CHAPTER 6
CODE OF ETHICS FOR DENTISTS
Section 1. Patient Autonomy. This principle expresses the concept that professionals have a duty to treat the patient according to the patient's desires, within the bounds of accepted treatment, and to protect the patient's confidentiality. Under this principle, the dentist's primary obligations include involving the patients in treatment decisions in a meaningful way, with due consideration being given to the patient's needs, desires and abilities, and safeguarding the patient's privacy.
(a) Patient Involvement. The dentist shall inform the patient of the proposed treatment, and any reasonable alternatives, in a manner that allows the patient to become involved in treatment decisions.
(b) Patient Records. Dentists shall safeguard the confidentiality of patient records. Dentists shall maintain patient records in a manner consistent with the protection of the welfare of the patient. Upon request of a patient or another dental practitioner, dentists shall provide any information, including X-rays that will be beneficial for the future treatment of that patient.
Section 2. Nonmaleficence. This principle expresses the concept that professionals have a duty to protect the patient from harm. Under this principle, the dentist's primary obligations include keeping knowledge and skills current, knowing one's own limitations and when to refer to a specialist or other professional, and knowing when and under what circumstances delegation of patient care to auxiliaries is appropriate.
(a) Education. The privilege of dentists to be accorded professional status rests primarily in the knowledge, skill and experience with which they serve their patients and society. All dentists, therefore, shall keep their knowledge and skill current through continuing education.
(b) Consultation and Referral. Dentists shall seek consultation, if possible, whenever the welfare of patients will be safeguarded or advanced by utilizing those who have special skills, knowledge, and experience. When patients visit or are referred to specialists or consulting dentists for consultation:
(i) The specialists or consulting dentists upon completion of their care shall return the patient, unless the patient expressly reveals a different preference, to the referring dentist, or, if none, to the dentist of record for future care; and
(ii) The specialists shall be obliged when there is no referring dentist and upon completion of their treatment to inform patients when there is a need for further dental care.
(c) Use of Auxiliary Personnel. Dentists shall be obliged to protect the health of their patients by only assigning to qualified auxiliaries those duties which can be legally delegated. Dentists shall be further obliged to prescribe and supervise the patient care provided by all auxiliary personnel working under their direction.
(d) Patient Abandonment. Once a dentist has undertaken a course of treatment, the dentist shall not discontinue that treatment without giving adequate notice and the opportunity to obtain the services of other dentists. Care shall be taken that the patient's oral health is not jeopardized in the process.
(e) Personal Relationships. Dentists, because of their position of power and authority over both patients and staff, shall exercise extreme discretion in their conduct and avoid any form of sexual coercion and/or harassment.
(f) Personal Impairment. It is unethical for a dentist to practice while abusing controlled substances, alcohol, or other chemical agents that impair the ability to practice. All dentists have an ethical obligation to urge chemically impaired colleagues to seek treatment. Dentists with first-hand knowledge that a colleague is practicing dentistry when so impaired have an ethical responsibility to report such evidence to the professional assistance committee of a dental society.
(g) Duty to inform. When, during the course of dental treatment, an unexpected or undesirable outcome is obtained, the dentist has the duty to inform the patient of such outcome and to make arrangements for any follow up or additional treatment deemed necessary.
Section 3. Beneficence. This principle expresses the concept that professionals have a duty to act for the benefit of others. Under this principle, the dentist's primary obligation is the competent and timely delivery of dental care within the bounds of clinical circumstances presented by the patient, with due consideration being given to the needs, desires, and values of the patient. The same ethical considerations apply whether the dentist engages in fee-for-service, managed care or some other practice arrangement. Dentists may choose to enter into contracts governing the provisions of care to a group of patients; however, contract obligations do not excuse dentists from their ethical duty to put the patient's welfare first.
(a) Community Service. Since dentists have an obligation to use their skills, knowledge and experience for the improvement of the dental health of the public and are encouraged to be leaders in their community, dentists involved in such service shall conduct themselves in such a manner as to maintain or elevate the esteem of the profession.
