Every profession that deals with human rights and liberties eventually develops a professional code of ethics to guide the responsible behavior of its members. Regulatory boards that oversee the practice of healthcare professionals require their members to be cognizant of the specific rules of conduct relating to their profession. In health care, the deductive process by which ethical principles are applied to situations common to the profession is called bioethics. Bioethics is a relatively new field emerging in the 1960s, however, the concept of bioethics, as a branch of applied ethical theory is as old as the Hippocratic oath. Legislatures often enact laws when there are repeated failures by individuals to adhere to ethical standards. With the many cases of dental insurance fraud, as well as other malpractice cases, that have received national attention, it is imperative that dental professionals understand the role that ethics play in the legitimacy of the profession.

Education Category: Ethics - Human Rights
Release Date: 02/01/2014
Expiration Date: 01/31/2017


This course is designed for all dental professionals.

Accreditations & Approvals

NetCE is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 10/1/2015 to 9/30/2021. Provider ID 217994. NetCE is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp. NetCE is a Registered Provider with the Dental Board of California. Provider Number RP3841. Completion of this course does not constitute authorization for the attendee to perform any services that he or she is not legally authorized to perform based on his or her license or permit type. NetCE is approved as a provider of continuing education by the Florida Board of Dentistry, Provider #50-2405.

Designations of Credit

NetCE designates this activity for 2 continuing education credits. AGD Subject Code 555. This course meets the Dental Board of California's requirements for 2 unit(s) of continuing education. Dental Board of California course #02-3841-16148.

Course Objective

The purpose of this course is to provide dental professionals with a review of ethics and ethical theoretical systems that pertain to their profession. The content of this course is not intended as legal advice for patients or practitioners.

Learning Objectives

Upon completion of this course, you should be able to:

  1. Describe the roles and responsibilities of dental professionals.
  2. Review the definitions of ethics and law.
  3. Compare and contrast ethical theoretical systems.
  4. Define ethical terms and ethical decision making, as related to the dental professional.
  5. Define dental malpractice, specifically as it relates to Medicare/Medicaid fraud.


William E. Frey, DDS, MS, FICD, graduated from the University of California School of Dentistry, San Francisco, California, in 1966. In 1975, he completed residency training in Periodontics and received a Master\'s degree from George Washington University. He has been a member of the American Dental Association for over thirty-five years, and is a member of the American Academy of Periodontology and a Fellow in the International College of Dentists (FICD).

Dr. Frey retired from the United States Army Dental Corps in 1989 after 22 years of service. Throughout the course of his professional career, he has continuously practiced dentistry, the first 7 years as a general dentist and the past more than 30 as a periodontist. His military experience included the command of a networked Dental Activity consisting of five dental clinics. In his last assignment, he was in charge of a 38-chair facility. Colonel Frey was selected by the Army to serve on two separate occasions as the Chair of the Periodontal Department in Army General Dentistry Residency Training Programs.

Dr. Frey currently maintains a practice limited to Periodontics in Jackson, California, and is the founder and president of Perio Plus, a practice management firm specializing in creating individually-designed hygiene and periodontal care programs for general dentists. He is also the creator of the Inspector Gum patient education series.

Michele Nichols, RN, BSN, MA, received her Associates Degree in Nursing in 1977, her Bachelor of Science Degree in Nursing in 1981 and obtained her Master of Arts Degree in Ethics and Policy Studies in 1990 through the University of Nevada, Las Vegas. She was Chief Nurse Executive at Valley Hospital Medical Center in Las Vegas, Nevada. Currently, Ms. Nichols is the System Director for the Valley Health System University, a five hospital system in Las Vegas, Nevada.

Faculty Disclosure

Contributing faculty, William E. Frey, DDS, MS, FICD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Contributing faculty, Michele Nichols, RN, BSN, MA, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Table of Contents

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#57421: Dental Ethics: A Brief Review

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Every profession that deals with human rights and liberties eventually develops a professional code of ethics to guide the responsible behavior of its members. In addition, most regulatory boards that oversee the practice of healthcare professionals require their members to be cognizant of the specific rules of conduct relating to their profession. In dentistry, the American Dental Association (ADA) has developed the ADA Principles of Ethics and Code of Professional Conduct to express the "obligations arising from the implied contract between the dental profession and society" [1]. Additionally, the American Dental Hygienists' Association (ADHA) has developed its own code of ethics.

