                 “Young people today are going into
    representing particular interests in an
                                              dentistry for the money.”
    effort to draw membership from those                                                 [N = 18] Lack of collegiality: view
    seeking personal advantage at the                                                    other dentists as competitors
                                              [N = 2] Mid-level providers are a
    expense of colleagues generally.”                                                       “Some make unjustifiable negative
                                              question mark.
                                                “The effects of mid-level providers      remarks about others’ work.”
    [N = 2] Weak leadership, tolerate                                                       “Overtreatment comes from feeling
                                              may be positive for patients and
    unethical members, commercial                                                        of competitive need.”
                                              negative for dentists.”
    interests
       “State boards have lost control of                                                [N = 8] The profession does a poor job
                                              [General comment: “There are so
    the profession.”                                                                     of policing itself.
                                              many definitions of ethics and so
       “Ethics has become ‘enforceable up                                                   “Justifiable criticism is mistaken for
                                              many applications of principles. We
    to the cost of legal defense.’”                                                      unprofessional poaching, so avoided.”
                                              need to work on what to do when
                                              there are differences.” There appeared
                                              to be more concern over dentist-to-        [N = 5] Unclear relations with
                                              dentist ethical issues than over those     specialties and medicine unclear
                                              involving patients.]                          “Currently care for the patient is
                                                                                         divided and allocated to individuals

8                                                                                                  2020    Volume 87, Number 1
The Evidence for Ethics

with specialized training or public           disguises what oral health is really          “Dentistry is defining itself in
perception of best care, including on         about.”                                    terms of services delivered, especially
the basis of patients’ perceptions of            “Patients treat dentists as providers   at very high levels of excellence. But
cost/benefit calculations.”                   of commercial services rather than         this is not the way patients define
   “Fragmentation causes appearance           professionals.”                            dentistry. They seem to define good
of competition is for market share.”             “Loss of trust, bad-mouthing,           oral health as not needing to see the
   “Generally, evidence is lacking to         skipping payment, shopping (both           dentist.”
support often voiced claims of                dentists and patients are doing this).”
superiority of outcomes for many                 “Patients demanding specific care       [N = 7] Failing to present all treatment
kinds providers.”                             based on advertising or recommen-          alternatives, lack of informed consent
   “Better interprofessional                  dations from other dentists.”                 “Treatment options are often
communication and outcomes-based                 “Conflicts between treatment            tailored to maximize profit or the
decision making are needed.”                  priorities and patients’ financial         dentist’s view of optimal oral health.”
                                              resources.”                                   “Dentists are trying to take treat-
[N = 3] Different practice models                “In the corporate model we are          ment decisions away from patients.”
and reimbursement systems                     seeing ‘diagnosis’ at front desk.”
   “Dentists working for dentists                “Treating to insurance.”                [N = 4] Others than dentists or other
introduces new layers of ethical                                                         dentists are influencing patient
complexity and responsibility.”               [N = 11] True market demand does           expectations; extra-professional values
                                              not reach what dentists hope for.
Dentist-to-Patient Ethical Issues                “Dentists blame government and          [N = 4] Increasing specialization
[N = 21] Overtreatment                        insurers for not putting enough            and defining practice in terms of
   “Overtreatment is driven by                money into the system.”                    techniques rather than comprehensive
competition among dentists.”                     “Dental care trends toward services     health outcomes causes fragmenta-
   “Advertising serves greed rather           beyond true oral health needs because      tion of both the profession and care.
than trying to reach those most in            that is where the money is. This makes
need of dental care.”                         dental care appear ‘elective.’”            [N = 4] Patients no longer trust
   “The new standards are money,                                                         dentists, weak relationship, shift to
technology, and egotism.”                     [N = 10] Advertising, misrepresen-         financial basis of relationship
   “Patients and insurance companies          tation, media advertising                     “Old model of dentist and patient
are putting downward pressure on                 “Patients do not hear same story        (with dentist having recognized
dentists’ ability to maximize treatment       from all dentists.”                        authority) being replaced by multiple
offered.”                                        “Patients are being told that           forces competing to represent dentists’
                                              dentistry is a series of one-off           and patients’ interests.”
[N = 21] Bad dental practices                 transactions rather than a                    “Patients can no longer afford to stay
   Over-diagnosis, Botox, not being           relationship.”                             with a dentist long enough to build
honest about own bad work, fraud,                “Claims of superior or exclusive        relationship because of cost factors.”
cherry-picking treatment, treatment           skills or services.”
beyond competence, insurance                     “Appeal to uneducated public            [N = 2] Conflict between ideal care
manipulations                                 rather than colleagues to decide who is    and what patients can afford
                                              good dentist.”
[N = 16] Commercialism: business is              “Getting too close to commercial        [N = 2] Undertreatment of those
the new standard.                             organizations, advertisers, web            without funds
   “Patients as ‘customer’ rather than        designers, group-ons.”
individual needing professional care.                                                    Dentist-to-Organization
Dentistry is now something to ‘sell’;         [N = 8] Patients and dentists have         Ethical Issues
treating teeth instead of patients.”          different views of good dentistry.         [N = 21] Organized dentistry cannot
   “Rebranding (anti-aging dentistry),                                                   influence the way dentistry is
smiles, brand named technologies                                                         practiced.

