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American College of Dentists

839J Quince Orchard Boulevard

Gaithersburg, MD 20878-1614

Periodicals Postage

PAIDat Gaithersburg, MD

and additional

mailing officesJournal of the

American Collegeof Dentists

Standards:Part I

Summer 2019

Volume 86

Number 3

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A publication advancing excellence, ethics, professionalism,and leadership in dentistryThe Journal of the American College of Dentists(ISSN 0002-7979) is published quarterly by the American College of Dentists, Inc., 839JQuince Orchard Boulevard, Gaithersburg, MD20878-1614. Periodicals postage paid atGaithersburg, MD, and additional mailing offices. Copyright 2019 by the American College of Dentists.

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

The 2019 subscription rate for members of the American College of Dentists is $30 and is included in the annual membership dues. The 2019 subscription rate for nonmembers in the United States, Canada, and Mexico is $40. All other countries are $60. Foreign optional airmail service is an additional $10.Single-copy orders are $10.

All claims for undelivered/not received issues must be made within 90 days. If the claim is made after this time period, it will not be honored.

While every effort is made by the publishersand the Editorial Board to see that no inaccurateor misleading opinions or statements appear in the Journal, they wish to make it clear that the opinions expressed in the articles, correspondence, etc., herein are the responsibility of the contributor. Accordingly, the publishers and the Editorial Board and their respective employees and officers accept no liability whatsoever for the consequences of any such inaccurate or misleading opinions or statements.

For bibliographic references, the Journalis abbreviated J Am Col Dent and should be followed by the year, volume, number, and page. The reference for this issue is:J Am Col Dent 2019; 86 (3): 1-48.

Journal of the


Communication Policy

It is the communication policy of the American College of Dentists to identify andplace before the fellows, the profession, and other parties of interest those issuesthat affect dentistry and oral health. The goal is to stimulate this community toremain informed, inquire actively, and participate in the formation of public policyand personal leadership to advance the purpose and objectives of the college. The college is not a political organization and does not intentionally promotespecific views at the expense of others. The positions and opinions expressed incollege publications do not necessarily represent those of the American College of Dentists or its fellows.

Objectives of the American College of Dentists

THE AMERICAN COLLEGE OF DENTISTS, in order to promote the highest ideals in health care, advance the standards and efficiency of dentistry, develop good human relations and understanding, and extend the benefits of dental health to the greatest number, declares and adopts the following principles and ideals asways and means for the attainment of these goals.

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

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

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

D. To encourage, stimulate, and promote research;

E. To improve the public understanding and appreciation of oral health service and its importance to the optimum health of the patient;

F. To encourage the free exchange of ideas and experiences in the interest of better service to the patient;

G. To cooperate with other groups for the advancement of interprofessionalrelationships in the interest of the public;

H. To make visible to professional persons the extent of their responsibilities to the community as well as to the field of health service and to urge theacceptance of them;

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

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Standards: Part I

4 Standards and OrganizationsStephen A. Ralls, DDS, EdD, MSD, FACD

10 Defining the Standard of CareLaurance Jerrold, DDS, JD, FACD

20 The Academy of General Dentistry’s Standards for Continuing EducationNeil J. Gajjar, DDS, FACD

24 Can a Dentist Maintain Standards on Social Media?Chris Salierno, DDS

28 The Impact of Peer Review on the Quality of Dental CareRichard E. Jones, DDS, MSD, FACD

31 Standards for the Oral Health of the PublicCaswell A. Evans, DDS, MPH, FACD

42 Conscience, Training, and ProfessionalismWilliam van Dyk, DDS, FACD

Departments

2 From the EditorMaybe Darwin Was Right

47 Submitting Manuscripts for Potential Publication in JACD

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

Managing EditorTheresa S. Gonzales, DMD, MS, MSS

Editorial BoardRick Asai, DMDPhyllis Beemsterboer, EdM, MSGreg Chadwick, DDS, MSR. Bruce Donoff, MD, DMDNanette Elster, JD, MPH Geraldine Ferris, DDSNancy Honeycutt, CAE Robert Lamb, DDS, MSD Philip Patterson, MA, PhD Carlos Quiñonez, DMD, MSc, PhDKen Randall, DMDLindsey A. Robinson, DDSHarriette Seldon, DMDRobert Sherman, DDSClifton Simmons, DDSRonald Tankersley, DDS

Design and ProductionAnnette Krammer, Forty-two Pacific LLC

CorrespondenceAddress correspondence relating to the Journal to: Managing EditorJournal of the American College of Dentists839J Quince Orchard BoulevardGaithersburg, MD 20878-1614

Letters from ReadersComments concerning any material appearing inthis journal are welcome at [email protected] should be no longer than 500 words and willnot be considered after other letters have already been published on the same topic. The editorreserves the right to refer submitted letters to the Editorial Board for review.

Business OfficeJournal of the American College of DentistsTel. (301) 977-3223; Fax. (301) 977-3330

OfficersThomas J. Connolly, PresidentStephen A. Ralls, President-electMark A. Bauman, Vice PresidentRobert M. Lamb, TreasurerRichard F. Stilwill, Past PresidentTheresa S. Gonzales, Executive DirectorDavid W. Chambers, Editor

RegentsPaula K. Friedman, Regency 1David A. Anderson, Regency 2Carole M. Hanes, Regency 3Richard E. Jones, Regency 4Charles F. Squire, Regency 5Robert M. Anderton, Regency 6Gary S. Yonemoto, Regency 7Lawrence R. Lawton, Regency 8Teresa A. Dolan, At LargeRobert A. Faiella, At LargeStephen M. Pachuta, At LargeLeo E. Rouse, At Large

Toni M. Roucka, ASDE LiaisonMichael C. Meru, SPEA LiaisonErik C. Klintmalm, Regent Intern Cover image Measuring up to the profession’s standards.

© 2019 DNY59, istockphoto.com. All rights reserved.

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And I would not want to hold themback by insisting that they first helpme solve the issues I am still strugglingwith. I could not grow old in comfortwithout some assurance that thethings we care most about are in thehands of those able to carry on. Thatincludes my family, my professionalwork, and the energy and civility of our community.

Perhaps the most memorable,certainly the most ambivalent, day ofmy life was 15 years ago. My sons andI played a lot of one-on-one basketballin the court behind our house. Bothmy sons are good, but the old man issmart and, when it comes to playingdirty, I am a master of plausibledeniability. Then it happened. Myoldest son beat me. Not a fluke, hestarted beating me consistently. Myself-image had never taken this kindof blow before. At the same time youwould never find a prouder parent. It cost me something to move to the next level in life. Life withouttransitions is just waiting to fulfilldreams that are walking away fasterthan we can chase them.

There is a well-known axiom in the business world: “Form followsfunction.” Roughly, this means the big guys will play under the basket oron the line, houses in Hawaii will beraised off the ground and have lanais,we will structure our communicationplatform around our audience andtheir needs rather than the other wayaround, we will have a good reason for raising money, and we will assignpeople to tasks rather than titles.

Tithonus loved Eos. This was acommon enough theme about a

man and a maiden among the legendsof Greek mythology. What made itunique and ultimately tragic was thatEos was a goddess (the Romans calledher Aurora) and Tithonus was amortal. Even on Olympus, that wasregarded as an unnatural relationship.Eos made matters worse by pesteringZeus to grant her lover eternal life. Becareful what you wish for…Tithonuscontinued to age, but he could not die.One shudders to think of immortalitywithout eternal youth.

As I grow older, I have graduallyplaced more emphasis on wisdom. Ibegan thinking of myself as somewhatsenatorial. That was before I saw theGallup Poll showing that America’spublic trust in that body is in thesingle digits and before I looked it uponline and found that “senator”means literally “old man.”

Being around students and residentsis wonderful. They think I am smartbecause I know things they do not. Inreality I am just adept at changing thesubject and talking about the things Iwas once expert in. I am getting hardof hearing, so I talk more. I am assmart as the young folks today, but Iam not as current in managing theemerging challenges of the professionusing the newly available approaches.

2 2019 Volume 86, Number 3

Editorial

From the Editor

Maybe Darwin Was Right

Editorial

We might even go so far

as to propose the

hypothesis that the vitality

of an individual or

organization can be read

by observing whether form

follows function or the

other way around.


There is probably a “should”somewhere in that formula. Formdoes not always follow function, but it should. This is straightforwardDarwinian thinking. Regardless ofhow well the group practice or largecommercial clinic works in thesuburbs of Los Angeles, it will notsurvive in White Falls, Montana. Nomatter how well written the 3,000-word articles are in respected journals,few will read them, and fewer willchange their practices in response.Most dentists want short, actionableinteractions or just to not be botheredso much. When the function is nolonger served, the form becomes rigid and loses its effectiveness. Justask Tithonus.

Stanley Liu is a professor oforthodontics at the Stanford MedicalSchool. He recently put a new twist on the “form follows function” rule.He said that as long as the organism isvital, form will follow function. Teethand jaws move where they aresupposed to be, sometimes with a littleprofessional help. The young mouthgrows to adapt to the needs of itsowner. But with age, function beginsto follow form. As the mouth starts tobreak down, we adapt by changing ourdiet, mumbling, and falling victim toobstructive sleep disorders.

We might even go so far as topropose the hypothesis that the vitalityof an individual or organization can beread by observing whether form followsfunction or the other way around.

The American College of Dentistshas maintained its vigor for a century.The essential formula has been tochange its focus every decade or so.The founding purpose was toencourage young dentists to pursueadvanced training. That was followedby attention to standards for educationand licensure and then betterjournalism. In the 1940s attentionturned to insurance, denturism, andAmerica’s role in the world. By the1960s and 1970s, the college wasfocused on research and recruitingstudents to the unfilled places indental schools. Most recently, we areworking on ethics. The college is long-lived because it “functions” well.

The trick to perpetual renewal is toidentify the right unit of analysis. Weare not a club of honorable individualswho have been giving awards for ahundred years. We are an honorablegroup of outstanding individualsworking for the betterment of the

3Journal of the American College of Dentists

Editorial

profession. Groups can functionindefinitely by replacing theirmembers with those responding tonew times. The Mormon TabernacleChoir remains relevant despite the factthat there are no members singingtoday who were in the original group.Darwin was pretty clear about this.Species survive or thrive or vanishbecause old individuals are replacedby new ones who are adapted to thechanging environment. Of course thenew ones need a little guidance alongthe way. But we should be proud tohave them moving into position.

(Did I say that I was originally taughtto shoot free-throws underhand?)

The Dodo birds of a century agoprobably thought they were about thebest Dodo birds around and thatDarwin was a pessimistic academic.But maybe Darwin was right.

Life without transitions is just waiting to fulfill dreams that are walking away faster

than we can chase them.


Stephen A. Ralls, DDS, EdD,

MSD, FACD

Abstract

This paper defines and reviews the use ofstandards in organizations and offersinsights. Some standards are direct, whileothers are indirect and diluted within otherorganizational text. Standards allowmeaningful assessments of actions, whichcan lead to positive organizational changes.The level at which standards are set isimportant and has ramifications for anorganization. Factors in setting standards arediscussed and the sensitive topic of fauxstandards is introduced. Standards andquality are interrelated—the quality of anorganization is a reflection of its standards.

The American College of Dentistswas founded in 1920 to elevate

the standards of dentistry. This was ata time when dentistry was strugglingwith low standards, proprietaryinfluences, and trade-like pockets ofless-than-professional activity. Thehigh standards espoused by thecollege, particularly in education,research, and journalism, moveddentistry in the right direction. Anemphasis on standards has remained a special interest of the college. Thispaper explores standards in dentistryfrom an organizational perspective, to include insights on their use and misuse.

The concept of a standard goesback at least as far as the Greek wordfor canon (kanvn), which initiallymeant measuring rod, but came tomean a standard or norm. Theimagery of a measuring rod isinstructive here—a reference pointthat allows comparisons or testing. As used here, a standard is defined as a descriptive statement of a desiredstate against which an actual state canbe compared. The descriptive elementmay be qualitative or quantitative,while the term state encompassessubsets of performance, outcomes,behavior, status, and condition. Thisrather inclusive definition is consistentwith the broader perspective soughtthrough this work. Time is also asometimes-overlooked component ofstandards. A standard can be tested ata single point in time—comparing the

desired with the actual—or at multiplepoints in time. The differentialbetween the desired state and actualstate can represent either a staticshortfall or excess, or an expression of change depending on the situationand standard.

Unfortunately, a discussion ofstandards in organizations is notwithout some built-in confusion.Organizations in dentistry aretypically composed of individuals inone or more of the followingcategories: employees, members,volunteers, and students. The issue isthat standards at the entity levelcannot be divorced from standardsapplicable to the individualsparticipating in that entity. There isoverlap. Organizations typicallyestablish standards that apply to boththe entity per se as well as to theindividuals within the entity. Examples of entity-level standards are shown in Table 1. Examples ofstandards for individuals within anentity as employees or members arepresented in Table 2. As anillustration, an organization may havea corporate statement of ethics for theentity in addition to a code of ethicsfor its members or employees, or itmay have a single code that servesdual purposes. In similar fashion, thebylaws of the organization may statestandard-like principles that apply tothe entity in addition to principles orcriteria that relate to the members oremployees of the entity.

To further complicate the issue,there are also the pervasive umbrella


Standards: Part I

Standards and Organizations

Dr. Ralls is the president of theAmerican College of Dentists.He served as the executivedirector of the college for over20 years and prior to that wascommanding officer of theformer Naval Dental ResearchInstitute.


standards lying unobtrusively in thebackground that can apply to both theentity and its individuals. The impactof the applicable umbrella standardscannot be separated from the entity or the individuals within it. Examplesof umbrella standards are shown inTable 3. As a case in point, federal andstate laws and regulations will governaspects of an entity’s operation while other laws and regulations willgovern the licensure and practice of aprofessional who works in the entity.Organizational standards are notestablished in isolation of umbrellastandards—the umbrella standardsinfluence both entity-level standardsand standards of individuals withinthe entity.

We intuitively understand thatstandards are important, but we rarely ponder life without them.Without standards, we approachchaos. Without standards, there can be no ethics, no professionalism, noprofessions, no excellence, no quality,no effective leadership, no plannedperformance, no intentional outcomes—virtually no meaningful assessment,measurement, or evaluation of anykind. A measurement without astandard is just a number. An eventwithout a standard for context is just an undefined, unassigned, orunattributable episode in time.