(b) Government of a Profession. Every profession owes society the responsibility to regulate itself. Such regulation is achieved largely through the influence of the professional societies. All dentists, therefore, have the dual obligation of making themselves a part of a professional society and of observing its rules of ethics.
(c) Research and Development. Dentists have the obligation of making the results and benefits of their investigative efforts available to all when they are useful in safeguarding or promoting the health of the public.
(d) Patents and Copyrights. Patents and copyrights may be secured by dentists provided that such patents and copyrights shall not be used to restrict research or practice.
(e) Abuse and Neglect. Dentists shall become familiar with the signs of abuse and neglect and to report suspected cases to the proper authorities, consistent with state laws.
Section 4. Justice. This principle expresses the concept that professionals have a duty to be fair in their dealings with patients, colleagues and society. Under this principle, the dentist's primary obligations include dealing with people justly and delivering dental care without prejudice. In its broadest sense, this principle expresses the concept that the dental professional shall actively seek allies throughout society on specific activities that will help improve access to care for all.
(a) Patient Selection. While dentists, in serving the public, may exercise reasonable discretion in selecting patients for their practices, 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 or national origin.
(b) Patients with Bloodborne Pathogens. It is unethical to decline treatment to any individual based on the fact that they are infected with a bloodborne pathogen such as Human Immunodeficiency Virus, Hepatitis B virus, Hepatitis C virus or any others.
(c) Emergency Service. Dentists shall make reasonable arrangements for the emergency care of their patients of record. Specifically, dentists shall make it possible for their patients of record to contact them after business hours. Additionally, dentists shall make reasonable arrangements with a colleague to provide emergency care whenever they are unavailable for such service.
(d) Justifiable Criticism. Dentists shall report to the appropriate reviewing agency as determined by the local component society instances of gross or continual faulty treatment by other dentists. Patients shall be informed of their present oral health status without disparaging comment about prior services.
(e) Expert Testimony. Dentists may provide expert testimony when that testimony is essential to a just and fair disposition of a judicial or administrative action.
(f) Rebate and Split Fees. Dentists shall not accept or tender "rebates" or "split fees."
Section 5. Veracity. This principle expresses the concept that professionals have a duty to be honest and trustworthy in their dealings with people. Under this principle, the dentist's primary obligations include respecting the position of trust inherent in the dentist-patient relationship, communicating truthfully and without deception, and maintaining intellectual integrity.
(a) Representation of Care. Dentists shall not represent the care being rendered to their patients in a false or misleading manner. A dentist who represents that treatment or diagnostic techniques recommended or performed by the dentist has the capacity to diagnose, cure or alleviate diseases, infections or other conditions, when such representations are not based upon accepted scientific knowledge or research is acting unethically.
(b) Dental Amalgam. Based on current scientific data the Board has determined that the removal of amalgam restorations from the non-allergic patient for the alleged purpose of removing toxic substances from the body, when such treatment is performed solely at the recommendation or suggestion of the dentist is improper and unethical. The same principle of veracity applies to the dentist's recommendation concerning the removal of any dental restorative material.
(c) Representation of Fees. Dentists shall not represent the fees being charged for providing care in a false or misleading manner.
(d) Waiver of Copayment. A dentist who accepts a third party payment under a copayment plan as payment in full without disclosing to the third party that the patient's payment portion will not be collected, is engaged in overbilling. The essence of this ethical impropriety is deception and misrepresentation; an overbilling dentist makes it appear to the third party that the charge to the patient for services rendered is higher than it actually is.
(e) Overbilling. A dentist shall not increase a fee to a patient solely because the patient is covered under a dental benefits plan.
(f) Treatment Dates. A dentist who submits a claim form to a third party reporting incorrect treatment date for the purpose of assisting a patient in obtaining benefits under a dental plan, which benefits would otherwise be disallowed, is engaging in making an unethical, false or misleading representation to such third party.