Journal of the American College of Dentists                                                                                          9
The Evidence for Ethics

         “We are aware of the problem                “The ADA has become a                       “Money and technical excellence
     (confusion and miscommunication              bureaucracy that does not represent         on big cases (“show-off dentistry”) is
     leading to reduced trust), and we talk       individual practitioners.”                  becoming an independent standard.”
     about it. But organized dentistry really        “Organized dentistry is prevented           “HMO [health maintenance
     cannot do anything about the                 by law from interfering in individual       organization] practice model is
     problems.”                                   dentist’s commercial activities.”           inserting new values.”
         “There is no common place to                “The [ADA] code of ethics is                “Practice is increasingly being
     discuss ethics or the alternatives to the    aspirational and not enforceable.”          steered by marketing values.”
     way dentistry is trending.”                     “Is it wise to have one organization
         “Even in the face of strong              attempting to speak for all dentists?”      [N = 13] Benefits companies will
     messaging from organized dentistry              “Oral health no longer a standard.”      not pay for all work dentists want
     and mandatory continuing education,             “Using political position to advance     to provide
     the fact that dentists do not depend on      private practitioner income.”
     each other collectively for achieving                                                    [N = 6] Turf battles (in court), who
     best outcomes, or even financial             [N = 20] Benefit of organized dentistry     gets to provide care, competition
     success, means that public relations         not clear, too many organizations,          among groups, organized dentistry no
     campaigns will be superficial and the        fragmented participation                    longer single clear voice
     potential impact of professional                “Organized dentistry could                  “Many organizations besides
     communication is diluted by messages         overcome the isolation of individual        organized dentistry are now
     from other, often commercial, sources.       dentists, but it does not seem to be        influencing practice.”
     Organized dentistry may not be using         effective at doing so.”
     its communication platform effectively,         “It is hard for individual dentists to   [N = 6] Student debt
     or it may be too focused on legal and        resist the pressures of commercialism,          “Dental schools cannot change
     financial aspects of dentistry.”             advertising, politics and regulation by     ethical orientation in the face of what
         “Enforcement is spotty. State            themselves.”                                is happening in practice.”
     boards no longer involved except in             “Young practitioners learn how to            “The young want to live the life
     most outrageous cases or cases where         practice from senior dentists.”             style of their parents.”
     dentist does not put up a fight.”               “We want more from organized                 “As a younger dentist, I resent the
         “There are silos; folks are now          dentistry.”                                 claims that I must be unethical just
     using private definitions of what is                                                     because I have a high debt load when
     right. There is a growing sense in           [N =18] Fragmentation in under-             no one has shown me any evidence
     American culture that ‘everyone              standing what it means to be a              that this is true of me or of my peers in
     has a right to be right by his or her        professional                                general.”
     private standards.’”                            “We are not sure how to reach the
         “It is inappropriate to comment on       cost/value point of practitioners.”         [N = 4] “Good old boys’ club”: no
     a colleague’s work. It is even becoming         “One can be ‘professional’ without       longer representing all dentists.”
     inappropriate to discuss this. We lack       sharing values or activities with one’s
     the language and opportunities to            colleagues. Traditional dental              [N = 4] Corporate is a viable
     have discussions (other than attacking       professionalism competes with many          alternative
     others self-righteously).”                   other value sets.”                             “Corporate and ‘institutes’ are a
         “Organized dentistry focuses on             “Non-membership is a growing             viable alternative home for dentists
     legal and regulatory action rather than      issue.”                                     drifting toward a business definition of
     dealing directly with influential others.”      “Educational debt must be                dentistry rather than a professional one.”
         “The most questionable dentists are      managed.”
     probably not members of organized               “We now expect organized                 [N = 3] Online discussions, social
     dentistry, so we have no influence           dentistry to promote profession only,       media, unproductive
     over them.”                                  not profession and patients.”                 “I do not trust or participate in
                                                     “Dentists are getting their values       online discussions because they are
                                                  from places other than their colleagues.”