Standards: Part I

TABLE 1. Examples of Entity-level Standards

Codes of ethics (entity-level)Core values Strategic Mission statement Vision statement Guiding principles Strategic goals Strategic objectives Branding promisePrescriptive Bylaws Policies and procedures manual Standard operating procedures Best practicesCommunication Public relations statements Advertising statementsPerformance and outcomes Entity Board DepartmentsFinances Budget projections Market-share goals Investment goals Fundraising goalsEmployees Employee manual Employee hiring criteria Employee termination criteria Employee reward criteria Employee advancement criteria Employee discipline criteria Employee retirement criteria Employee development criteriaMembers Sustaining membership criteria Member admission criteria Member exit criteria Membership goals Member/customer satisfaction Member/customer serviceProfessional development Goals Outcomes by group Curricular criteria Assessment criteria Competency criteriaResearch Evidence-based policies

TABLE 2. Examples ofIndividual Standards within an Entity

Codes of ethics (individual level)Prescriptive Bylaws Code of conduct Policies and procedures manual Best practicesEmployee Employee manual Recognition criteria Disciplinary criteria Termination criteria Advancement criteria Retirement criteria Promotion criteria Performance criteria Behavioral criteria Competency standards Continuing education requirements Assessment criteria Learning objectivesMember Membership requirements Recognition criteria Disciplinary criteria Termination criteria Advancement criteria

TABLE 3. Examples ofUmbrella Standards

Laws and regulationsSocial standards and normsCommunity standardsCultural standardsSector standards Profession Education Institution Research Journalism Communication AdvertisingReligious principlesPolitical principlesImportance and use


Among other applications, standardspermit useful comparisons that allow assessment of status, condition,or results; measurement of progress or regress; or understanding of im-provement or decline. As aptly statedby Taiichi Ohno, “Without standards,there can be no improvement.”

An organization will havestandards, whether or not thosestandards are always recognized assuch. Any organization that hasbudgets has standards. Educationalinstitutions cannot function withoutstandards. Inappropriate behaviorcannot be assessed, counseled,directed, or sanctioned withoutstandards. Standards are vital incorporate work that involvesassessments of actions, events, orpeople. The complexity and use ofstandards often parallel the complexityand interests of the organization.Large organizations may have layers of standards while a very small officemay have very few in comparison.Standards allow purposive events,action, or movement within anorganization to be assessed and betterunderstood, which in turn allows theorganization to be more effective.Standards can be an accurate reflectionof an organization in terms of mission,direction, quality, size, management,deliverables, and interests.

There is also a dynamic aspect tostandards. They can be modified,scrapped, or replaced, depending on the needs and desires of theorganization. Standards do notdirectly change performance, butstandards can certainly influenceperformance. In one sense, a standardis a driver—a carrot that leads the

horse. In another sense, a standard is a stopwatch or odometer thatmeasures the race just run.

The use of the standards term in dentistry is common. Genericcategories of dental standards thatapply to both individuals andorganizations include journalism,research, education, advertising,professionalism, and ethics, amongothers. Specific dental examplesinclude Commission on DentalAccreditation standards, competencystandards, and standards of care.Standards are also implicit in anotherterm that is referenced quite liberallyin dentistry, evidence-based. The basisof virtually anything classified asevidence-based disintegrates withoutstandards. Standards are an essentialcomponent of an evidentiary process.The close relationship betweenstandards and evidence is inherent inthe term general standards of evidence,which is found in communities suchas law and science.

In a very real sense, an organizationalstandard is the rose by any othername. Miscellaneous organizationalterminology can directly or indirectlysignal standards, including languageembracing projections, goals,objectives, policies, principles, criteria,guidelines, and even estimates orexpectations. These terms, and others,can form or be incorporated into thestandard statements that describe adesired state against which an actualstate can be measured.

It is important at this point todistinguish another aspect ofstandards that bears directly on ourunderstanding. A standard is only astandard if it is used or enforced. It isotherwise just a façade or prop withsome other motive or purpose in play.A statement of desired performance is not a standard if never followed orused. A policy statement regarding


Standards: Part I

Without standards

there can be no ethics,

no professionalism, no

professions, no excellence,

no quality, no effective

leadership, no planned

performance, no intentional

outcomes—virtually no

meaningful assessment,

measurement, or evaluation

of any kind.


employee conduct is not a standard ifnever enforced. There are no potentialstandards. While standards establishedat the present can be applied toprevious situations as part of aretrospective analysis, the termstandard more conventionally appliesto present and future comparisons.

Direct and IndirectStandards

Standards can be categorized as director indirect. A direct standard is astatement whose primary purpose isas a standard and that is developedand presented as such. An indirectstandard is a statement that fits thegeneral requirements of a standard but is not always obvious in that rolebecause it is usually woven into alarger or different textual context. For example, the primary purpose of a mission statement is normally to succinctly state the mission of anentity, not to express standards. Inactual practice, though, a missionstatement may serve as a standard and its language measured againstactual mission accomplishment. If the mission of an entity is to be “the voice for professional excellencein dentistry,” then the actual “voice” ofthe entity that emerges over time,whatever that entails, can be comparedwith the mission statement in itscapacity as an indirect standard.Because of their more disguisednature, sometimes less-preciselanguage, and risk of beingoverlooked, indirect standards canhave some interpretive leeway, whichcan be a disadvantage over directstandards. On the other hand, indirectstandards allow organizations to haveunderstated standards targeted forcertain situations without the

formality of direct standards, andsometimes that can be an advantage.The almost-subliminal messagingfound with some indirect standardscan be very effective.

Qualities of Standards

Standards are characterized by severalqualities, namely: intentionality,clarity, specificity, measurability,relevancy, and realistic achievability.There are no accidental directstandards—direct standards bydefinition have intentionality andreflect advance planning and design.That level of intentionality may or may not exist with indirect standards.Any intentionality behind an indirectstandard is usually latent or secondaryto the purpose of the larger contextuallanguage containing the indirectstandard. The particular language thatbecomes an indirect standard mayarise with no original intent to be astandard, its status as such beingassigned retroactively.

Ambiguous standards should beavoided. Indirect standards, eventhough less obvious or conspicuousthan direct standards, should still haveclarity. As a general rule, the higherthe specificity of a standard, thegreater the precision that can beachieved in comparisons made withthe standard. Indirect standards bytheir nature are often wrapped in amore sweeping textual context andcarry a degree of associatedsubjectivity. Standards should also be relevant to an aspect of theorganization that is of interest to theorganization—they are not usuallyassociated with wild-goose chases.Lastly, standards should be realisticallyachievable. While some standards may intentionally be difficult to meet,impossibly high standards should beavoided. Standards attached to pipedreams serve no useful purpose.

Setting Standards

The level at which a standard is set isshaped by multiple factors. In general,low standards are low risk, low reward,while high standards are high risk,high reward. It can be stressful on anorganization when standards are notmet. If an organization establishes amembership goal and announces itpublicly, but does not meet the goal,then it can get very awkward for boththe leadership and the members.Organizations usually realize—as oneoption for consideration—that thisdiscomforting situation can beavoided if the bar is set low so thestandard will always be met.

The million-dollar question forboards and other organizationalleadership is where to set thestandards. Some organizations aretempted to draw a conclusion ofconvenience, reasoning that it is betterto have a low standard and meet it that have a high standard and fallshort. Unfortunately, the reality is not that simple. While low standardsare more easily met, they can result in an underperforming organization.On the other hand, although highstandards can be unmet and invitecriticism, the organization mayactually end up performing at a higher level than it would havewithout the high standards.

Just as low standards that are moreeasily met can bring comfort, unmethigh standards bring stress anddiscomfort, even unrest. Lowstandards can usually be met and thestatus quo maintained, but they can


Standards: Part I


short-change an organization’s growthand development. A good example is a fundraising goal, also a type ofstandard. A dental organization thatsets a $3 million goal for a capitalcampaign, but falls short of achievingthat goal by only raising $2.2 million,has the uncomfortable task ofacknowledging that “failure” to itsmembers and to those major donorswho contributed substantially to thecampaign. On the other hand, if thegoal had been set at $1.5 million but$2.2 million was raised, the responseand interpretation are reversed.Everyone is happy. A rollout of results is easy when expectations are exceeded—as in goals, quotas, and projections.

While low standards have theadvantage of being easily achieved,they create their own problems. Whenstandards are set too low, then theproblem is not achieving the standard,the problem is one of potentialunderperformance or under-achievement. To continue with thecapital campaign example, if the goalwere initially set low at $1.5 million,then the campaign may not havegenerated much interest or excitementfrom donors and, as a result, it maynot have come close to the $2.2million that would have been raisedhad the goal been set higher at $3million. This balancing act is adilemma frequently faced by thosewho establish organizationalstandards. Setting standards is atightrope walk between achieving andpushing limits. An experienced boardthat fully understands its organization

and membership will normally be bestequipped to determine the balancingpoint, but there are no guarantees.Standard setting is often a dynamicprocess where standards can beadjusted to meet changing needs,desires, and circumstances.

The impact of standard levels onperformance can also be illustratedwith a hypothetical example ofindividuals within an organization.Imagine that a student has todemonstrate a level of performance on an individual task that is part of aseries of tasks. Also imagine that thelevel of performance required toproceed from one task to the next is aminimum standard, termed here as“good enough.” This imaginedscenario is somewhat analogous tocompetency standards in dentaleducation. A good question then is: To what extent, if any, does a standardset at “good enough” detract frompotential performance above thestandard, say toward “excellence”? It isacknowledged that the answer is farmore complicated than the question—there are many considerations whensetting student standards—butconceptually the question needs to beasked. Do we still strive to perform atthe highest levels? At what expense?Does a low standard halt the inertia of performance at the level of thelower standard? How do we get fromgood to best? It is hoped futuredialogue on standards will includethese or similar questions. That wouldbe a useful conversation.

Faux Standards

A sensitive question regardingstandards warrants introduction tominimally raise the issue and ideallystimulate discussion. It is important tonote that the question is not meant topaint dentistry or dental organizationswith a broad brush. Specifically, do

some dental organizations makeclaims couched in standard-likelanguage without having any intentionof fulfilling their claims or living up tothe language? Unfortunately, ananswer to this question is largely in the realm of conjecture. Possibleexplanations do emerge from the fewfacts or credible observations that canbe pieced together. In a few instancesit does appear we are dealing withcosmetic props or cosmetic claims,disingenuously used for branding,public relations, or some other cloakedpurpose to improve the perception orstanding of the organization. Sinceclaims can be considered a type ofstandard, depending on intent, the useof such tactics could be termedstandards cosmetology.

Many dentists are involved inorganizations that shun such tactics.But occasionally there is enoughsmoke in the air to make us suspiciousof a few fires. There is certainly anavenue for faux or potential standardsto be used under ulterior motives.Situations are reported that raise oursuspicions. Anecdotally, we seeorganizations claim one thing in theirpublications, publicity, andadvertisements, then appear to dosomething quite different throughtheir actions. Or when organizationsfail to put resources needed to achievewhat they say is valued, we suspectfaux standards. Enough of this is atleast perceived that the reality must be considered.

The problem of gaming standardscould be addressed throughorganizational accountability, but thatsolution assumes the organizationwould have a desire to avoid gamingand deception, which puts thissquarely in the domain of a


Standards: Part I


contradictory, self-defeatingargument. Outside of invasiveoversight, which is usually the purviewof external agencies, there are scantstrategies to practically or consistentlyaddress an organization’s intent todeceive. Sunlight is one possibility, but revealing or exposing a problem is not without its own risks. There is no question this is a difficult issue to approach.

The Takeaway

Change does not happen because wewish it to happen. Change is an effectthat requires an antecedent cause.Change in an organization happensbecause influential people in theorganization take action, good or bad,one way or the other. Organizationsmake their own policies and operateunder their own corporate philosophies.Standards are an integral part oforganizational plans and action, andthey mirror the goals and aspirationsof the organization. Consistentlysuperior organizations will have goodleadership and strong standards,among other traits. The reverse istypically true for weak organizations.A healthy organization understandsthe value of regularly reviewing itsstandards and the importance ofsetting standards that optimize thefuture of the organization.

Standards and quality areinterrelated, particularly at anorganizational level. Standards are thecatalyst for quality. Integrity is alsointrinsically connected—fraud,dishonesty, and corruption areincompatible with organizationalquality. The level of quality is directlyinfluenced by the level at whichapplicable standards are set. It seemsclear that as standards loosen, qualitycorrespondingly declines, andorganizational stature eventually

weakens. As has been attributed toRay Kroc, “The quality of a leader isreflected in the standards they set forthemselves.” A corollary is mostdefinitely applicable to organizations:the quality of an organization isreflected in its standards. A founda-tional question for any organization isthe level of quality it seeks for itself.The answer will involve standards. n

Suggested Reading

Galbraith, J. R. (2014). Designingorganizations: Strategy, structure, and processat the business unit and enterprise levels. San Francisco, CA: Jossey-Bass.

Herriott, S. R. (2016). Metrics for sustainablebusiness: Measures and standards for theassessment of organizations. New York, NY:Routledge.


Standards: Part I

We anecdotally see organizations claim one thing in their

publications, publicity, and advertisements, then appear

to do something quite different through their actions.

Or when organizations fail to put resources needed to

achieve what they say is valued, we suspect faux standards.


Laurance Jerrold, DDS, JD, FACD

Abstract

The standard of care is worked out inindividual cases based on a balance ofmultiple factors, including duty to care andcompensable injury, the reasonable person,locality, respectable minority schools ofthought regarding practice, specialty versusgeneral care, and referral. Practitioners areexpected to possess and exercise SKEEET (skill, knowledge, experience, expertise,education, and technology) appropriate tothe treatment they provide.

The Legal Basis

The standard of care is a nebulousconcept that defies a black or

white definition. Its amorphous natureis, in part, subject to the specific factsregarding the situation to which it isapplied. In order to appreciate thestandard of care, which is another way of saying the duty to which onewill be held, one has to understand the context in which it is considered.In tort law, medical/dental malpracticeis considered a type of negligence, and negligence, whether simple orprofessional, is a type of tort. A tort is a civil wrong based on havingbreached a reasonably imposed duty of care owed someone to do, or refrainfrom doing, something under anexisting set of circumstances thatproximately (directly) results in acompensable injury to that person, the person’s property, or the person’sreputation. This reasonable duty ofcare owed can be heightened uponfinding the existence of a specialrelationship. Examples of specialrelationships are priest/penitent,teacher/school/pupil, innkeeper/patron,common carrier/passenger, and ofcourse that found between a doctorand a patient.