With the many cases of dental insurance fraud, as well as other malpractice cases, that have received national attention, it is imperative that dental professionals understand the role that ethics play in the legitimacy of the profession.


According to the ADA, dentistry is defined as "the evaluation, diagnosis, prevention, and/or treatment (nonsurgical, surgical, or related procedures) of diseases, disorders, and/or conditions of the oral cavity, maxillofacial area, and/or the adjacent and associated structures and their impact on the human body; provided by a dentist, within the scope of his/her education, training and experience, in accordance with the ethics of the profession and applicable law" [2].

The dentist is responsible for all services provided to the "patient of record," which is a patient upon whom a dentist has taken a complete medical history, completed a clinical examination, recorded any pathological conditions, and prepared a treatment plan.

Depending on state regulations, dental hygienists may be delegated the task of removing calculus deposits, accretions, and stains from exposed surfaces of the teeth and from the gingival sulcus. They may also perform root planing and curettage. In addition, dental hygienists may expose dental x-ray films, apply topical preventive or prophylactic agents, and perform all tasks delegable by the dentist. However, the dentist remains responsible for the care of the patient.

David T. Ozar and David J. Sokol, in Dental Ethics at Chairside: Professional Principles and Practical Applications, suggest that the ethical issues faced by dentists have become more complex and seem to arise more often [3]. Ozar and Sokol present representative ethical decisions dentists face regularly with the goal of increasing the dental professional's attention to and reflection on these problems. Whether it is a dentist finding the work of another dentist inferior, warning a patient about the dangers of smoking when the patient is unwilling to change, or manipulating data on an insurance form to secure better treatment for the patient, the dentist is faced with a myriad of ethical decisions [3].


A discussion of professional ethics and law requires background knowledge of ethics and the definition of ethical principles. Ethics is a branch of philosophy that considers and examines the moral life. The word ethics comes from the Greek ethos and originally meant character or conduct; the word morals comes from the Latin mores, which means customs, values, or habits. These two terms are frequently used interchangeably; however, simply put, ethics are the standards of conduct an individual uses to make decisions and morality involves the judgment or evaluation of an ethical system, decision, or action based on social, cultural, or religious norms [13,14]. They both incorporate notions of approval or disapproval and in some cases are also applied to the character or virtues of the individual.

Although law and ethics have similarities, law may be better defined as the sum total of rules and regulations by which a society is governed. Ethics, on the other hand, are informal or formal rules of behavior that guide individuals or groups of people. Legal rights are grounded in the law, and ethical rights are grounded in ethical principles and values. Where the law might say, for example, that it is illegal to commit suicide/murder under any circumstance, even when a terminally ill patient has no quality of life and intractable pain, ethics may guide a physician to administer a lethal dose of morphine. Ethics often shapes law; some states (e.g., Oregon) have adopted "death with dignity" acts, whereby an individual with a medically confirmed terminal disease may request medication to end their life.


There are numerous ethical theories. Six fundamental theories that directly concern dental professionals will be described here. They are the deontological, teleological, motivist, natural law, transcultural, and relative/multicultural ethical theoretical systems. These systems are each made up of principles, precepts, and rules that form a specific theoretical framework that provides the follower with general strategies for defining the ethical actions to be taken in any given situation.


Under the deontologic umbrella, an action is deemed right or wrong according to whether it follows pre-established criteria known as imperatives. An imperative in our language is viewed as a "must do," a rule, an absolute, a black and white issue. This is an ethic based upon duty linked to absolute truths set down by specific philosophical schools of thought. As long as the principles dictated by these imperatives are met with dutiful compliance, one is said to be acting ethically.

One of the most significant features of deontological ethics is found in John Rawls' Theory of Justice, which states that every person of equal ability has a right to equal use and application of liberty. However, certain liberties may be at competition with one another. There are also some principles within the same ethical theoretical system that can conflict with one another. An example of this conflict might involve a decision over allocation of scarce resources. Under the principle of justice, all people should receive equal resources (benefits), but allocation can easily become an ethical dilemma when those resources are scarce.

The precepts in the deontological system of ethical decision making stand on moral rules and unwavering principles. No matter what situation presents itself, the purest deontological decision maker would stand fast by a hierarchy of maxims. They are as follows [17]:

  • People should always be treated as ends and never as means.

  • Human life has value.

  • One is always to tell the truth.

  • Above all in healthcare, do no harm.

  • All people are of equal value.