10                                                                                                      2020    Volume 87, Number 1
The Evidence for Ethics

dominated by commercial interests                        Appearance of office,                            Finding a Dentist
and people with axes to grind.”                          current equipment......................... 7
                                                                                                          References from friends...............11
                                                         Care about pain, taking time.........4
                                                                                                          Looking for location,
Patient Focus Groups                                     Reputation in community .............3
                                                                                                          convenience ....................................5
Eight-six patients in eight focus                        Online references ...........................3
                                                                                                          Consult lists, shop for price,
groups in San Francisco, California;                                                                      insurance .........................................4
rural and urban North Carolina;                          Public Emblems of Quality
                                                                                                          Avoid appearance of oversell.........3
Cleveland, Ohio; and Oklahoma City,                      of Little Value
                                                                                                              “I actually do an internet search
Oklahoma.                                                License on the wall is a given ........7         and look on the website where they
                                                         Report card of little value ..............5      got their degree, when, what they
First Thought That Comes to                              Too much technology ....................2        studied. I read all of that.”
Mind Regarding Dentistry                                     “I think when you are a professional             “One of the things I look at is do
Cost................................................17   you will show that, when you are                 they work in the community for
Issues of competence......................7              examining a patient, or whatever; it’ll          people who are in need. That ranks
Overcharge, overtreat.....................6              show. You will know whether they are             high. A lot of times they say if they
Pain, scary ...................................... 6     dedicated to their craft or are just             volunteer. When you go online, you
Hassle, inconvenience,                                   going through the motions. The way               find all kinds of stuff.”
unavoidable necessity................... 4               they interact with you. You’ll know                  “I want to steer away from the
Cleaning, health,                                        whether they know what they are                  people with the new technology and
professionalism, quality ................ 5              doing, or not.”                                  stuff because, I mean, like, you’re
Communication issues ..................4                     “I went to a dentist before and he           going to be doing fillings and root
                                                         caused the start of my problem. He               canals and things like that just like
Quality                                                  first said I needed a root canal, so he          everybody else and you’re going to
No specific question was asked about                     shaved it all the way down to a point.           have to charge three times as much for
how patients define quality of oral                      The next day it broke off at the gum             all your new machinery and it doesn’t
health care. Generally, quality seemed                   line, so I had no tooth left. When I             necessarily make you a better dentist.”
to mean technical outcomes and                           first started going to him, I just didn’t            “I refused to get involved in the
treatment in the process as expected.                    think he was the right one for me. I             huge medical school, dental school
“Durable,” “no mistakes,”                                shouldn’t have gone back to him. He              system. It is so impersonal. I won’t see
“preventive,” “effective,” “explained                    didn’t even say hello to you. I stopped          any healthcare provider in that setting.
so I understand,” “not being                             going to him after that.”                        I want them to remember me from
pressured,” “nothing unnecessary.”                           “I don’t think you know it until             time to time.”
    Overall, about half have been                        you actually go to them and see what
satisfied with their dentist; those                      he’s like.”                                      Communication
dissatisfied have moved on.                                  “I take ratings kind of with a grain
                                                                                                          Could be better .............................11
   “Good is not having to go back or                     of salt.”
                                                                                                          Generally good when talking
to hassle the encounter.”                                    “It [dental license] doesn’t
                                                                                                          about procedures ............................8
   “I think most of the dentists have                    differentiate any of them from each
                                                         other because they all have it.”                    “The hygienist will come in and
competence. It really boils down to                                                                       explain what she’s doing and what she
their personality. Do they make you                          “A professional testing organization
                                                         would be fine for the technical aspects          found. The dentist comes in and
feel at ease?”                                                                                            agrees with her assessment. Then I go
                                                         of what type of equipment they have,
                                                         what their training is, how good their           to the front desk.”
Judging Competence [Criteria                                                                                 “Don’t like the way he comes
valued by patients]
                                                         training was. This is a given. But, once
                                                         you get into various mouths, everyone            across as knowing everything but not
Interpersonal relationship ...........18                 in here has different sensitivity.”              really telling me anything.”
Clear explanations........................15
Friendly, efficient staff .................. 8