In order for a potential plaintiff to succeed in a malpractice suit againsta healthcare professional, the plaintiffmust prove all four elements includedin a lawsuit based on professional

negligence. They are:that the defendant had a duty to•conform to an established standardof carethat this duty was breached, not•adhered to, in some fashion that the plaintiff suffered a•compensable injury of some sortthat the breach of the duty owed•was the direct or proximate cause of the injury sustained

The Evolutionary Road to Reasonableness

Prosser, in Keeton et al (1984), notes:“Traditional tort law gives the medicalprofession …the privilege, which isusually and emphatically denied toother groups, of setting their own legal standards of conduct, merely by adopting their own practices. …Physicians are expected to behavereasonably; the reasonableness of theirconduct is determined by ascertainingtheir compliance with customarypractices.” This standard of care, onebased on custom and usage, wasarticulated in Garthe v. Ruppert(1934); the court stated: “The duty ofthe defendant was none other than tokeep the place reasonably safe for thepurpose for which it was maintained.…One man is not obliged to run hisbusiness the same as some other man,nor can he be judged before the lawaccording to the methods employedby others. However, when certaindangers have been removed by acustomary way of doing things safely,this custom may be proved to show


Standards: Part I

Defining the Standard of Care

Dr. Jerrold is Chair ofOrthodontics at NYU LutheranMedical Center and Director of the Advanced EducationResidency Program inOrthodontics;[email protected].


that a [defendant] has fallen below therequired standard. …When a questionof negligence is involved, the generalusage or practice is competent to showeither ordinary care or the failure toexercise such care. One is not obliged,however, to use the best methods or tohave the best equipment or the safestplace, but only such as are reasonablysafe and appropriate for the business.”

Relying on customary practices,however, can be somewhatproblematic and so through a processof legal evolution that occurred overdecades, the reliance on custom andusage slowly gave way to the standardof care being determined according towhether one acted with reasonableprudence. In Texas & Pacific RailwayCo. v. Behymer (1903), the court statedthat “What usually is done may beevidence of what ought to be done, butwhat ought to be done is fixed by astandard of reasonable prudence,whether it usually is complied with ornot.” The reasoning behind thisthinking is that there are situations inwhich an entire calling, business, orprofession can be found to have beenconducting its business in anunreasonable or unacceptable manner.The courts recognized that thisdeviation from compliance withreasonableness, the argument that“I’m merely doing what everybodyelse is doing,” could not be allowed toprovide a defense for not conformingto a given duty owed.

In the case of The T. J. Hooper(1932), some tugboats sank in asudden storm because they did nothave radio receiving sets to apprisethem of the upcoming gale. There wasno uniform custom for the timeperiod in question to equip or not toequip ocean-going tugs with this newtechnology that would act as “…theears of the tug to catch the spokenword, just as the master’s binocularsare her eyes to see a storm signalashore.” The court noted thatreceiving sets could be had for areasonably small cost, they werereasonably reliable if kept up, and theywere a great source of protection tothe vessels that employed them. As aresult of this logic, the court stated:“Reasonable prudence is in factcommon prudence; but strictly it isnever its measure; a whole calling mayhave unduly lagged in the adoption ofnew and available devices. [Thatcalling] may never set its own tests,however persuasive be its usages. Courtsmust in the end say what is required;there are precautions so imperativethat even their universal disregard willnot excuse their omission.”

Another example of the courts notallowing an entire calling to set itsstandard of care so low that it cannotbe breached can be seen in Helling v.Carey (1974). In Helling, the plaintiff,in her late twenties, complained ofvision problems ten times over a five-

year period. The defendants were ofthe opinion that the complaints weredue to issues concerning the contactlenses that had been prescribed.Finally, one of her physiciansperformed a glaucoma test thatrevealed substantial and irreversiblevision loss. The plaintiff claimed thatthe test should have been done sooner,and if it had she would not havesuffered the devastating injury she did.The defendants claimed that theyconformed to the ophthalmologicalstandard of care, which held thatglaucoma tests were not routinelyperformed on patients under the ageof 40. It seems the incidence ofglaucoma occurring in persons underthe age of 40 is .01%, while theincidence after the age of 40 is 2% to3%. The court opined that a patientunder the age of 40 should be affordedthe same protections as someone overthat age because a glaucoma test issimple to do, it is inexpensive, there is no real judgment involved ininterpreting the results, evidence ofthe disease can easily be detected, and the disease can be arrested ifdiscovered early, hence avoiding thedevastating results if the test is notadministered. The court held: “Under


Standards: Part I

A tort is a civil wrong based on having breached a reasonably

imposed duty of care owed someone to do, or refrain from

doing, something under an existing set of circumstances that

proximately (directly) results in a compensable injury to that

person, the person’s property, or the person’s reputation.


the facts of this case reasonableprudence required the timely giving ofthe pressure test to this plaintiff. Theprecaution of giving this test to detectthe incidence of glaucoma to patientsunder 40 years of age is so imperativethat irrespective of its disregard by the standards of the ophthalmologyprofession, it is the duty of the courtsto say what is required to protectpatients under 40 from the damagingresults of glaucoma.”

The Reasonable Person and the Standard of Care

It might be tempting to believe thatdoing the best that one can do is areasonable enough standard for one tohave to adhere to. However, the courtslong ago dismissed this argument. InVaughan v. Menlove (1837), the issue of whether the defendant actedreasonably in stacking his hay, whichspontaneously combusted causingsignificant property damage, cameinto question. The defendant claimedthat he acted to the best of his ability,in good faith, and using his bestjudgment. The court held: “Whetherthe defendant had acted honestly and bona fide to the best of his ownjudgment would leave so vague a lineas to afford no rule at all. Because thejudgments of individuals are asvariable as the length of the foot ofeach we ought rather to adhere to therule which requires in all cases aregard to caution such as a man ofordinary prudence would observe.”

A “man of ordinary prudence,”also known as a “reasonable man,” wasdefined in State v. Cripps (1995) as: “Afictional person with an ordinarydegree of reason, care, prudence,foresight, or intelligence; whoseconduct, conclusion or expectation inrelation to a particular circumstance

or fact is used as an objective standardby which to measure or determinesomething.”

However, medical and dentalpractitioners are held to a higherstandard of reasonableness or care.West’s Encyclopedia of American Law(1980) defines a reasonable doctor asone who possesses greater thanaverage skills; and because he or sheholds a special relationship with his orher patients, is obligated to conform tohigher duties of care. The definitiongoes on to note that doctors are to bejudged according to how a reasonablehealthcare practitioner would haveacted under the circumstances aspresented. They should be judgedaccording to the level of theirprofessional education and training,and they should have to conform tothe customary practices and generalprocedures as are followed by similarlytrained and practicing professionals.

Geography and theStandard of Care

The standard of care is an evolvingconcept. Civil jurisprudence from anevolutionary perspective is oftensituationally based. Lewis et al (2007)notes that when medical care in earlyAmerica was mostly performed byrural doctors who did not have thesame access to the same levels of basicmedical training, certain medicalsupplies, equipment, support facilities,continuing education, and a myriad ofother resources as were available totheir big-city brethren, the standard of care was determined to be what areasonable practitioner in goodstanding did or should have done whowas practicing under the same orsimilar circumstances in the same orin a similar geographic locale. Thisgave rise to what was known as the“locality rule.” One tangential aspectof the locality rule was that it tended

to make expert witnesses harder tocome by as local doctors were oftenunwilling to testify against theircolleagues. This actually perpetuatedthe locality rule mentality and helpedkeep a lesser standard of care in place.

As access issues slowly disappearedand medical education became more standardized, with nationalaccreditation of medical schools andall doctors having to pass nationallyaccepted certifying examinations, a“national standard” was adopted by a majority of jurisdictions. Even so,approximately 30% of states stillmaintain some form of the localityrule in determining the standard ofcare. A good example is Virginiawhose legislative code states: “Thestandard of care by which the acts oromissions are to be judged shall bethat degree of skill and diligencepracticed by a reasonably prudentpractitioner in the field of practice orspecialty in this Commonwealth andthe testimony of an expert witness,otherwise qualified, as to suchstandard of care, shall be admitted;provided, however, that the standardof care in the locality or in similarlocalities in which the alleged act or


Standards: Part I

“The law cannot

undertake to decide

technical questions

of proper practice

over which experts

reasonably disagree.”


omission occurred shall be applied ifany party shall prove by apreponderance of the evidence thatthe health care services and healthcare facilities available in the localityand the customary practices in suchlocality or similar localities give rise toa standard of care which is moreappropriate than a statewide standard.Any physician who is licensed topractice in Virginia shall be presumedto know the statewide standard of carein the specialty or field of medicine inwhich he is qualified and certified.”

Factors Influencing theStandard of Care

Curley and Peltier (2013) note that thestandard of care is influenced by amultitude of factors, including externalpowers and forces generated bysocietal mores and economics such aswhat patients want, the court of publicopinion, and the policies of third-party payers. In addition, there areinternal powers and forces that aregenerated by the dental professionsuch as the content of continuingeducation courses, clinical practiceguidelines or parameters of care aspromulgated by various factions oforganized dentistry, policies andprocedures espoused by state dentalboards and various certifying boards,journals and textbooks, dentists’opinions, practitioner preferences, andprofessional consensuses of opinion.Finally, there are governmentalinroads and oversight that influencethe standard of care, such as state andfederal laws, rules, and regulations,and appellate court decisions resultingfrom adjudicated legal actions.

Grasskemper (2004) notes that thestandard of care is NOT defined bywhat everybody else is doing, what thespecialist is doing, what the dentalschools are teaching, what one’s studyclubs agree upon, what certifying

boards say the standard should be,what organized dentistry recommendsor has a position on, what thetextbooks say, or doing the best that one can. He goes on to state thatwhile none of the above in and of itselfis dispositive, all will, to one degree oranother, be considered in determiningwhether one is practicing within adefined standard of care. He furthernotes that in addition to the consider-ations stated above, the standard ofcare is, in part, defined by newdevelopments and advancementswithin one’s field of endeavor such as new materials, new treatmentmodalities, and new techniques. Inaddition, he notes that the standard ofcare is defined, to a degree, by thosetreatment failures that are subsequentlyadjudicated in the courts.

Retrospectively, the reality is that when looking at breaches of thestandard of care, it is our sins ofomission, those acts, tests, referrals,etc. that we did not make, as opposedto those sins of commission, actuallyperforming a procedure negligently,that are far more likely to result in litigation.

Pike v. Honsinger (1898) depictsthree components that make up thestandard of care. The first is that onemust possess the requisite amount ofwhat I refer to as SKEEET (skill,knowledge, experience, expertise,education, and technology). As notedin the court’s decision, “It does notrequire the surgeon to possess thatdegree of extraordinary learning andskill which belong only to a few menof rare endowments, but such aspossessed by the average member ofthe profession and in good standing.”

The second prong, that one mustexercise that degree of SKEEET in areasonable manner, is noted by thefollowing statement: “It does not

require the exercise of the highestpossible degree of care, but there mustbe a want of ordinary and reasonablecare, leading to a bad result.”

Finally, the third prong of thestandard of care, that one must useone’s best judgment in the treatmentof a patient, was articulated by thefollowing sentence: “The physician isnot liable for a mere error ofjudgment, provided he does what hethinks best after careful examination.”

More recently, a fourth componentwas expressed in Pennsylvania’s JuryInstructions (2015); it stated that “Aphysician must also keep informed ofthe contemporary developments in hisor her specialty.” If a physician fails tokeep current or fails to use currentknowledge in the treatment of apatient, the physician is negligent.

The courts have recognized that to some degree, we are limited by ourlanguage, particularly when we useany phrase espousing conformance tothe degree of SKEEET as possessed orexercised by the average practitioner ofgood standing and practicing underthe same or similar circumstances(location, point in time, same schoolor specialty, etc.). The Restatement ofTorts (1965) admonishes: “Thestandard is not that of the most highlyskilled, nor is it that of the averagemember of the profession..., sincethose who have less than median oraverage skill may still be competentand qualified. Half of the physicians ofAmerica do not automatically becomenegligent in practicing medicine at all,merely because their skill is less thanthe professional average. On the otherhand, the standard is not that of thecharlatan, the quack, or the unqualifiedor incompetent individual who hassucceeded in entering the profession.”


Standards: Part I


Setting the Bar for theStandard of Care

The question then becomes, insofar as the standard of care is concerned,where is the bar actually set? Hall v.Hilbun (1985) would have us believethat minimal competency is where the bar is set; the court noted in itsopinion: “When a physician undertakesto treat a patient, he takes on anobligation enforceable at law to useminimally sound medical judgmentand render minimally competent carein the course of the services he provides.A physician does not guaranteerecovery. If a patient sustains injurybecause of the physician’s failure toperform the duty he has assumedunder our law, the physician may beliable in damages. A competentphysician is not liable per se for a mere error of judgment, mistakendiagnosis, or the occurrence of anundesirable result.”

We must always be aware of thefact that someone graduates dentalschool last in the class and someonepasses the applicable licensure examswith the minimal passing score. The state then grants this individual a license to practice dentistry based on the fact that the individual hasexhibited a minimally required level of competency, meaning the doctor inquestion has shown and exercised therequisite degree of SKEEET. While thismay meet the administrative requisitesfor licensure, from a legal perspectivewe note that the possession andexercise of one’s SKEEET must bemore; it requires reasonableness asarticulated in Vassos v. Roussalis(1983). “As we noted in our firstdisposition of this case, a doctor’s duty

to his patient is established by the existence of a physician-patientrelationship. The extent of that duty or the standard of care owed by aphysician is that a physician orsurgeon must exercise the skill,diligence and knowledge, and mustapply the means and methods, whichwould reasonably be exercised andapplied under similar circumstancesby members of his profession in goodstanding and in the same line ofpractice. The skill, diligence,knowledge, means and methods arenot those ‘ordinarily’ or ‘generally’ or ‘customarily’ exercised or applied,but are those that are ‘reasonably’exercised or applied. Negligencecannot be excused on the grounds that others practice the same kind ofnegligence. Medicine is not an exactscience and the proper practice cannotbe gauged by a fixed rule.”

The Expert Opinion

It is the function of the jury todetermine whether the standard ofcare in a given situation was breachedor not. Not being trained in themedical area being litigated, how arethey to know what the standard of careshould be? This is the function of theexpert witness. Must there always bean expert witness? No, as noted in Vassos v. Roussalis (1981): “When the circumstances…are within thecommon knowledge of the jury, thejury does not need assistance incomprehending the standard fixed by the court. But when suchcircumstances are not of suchcommon knowledge, the jury mustdepend upon testimony of experts toexplain the standard and thus preventa conclusion based on conjecture andspeculation. The facts, means andmethods relative to the skill, diligenceand knowledge to be reasonablyexercised under the circumstances bymembers of the profession in good

standing and in the same line ofpractice must of necessity be determinedon the basis of opinion evidence.”