(g) Dental Procedures. A dentist who incorrectly describes on a third party claim form a dental procedure in order to receive a greater payment or reimbursement or incorrectly makes a non-covered procedure appear to be a covered procedure on such a claim form is engaged in making an unethical, false or misleading representation to such third party.
(h) Unnecessary Services. A dentist shall not recommend and perform unnecessary dental services or procedures.
(i) Devices and Therapeutic Methods. Except for formal investigative studies, dentists shall prescribe, dispense, or promote only those devices, drugs and other agents whose complete formulae are available to the dental profession. Dentists shall not hold out as exclusive any device, agent, method or technique if that representation would be false or misleading in any material respect.
(j) Marketing or Sale of Products or Procedures. Dentists who, in the regular conduct of their practices, engage in or employ auxiliaries in the marketing or sale of products or procedures to their patients shall take care not to exploit the trust inherent in the dentist-patient relationship for their own financial gain. Dentists shall not induce patients to purchase products or undergo procedures by misrepresenting the product's value, the necessity of the procedure or the dentist's professional expertise in recommending the product or procedure. Dentist shall disclose to their patients all relevant information the patient needs to make an informed purchase decision.
(k) Professional Announcement. In order to properly serve the public, dentists shall represent themselves in a manner that contributes to the esteem of the profession. Dentists shall not misrepresent their training and competence in any way that would be false or misleading in any material respect.
(l) Advertising. Although any dentist may advertise, no dentist shall advertise or solicit patients in any form of communication in a manner that is false or misleading in any material respect.
(m) Referral Services. There are two basic types of referral services for dental care: not-for-profit and the commercial. The not-for-profit is commonly organized by dental societies or community services. It is open to all qualified practitioners in the area served. A fee is sometimes charged the practitioner to be listed with the service. A fee for such referral services is for the purpose of covering the expense of the service and has no relation to the number of patients referred. In contrast, some commercial referral services restrict access to the referral service to a limited number of dentists in a particular geographic area. Contractual arrangements whereby the dentist is paying the referral service for patients referred on a per patient basis shall be strictly prohibited. A dentist is allowed to pay for any advertising permitted by the Code, but is generally not permitted to make payments to another person or entity for the referral of a patient for professional services.
(n) Name of Practice. Since the name under which a dentist conducts his or her practice may be a factor in the selection process of the patient, the use of a trade name or an assumed name that is false or misleading in any material respect is unethical. Use of the name of a dentist no longer actively associated with the practice may be continued for a period not to exceed one (1) year.
(o) Dentist Leaving Practice. Dentists leaving a practice who authorize continued use of their names should seek advice on the legal implications of this action. With permission of a departing dentist, his or her name may be used for more than one year, if, after the one year grace period has expired, prominent notice is provided to the public through such mediums as a sign at the office and a short statement on stationery and business cards that the departing dentists has retired from the practice.
(p) Announcement of Specialization. A dentist shall not advertise or otherwise hold himself or herself out to the public as a specialist, or use any variation of the term, in an area of practice if the communication is false or misleading.
(i) It shall be false or misleading for a dentist to hold himself or herself out to the public as a specialist, or any variation of that term, in a practice area unless the dentist:
(A) has completed a qualifying postdoctoral educational program in that area as set forth in subsection (ii) of this rule; or
(B) holds a current certification by a qualifying specialty board or organization as set forth in subsection (iii) of this rule.
(ii) For purposes of this rule, a "qualifying postdoctoral educational program" is a postdoctoral advanced dental educational program accredited by an agency recognized by the U.S. Department of Education.