Journal of the American College of Dentists                                                                                                                      11
The Evidence for Ethics

     Paying for Care                                           “(Even with insurance), it’s still too   They jack up the price for any one
                                                            much. From my experience, I feel like       desperate enough to pay it, and then
     Selling, overselling........................21
                                                            a lot of dental offices charge extra        offer discounts.”
     Generally, dentistry is too
                                                            because they know it’s covered.”                “Now I’ve found a good dentist.
     expensive.......................................19
                                                               “They have these vouchers where if       Previously I had one I felt was in it for
     Cost affects when and whether
                                                            I hand them out and get referrals, I get    the money. He had a high priced office
     care is sought ................................11
                                                            $100 for every person I get. So, I could    and needed to make money. He was
     Postponed work because of cost ...7
                                                            get 4 people to go, I could get the $400    probably 50% higher than the rest of
     Medicaid coverage is
                                                            (for a mouth guard).”                       the dentists in the area.”
     inadequate for costs....................... 6
                                                               “The only other option was to do a           “I have doubts about my dentist. He
     Combine dental and medical
                                                            credit-type thing where you get a           let some stuff go…. I didn’t trust him
     insurance .........................................6
                                                            credit card and put money there and         and went to see someone else.”
     Treatment offered as “Take
                                                            there is 37% interest, so you are paying        “I think he wants to do things just
     it or leave it”....................................5
                                                            on it beyond the year you die.”             because he can do them.”
     Private insurance is good...............4
                                                               “A good dental visit is when I don’t
     Credit, other option
                                                            see the dentist or he doesn’t have          Behaviors That Are Not
     “bad deals”......................................4
                                                            much to say.”                               Appreciated
     Like that insurance covers
                                                               “I have insurance, but I’m paying        Excessive cost................................16
     prevention .......................................4
                                                            more and more out-of-pocket; it’s like      Overtreating..................................11
     Fail to distinguish optional from
                                                            the dentist is trying to get paid twice.”   Poor communication ....................4
     necessary .........................................4
                                                               “Dentistry has become preventive;        Assess for the well-off ....................3
         “This ‘full amount up front and                    I don’t expect to need treatment for
     then we’ll see what we can squeeze out                                                             Self-promotion................................3
                                                            things I am unaware of.”
     of the insurance company’ attitude                                                                     “Cost of procedures.”
                                                               “It’s like going to get your oil
     makes me think they are in it for the                                                                  “Overcharging.”
                                                            changed, then the sales guy comes in
     money.”                                                                                                “If they can turn it around and have
                                                            with a list of things that ‘really’ need
         “Way too expensive.”                                                                           a good practice for years, they become
                                                            to be taken care of even though I
         “I’m missing two teeth because I                                                               a millionaire they charge such high
                                                            didn’t know they were a problem.”
     couldn’t pay for what I needed…. I’d                                                               prices.”
                                                               “Is it really true that I need a cone
     still have these teeth if they’d given me                                                              “Dentists go into a lot of debt for
                                                            beam every year without the dentist
     a payment arrangement.”                                                                            schooling. I don’t know if that is tied
                                                            even looking to see if things have
         “Under Medicaid we’re usually not                                                              to what they charge.”
                                                            changed in my mouth?”
     covered for crowns or major work or                                                                    “At least cover part of the cost
                                                               “They do a lot of stuff that is
     cosmetic work.”                                                                                    rather than saying you’re out of
                                                            unnecessary.”
         “Cleanings and screenings—I                                                                    luck, man.”
                                                               “Several charge you interest as high
     think they should be made available to                                                                 “I think there are a lot of goof-balls
                                                            as 18%.”
     everybody as often as necessary.                                                                   out there who are dentists.”
                                                               “I think dentists just charge as
     Anything that has to be done after that                                                                “Somehow he changed after he
                                                            much as they think they can get. They
     will have to be negotiated.”                                                                       built that beautiful new office.”
                                                            get paid by both the insurance
         “It is a put-off when they start                                                                   “Make sure everyone has access
                                                            company and the patient. They are
     talking about a ‘perfect mouth.’”                                                                  to care.”
                                                            willing to give me a discount, so I know
         “Dentists charge extra if they know                                                                “Make sure they don’t gouge
                                                            they are overcharging somewhere.”
     you have insurance.”                                                                               anybody.”
                                                               “I asked for a payment plan and got
         “Our dentist says, if you want to                                                                  “When you go to the dentist, even
                                                            no sympathy.”
     pay cash, I’ll take some off.”                                                                     if you are going for your six months,
                                                               “Dentists want it both ways. They
         “Dental insurance makes a lot more                                                             every time I go in I get nervous in the
                                                            sell as much as they can, so insurance
     sense than medical insurance.”                                                                     chair because first I’m looking to see
                                                            picks up some and the patient gets
                                                                                                        if they find something and then if
                                                            stuck with the rest. Those without
                                                                                                        they don’t, it always feels like a little
                                                            insurance, are just out of luck.”
                                                                                                        bit of a hustle to get more money from
                                                               “Just like business at the malls.