The Federal Rules of Evidence(2018) have been adopted by virtuallyevery jurisdiction in the country.Article VII, Rule 702 states: “Witnesswho is qualified as an expert byknowledge, skill, experience, training,or education may testify in the form of an opinion or otherwise if: (a) theexpert’s scientific, technical, or otherspecialized knowledge will help thetrier of fact to understand theevidence or to determine a fact inissue; (b) the testimony is based onsufficient facts or data; (c) thetestimony is the product of reliableprinciples and methods; and (d) theexpert has reliably applied theprinciples and methods to the facts of the case.”

Rule 703 states: “An expert maybase an opinion on facts or data in thecase that the expert has been madeaware of or personally observed: (a) if the experts in the particular fieldwould reasonably rely on those kindsof facts or data in forming an opinionon the subject and (b) the proponentof the opinion may disclose such facts or data to the jury only if theirprobative value substantiallyoutweighs their prejudicial effect.”

When each party has its expertwitnesses, one side espousing that thestandard of care was breached whilethe other is arguing that it was not, itsets up the proverbial “battle of theexperts.” This often presents aconundrum of sorts in the jury’s questto determine what the standard of careis and whether it was adhered to. Thesolution was stated nicely in Daubertv. Merrell Dow Pharmaceuticals, Inc.(1995) wherein the court noted that“Vigorous cross-examination,presentation of contrary evidence, andcareful instruction on the burden of


Standards: Part I


proof are the traditional andappropriate means of attacking shakybut admissible evidence.”

The problem lies in the fact thatmedicine and dentistry are clinicalsciences and there is not just one way to see and assess a given clinicalpresentation. Quite often, there may be more than one way to address treating the entity that isfinally diagnosed.

Two Schools of Thoughtand the Standard of Care

There would not be opposing expertsif there were not differences of opinionregarding the diagnosis that wasmade, the treatment plan that wasdeveloped, and the clinical approachchosen to effectuate those treatmentgoals. Legally, this differing of opinionregarding whether one acted withinthe standard of care was elucidated inMcCourt v. Abernathy (1995). Thecourt provided a clear analysis of thisissue by stating: “A physician is not aninsurer of health, and a physician isnot required to guarantee results.He undertakes only to meet thestandard of skill possessed generallyby others practicing in his field undersimilar circumstances. The mere factthat the plaintiff ’s expert may use adifferent approach is not considered adeviation from the recognizedstandard of medical care. Nor is thestandard violated because the expertdisagrees with a defendant as to what isthe best or better approach in treating apatient. Medicine is an inexact science,and generally qualified physicians may differ as to what constitutes apreferable course of treatment. Suchdifferences due to preference…do notamount to malpractice.”

A patient’s clinical presentation mayresult in two or more practitionersassessing that patient’s oral healthstatus differently. A doctor’s

experience with various treatmentsmay yield a clinically acceptabletreatment bias as there are manysubjective factors that are oftenconsidered among the doctor’sobjective brethren. Training,experience, and patient-directedconsiderations all come into playwhen formulating diagnostic andtreatment decisions. Fall v. White(1983) addressed this by noting:“Where there are two or moremethods of treating a problem whichare recognized as proper by physiciansin similar practices at the time inquestion, it is not negligence for thephysician to adopt any one of therecognized treatment methods. Thefact that a different treatment methodwas available or that a different doctormight have chosen a differenttreatment method is not evidence ofnegligence. A physician is negligentwhere he selects a treatment methodwhich is not recognized as proper byphysicians with the same specialty inthis or similar communities at thetime in question.”

When applying the Two Schools ofThought doctrine, one has to wonderif it is the judge (the trier of law) or thejury (the trier of fact) who in the endhas to make the determination as towhether a doctor acted reasonably andconformed to one of many acceptableor viable diagnoses or treatment plansand approaches. This was addressed inFurey v. Thomas Jefferson UniversityHospital (1984) wherein the courtstated: “The rule [two schools ofthought doctrine] is that, wherecompetent medical authority isdivided, a physician will not be liable if in the exercise of his judgment hefollowed a course of treatmentsupported by reputable, respectable,and reasonable medical experts. The

testimony clearly showed a differenceof medical opinion, expressed byphysicians and surgeons ofunquestioned standing andreputation. The jury are not to judgeby determining which school, in theirjudgment, is the best. If the treatmentis in accordance with a recognizedsystem of surgery, it is not for thecourt or jury to undertake todetermine whether that system is best,nor to decide questions of surgicalscience on which surgeons differamong themselves.”

What constitutes a school ofthought? Section 299A of theRestatement of Torts (1965) notes that“The law cannot undertake to decidetechnical questions of proper practiceover which experts reasonablydisagree.” It has often been expressedthat so long as a respectable minorityof practitioners practiced in themanner under consideration, thisgroup constituted a school of thought.Hood v. Phillips (1977) noted that “Aphysician is not guilty of malpractice


Standards: Part I

“What usually is done may

be evidence of what ought to

be done, but what ought to

be done is fixed by a standard

of reasonable prudence,

whether it usually is complied

with or not.”


where the method of treatment used issupported by a respectable minority ofphysicians, as long as the physicianhas adhered to the acceptableprocedures of administering thattreatment.” Mosciki v. Shor (1932)framed it in the following language:“Where competent medical authorityis divided, a physician or surgeon willnot be held responsible if in theexercise of his judgment he followedthe course of treatment advocated bya considerable number of hisprofessional brethren in good standingin his community.” Obviously, a“respectable minority” is qualitative innature while a “considerable number”is more quantitative. The court inJones v. Chidester (1992) attempted to address this discrepancy bydeveloping a hybrid solution bystating: “We are called upon in thiscase to decide once again whether aschool of thought qualifies as suchwhen it is advocated by a ‘considerablenumber’ of medical experts or when itcommands acceptance by ‘respective,reputable and reasonable’ practitioners.The former test calls for a quantitativeanalysis, while the latter is premised onqualitative grounds. Where competentmedical authority is divided, a physicianwill not be held responsible if in theexercise of his judgment he followed a course of treatment advocated by aconsiderable number of recognizedand respected professionals in hisgiven area of expertise.”

Standards of Care for the General Practitionerand the Specialist

Are there different standards of care for a general dentist as opposed to a specialist?

Carbone v. Warburton (1953) holdsthat “One who holds himself out as aspecialist must employ not merely theskill of a general practitioner, but alsothat special degree of skill normallypossessed by the average physician whodevotes special study and attention tothe particular organ or disease orinjury involved, having regard to thepresent state of scientific knowledge.”

Unfortunately, this is a states’ rightsissue and the various jurisdictions are split. Some states hold that if ageneral dentist performs proceduresassociated with a particular specialtydiscipline, the standard of care that thedentist should be held to is lessened tosome degree, as a generalist would notbe expected to possess the samedegree of SKEEET as a specialist. Twoexamples of this thinking are seen inBirmingham v. Vance (1994) and Burksv. Meredith (1976). In Birmingham,the court noted “We are of the opinionthat the standard of care by whichgeneral practitioners are now judgedpermits them to perform certainprocedures under a less strict standardof care than that which they should beexpected to adhere.” A similar holdingwas espoused in Burks wherein thecourt stated: “A specialist is generallyexpected to possess a higher degree of skill and learning than a generalpractitioner. …If the general practi-tioner exercises the care and skill of other physicians similarly situated, he is not responsible for an error ofjudgment even though a specialist wouldnot have made the same mistake.”

On the other hand, a number ofstates take the position that a generalist

should be held to the standard of careof a specialist if the generalist choosesto perform specialty-recognizedprocedures. The American Law Reports(1969) defines a specialist as one who(a) has taken a residency, subsequentlyundertaking and passing specialtycertification examination(s); (b) limitshis or her area of practice to a parti-cular area or discipline of medicine;and (c) holds himself or herself out aspossessing special knowledge and skillin the treatment of particular organsor diseases. Examples of this positioncan be noted in both Jordan v. Bogner(1993) and Lane v. Skyline FamilyMedical Center (1985). As noted inJordan, “A physician will be held to thestandards of physicians within thatsame specialty.” In Lane, the courtstated: “If a practitioner discovers thepatient’s ailment is beyond hisknowledge or technical skill or abilityor capacity to treat with a reasonablelikelihood of success, he is under aduty to disclose this situation to thepatient or advise him of the necessityfor other or different treatment. Aphysician is held to the standard ofcare applicable to the specialty towhich referral should have been made.”

Referral Liability and theStandard of Care

Whenever the issue of a generalistperforming specialty care comes up, it begs the question of the generalist’sobligation to refer the patient to onemore qualified if the generalist decidesthat referral is in the patient’s best


Standards: Part I

The argument that “I’m merely doing what everybody

else is doing” could not be allowed to provide a

defense for not conforming to a given duty owed.


interests. There are essentially threereasons supporting referral as thestandard of care. They are (a) whenthe practitioner in question lacks therequisite level of SKEEET required tosuccessfully address the patient’sparticular problem; (b) when apractitioner knows or should knowthat referral to a specialist is in thepatient’s best interest; and (c) if otherpractitioners would have made thereferral under the same or similarcircumstances. Examples of theserationales can be seen Larsen v. Yelle(1976), King v. Flamm (1969), andSimone v. Sabo (1951). “If a generalpractitioner discovers, or shouldknow, or should discover, that apatient’s ailment is beyond hisknowledge or technical skill or abilityor capacity to treat with a likelihood of reasonable success, he is under aduty to disclose this to his patient, orto advise him of the necessity of otheror different treatment. A generalpractitioner is not required to consultwith a specialist but there is a duty toseek consultation with, or referpatients to, a specialist when he knowsor should know the services of aspecialist are indicated. A physicianhas a duty to refer his patient to aspecialist if expert testimony supportsthe conclusion that reasonably carefuland prudent practitioners would have made the referral or soughtconsultation under the same or similar circumstances.”

Many dentists are erroneouslytaught that if they refer a patient to aspecialist and that practitionercommits malpractice, they are thenliable for having made a negligentreferral because of the referred-todoctor’s breach of the standard of care.Negligent referrals can be based on thefinding of an agency relation-shipbetween the referring and thereferred-to doctor. However, from anegligence perspective, the making of

a negligent referral requires that thereferring doctor knows or should haveknown that the referred-to doctor wasincompetent by virtue of a lack ofSKEEET or that the doctor waspracticing while impaired. Smith v.Beard (1941) depicted this by holdingthat “A physician who is unable orunwilling to assume or continuetreatment of a case, and recommendsor sends in [refers to] anotherphysician, is not liable for injuriesresulting from the latter’s want of skillor care, unless the recommendedphysician is in the referring doctor’semploy or is definitely his agent, or ishis partner, or unless due care is not exercised in making therecommendation or substitution.”

Greenwell v. Aztar Indiana GamingCorp. (2001) states this concept a littlemore bluntly. “Steering a patient to a doctor who commits malpracticeis not itself malpractice or otherwisetortious unless the steerer believes or should realize that the doctor is substandard.”

The only other means of imputingliability for having made a negligentreferral is when the referring doctormaintains a degree of participation orcontrol in the treatment rendered bythe referred-to doctor as was noted inProoth v. Wallsh (1980). “A patient’spersonal physician bears theresponsibility to assure the welfare of his patients in all phases of thepatient’s treatment. Such treatmentmust, of necessity, include diagnosisand the prescription of a course oftreatment by others, such as specialists.…If the treating physician refers hispatient to another physician andretains a degree of participation, byway of control, consultation, orotherwise, his responsibility continuesto properly advise his patients with

respect to the treatment to be performedby the referred to physician.”

The final point to discuss regardingthe standard of care in referralscenarios is when the doctor makes areferral to a specialist, the patientrefuses the referral, and insteadimplores the generalist to perform therecommended specialty treatment.The court in West v. Sanders Clinic forWomen (1995) noted that “When adoctor makes a referral to anotherspecialist, but the patient refuses tofollow the referral, then the patientcannot complain later of the referringdoctor’s lack of skill and may onlycomplain if the doctor negligentlyperforms the treatment.”

Clinical Practice Guidelinesand the Standard of Care

Clinical practice guidelines (CPGs)have been both lauded and lamentedby some regarding the role that theyshould play in determining thestandard of care. Some believe they are reflective of how medicine shouldbe practiced while others see them asmore advisory in nature. The Agencyfor Healthcare Research and Quality(2014) defines clinical practiceguidelines as “systematically developedstatements including recommenda-tions intended to optimize patient care and assist physicians and/or otherhealth care practitioners and patientsto make decisions about appropriatehealth care for specific clinicalcircumstances.”

These statements are oftenconsidered as one more piece ofevidence to be weighed whenattempting to determine the standardof care in a given situation. They arenot, in and of themselves, dispositive


Standards: Part I


of the standard of care. For anyguideline to be included in theNational Guideline Clearinghouse ithas to conform to the followingcharacteristics.

It must be produced under the1.auspices of a medical specialtyassociation, relevant professionalsociety, or public or privateorganization, a governmentorganization at the federal, state, orlocal level, or a healthcareorganization or plan.It must be based on a systematic2.review of the evidence.The guideline or its supporting3.documentation must contain anassessment of the benefits or harmsof the care being recommended andalternative care options.A full text of the guideline must be4.available to the public.It must be the most recent version5.of the guideline and must have beenpublished within the last five years.Silverman et al (2015) state that

CPGs “are not intended to serve or beconstrued as a ‘standard of medicalcare.’ Judgments concerning clinicalcare depend on clinical circumstancesand data available and are subject tochange as scientific knowledge andtechnology advance and practicepatterns evolve.”

CPGs are not without theirproblems. Some of the factorspredisposing them to carry less weightwhen used to define a standard ofcare, as elaborated by Recupero(2008), are first that they have a shortlifespan because of technologicaladvances, new research, and changesin approaches to the delivery of carethat is under consideration. Secondly,

there are conflicting guidelinesbecause there are a number of viabletreatment modalities to address aparticular clinical condition. Next,there is often a lack of evidentiaryconsensus and support. Olderliterature, which is often very valid, isdisfavored merely because of its age. In addition, different guidelines usedifferent literature to support therecommendations being made. This is seen when various groups ororganizations produce guidelinesconcerning the treatment of particularconditions based on the existence oftwo schools of thought. Finally, thereis bias. Guidelines are often producedby groups who lack a fiduciaryrelationship to the patient such asthird-party payers, liability insurancecarriers, pharmaceutical companies,supply vendors, etc. There is also theinherent bias that exists betweenclinicians, researchers, and scientistswithin any given field that is reflectedin the guidelines ultimately developedby each group.