Theological Ethics

A well-known deontological ethical theory is based upon religious beliefs and is known as the theological ethical theory. The principles of this theory promote a summum bonum, or highest good, derived from divine inspiration. A very familiar principle is to do unto others as you would have them do unto you. One would be viewed as ethically sound to follow this principle within this system of beliefs.

Categorical Imperative

Another deontological ethical principle is Immanuel Kant's "Categorical Imperative." Kant believed that rather than divine inspiration, individuals possessed a special sense that would reveal ethical truth to them. That ethical truth is thought to be inborn and causes humans to act in the proper manner. Some of the ethical principles to come from Kant will become more familiar as the principles associated with bioethics are discussed. These include individual rights, self-determination, keeping promises, privacy, personal responsibility, dignity, and sanctity of life.


The teleological ethical theories or "consequential ethics" are outcome-based theories. It is not the motive or intention that causes one to act ethically, but the consequences of the act [18]. If the action causes a good effect, it is said to be ethical. So here, the end justifies the means.


Utilitarianism is the most well-known teleological ethical theory. This is the principle that follows the outcome-based belief of actions that provide the greatest good for the greatest number of people. So, rather than individual goodness or rightness, this principle speaks for the group or society as a whole. Social laws in the United States are based upon this principle. The individual interests are secondary to the interest of the group at large. There are two types of utilitarianism: act utilitarianism and rule utilitarianism. In act utilitarianism, the person's situation determines whether an act is right or wrong. In rule utilitarianism, the person's past experiences influence one to greatest good. There are no rules to the game; each situation presents a different set of circumstances. This is also referred to as situational ethics. Situational ethics would say that if the act or decision results in happiness or goodness for the person or persons affected, it would be ethically right.

Individuals may choose the utilitarian system of ethics over another because they find it fulfills their own need for happiness, in which they have a personal interest. It avoids the wall of rules and regulations that may cause a person to feel a lack of control. In Western society, the rule of utility is whatever leads to an end of happiness fits the situation.

The downside of utilitarianism is its application to healthcare decision making. In making healthcare policy for a nation of people based upon the principle of doing the greatest good for the greatest number, several questions arise. Who decides what is good or best for the greatest number? Is it society, the government, or the individual? For the rest of the people, are they to receive some of the benefits, or is it an all or nothing concept? How does "good" become quantified in healthcare in such concepts as good, harm, benefits, and greatest? Where does this leave the individual trying to make healthcare decisions?


One modern teleological ethical theory is existentialism. In its pure form, no one is bound by external standards, codes of ethics, laws, or traditions. Individual free will, personal responsibility, and human experience are paramount. Existentialism lends itself to social work because one of the tenets is that every person should be allowed to experience all the world has to offer. A critique of the existential ethical theory is that because it is so intensely personal, it can be difficult for others to follow the reasoning of a healthcare worker, making proof of the ethical decision-making process a concern.


Another modern teleological ethical theory is pragmatism. To the pragmatist, whatever is practical and useful is considered best for both the people who are problem solving and those who are being assisted. This ethical model is mainly concerned with outcomes, and what is considered practical for one situation may not be for another. Pragmatists reject the idea that there can be a universal ethical theory; therefore, their decision-making process may seem inconsistent to those who follow traditional ethical models.


The motivist would say that there are no theoretical principles that can stand alone as a basis for ethical living. Motivist belief systems are not driven by absolute values, but instead by intentions or motives. It is not the action, but the intent or motive of the individual that is of importance. An example of a motivist ethical theory is rationalism. Rationalism promotes reason or logic for ethical decision making. Outside directives or imperatives are not needed as each situation presents the logic within it that allows us to act ethically.


Natural law ethics, also known as the virtue system of ethics, is a system in which actions are seen as morally or ethically correct if in accord with the end purpose of human nature and human goals. The fundamental maxim of natural law ethics is to do good and avoid evil. Although similar to the deontological theoretical thought process, it differs in that natural law focuses on the end purpose concept. Further, natural law is an element in many religions while at its core it can be either theistic or non-theistic.

In theistic natural law, one believes God is the Creator, and the follower of this belief sees God as reflected in nature and creation. The nontheistic believer, on the other hand, develops understanding from within, through intuition and reason with no belief rooted in God. In either case natural law is said to hold precedence over man-made law.

The total development of the person, physically, intellectually, morally, and spiritually, is the natural law approach. Therefore, ethical decision making should not be problematic, as judgment and action should come naturally and habitually to the individual follower of natural law.