(iii) In determining whether an organization is a qualifying specialty board or organization, the Board shall consider the following criteria:
(A) whether the organization requires completion of an educational program with didactic, clinical, and experiential requirements appropriate for the specialty or subspecialty field of dentistry in which the dentist seeks certification, and the collective didactic, clinical and experiential requirements are similar in scope and complexity to a qualifying postdoctoral educational program. Programs that require solely experiential training, continuing education classes, on-the-job training, or payment to the specialty board shall not constitute a qualifying specialty board or organization;
(B) whether the organization requires all dentists seeking certification to pass a written or oral examination, or both, that tests the applicant's knowledge and skill in the specialty or subspecialty area of dentistry and includes a psychometric evaluation for validation;
(C) whether the organization has written rules on maintenance of certification and requires periodic recertification;
(D) whether the organization has written by-laws and a code of ethics to guide the practice of its members;
(E) whether the organization has staff to respond to consumer and regulatory inquiries; and
(F) whether the organization is recognized by another entity whose primary purpose is to evaluate and assess dental specialty boards and organizations.
(iv) A dentist qualifying under subsection (iii) of this rule and advertising or otherwise holding himself or herself out to the public as a specialist, or any variation of that term, shall disclose in the advertisement or communication the specialty board by which the dentist was certified and provide information about the certification criteria or where the certification criteria may be located.
(v) A dentist shall maintain documentation of either completion of a qualifying postdoctoral educational program or of his or her current specialty certification and provide the documentation to the Board upon request. Dentists shall maintain documentation demonstrating that the certifying board qualifies under the criteria in subsection (iii) of this rule and provide the documentation to the Board upon request.
(q) Superior Designation. A dentist shall not hold himself out as an expert or imply superiority.
(r) General Practitioner Announcement of Services. General dentists who wish to announce the services available in their practices are permitted to announce the availability of those services so long as they avoid any communication that express or imply specialization. General dentist shall also state that the specialty services are being provided by general dentists. That disclaimer shall appear in same font and size as the advertised specialty service. A dentist shall not announce available services in any way that would be false or misleading in any material respect.
(s) Dental Practice Ownership Disclosure.
(i) If the name or ownership of the dental practice differs from the dentist(s) providing the services, the dentist providing services shall provide a written disclosure that indicates any and all individuals with a financial interest in the dental practice to be signed by the patient.
(ii) If a general dentist is employed at a specialty practice, the practice shall disclose when services are provided by a general dentist.
Section 6. Compliance with Code of Ethics. Dentists shall comply with the provisions of this Chapter, the ADA's Principles of Ethics and Code of Professional Conduct, the ADHA's Bylaws and Code of Ethics, and the Centers for Disease Control's Summary of Infection Prevention Practices in Dental Settings as referenced in Chapter 1.
Section 7. Prescribing Opioids.
(a) When considering prescribing opioids, dentists shall conduct a medical and dental history to determine current medications, potential drug interactions and history of substance abuse.
(b) Dentists shall register with and utilize prescription drug monitoring programs (PDMP) to promote the appropriate use of controlled substances for legitimate medical purposes, while deterring the misuse, abuse and diversion of these substances.
(c) Dentists shall have a discussion with patients regarding their responsibilities for preventing misuse, abuse, storage and disposal of prescription opioids.
(d) Dentists shall consider treatment options that utilize best practices to prevent exacerbation of or relapse of opioid misuse.
(e) Dentists shall consider nonsteroidal anti-inflammatory analgesics as the first-line therapy for acute pain management.
(f) Dentists shall recognize multimodal pain strategies for management for acute postoperative pain as a means for sparing the need for opioid analgesics.
(g) Dentists shall consider coordination with other treating doctors, including pain specialists when prescribing opioids for management of chronic orofacial pain.
(h) Dentists who are practicing in good faith and who use professional judgment regarding the prescription of opioids for the treatment of pain shall not be held responsible for the willful and deceptive behavior of patients who successfully obtain opioids for non-dental purposes.
Section 8. Morbidity/Mortality Reporting Requirements.
(a) All licensees shall report any morbidity, mortality, or other incident that results in temporary or permanent physical or mental injury of a patient requiring hospitalization to the Board within thirty (30) days.
(b) All licensees shall provide the following documents:
(i) Detailed description of dental procedures performed;
(ii) Names of all licensees involved in procedure;
(iii) All relevant patient records; and
(iv) Detailed description of sedation procedures used, if any.
(c) The Board may request other information or materials as it deems necessary.