Recupero goes on to note that inthe courtroom, CPGs are viewed, atleast from an evidentiary perspective,as being akin to learned treatises muchlike textbooks and journal articles.They may be introduced as evidenceby qualified expert witnesses, who arethen subject to cross examination notonly about various aspects of theirtestimony, but about the recommend-ations, findings, or positions that arearticulated in the CPG in question.Dissenting and opposing CPGs mustalso be allowed to be introduced, bothfor the purposes of showing that aparticular approach to care was or was not followed as well as to impeachthe testimony of an opposing expertwitness’s opinion. In the end, CPGsare also useful in determiningpractices that constitute the standardof care. In addition, they can be usedto identify experimental or fringe

therapy, distinguish good from badrisk management practices, and definenew or emerging standards of care.

Lane, et al v. Otts (1982) noted that in order for guidelines to beconsidered as having evidentiaryvalue, they had to be based onempirical research, be subject to peerreview, and have been periodicallyreviewed and updated. Jewitt v. OurLady of Mercy Hospital (1992) notedthat CPGs cannot usurp the soundpractice of medicine by holding that“following clinical practice guidelinesdoes not negate the need to followsound clinical judgment given thefacts of the case.”

Summary

As has been shown, the standard ofcare, also known as the duty that weowe our patients, is not easily defined.It changes with advances in science,technological improvements, thedemands of the public, and thepractices of those providing the care. It concerns itself with not only what is, but to some degree what should orcould be. It keeps us in check andresponsive to the tenets of profes-sionalism, incorporating all of thebalances and nuances associated with providing the public with anappropriate level of health care giventhe circumstances inherent in thetime, place, and manner of a patient’sclinical presentation.

Yet, it is still not as clearly definedor as firm as some desire. Maybe thatis as it should be. Asbell (1990) noteda line in a personal communicationfrom Milo Hellman to W. H. Krogmanin 1935 wherein Dr. Hellman opinedthat while “Perfection is the goal,adequacy is the standard.”Manywould argue that truer words werenever spoken. n


Standards: Part I


References

Agency for Healthcare Research and Quality(2014). NGC and NQMC inclusion criteria.U.S. Dept of Health and Human Services:Rockwell, MD.

American Law Reports (1969). 21. WestPublishing; St. Paul, MN.

Asbell, M. B. (1990). A brief history oforthodontics. American Journal ofOrthodontics and Dentofacial Orthopedics, 98(3), 176–183.

Curley, A. W., & Peltier, B. (2013). Standard ofcare: The legal view. Journal of the AmericanCollege of Dentists, 80 (3), 53-58.

Federal Rules of Evidence (Adopted 2018).The Committee of the Judiciary, House ofRepresentatives; U.S. Government PrintingOffice, Washington D.C.

Grasskemper, J. P. (2004). The standard ofcare in dentistry: Where did it come from?How has it evolved? Journal of the AmericanDental Association, 135, 1449-1455.

Keeton, W. P. et al (1984). Prosser and Keetonon Torts, 5th ed. West Publishing: St. Paul, MN.

Lewis, M. H., Gohagan, J. K., & Merenstein, D.J. (2007). The locality rule and the physician’sdilemma: Local medical practices vs thenational standard of care. Journal of theAmerican Medical Association, 297 (23),2633-2637.

Recupero, P. R. (2008). Clinical practiceguidelines as learned treatises: Understandingtheir use as evidence in the courtroom.Journal of the American Academy ofPsychiatry and Law, 36 (3), 290–301.

Silverman, J. J., Galanter, M., Jackson-Triche,M., et al. (2015). The American PsychiatricAssociation practice guidelines for thepsychiatric evaluation of adults. AmericanJournal of Psychiatry, doi.org/10.1176/appi.ajp.2015.1720501

West’s Encyclopedia of American Law, 2ndEd.; J. Lehman, & S. Phelps (Eds). (1980).West Publishing; St. Paul, MN.

Table of Cases

Birmingham v. Vance, 516 NW 2d 95 (Mich.App.) 1994

Burks v. Meredith, 546 SW 2d 366 (Ct. App.Tx.) 1976

Carbone v. Warburton, 94 A.2d 680 (N.J.)1953

Daubert v. Merrell Dow Pharmaceuticals, Inc.,43 F3d 1311 (9th Cir.) 1995

Fall v. White, 449 N.E.2d 628 (Ind. Ct. App.4TH Dist.) 1983

Furey v. Thomas Jefferson University Hospital,472 A.2d 1083 (Pa. Sup. Ct.) 1984

Garthe v. Ruppert, 190 N.E. 643 (NY Ct. App.)1934

Greenwell v. Aztar Indiana Gaming Corp., 268F3d 486 (Ct. App. 7th Cir., IN) 2001

Hall v. Hilbun, 466 So2d 856 (Miss) 1985

Helling v. Carey, 519 P2d 981 (Wash. Sup.Ct.) 1974

Hood v. Phillips, 544 SW2d 160 (Tx Sup Ct)1977

Jewitt v. Our Lady of Mercy Hospital, 612NE2d 724 (Ohio Ct App) 1992

Jones v. Chidester, 610 A.2d 964 (Sup. Ct.Penn.) 1992

Jordan v. Bogner, 844 P2d 664 (Colo) 1993

King v. Flamm, 442 S.W.2d 769 (Tex. Sup. Ct.)1969

Lane, et al v. Otts, 412 S2d 254, (Ala.) 1982

Lane v. Skyline Family Medical Center, 363NW2d 318 (Ct. App., Minn.) 1985

Larsen v. Yelle, 246 NW2d 841 (Sup Ct,Minn.) 1976

McCourt v. Abernathy, 457 SE2d 603 (S.C.Sup. Ct.) 1995

Mosciki v. Shor, 163 A 341 (Pa Super Ct)1932

Pennsylvania Jury Instructions (Pa. S.S.J.I.,Civ.) Sec 14.10 (2015)

Pike v. Honsinger, 49 NE 760 (1898)

Prooth v. Wallsh, 105 Misc 2d 603, (Sup CtNY County) 1980

Restatement (Second) of Torts §299 A; WestPublishing; St. Paul, MN (1965)

Simone v. Sabo, 231 P.2d 19 (Sup. Ct., Calif.)1951

Smith v. Beard, 110 P2d 260 (Sup. Ct. WY)1941

State v. Cripps, 533 NW2d 388 (1995)

Texas & Pacific Ry. Co. v. Behymer, 189 U.S.468 (1903)

The T. J. Hooper, 60 F.2d 737 (2d Cir.) 1932

Vassos v. Roussalis, 625 P.2d 768 (1981)

Vassos v. Roussalis, 658 P.2d 1284 (1983)

Vaughan v. Menlove, 132 Eng.Rep. 490 (Court of Common Pleas) 1837

Virginia Code Annotated. Title 8.01 CivilRemedies and Procedures, Chapter 21.1Medical Malpractice, Sec 8.01-581.20, 2006

West v. Sanders Clinic for Women, 661 S2d714 (Sup Ct. Miss.) 1995


Standards: Part I


Neil J. Gajjar, DDS, FACD

Abstract

The Academy of General Dentistry works to raise the standards of general dentistry,primarily through intensive continuingeducation. Since the 1960s, AGD has guided general dentists to educationalopportunities that meet appropriatestandards and recognized those who haveachieved 600 hours of education and passeda comprehensive examination with afellowship designation. There is a furtherlevel of accomplishment, requiring anadditional 500 hours of education,culminating in a master’s designation. In recognition of additional training andcommunity service, AGD dentists can earnthe Lifelong Learning and Service Recognition.This award can be achieved multiple times.AGD provides a service to the entire dentalprofession through its Program Approval for Continuing Education (PACE) system. CE providers can be recognized for meeting13 standards/criteria, including those foradministration, fiscal responsibility, learningobjectives, evaluation, and self-instructionand electronically mediated programs.

Since its founding in 1952, theAcademy of General Dentistry

(AGD) has striven to raise thestandard of excellence for generaldentists. AGD accomplishes this goalprimarily by offering high-qualitycontinuing education (CE) specificallysuited for general dentists and byrecognizing its members who haveexceeded industry expectations for theadvancement of their professionaleducations with the earned distinctionsof fellow (FAGD) and master (MAGD).These distinctions are voluntary, butthey far exceed the CE requirements ofstate licensing boards and demonstratea commitment to furthering one’seducation in order to provide superiorcare for the benefit of one’s patients.

The Importance of CE

In 1966, one of AGD’s foundingmembers, Thaddeus V. Weclew, wroteabout the need for continuingeducation in the Journal of theAmerican Dental Association, notingthat, “Up until the late 1950s, therewas little pressure for continuingeducation from the profession.” Hewent on to say that, “Unless therecipient of a degree earned 10 to 30years ago progressively reinforces hisknowledge with current developmentsand ideas, Supreme Court decisions,advances made in antibiotics, newconcepts of science, and other forwardstrides that have been made, hisdegree will have become obsolete. The practitioner…has not fulfilled thedebt owed himself and the community

if he is not keeping up with the currentadvances of his profession.”

With the astoundingly fast rate ofchange and technological advance-ments in modern dentistry, it is likelythat, if you are an experienced andestablished clinician, there areprocedures you perform differentlyfrom how you were taught in dentalschool; if you are a student now, it islikely that the landscape of dentalmaterials will change before you reachthe middle of your career, and so willthe technologies you use in yourpractice. The education you receive indental school is only the beginning.

Voluntary standards represent acommitment to personal excellenceand professional growth. AGDmembers are committed to maintainingand building on their proficiencybeyond simply meeting state dentalboard CE requirements. In order tobroaden patient access to care andservices, the general dentist isexpected to have a much widerknowledge base than a specialist andensure that this knowledge base is upto date, making CE that much moreimportant. The founders of AGDrecognized that the CE needs ofgeneral dentists differ from specialists,and, therefore, the driving force ofAGD has been to provide that broad-based lifelong learning to generaldentists. Due to the variety andnumber of services dentists provide to their patients, if a general dentist


Standards: Part I

The Academy of General Dentistry’s

Standards for Continuing Education

Dr. Gajjar is immediate past-president of the Academy ofGeneral Dentistry. He practicesin Mississauga, Ontario, Canada.


settles for the minimal number of CEcredits required by the state licensingboard, the dentist risks falling behindon important new knowledge withinthe profession. It is impossible to staycurrent with every area of care generaldentists provide without exceeding the minimal CE requirements.

In order to formally recognizemembers who prioritized professionalgrowth in the form of CE, the AGDfellowship program began in 1962.The FAGD distinction requires thecompletion of 500 hours of CE, at leastthree years of membership, and thepassing of a comprehensive fellowshipexam. The MAGD distinction wascreated in 1968 for AGD members whowish to continue beyond the FAGDdistinction and requires the completionof 600 additional hours of CE.

These distinctions serve twoimportant purposes: On the surfacelevel, they recognize practitioners whohave made a commitment to lifelongprofessional education. They alsoprovide a framework for professionalimprovement; for example, the MAGDdistinction requires 400 hours ofparticipation-based CE as well asminimum credit requirements in 18major subject areas. These requirementsset a high standard for the quality aswell as the well-rounded nature of theeducation received. These distinctionsencourage members to maintain ahigh level of education long after theirdental school graduations by regularlyparticipating in CE courses andengaging with new knowledge that

can be applied in their practices forthe benefit of their patients.

In addition to the standards FAGDand MAGD candidates are measuredagainst, AGD also has rigorousstandards for CE providers through itsProgram Approval for ContinuingEducation (PACE). The 13 standards/criteria for approval by the PACEprogram include standards foradministration, fiscal responsibility,learning objectives, evaluation, andself-instruction and electronicallymediated programs, among others,and ensure PACE-approved CEproviders develop programs inaccordance to quality standards. PACEis overseen by AGD’s PACE Council,and two of the purposes and goals ofPACE are to improve the educationalquality of continuing dental educationprograms and to promote uniformityof standards for continuing dentaleducation that can be accepted by thedental profession. When choosing CEcourses, clinicians can feel confidentthat PACE-approved providers havethe organizational structure andresources necessary to provide CEactivities of acceptable educationalquality. The PACE standards serve thedental profession by setting a bar forcontinuing dental education, and this,when combined with the measurabledistinctions provided by AGD, createsa quantifiable measurement for


Standards: Part I

“The practitioner…has

not fulfilled the debt owed

himself and the community

if he is not keeping up with

the current advances of

his profession.”


professional excellence throughout aclinician’s career with regard tolifelong learning and development.

Going Beyond

In addition to the FAGD and MAGDdistinctions, AGD offers anothermeasureable distinction: LifelongLearning and Service Recognition(LLSR). LLSR requires an additional500 CE credits—150 of which must be from participation-based courseattendance—from at least eight of themajor disciplines. LLSR also goesbeyond CE by requiring thecompletion of 100 hours of dental-related community/volunteer serviceand/or service to organized dentistry.Acceptance of submitted service hoursis subject to review by the DentalEducation Council. Examples ofrecognized community and volunteerservice include providing pro bonodental services through a not-for-profit organization, service in avolunteer dental clinic, service on adental mission, and providing oralcancer screenings at a communitylocation or event.

While the CE requirements of theFAGD, MAGD, and LLSR distinctionsmeasure clinicians’ dedication tocontinuously improving their skillsand knowledge base in order to applytheir improved education to patientcare within their own practices, theservice requirements of LLSR place animportant voluntary standard onoutward action. Many dentistsprioritize volunteer service in an effort

to fill the gaps in oral health careaccess in their own communities as wellas in regions around the globe whereaccess to oral health care is limited.Despite the numerous modernadvances in dental treatment for cariesand periodontal disease, significantbarriers to accessing care remain, andthese barriers hinder the progressdental professionals can make towardaddressing the oral health concerns oftheir communities. Providing pro bonoservices can bring care to patients who could otherwise not afford it, andit can make a phenomenal differencein their lives. The LLSR distinctionrepresents a flagpost goal thatencourages clinicians to participate in these activities and give back as away to achieve a more fulfillingprofessional and personal life. Andwhile fellowship and mastership statusare one-time achievements, LLSR canbe earned repeatedly. Some AGDmembers have earned LLSR as many as four and five times. Thesededicated clinicians are an excellentexample of the benefit of voluntarystandards, both for the clinician as anindividual and for the community as a greater whole.