Although appearing to be the perfect approach to all ethical situations requiring decision making, there are some significant drawbacks; for example, a person's maximum potential is relative or subjective. Additionally, what constitutes natural law? The precept to do good and avoid evil leaves a very large space for interpretation. Because it acts largely outside of individual wishes, often separating human life into a set of separate events, it is an impersonal approach, devaluing the focus upon dignity. To some, it is also a rather cold-hearted approach—not making decisions with an individual, but for the individual based upon what others believe to be good for that person. The principle of paternalism would fit within this context.


The transcultural ethical theory is a modern ethical system of thought that centers on the diversity of cultures and beliefs among which we all live. Therefore, at its core, this ethic assumes that all discourse and interaction is transcultural because of the strengths and differences in values and beliefs of groups within society.

The advantage to the transcultural ethical system is that it folds parts of the other ethical systems together while recognizing the differences between people. A disadvantage might be that Western society largely follows the deontological and teleological principles that also make up our legal system. Therefore, there may be some difficulty in making decisions based upon other cultural beliefs and values. Our society largely operates on a basis of facts, conclusions, and predetermined, agreed-upon solutions based upon male Anglo-American ideals. Many healthcare professionals may find difficulty with the transcultural ethic's reliance on close inter-relationships and mutual sharing of differences required in this framework of ethical decision making.


The ethical theory of relativism/multiculturalism falls under the postmodernist philosophical perspective and may be referred to as moral relativism [15]. Multiculturalism promotes the idea that all cultural groups be treated with respect and equality [16]. According to ethical relativists, ethical principles are culturally bound and one must examine ethical principles within each culture or society [15]. The question then becomes how ethical principles that are primarily deontological and rooted in Western values are applicable in other societies. The challenge of ethical relativism is how to determine which values take precedent [15].


It is important to remember that ethical theories are just that, theories. They do not provide the absolute solutions for every ethical dilemma. They do provide a framework for ethical decision making when adjoined to the critical information obtained from patients and families.

In reality, most dental professionals combine the theoretical principles that fit best for the particular patient situation. When the practitioner-patient relationship is established, a moral relationship exists. Though not an inherent gift, moral reasoning is required to reach ethically sound decisions. This is a skill, and moral reasoning must be practiced so it becomes a part of any dental professional's life.

Although all ethical systems concern decisions about ethical problems and ethical dilemmas, the decision reached in regard to a specific conflict will vary depending on the system used. For example, a dentist assigned to care for a patient with acquired immunodeficiency syndrome (AIDS) might have strong fears about contracting the disease and transmitting it to his or her family. Is it ethical to refuse the assignment?

A dentist deciding on the basis of utilitarianism would weigh the good of his or her family members against the good of the patient. Based on the greatest good principle, it would be ethical to refuse to care for the patient. In addition, because utilitarianism holds that the end justifies the means, preventing the spread of human immunodeficiency virus (HIV) to the dentist's family would justify refusal of the patient.

Based upon deontology, duty and justice are the underlying and unchanging moral principles to follow in making the decision. A person who becomes a dentist accepts the obligations and duties of the role. Caring for patients with infectious diseases is one of those obligations; therefore, refusal, except in particular circumstances, would be a violation of this duty. In this system, another unchanging moral principle, justice, would require healthcare professionals to provide adequate care for all patients. Refusing to care for an AIDS patient would violate this principle.

According to the natural law system, refusing to care for an AIDS patient would be unethical. One of the primary goals of the natural law system is to help the person develop to maximum potential. Refusing to have contact with an AIDS patient would diminish the patient's ability to develop fully. A good person, by natural law definition, would view the opportunity to care for an AIDS patient as a chance to participate in the overall plan of creation and fulfill a set of ultimate goals.

Although such decisions are usually made on a practical level rather than a theoretical level, at times it is important to be able to relate a decision to its underlying system or principle. It is important to note that in its advisory opinion, the ADA states that, "a dentist has the general obligation to provide care to those in need. A decision not to provide treatment to an individual because the individual is infected with human immunodeficiency virus, hepatitis B virus, hepatitis C virus, or another bloodborne pathogen, based solely on that fact, is unethical" [1].


The ADA recognizes five major ethical principles of significance to dental professionals: autonomy, veracity, beneficence, nonmaleficence, and justice [1].