12                                                                                                                   2020      Volume 87, Number 1
The Evidence for Ethics

you. ‘Why don’t you think about                            “I’d go back and if I don’t get
whitening?’ or, ‘What about that tooth                  resolution to my satisfaction, I leave
that’s missing?’ There’s always                         and find somebody else.”
something extra.”                                          “I am beginning not to trust [some]
    “They have to take continuing                       dentists. But I trust lawyers and the
education, right? Unfortunately, I can                  government even less. I hope dentists
tell you my beautician takes more                       don’t become like lawyers or big
continuing education than my dentist.                   business retailing.”
                                                                                                                     Licensure only establishes
How do you know they actually went                         “I’m more concerned about fixing
to those classes?”                                      the problem without putting more                             minimal competency, and is
    “Reduce the amount the dentist                      money into it.”
                                                                                                                     often unevenly enforced.
takes.”                                                    “Part of the question for me is the
    “Consistency in pricing.”                           trustworthiness of any agency that                           There was little interest in a
    “Universal healthcare should be a                   monitors the healthcare professions.”
                                                                                                                     “report card” or other
percentage of your gross income.”                          “Is it about teeth or is it about
    “If there were some way to keep the                 money?”                                                      external monitoring of
dentist honest. They are in private                        “I would show up and ask
                                                                                                                     continuing competence.
practice so they charge whatever they                   questions.”
want, do whatever they want.”                              “I wouldn’t pay.”
                                                           “Address it; fix it; change the
Response to Bad Encounters                              practice; not charge you.”
Unaware of reporting options.......8                       “If they screw something up, they                         “The dentist is playing a smaller
Online and word of mouth............5                   better damned well pay for it.”                           and smaller part in the system, just the
Go somewhere else ........................5                “Ethical issues are likely                             technical stuff.”
Confront the dentist.......................5            underreported.”                                              “Keep it simple—go to the
Fix the problem, complaints                                “We should reduce cost by having                       hygienist unless you need something
are useless........................................4    dentists take home less money.”                           more serious.”
Profession and state boards                                “Is there a dentist’s association that                    “For basic cleaning it would be
cover it up........................................4    a patient could go to?”                                   better to make an appointment
Report to insurance company                                                                                       directly with the hygienist and have it
or somebody ...................................3        Second Opinions                                           be cheaper and easier. All the dentist
Avoid multidentist offices .............3               Yes, if did not like options                              does is go over and look at it for 30
Preserve dentist’s reputation                           offered..............................................8    seconds and you have to spend
if possible.........................................3   Expensive and questionable                                however much money just for that.”
                                                        value.................................................5      “I go to the hygienist; they have a
   “The oral hygienist put me in so
                                                        Second opinion if suspicious.........3                    dentist there too.”
much pain. I told her and she started
crying. The next thing I know, the                      Second opinion if large and
                                                        irreversible case ............................. 3         Policy Experts Focus Group
dentist comes in and I can’t tell you
how rude she was. My friends told me                       “The first guy seemed drunk. My                        Nine individuals representing various
that’s how she is.”                                     sister went to him anyway and they                        healthcare and patient advocacy
   “I’d talk about it at work because                   double-charged her, so I decided to                       groups, such as AARP, who interact
everyone has the same insurance. It                     get a second opinion.”                                    with dentistry; one state board
gets around that a certain dentist sucks                                                                          representative.
and people won’t go to him.”                            Impression of Hygienists
   “I wish there were some sort of                      Positive volunteered comments...13
peer review. Four or five years ago I                   Favor independent hygiene...........5
had a really bad crown put in and I
                                                           “To me, the hygienists—they are
had 4 dentists in 3 different states tell
                                                        the face of the practice. They are the
me it was a horrible crown.”
                                                        ones you’re going to work with.”

Journal of the American College of Dentists                                                                                                                  13
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