In addition to voluntary clinicalservice, AGD members also propel theprofession forward through activitiesrelated to organized dentistry. AGDhas a strong advocacy arm that worksto ensure the voices of general dentistsare heard loud and clear within thestate and national governments.Members unite to advocate on issuessuch as anesthesiology and sedation,barriers and access to care, Food andDrug Administration issues, andMedicare, as well as scientific andpractice issues. Involvement inadvocacy through organized dentistryenables members to directly impact thestandards against which all membersof the profession are measured.


Standards: Part I

If you are a student now,

it is likely that the

landscape of dental

materials will change

before you reach the

middle of your career, and

so will the technologies

you use in your practice.

The education you receive

in dental school is only

the beginning.


Pursuing ExcellenceTogether

Pursuing distinction and recognitionfrom a professional organization likeAGD mimics the benefits of dentalschool on a much larger scale and with more individual control. Othermembers become your professionalcolleagues, much like your classmatesin dental school. AGD membersreceive support on their paths tofellowship, mastership, and LLSR fromother members who are in the sameplace in their careers as well as fromthose who have already achieved thesedistinctions. Members who are on thetrack toward these distinctions sharethe goal of bettering themselves asclinicians, and this shared motivationcan enable close personal bondsbetween colleagues. These bondsprovide mutual support as well asinspiration to succeed.

Unlike during a clinician’s initial dental education, where thecurriculum is packed and there is little room for deviation, CE allowsclinicians to tailor their education totheir professional needs and interests.While AGD mastership requiresrecipients to meet minimum CE creditrequirements in all 18 major disciplineareas in order to prove the generalstandard of excellence has been met,fellowship and LLSR both allow for amore open-ended approach to CE.Clinicians often serve patientpopulations with different needs, andthose pursuing these distinctions canimmerse themselves within the areasthat will best serve their patients.Additionally, as clinicians consideradding new services to their treatmentrepertoire, they can pursue coursesthat meet their interests and learningobjectives with the confidenceprovided by the PACE umbrella whenchoosing a CE provider.

It is important to emphasize thatthe CE credits AGD members pursueand the service hours they clock havefar-reaching benefits. Keeping abreastof the latest in science and clinicalpractice translates directly into better care for patients. By pushingthemselves to continuously learn newinformation and treatment methods,AGD members raise the bar for thedental profession to exceptionalheights. By setting and meeting ahigher standard for themselves, theseclinicians set the standard for theprofession. Staying current with the rapid pace of change andadvancement in the dental industry as well as the latest recommended best practices is necessary in order toprovide the highest level of care forpatients, and the distinctions AGDconfers encourage, recognize, andhonor that commitment.

Conclusion

AGD commends the AmericanCollege of Dentists for focusing on thebroad issue of standards in dentistryand inviting AGD to participate.Dentistry is highly regulated, and eachof the mandatory standards serves aspecific purpose, which is oftenchallenging to translate to thepracticing dentist. Pursuing voluntaryrecognitions like FAGD, MAGD, andLLSR is about personal goal settingand lifelong learning and culminateswith a sense of sharedaccomplishment. It is about setting ahigher standard for yourself than whatis required of you. The initials after myDDS also serve as a conversation

starter with patients, giving me theopportunity to tell them about mydedication to continuing my dentaleducation as a lifelong learner andkeeping up with the latest in science,technology, and techniques in order to better serve my patients. Thepursuit of these voluntary standards is a way for me to differentiate myselffrom the status quo, and it is also away for me to elevate my own skillsbeyond what is merely required andinstead work to achieve my ownmaximum potential as a clinician. By pursuing these voluntary standardsas AGD members, we elevateourselves and each other, and in doingso, we also elevate the profession. n


Standards: Part I

Voluntary standards

represent a commitment

to personal excellence

and professional growth.


Chris Salierno, DDS

Abstract

Traditional educational media, such as live lectures and journals, have filters tomaintain certain standards for quality. Those filters have checks and balances inplace to ensure that they are screening outsubstandard content. As the Internet andsocial media have evolved, there have beenmore opportunities for people to create anddistribute educational content themselves.These new media channels often lack filtersand checks and balances, thus leavingdentists to decide for themselves whatcontent is to be trusted and what should be doubted.

Iwas in between patients one daywhen I decided to browse a Private

Facebook Group. Over the past fewyears, thousands of dentists, dentalteam members, and members of thedental industry have flocked to thesegated forums for clinical discussions,for business advice, and as a means toblow off some steam. As I scrolleddown my Facebook feed, I noticed apost from a dentist who provided a full-arch, cosmetic rehabilitation witha combination of full-coverage crownsand fixed partial dentures. Thepreoperative clinical photos showedwhat appeared to be relatively healthyteeth that might have been restored by more conservative means, but ofcourse I had no understanding of the patient’s personal goals, no pre-operative radiographs, nor any othercritical diagnostic information thatwould allow me to critique thistreatment plan. Sharing some pre-opand post-op photos on Facebook isnot a formal case presentation at astudy club, so I thought little of it.

A few weeks later, I noticed asimilar post by the same dentist with asimilar treatment plan. Upon lookinginto his post history, I noticed heapparently favored full-mouth, full-coverage restorations for all of thecases he had shared. Of note was onepost where he stated he delivered local anesthesia to a patient for anextraction, “then i [sic] proceeded todo an entire smile makeover withouthim knowing or even giving me

permission to.” The dentist appearedto be seeking praise for donating hisservices to help a patient in needwithout realizing that he hadcommitted a breach of the doctor-patient relationship, given the facts aspresented. The comments section wasdivided; many praised his generositywhile only some raised concerns about the lack of patient consent.

The Duty of Filters

I am the chief editor for DentalEconomics. As an editor of one of the journals that is neither academicnor association-bound, I receivesubmissions that are brilliant, but I also bear witness to more egregiousexamples of poor dental education. I read proposed articles that wereclearly written to serve the author’spersonal agenda. I have seen clinicalcases that were clearly Photoshoppedor were otherwise fraudulentlypresented. This kind of content is, ofcourse, rejected for publication.

Let me be clear, the majority ofsubmissions to Dental Economics aresuperb. I have the good fortune to readabout business models, marketing,and human resources from some ofthe best minds in their respectivefields. Clinicians whose names aresynonymous with integrity havesummarized the latest research andhave articulated the prevailing wisdominto prose that we all can understand.Perhaps you have seen these dentaldignitaries in live lectures and you havemarveled, as I have, at their ability toreduce the complexity of clinical


Standards: Part I

Can a Dentist Maintain Standards on Social Media?

Dr. Salierno is chief editor ofDental Economics and practicesin Melville, New York;[email protected].


decision making. When Dr. GordonChristensen states that a post-and-core will work in a particular clinicalsituation, it is easier to doubt my own skills than to disagree with hisrecommendation. Dr. Christensen hasan outstanding reputation in our fieldin part because he supports his claimswith sound research.

I also have the privilege to reviewcase studies from trailblazing clinicianswho question our prevailing wisdom.New materials and new techniquesthat have not yet stood the test of timeare presented responsibly and the needfor further study is made clear. Thedentist-patient relationship has beenrespected and the dentist has clearlyupheld standards for quality of care.

What I continue to find personallyinteresting is where exactly the linewould be crossed between the nobleadvancement of our learning and theignoble abuse of a patient’s trust. With resources like the ACD’s EthicsHandbook for Dentists to draw upon,we may conclude that we have notcrossed that line as long as (a) thepatient gave informed consent to theprocedures and (b) the cliniciantreated the patient with the best ofintentions and paid all due respect toexisting standards of care and safety.

For example, I recently published a themed issue on the use of 3Dprinting in dentistry. Our professionmaintains standards for removableprosthodontic outcomes and theclinicians whose articles I shared alldemonstrated a passion to maintainthat standard. They acknowledged the shortcomings of the current 3D printing workflow in denturefabrication and made no false claimsabout where this emerging science hasbrought us today.

Such is the role of the chief editor,peer-review boards at journals, andcontinuing education providers. We serve as filters, protecting ouraudiences from bad science and badpractices. We fact-check and wetemper claims that venture beyondwhat can be supported by evidence.We help maintain the standards of ourprofession in educational media. Buthow are the filters held accountable?

Who Will Watch theWatchmen?

There is a series of checks andbalances in place for traditional mediathat helps maintain standards and thequality of information.

As an editor, I set forth andmaintain editorial guidelines andstrive to achieve a certain quality ofinformation for the audience. But let’s

imagine what would happen if I wereto lower my editorial standards to thepoint of dereliction of duty. Mypublisher would most likely replaceme with someone with higherstandards or, if left in my position fortoo long, the audience would abandonthe publication. Printing and mailing100,000 copies of a magazine is costly;if the audience leaves, the magazinewould be out of business. So by theaudience either appealing to a higherauthority or by dropping theirsubscriptions, my failings as a filterwould result in my dismissal from my post.

When a continuing educationprovider fails to follow the AmericanDental Association’s ContinuingEducation Recognition Programguidelines and allows bad informationand overt commercialism to runrampant, the ADA can receivecomplaints and either discipline theprovider or remove the provider’sability to provide CE. Like printpublications, live lectures are costly to produce, thus a failed filter couldalso result in the provider ceasingoperations if audiences choose to notattend their events.

These systems are not perfect, butthere is at least some recourse foraudiences who see these media filtersfail. Dentists can appeal to higherauthorities such as publishers or CEregulators. They can also drop


Standards: Part I

Such is the role of the chief editor, peer-review boards

at journals, and continuing education providers.

We serve as filters, protecting our audiences from

bad science and bad practices. We help maintain the

standards of our profession in educational media.


subscriptions and choose to not attend conferences, thus forcing thetraditional media source to change its ways or to go out of business. But what if there were no checks andbalances in place? What if a contentproducer could reach audiences withlittle to no cost and bypass thetraditional filters?

The Democratization of Media

The rise of social media has been amixed blessing for our society. Blogs,podcasts, Private Facebook Groups,Instagram personas, Twitter feeds, and the like have three significantcharacteristics: (a) content can beproduced and distributed at near-instantaneous speeds and at little to no cost; (b) content can be created by

anyone and can be done anonymously;and (c) the creation of “filter bubbles,”digital communities can perpetuateand reinforce self-selected concepts.For the cost of a laptop or mobilephone, anyone can create anddistribute content to large audiencesand compete with traditional mediaoutlets, such as newspapers, journals,and television networks. The numberof media channels has increasedexponentially and they compete forour limited attention. We risk selectingdigital outlets and communities thatreinforce our existing ideas rather thanthose that present well-researched,objective data. It is arguably a positivething for our society that people whowould never have had a platformbefore are now able to share theircontent; however, these platformsoften lack any standards for thatcontent. The traditional filters that arein place for print journals and livelectures do not exist for Instagraminfluencers or Private FacebookGroups. The burden of research andfact checking falls upon the audience.

But let us leave generalities andspeak specifically about ourprofession. You have no doubtlamented the sometimes poor qualityof dental information available online,which can sway our patients’ decisionsabout their care. In a well-intentionedeffort to educate themselves, ourpatients can stumble across oral healthinformation online that either is takenout of context or is objectively false.We hope that they look to trustedresources, like the American DentalAssociation, that only share validinformation with their audiences.

But self-published blogs, Facebookfeeds, and Instagram influencers havequestionable filtration practices, if any at all.

Unfortunately, the same challengesexist for members of the dentalcommunity who look to onlinecommunities and social mediaplatforms for clinical and businessadvice. Dentists without propercredentials or real expertise in a fieldcan present educational content thathas not been properly researched orperformed to the profession’sstandards of care. Without a filter inplace, the content is shared directlyand immediately with the dentalcommunity. While it is alwaysincumbent upon a healthcareprofessional to evaluate advice frompeers before putting it into practice, I am concerned that the volume ofunsupervised educational content andthe persuasiveness of some of thecontent producers are occasionallyteaching healthcare professionals topractice beneath the standard of care.

While there have been studies thatdiscuss the dangers of social mediaconsumption by patients seekingeducation (Moorhead et al, 2013) andthe dangers of social media posting byhealthcare professionals (Ventola,2014), I am not aware of any researchon social media consumption byhealthcare professionals seekingeducation. While we wait for studies toreveal how healthcare providers areinfluenced by unfiltered media,practicing dentists who consumesocial media and participate in onlinedental communities should be advisedto tread carefully when basing theirclinical and practice decisions on that content.


Standards: Part I

I believe that licensed

healthcare practitioners can

rise above the noise of

unfiltered, poorly vetted

educational content with

simple common sense and

respect for proper research.


How We Might ProtectStandards in Social Media

I believe that licensed healthcarepractitioners can rise above the noiseof unfiltered, poorly vetted educationalcontent with simple common senseand respect for proper research. Butour profession would do well to notleave dentists unaided in the quest toseek quality education. Traditionalmedia channels, social and digitalmedia channels, professionalorganizations, and other key playersshould consider the followingsuggestions to help dentists assesstheir content and build trust with their audiences.

Clinical techniques and businesspractices that are not yet standardshould be clearly identified as such.Our profession advances because weexperiment, but audiences shouldknow when products are being usedoff-label and when a field of study isstill in its infancy. The appeal tonovelty is a common fallacy used inmarketing, but it should not be used in legitimate education.

Online forums, such as PrivateFacebook Groups, should clearly statetheir rules for discussion and theyshould be properly moderated. Digitalcommunities are more akin to a localstudy club than a scientific journal,but their discussions are preserved forfuture reference. Thus an onlineforum should recognize and respondappropriately when questionablepractices are being promoted.

In all forms of digital media,dentistry that has been clearlyperformed beneath the standard ofcare and clear violations of ethicsshould be immediately identified andaddressed. While online forumstypically have moderators who canintervene, self-published media likeblogs and podcasts have no filters in

place. It is up to the audience to reportthese egregious errors, and there maynot always be a clear pathway to do so.I recommend that, at the very least,members of the audience approach the publishers of offending contentprivately and notify them about theissue. A successful outcome would bethat the publishers remove saidcontent, learn from their error, correctthe substandard care or ethicalviolations with patients, and theneducate their audiences about bestpractices moving forward.

Our profession will benefit from arenewed effort to improve our criticalthinking skills. Even traditional,filtered media can publish badresearch, so we must all endeavor tomaintain healthy skepticism and topractice sound scientific reasoning.