Autonomy refers to the right of the patient to determine what will be done with his or her own person (i.e., self-governance). It also involves the patient's right to have confidentiality of his or her own medical history and records, and for the medical personnel to safeguard that right. The dentist must involve the patient in treatment decisions in a meaningful way, with due consideration being given to the patient's needs and desires [1].

Ozar and Sokol present a model of the patient-dentist relationship in which the dentist and patient are equal partners in the relationship in three defined areas. First, they each have standing and deserve each other's respect. Second, each has a set of values by which to live. Finally, each comes to the decision-making process about the patient's oral health with the understanding that information must be shared. This can only be achieved through communication and mutual cooperation [3]. They summarize:

"The dentist and patient have equal moral standing within their relationship. But their equality, their equal claim to voice and vote within their relationship, derives from different grounds on the two sides. On the patient's side, it derives from the value of autonomy and the fact that it is the patient's body and life that are being affected. On the dentist's side, it derives from the fact of expertise regarding the patient's needs and enabling the patient to regain or maximize control over his or her body and life, which is precisely expertise concerning the central values of dental practice" [3].

Federal privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other healthcare providers took effect on April 14, 2003. Congress called on the U.S. Department of Health and Human Services (HHS) to issue patient privacy protections as part of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA includes provisions designed to encourage electronic transactions and also requires new safeguards to protect the security and confidentiality of health information [4].

Developed by HHS, these standards provide patients with access to their medical records and more control over how their personal health information is used and disclosed. They represent consistent federal privacy protections for consumers across the country [4]. HHS has issued extensive guidance and technical materials to explain the privacy rule, including an extensive, searchable collection of frequently asked questions that address major aspects of the rule. HHS will continue to expand and update these materials to further assist covered entities in complying. These materials are available at http://www.hhs.gov/ocr/privacy.

The efficiencies of electronic recordkeeping are obvious. There is, however, a downside that accompanies these efficiencies, including inappropriate and "unknown-to-the-patient" data transfers resulting from numerous linked locations, such as third-party financial entities and employers. As paper-based recordkeeping segues to electronic, the risk of unintentional privacy violations related to new-user lack of expertise increases. Precautions must also be in place to prevent intentional misuse of patient data. This presents an additional burden for dentists and other healthcare providers from both internal staff (on-site) and external service providers (off-site), not to mention deliberate electronic intruders.


Veracity involves truthfulness and keeping promises. We are obligated to be truthful with patients and/or their families and to avoid withholding information or representing care in a false or misleading manner. Dentists must avoid making representations or suggestions to their patients for treatment that is not based on scientifically accepted principles or research. It is unethical for a dentist to recommend unnecessary dental procedures to their patients.


One case regarding advertising disclaimers almost went as far as the U.S. Supreme Court. The case involved a general dentist who sought to advertise his credentials from the American Academy of Implant Dentistry and its sponsored board, the American Board of Implantology/Implant Dentistry, without including a disclaimer. The Florida Dental Board, since 1999, has required dentists to use a disclaimer when advertising a specialty that the state does not recognize. In 2001, the dentist in question filed suit against the dental board stating that the requirements violated his First Amendment right to free speech. A federal judge ruled in favor of the dentist; however, the ruling was overturned by the 11th Circuit Court of Appeals. The Supreme Court subsequently declined to hear the case, although Justices Thomas and Ginsburg believed that the case presented an opportunity to clarify recurring issues in the First Amendment treatment of commercial speech [9]. Many states prohibit paid advertising in which a dentist claims that his or her services or practice is better or exceeds the standards of another dental professional. However, advertising regarding having been voted the top dentist may be allowed.


The ADA is against dentists seeking to attract patients by advertising their HIV/AIDS-free status. This position is based on the idea that such a statement would be misleading, as it only pertains to the dentist's status at the time of the test. However, a dentist could satisfy his or her obligation under this advisory opinion to convey additional information by clearly stating in the advertisement or other communication: "This negative HIV test cannot guarantee that I am currently free of HIV" [1].


The ADA, in their Advisory Opinions, speaks specifically to issues of fees and overbilling and calls upon dentists to follow high ethical standards with the benefit of the patient as the primary goal. Increasing fees because the patient has dental health plan coverage or nondisclosure of co-payment waiver to a third-party payer is unethical [1]. A dentist must carefully evaluate recommendations to patients that are influenced by the patient's participation in a capitation health plan. The minimal yet clinically acceptable therapy may not be sufficient or acceptable to the patient and presents a burden on the caregiver, as patients may not understand the limitations of their coverage until a procedure is necessary. It may be the dentist or his or her staff that must intercede with the insurer as an advocate for the patient's general health and quality of life [3].


Beneficence refers to the ethical principle of doing or promoting good. Community service, in the form of offering free dental care to the needy, is one example of how a dentist can elevate the esteem of the profession. The Academy of General Dentistry requires that Lifelong Learning and Service Recognition Candidates complete at least 100 hours of approved dental-related community service, such as community education panels and the provision of pro bono patient care, or service to organized dentistry [12]. When a dental professional has achieved, through research or investigation, results that promote or safeguard the health of the public, he or she has an obligation to share those results with the profession. This does not prevent a dentist from seeking copyright or patent protection.

Orofacial trauma is common in cases of abuse, and in most states, dental professionals are obliged to report patients with symptoms consistent with domestic violence and child or elder abuse. The dentist is often the first healthcare provider to treat the victim and is therefore ideally positioned to provide intervention by reporting to the appropriate authorities.


Nonmaleficence simply means that we must try to avoid doing harm to the patient. It is the duty of the dental professional to evaluate his or her own skills and recognize when further education is required or when referral to a specialist is in the best interest of the patient.

Dental professionals who continue to practice while using substances that impair their ability to practice or who suffer from mental or physical impairment are not acting ethically and are violating the law. Colleagues of an impaired dental professional (e.g., in the case of substance abuse) should report the individual to the professional assistance committee of their dental society.

A dentist must complete a patient's treatment once it has begun or make arrangements for appropriate care if for any reason the dentist cannot complete the care.

Dentists who are consulted for a second opinion should not have a vested interest in the recommended treatment. According to the ADA's Principles of Ethics and Code of Professional Conduct, when delegating patient care, the dentist is required to protect the health of the patient using only qualified auxiliary personnel while prescribing and supervising the patient care. A dentist may delegate remediable tasks to dental hygienists and dental assistants so long as delegation of the task poses no increased risk to the patient and the task can be legally delegated. In general, tasks that can be delegated are those that do not create unalterable changes in the oral cavity or contiguous structures, are reversible, and do not expose a patient to increased risks. The use of a laser or laser device of any type is not a remediable task [1].

All dentists, regardless of their bloodborne pathogen status, have an ethical obligation to immediately inform any patient who may have been exposed to blood or other potentially infectious material in the dental office of the need for postexposure evaluation and follow-up. They are obligated to immediately refer the patient to a qualified healthcare practitioner who can provide postexposure services. The dentist's ethical obligation in the event of an exposure incident extends to providing information concerning the dentist's own bloodborne pathogen status to the evaluating healthcare practitioner if the dentist is the source individual, and to submitting to testing that will assist in the evaluation of the patient. If a staff member or other third person is the source individual, the dentist should encourage that person to cooperate as needed for the patient's evaluation.

Dentists must avoid personal relationships with their patients, as the potential for exploitation cannot be overstated. The judgment of what may be in the patient's best interest may be impaired where there is a personal relationship. Dentists must be sensitive to the patient's perception of inappropriate behavior [1].


Justice is broadly understood as fairness; however, it also pertains to what someone or a group is owed. It implies fairness in relationships and dealings with patients, colleagues and society. It also relates to the distribution or allocation of a scarce resource or treatment without prejudice. Ozar and Sokol write, "when a society's structures for distributing resources are ethically sound, a common adjective used to describe the society is just. When a society's structures are ethically deficient, one proper term is unjust." Distributive justice, coined by Aristotle to describe the effort to determine which kinds of distributive structures are ethical and which are not, could also be called social justice as it applies to dentists, dental patients, and society's distributive structures [3].

Dentists shall not refuse to accept patients into their practice or deny dental service to patients because of the patient's race, creed, color, sex, gender identity, or national origin [1]. Dentists must also avoid discriminating when making referrals to other dental professionals and in their hiring practices. According to Ozar and Sokol, the primary considerations when making referrals are the specialists' technical and communication skills, manner, and philosophy of dental practice [3].