Conclusion

The digital media revolution hasallowed anyone to build an audienceand create and distribute content forlittle to no cost. Without traditionalquality control filters in place, andwithout traditional checks andbalances for those filters in place, ourprofession must be more vigilant inassessing the veracity of claims madeon social media channels and inonline forums. Our critical thinkingskills are being tested. The standard of care can be challenged by thepopularity of an influencer rather than by the integrity of a researcher.While there is excellent content beingshared on social media and in digitalcommunities, there is also content thatnever would have passed through atraditional media filter and made it to an audience. Maintaining ourprofession’s standards is morechallenging than ever before. n

References

Moorhead, S. A., Hazlett, D. E, Harrison, L.,Carroll, J. K., Irwin, A., & Hoving, C. (2013). A new dimension of health care: Systematicreview of the uses, benefits, and limitationsof social media for health communication.Journal of Medical Internet Research, 15(4), e85.

Ventola C. L. (2014). Social media and healthcare professionals: Benefits, risks and bestpractices. Pharmacy and Therapeutics, 39 (7),491-499, 520.


Standards: Part I

I am concerned that the

volume of unsupervised

educational content and

the persuasiveness of some

of the content producers

are occasionally teaching

healthcare professionals

to practice beneath the

standard of care.


Why Standards Matter

Professional standards are essential to these functions.

They define the profession.•They guide us through the•complexity of professional practice.They elevate patient care.•They enhance the uniformity of care•over the population of providersand patients.They protect the patient and the•public.They protect the provider from•inaccurate judgment.They provide legitimate dental•guidelines to the legal system thatmay evaluate the treatment; thatjudgment is superior to decisionsmade by an individual with authoritybut lacking technical understanding.Although there are standards,

positions, policies, and parameters indentistry, they may not be comprehen-sive and are not always clearly defined.There are reasons that we do not havemore defined standards.

They are often difficult to establish.•Dentistry has a historical paradigm•of individualized practice by solopractitioners.They may restrict the art in the art•and science of dentistry. Legislative bodies of organized•dentistry have been reluctant torestrict the individualized practiceof dentistry.Evidence-based dentistry has •only been maturing in the pastquarter-century.

Dental science and techniques have•been advancing rapidly. The American Dental Association

(ADA) does not define many standardsof care, but it does have policies,clinical guidelines, recommendations,and position statements that enhanceself-regulation. Examples of moreclearly stated “standards” are relatedto infection control and radiographs.The ADA Center for Evidence-BasedDentistry states: The ADA maintainsthat recommendations for treatmentare left to the treating dentist’sprofessional judgment and that you, asthe treating dentist, should do what isin the best interests of the patient.

The ADA places emphasis onprotection of the public and itprovides three systems of oversight:committees on ethics and judicialaffairs, peer review, and wellness.Although the ADA has not beenaggressive in establishing universalstandards, there is a requirement thatthere be some process and mechanismin both components and constituentsthrough which allegations ofmisconduct are heard. The ADA doesnot track the compliance of thistripartite requirement. There may onlybe a handful of states that actuallyhave active mechanisms. Wellnesscommittees are concerned with issuesconcerning a dentist’s well-being,which will not be discussed here. Thewellness program demonstrates theADA’s concerns and standardsregarding personal demeanor.

Peer review, as a mechanism forinterfacing between dentists andpatients when a disagreement arises, isquite prevalent at all levels of thedental association and is a keyexample of self-governance. Peerreview is the focus of this paper.

How Peer Review Works

Peer review is organized dentistry’sdispute resolution service. Individualsenter the process voluntarily and, inmost cases, voluntarily accept thecommittee’s recommendation. Mostcomponents and constituents use theADA protocol as a guide. The ADA


Standards: Part I

Most dentists are anxious

to know in advance how

they might be judged, what

common expectations exist

for treatment, and how they

might avoid difficulties.


model suggests three stages:mediation, panel review, and appeal.Mediation is nonjudgmental and is an effort to guide the parties to amutually acceptable resolution.Mediation is free, quick, and verysuccessful. Panel review is anarbitration by a committee of expertswho are required to reach adetermination of whether thetreatment in question met thestandard of care. Appeal is the thirdstep and is clearly defined.

A panel of expert peer-reviewdentists is required to determine therelevant standard of care in the panelreview process. This process istechnically more accurate andequitable than the equivalent legalprocess. Unfortunately, there is nodental rule book for determiningstandard of care; the committee isusually left to its own devices.

In peer review, standard of care istypically considered what commonlyshould be done or the degree of skillexhibited by similar practitioners. Thechallenge is to determine whatpractitioners should be doing. Dentalstandards are mostly universal with

little regional difference. Thisuniversality has been greatlyinfluenced by evidence-baseddentistry. Specialty-level treatmentsare held to the standards of specialists.Most dental specialty organizationshave been proactive in definingstandards. It is important to realizethat standard of care does not measureperfection, but is a measure ofacceptability. The dentist does notguarantee an excellent or particularresult but there is an implied contractthat the standard of generalacceptability will be met.

There is a hierarchy of determinantsfor the peer review committee:

official standards, parameters of1.care, policies from the ADA,specialty organizations, or otherdental organizationsevidence-based dentistry2.prevalent teachings from the3.accredited dental schoolspeer-reviewed scientific texts and4.dental journalsthe majority subjective opinion 5.of a jury of peersNaturally, the panel would also

consider professionalism, practiceacts, codes of ethics and conduct, andother official guidelines before it yieldsto the final determining process,which is: What does the majority of thecommittee believe peer practitionerswould have done in that circumstance?

The peer review panel collects avail-able evidence, including examinationsand interviews. The recommendationis issued to the patient and the dentist.The findings are not binding and theprocess is confidential.

Why It Matters

Although the volume of cases is often small, peer review may use theprocess of determining standard ofcare more than any group in dentistry.

But what is the impact if the volume is small and the judgment isconfidential? The answer is likely notmeasurable but there are significantfactors involved.

Peer review has come to be knownand respected by malpracticeattorneys and insurance companies,governmental agencies, and society.Those groups are beginning to rely onthe dental peer review committees forguidance in their own judgments and,especially insurance companies, usepeer review determinations to establishsome of their own expectations ofwhat dentists should do. And dentistsusually follow the guidance of theaforementioned groups.

The peer review committees arechallenged to publicize their purposeand activity to the associationmembership, students, and others.Anecdotes are reported and standardsare revealed. Most dentists are anxiousto know in advance how they might be judged, what common expectationsexist for treatment, and how theymight avoid difficulties. Workshopsare held for the peer review committeemembers and other groups, withdiscussions regarding standard of care.Dentists talk to their friends andcompare notes. The trickle-downeffect snowballs because almost alldentists want to treat their patientswithin the standard.

The peer review committees of theAmerican Dental Association tripartiteorganization play an important role indefining standard of care. Despite theinability to measure the specific effectfrom this low volume and confidentialprocess, there is an impact upondental standards. Dental peer reviewhas an impact in establishing andpromoting standard of care. n


Standards: Part I

The ADA maintains that

recommendations for

treatment are left to the

treating dentist’s professional

judgment and that you, as

the treating dentist, should

do what’s in the best

interests of the patient.


Caswell A. Evans, DDS, MPH, FACD

Abstract

Organizations and collaborations acrossgroups of experts periodically issue reportsthat build on evidence and forecasts torecommend desired future descriptions ofthe oral health of the public and variousactivities thought necessary to achieve thesegoals. Such recommendations seldomidentify resources or place bindingconditions on the organizations that authorthe recommendations, and they usually call on others to make commitments.Nonetheless, such policy statements oftenserve as guides to a better future for oralhealth. This paper summarizes the majorrecommendations over recent decades.

As a group of health professionals,dentists typically consider the

oral health of individuals one at atime. Dentists may also have familiesin their practices, which offers theopportunity to consider oral health inthe context of the family unit. It is lesscommon for dentists to be involvedwith issues that affect the oral healthof populations. Population health isless dependent on technical andprocedural elements of direct provisionof dental care to individuals. Efforts to improve population health canemanate from outcome goals intendedto achieve improved health outcomes.Typically, attainment of goals isdependent on systems changes thatprevent disease, improve access tocare, and reduce oral health inequitiesamong population groups.

The origin of goals can come frommany sources, including federal, state,and local governments, foundations,advocacy organizations, andcommercial interests, to name a few.

Profound standard change in dentaleducation followed the 1926 issuanceof the Gies Report. The report,supported by the Carnegie Foundation,contained five conclusions, orrecommendations, that ultimatelyaffected standards for dental educationthroughout the United States. A morerecent report, Dental Education at theCrossroads, issued by the Institute ofMedicine, National Academy ofSciences in 1995, contained 22recommendations, many of which havebeen incorporated into the standardsfor dental education. (Please note: the

Institute of Medicine has recently been renamed the National Academyof Medicine, National Academies of Science.)

The Surgeon General’s Report onOral Health, released in 2000 by U.S.Surgeon General David Satcher,provided a comprehensive anddetailed review of oral health (see sidebar, page 33). The report pointed outthe essential role played by oral healthin general health and well-being. Italso provided a review of the oralhealth status of various populationgroups, disease preventioninterventions, and salient facets of theoral health systems of care. The reportcontained eight major findings andincluded a five-part framework foraction. In 2003, under the leadershipof Surgeon General Richard Carmona,the National Call to Action to PromoteOral Health was issued. It containedrecommendations for action thatprovided standards and objectives forimproving oral health, preventingdisease, and reducing oral healthinequities among populations. Takentogether, successive Surgeons Generalreleased major oral health documentsthat served to provide standards forimproved oral health. While thesereports focused on oral health, notdentistry as a professional practice, thereports were quite clear that achieve-ment of the objectives to improve oralhealth would necessitate fullcollaboration of dental practitioners.

In 2001, the American DentalAssociation released a Future of


Standards: Part I

Standards for the Oral Health of the Public

Dr. Evans is associate dean forprevention and public healthservices at the University ofIllinois, Chicago, College ofDentistry; [email protected].


Dentistry report (see side bar, page35). This was the second such report.The earlier report, released in 1983,explored the state of the profession,offered predictions regarding futurechallenges, and made recommendationsthat set a foundation for strategicplanning. The 2001 report followed anoutline similar to the earlier reportand addressed trends in six essentialsubject domains addressed by separateexpert panels: clinical dental practiceand management; financing of andaccess to dental services; dentallicensure and regulation of dentalprofessionals; dental education; dentaland craniofacial research; and globaloral health. The predictions wereintended to cover a five- to fifteen-year time horizon, and each subjectpanel was expected to provide

recommendations to assist theprofession in meeting identified futurechallenges. A vision statement and six guiding principles framed thereport. In its summary, the reportprovided seven broad recommend-ations and 100 others tailored to thesubject domains.

Chapter four of The Guide toCommunity Preventive Services,published in 2005 by the Task Force of Community Preventive Servicesconvened by the Centers for DiseaseControl and Prevention, focused onoral health. The Task Force, convenedin 1996, was charged with developingrecommendations for community-level interventions to promote healthand prevent disease. The reportprovided strong recommendations forcommunity water fluoridation andschool-based or school-linked pit andfissure sealant delivery programsbased on a systematic review of thescientific evidence of their effective-ness. These findings have affected thestandards and practices of theseinterventions in many communitiessince the report was issued.

In 2011 the Institute of Medicine(IOM), National Academy of Sciences(now the National Academy ofMedicine), issued two reports:Improving Access to Oral Health Carefor Vulnerable and UnderservedPopulations and Advancing OralHealth in America. The HealthResources and Service Administration(HRSA), U.S. Department of Healthand Human Services (DHHS),commissioned both reports; CaliforniaHealthcare Foundation also providedsupport for the Access to Oral HealthCare report. The reports entailedseparate committees, meetings, andreport review processes. Informationabout the conclusion andrecommendations of the committeeswas not shared between them. The

burden of unmet oral health needsamong the most vulnerablepopulations and the documentedconnections between oral health andoverall health led HRSA to requestIOM to provide advice aboutimproving access to care for thesegroups. HRSA, as a significantprovider of resource support for healthservices to vulnerable populations,was eager to have recommendations itcould consider in its effort to be aseffective as possible in its role andregarding the resources it provides.

The Access to Oral Health Carereport contained ten recommendations,a few of which went beyond HRSA’sdirect role, but were within HRSA’sscope of influence. The recommenda-tions included: integrating oral healthcare into overall health care; creatingoptimal laws and regulations;improving dental education andtraining; reducing financial andadministrative barriers; promotingresearch; and expanding capacity.

The Advancing Oral Health inAmerica report provided advice onactions that the DHHS should take foran oral health initiative. That committeeprovided seven recommendations insix areas, including: establishing andevaluating an oral health initiative;focusing on prevention; improvingoral health literacy; enhancing thedelivery of oral health care; expandingresearch; and measuring progress.

The Healthy People series ofreports, issued by the U.S. Departmentof Health and Human Services,presents major health improvementinitiatives and milestones for thenation. These reports have beenprepared each decade starting in 1990.Oral health objectives are includedamong these goals. The Healthy People2020 report lists more than 600 health-


Standards: Part I

The Surgeon General’s

Report on Oral Health,

released in 2000, pointed

out the essential role played

by oral health in general

health and well-being.


related objectives for the nation, to be achieved by the year 2020. Theobjectives are structured in the contextof 12 leading health indicators. For thefirst time in the 40-year history of thereports, oral health—specificallyaccess to care—is included as one ofthe 12 leading national healthindicators. Few dentists know thatthrough their services they cancontribute to attaining significant oralhealth objectives for the nation.

The Access to Dental Care Summitconvened in 2009 by the AmericanDental Association proved to be alaunching point for another set ofgoals to improve oral health. TheSummit participants included 144dentists and oral health advocatesselected to represent 12 key facets ofaccess to care such as practice,community clinics, education, and


Standards: Part I

U.S. Surgeon General’s Report on Oral Health, July 2000 The full report is available as a PDF: Oral Health in America: A Report of the Surgeon General(nidcr.nih.gov/sites/default/files/2017-10/hck1ocv.%40www.surgeon.fullrpt.pdf)

Major Findings• Oral diseases and disorders in and of themselves affect health and well-being throughout life. • Safe and effective measures exist to prevent the most common dental diseases—dental caries and

periodontal diseases. • Lifestyle behaviors that affect general health such as tobacco use, excessive alcohol use, and poor dietary

choices affect oral and craniofacial health as well. • There are profound and consequential oral health disparities within the U.S. population. • More information is needed to improve America’s oral health and eliminate health disparities. • The mouth reflects general health and well-being. • Oral diseases and conditions are associated with other health problems.• Scientific research is key to further reduction in the burden of diseases and disorders that affect the face,

mouth, and teeth.