A dentist may, in the course of his or her career, be called upon to provide expert testimony in the disposition of a judicial or administrative action. When a dentist has a poor result or outcome with his or her own patient, this may be difficult. When a patient presents for treatment with a poor result from another dentist, it is even more difficult. Dentists must have the ability to work with colleagues to achieve results that improve or maintain the patient's oral and general health. When a second opinion is sought, the patient's second dentist must take care to provide criticism that is justifiable. Avoidance of disparaging remarks to the patient about the first dentist's work cannot be overstated. The second dentist must balance this with his or her obligation to the profession when determining "whether the bad work is symptomatic of a potentially harmful pattern on the part of the first dentist and what sort of response is then appropriate" [3].


Although this course addresses dental ethics and not dental law, dental professionals should be aware of what constitutes dental malpractice. In general, dental malpractice has occurred when a dental provider, through improper treatment and/or diagnosis, causes significant injury, loss, or death to the patient. When malpractice issues arise, the consumer may report his or her complaint to a dental society, attorney, or licensing board. Although licensing boards strive to maintain high standards in the dental profession, it is not possible to conduct regular reviews of each licensed professional. Therefore, most boards rely on written complaints received from the consumer. Upon receipt of a complaint, licensing boards are usually required to open an investigation, the scope of which depends on the allegations [5].


Legal cases in dental care do not always involve malpractice that results in the injury and/or death of a patient. There have been several cases of dental Medicare/Medicaid fraud in the news. Although most insurance errors are the result of simple mistakes, cases of deliberate fraud ultimately undermine the dental profession and cost consumers millions of dollars in higher healthcare costs and health insurance premiums.

The enactment of HIPAA added new offenses to healthcare fraud, authorized various law enforcement agencies to investigate fraud, and increased monetary and criminal penalties of those convicted. It also allocated more money to the investigation of healthcare fraud. Those who commit healthcare fraud are subject to a penalty of 10 years imprisonment and a substantial fine. If serious bodily injury has occurred, the violator may be sentenced to 20 years, and if death has occurred, the sentence may be life imprisonment [10].

In September of 2004, the California Attorney General charged 20 dentists with defrauding the state Medi-Cal System of $4.5 million. The case charges that a dentist masterminded a scam involving 19 other dentists throughout the state. These dentists have been accused of offering gifts or rebates to Medi-Cal beneficiaries and new patients who sought services, receiving kickbacks of insurance payments, performing unnecessary dental procedures of poor quality, fabricating charts to obtain reimbursement for services, and illegally delegating tasks to dental assistants to obtain insurance reimbursements [8,9].

In 2010, a New York Attorney General indicted four individuals and three corporations on charges of stealing upwards of $5.7 million from the Medicaid system out of dental clinics in Brooklyn, Queens, and the Bronx [19]. The defendants owned the clinics (but were not dentists themselves, and therefore are prohibited from owning a dental clinic) and employed many dentists who were instructed to encourage patients, often homeless and lured by recruiters with McDonald's gift cards, CD players, and cash, to agree to "high-value" and "quick-turnaround" procedures (e.g., complete tooth extraction and denture fitting in the same office visit). The employed dentists were required to pay two-thirds of the Medicaid billings to the three corporations involved in the suit.

A West Palm Beach, Florida, dentist was arrested in 2013 on charges of Medicaid fraud, grand theft, and employing a person to perform duties outside the scope of their license, all felonies [6]. Between 2008 and 2012, the dentist employed an unlicensed dental hygienist whom he allowed to perform periodontal root cleaning and scaling on at least 71 children. The dentist then billed Medicaid for the procedures. This dentist faces 15 years in prison and up to $30,000 in fines.

Also in 2013, a dentist practicing in Connecticut (who was previously barred from practicing in every other state in New England) was sentenced to 8 years in prison and ordered to pay $10 million in fines and restitution for operating a number of assembly line-style clinics that performed unnecessary dental procedures targeting poor patients and collecting more than $20 million in fraudulent claims from Medicaid [7]. The clinics hired recruiters to canvas neighborhoods and paid bonuses to those who brought in patients. In some cases, transportation was arranged for patients to the clinics, which were located in low-income neighborhoods. Most of the unnecessary procedures involved drilling into perfectly healthy teeth but included other questionable treatments. The plaintiff had relocated to Connecticut following the announcement of a program to increase Medicaid payments in an effort to induce more dentists to treat low-income patients. The dentist hid his involvement in the Connecticut clinics by using false names and false corporations and by falsifying documents.


When there are repeated failures by individuals to adhere to ethical standards in any profession, a code of ethics must be called upon to guide the responsible behavior of its members. It would be well beyond the scope of this continuing education activity to address all possible ethical dilemmas that could potentially present themselves to a dental professional, let alone provide all of the definitive answers or solutions. It is, however, possible to provoke thought and provide a framework for reflection.

The American College of Dentists (ACD) produces a card for the wallet that contains on one side the Core Values, which guide the ethical behavior of Fellows of the ACD, and on the reverse a list of questions called the ACD Test for Ethical Decisions, following the ACD acronym [11].

Is it true?
Is it accurate?
Is it fair?
Is it quality?
Is it legal?
Have you listened?
Have you informed the patient?
Have you explained outcomes?
Have you presented alternatives?
Is now the best time?
Is it within your ability?
Is it in the best interest of the patient?
Is it what you would want for yourself?

This is a simplified but excellent reminder.

Works Cited

1. 1. American Dental Association, Council in Ethics, Bylaws and Judicial Affairs. Principles of Ethics and Code of Professional Conduct. Available at http://www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdf. Last accessed January 14, 2014.

2. American Dental Association. Dentistry Definitions. Available at http://www.ada.org/6154.aspx. Last accessed January 14, 2014.

3. Ozar DT, Sokol DJ. Dental Ethics at Chairside: Professional Principles and Practical Applications. 2nd ed. Washington, DC: Georgetown University Press; 2002.

4. U.S. Department of Health and Human Services. Health Information Privacy. Available at http://www.hhs.gov/ocr/privacy/index.html. Last accessed January 14, 2014.

5. Baratz RS. Complaints About Dental Care. Available at http://www.dentalwatch.org/reg/complaints.html. Last accessed January 14, 2014.

6. Florida Office of the Attorney General. Attorney General Bondi's Office Arrests West Palm Beach Dentist on Medicaid Fraud and Grand Theft Charges. Available at http://www.myfloridalegal.com/newsrel.nsf/newsreleases/884414CF74BD2F0E85257B0C005D68E6. Last accessed January 14, 2014.

7. The Courant. Dentist In Massive Medicaid Fraud Case Sentenced To 8 Years. Available at http://articles.courant.com/2013-10-09/health/hc-medicaid-fraud-1010-20131009_1_clinics-gary-anusavice-care-fraud. Last accessed January 14, 2014.

8. California Department of Justice. Attorney General Charges Central Valley Dentist and 20 Others in $4.5 Million Medi-Cal Fraud Scheme. Available at http://oag.ca.gov/news/press-releases/attorney-general-charges-central-valley-dentist-and-20-others-45-million-medi. Last accessed January 14, 2014.

9. Consumer Affairs. California Dentists Charged in Fraud Scheme. Available at http://www.consumeraffairs.com/news04/ca_dentists.html. Last accessed January 14, 2014.

10. Hyman D. HIPAA and health care fraud: an empirical perspective. Cato J. 2002;22(1).

11. American College of Dentists. ACD Test for Ethical Decisions. Gaithersburg, MD: ACD; 1997.

12. Academy of General Dentistry. Lifelong Learning and Service Recognition Guidelines. Available at http://www.agd.org/media/168944/llsrguidelines_2013.pdf. Last accessed January 14, 2014.

13. Corey G, Corey MS, Callanan P. Issues and Ethics in the Helping Professions. 5th ed. Pacific Grove, CA: Brooks/Cole Publishing Company; 1998.

14. Gladding ST. Counseling: A Comprehensive Profession. 4th ed. Upper Saddle River, NJ: Merrill; 2000.

15. Harper MG. Ethical multiculturalism: an evolutionary concept analysis. ANS Adv Nurs Sci. 2006;29(2):110-124.

16. Macklin R. Ethical relativism in a multicultural society. Kennedy Inst Ethics J. 1998;8(1):1-22.

17. Catalano JT. Critical care nurses and ethical dilemmas. Crit Care Nurse. 1991;112(1):20-25.

18. Congress EP. Social Work Values and Ethics: Identifying and Resolving Professional Dilemmas. Chicago, IL: Nelson-Hall; 1999: 31-33.

19. State of New York Office of the Attorney General. Attorney General Cuomo Announces Arrests In Multi-Million Dollar Medicaid Fraud Scheme Run Out Of Three New York City Dental Clinics. Available at http://www.ag.ny.gov/press-release/attorney-general-cuomo-announces-arrests-multi-million-dollar-medicaid-fraud-scheme. Last accessed January 14, 2014.

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