A Framework for ActionAll Americans can benefit from the development of a National Oral Health Plan to improve quality of life and eliminate health disparities by facilitating collaborations among individuals, healthcare providers,communities, and policymakers at all levels of society and by taking advantage of existing initiatives. Everyonehas a role in improving and promoting oral health. Together we can work to broaden public understanding of the importance of oral health and its relevance to general health and well-being, and to ensure that existingand future preventive, diagnostic, and treatment measures for oral diseases and disorders are made available to all Americans. The following are the principal components of the plan.• Change perceptions regarding oral health and disease so that oral health becomes an accepted component

of general health.• Accelerate the building of the science and evidence base and apply science effectively to improve oral health. • Build an effective health infrastructure that meets the oral health needs of all Americans and integrates oral

health effectively into overall health.• Remove known barriers between people and oral health services. • Use public-private partnerships to improve the oral health of those who still suffer disproportionately from

oral diseases.


research, among others. The Summitlaid the foundation for the concept ofa multifaceted effort to advanceinitiatives to improve access to care.From this origin the U.S. NationalOral Health Alliance was formed, withsupport provided by the DentaQuestFoundation. During the years 2011through 2013, a large and diversegroup of oral health advocates andstakeholders gathered in a series of sixcolloquia focused on goals that wouldachieve systems changes to improveoral health. The colloquia themeswere: Medical and DentalCollaboration; Prevention and PublicHealth Infrastructure; Oral HealthLiteracy as a Pathway to HealthEquity; Metrics for Improving OralHealth; Financing Models for OralHealth; and Strengthening the DentalCare Delivery System.

In addition to standards, or oralhealth goals and objectives, that areintended to have a national impact,

there are state and local efforts thataddress needs in state and localgeographies. Using one state, Illinois,as an example, several initiatives areillustrative. The Illinois Department of Public Health, under a mandate bythe state legislature, develops aperiodic State Health ImprovementPlan. In collaboration with the state, adiverse group of health advocatesdevelops the plan through data andtrend assessments, public meetings,written commentary, and directparticipation. There are oral healthelements within the Illinois StateHealth Improvement Plan.

There are also state-level examplesof foundation engagement in oralhealth with a specific focus. Forexample, in 2016 the Illinois Children’sHealth Care Foundation, incollaboration with the Delta Dental ofIllinois Foundation and the MichaelReese Health Trust, assessed oralhealth in the state. The report, OralHealth in Illinois, not only presentedfindings but also providedrecommendations for goals andsystems changes that could lead to oralhealth improvements in the state.

At the local level, city and countyhealth departments may develop plansfor their jurisdictions that containgoals and objectives, creatingstandards and related expectations forsubsequent health improvement. One

such example is Healthy Chicago 2.0:Partnering to Improve Health Equity,2016-2020. With the full support ofthe mayor and using a process thatincluded numerous community “town hall” meetings, the ChicagoDepartment of Public Healthdeveloped web-based surveys, whichwere promoted widely and madeavailable to all residents, with thecollaboration of 130 organizations.Oral health improvement goals wereincluded among the actionablestrategies to reduce inequities andimprove the health of Chicago residents.Reduction of dental emergency roomvisits in local hospitals and improvingcollaboration between childcarecenters and oral health providers toimprove the oral health of youngchildren were examples of the goalsrelated to oral health.

The extent to which dentists andorganizations representing the broadinterests of dentists are aware of thesetypes of population-focused goals andobjectives cannot be determinedeasily. Dentist and dental organizationinvolvement in these types of goal-setting initiatives is typically sought.However, the level of participationmay vary substantially. Disseminationof these types of community“standards” does include dentalorganizations, but the extent to whichthe information is passed on to theirmembership is not certain. It is rarefor a dental organization to formally“endorse” these types of efforts. n


Standards: Part I

The American Dental Association released a Future of

Dentistry report in 2001. A vision statement and six

guiding principles framed the report. In its summary,

the report provided seven broad recommendations and

100 others tailored to the subject domains.



Standards: Part I

The Future of Dentistry—Today’s Vision: Tomorrow’s Reality A report of the American Dental Association. The full report is available online atada.org/en/~/media/ADA/About%20the%20ADA/Files/fu%C2%ADture_execsum_fllreport

Broad Recommendations• Establish and support partnerships and alliances among dental, other health care professional, and public

health organizations, as well as business and social service groups, in order to address common goals toimprove oral health.

• Aggressively address the oral health needs of the public.• Strengthen and expand dentistry’s research and education capabilities.• Ensure the development of a responsive, competent, diverse, and “elastic” workforce.• Develop strategies to address the fiscal needs of the practice, education, and research sectors of dentistry

to ensure their viability and vitality.• Establish a formal organization with membership consisting of the American Dental Association representing

dental practice, the American Dental Education Association representing dental education, and the NationalInstitute of Dental and Craniofacial Research and the American Association of Dental Research representingresearch.

• Utilizing the combined resources of the dental profession and dental industry, emphasis should be placed onthe development of highly targeted, collaborative marketing and public relations initiatives.

Clinical Practice RecommendationsContinued comprehensive studies should be conducted to assess the capacity of the dental workforce1.addressing all of the possible factors and variables that affect the ability to provide adequate services to thepublic. The status of the workforce should be reassessed periodically.

The dental profession must continually evaluate its data requirements and collect needed data in sufficient2.quantity, frequency, and detail to form the basis for a rational assessment of workforce requirements.

Due to regional workforce imbalances, a consortium of appropriate leaders and other policymakers should3.be convened to develop a plan to address these issues.

Individual states or regions should develop workforce plans that address their specific needs. 4.

Workforce models should continually be evaluated and changed, refined and strengthened, as necessary 5.to forecast the future dental care needs and demands of the public.

The dental profession, through collaboration among all levels of organized dentistry, governmental6.agencies, and educational institutions, should devise a program of recruitment to encourage the youth ofminority populations to enter an educational track that would lead to joining the dental workforce.

The dental profession should support licensure by credentials for dentists and dental hygienists. 7.

Workforce studies should be undertaken to identify the optimum number and distribution of allied 8.dental personnel.

The dental profession should establish as a goal the standardization of approved duties for allied 9.personnel within the United States.

An alliance should be formed among the dental profession, organized dentistry, government health10.agencies, and the dental industry to develop and fund a “National Health Awareness Campaign” focusingon increasing the awareness of the public and policymakers of the importance of oral health.

Lobbying activities should be organized that include the participation of all levels of society to convince11.legislators that oral health is a major part of general health and that increased funding is necessary tosupport efforts to achieve the goal of optimum oral health for all.


The dental profession, together with all interested parties, should increase efforts to convince the public, as12.well as local, state, and national policymakers, that fluoridation of water supplies is a safe and cost-effectiveway to protect oral health.

The dental profession should conduct intensive public service information and education efforts to reduce13.the death rate due to oral cancer through early diagnosis.

A comprehensive study should be undertaken to assess the efficacy of risk-based dental care.14.

Dental practitioners, educators, researchers, and policymakers should develop a common definition of15.evidence-based practice.

The dental profession, in concert with all other interested parties, should identify ways in which to integrate16.science from systematic research, practitioner expertise, and patient choice to ensure the appropriateapplication of the latest knowledge into the delivery of care.

An appropriate system of diagnostic codes should be developed and integrated into the daily practice of17.dentistry. A network of practitioners, assembled by the appropriate professional organizations andconnected by electronic communication, could provide a large source of data on procedures andoutcomes. Clinical practitioners, to enhance their ability to monitor clinical and procedural protocols,should be able to access unbiased and reliable information easily.

The dental profession should strive to develop the leading repository of the most accurate diagnostic and18.therapeutic databases.

A consortium of representatives of dental practice, research, education, and the dental product industry19.should be established to ensure the rapid transfer of information regarding new modalities of oral healthcare to private practitioners.

A study should be undertaken to address the adequacy of the number of dental laboratory technicians and20.to develop a strategy for attracting qualified individuals into that profession.

The dental profession should develop strategies to maintain the dentist as a knowledgeable director of21.laboratory procedures to insure [sic] the safety of the patient.

Financing RecommendationsThe dental benefits industry should explore a market-oriented solution to financing dental services that1.would include tax-deferred dental/medical savings accounts and direct reimbursement plans.

Financing of dental services should be structured so it will not inappropriately interfere with the2.professional judgment of the dentist or create unwarranted intrusion into the decisions reached jointly bydentists and patients regarding appropriate and best treatment options.

The professional dental communities must continue their support of national legislation that will protect3.patients from health plans that place bottom-line profit ahead of quality and access to care. Even after thepassage of such legislation, the profession must remain vigilant in ensuring that the intent of the legislationis not undermined.

The dental profession should develop an active campaign to educate employers and employees regarding4.dental benefits choices so they can become better healthcare consumers. This campaign should includedentists as members of the educational team.

The dental profession should encourage the dental benefits industry to streamline procedures, reduce5.administrative burden and policy limitations, and provide greater flexibility for covered individuals in theirreimbursement for dental services.


Standards: Part I


The dental profession should commence constructive dialogue with third-party carriers to develop a user-6.friendly attitude and more efficient administrative procedures in their dealings with providers and purchasers.

The dental benefits industry should shorten its response time for including scientifically accepted new7.diagnostic and treatment options in its reimbursable plans.

Access RecommendationsPublic funding should be expanded to provide resources that would cover basic dental services for the1.long-term unemployed. In order to assure participation by providers and improve access, dentists shouldbe reimbursed at market rates for their services. Administration should be managed utilizing the sameprocedures and systems as employer-based dental prepayment plans.

New programs, subsidized in part by public funding, should be developed in which individual employees2.could purchase insurance plans directly from risk pools if their employers do not provide it.

Effective incentives should be offered to attract dentists to underserved areas. These could include loan3.forgiveness, tax credits, or adequate reimbursement rates.

The National Health Service Corps program should be expanded to help provide dental care in the4.underserved areas.

A publicly funded or subsidized dental program should be developed for people with disabilities,5.recognizing their special needs.

Outreach programs at the state and local levels, which might include the establishment of specialty 6.dental clinics, should be developed to meet the needs of patients unable to receive care in traditionaldental offices.

Tax-deferred dental/medical savings accounts should be established in which the balances accrue over7.time and can be used by the elderly as needed during their retirement.

Licensure and Regulation RecommendationsNational board examinations, as well as regional clinical licensing examinations, should evolve to reflect1.more accurately the change in dental disease patterns and clinical practice patterns.

The dental profession should support a study to address the issues of continuing competency.2.

The profession should strive for approaches aimed at evaluating the clinical competency of a dental3.practitioner by simulated methods or post-treatment case review.

In order to assure the quality of care for patients, the dental profession should maintain the role of dentists4.as the ultimate authority for the diagnosis of, treatment planning for, and delivery of care for oral disease.

The dental profession should establish as a goal the equivalence or unity of all examining bodies. 5.

The dental profession should encourage all licensing boards to develop guidelines and procedures that6.allow for the examination of educationally-qualified specialists in their respective areas of expertise withoutrequiring concurrent examination for a general dentistry license.

The dental profession should intensify efforts to achieve licensure by credentials in all states.7.

The profession must continue to be vigilant and proactive in identifying and researching potential hazards8.that might impact the safety of patients, the dental workforce, and the environment.

The dental profession must remain proactive in advocating scientifically valid solutions to identified hazards. 9.

The ADA’s Division of Government Affairs and Constituent Dental Societies must remain vigilant and10.vigorous in ensuring that the voice of dentistry is heeded in regulatory discussions.


Standards: Part I


Education RecommendationsThe provision of sustained federal/state funding to support dental student training, either in the form of1.scholarships or direct unrestricted block grants, should be a high-priority issue.

Creative financing and partnership with various communities of interest should be developed to increase2.the diversity of the dental workforce.

Programs should be developed to educate dental students and young graduates in debt and financial3.management.

Dentists should be encouraged to provide significantly increased financial support for their educational4.institutions. They should also suggest to grateful patients, as well as to other philanthropic individualsamong their friends, that they consider a gift to the local dental school.

Dental schools should explore regionalization in dental education in which dental schools collaborate to5.reduce costs and enhance quality in dental education. Dental schools should examine the cost effectivenessof sharing teaching faculty through electronic distance learning. Innovative techniques, such as placingcurriculum on a DVD, clinical simulation, and virtual reality, warrant further evaluation as means of reducinginstructional costs.

Dental educators should seek to use new technology and scientific advances that have the potential to6.reduce the cost of instruction.

Any plans for a dental school to expand its clinical activities outside the school’s primary location should be7.discussed with local practitioners, alumni, and local components of organized dentistry.

Research should be conducted on the cost effectiveness of off-site training opportunities.8.

Dental schools should develop programs in which students, residents, and faculty provide care for9.members of the underserved populations in community clinics and practices.

Dental education curricula should include training in cultural competency, as well as the necessary10.knowledge and skills to deal with diverse populations.

Dental schools should undertake a comprehensive evaluation of undergraduate curricula to ensure that the11.appropriate and modern scientific and clinical content is included.

Dental researchers (especially clinical researchers) should become more integrated in the foundation of12.curriculum and, when possible, in clinical activities.

The education community should enhance undergraduate exposure to the ethics of dental practice while13.also providing cultural competency that provides information and training on delivering care to allsegments of the population.

A formal dialogue among all healthcare professions should be established to develop a plan for greater14.cooperation and integration of knowledge in medical and dental predoctoral education, hospital settings,continuing education programs, and research facilities.

An interdisciplinary structure between dental and medical schools should be established to promote close15.cooperation between health teaching institutions and universities.

When economically and logistically feasible, a PGY-1 year should be a requirement for all dental graduates. 16.

In order to make PGY-1 economically feasible, the dental profession should develop lobbying efforts17.directed to increasing the funding support for additional General Practice Residency and AdvancedEducation in General Dentistry programs. This funding should be sufficient to offer all future dentalgraduates the opportunity for further clinical training.

The dental profession should design and implement a formal education program to train existing dental18.practitioners to become members of the dental faculty.


Standards: Part I


The dental profession should develop educational tracks with special degrees or certification for students19.interested in research, education, or public health futures. Specialized curricula should be developed totrain these individuals for work in those areas.

The dental profession should seek actions to extend debt forgiveness programs to dental graduates who20.are willing to make a commitment to academic dentistry.

Federal programs that underwrite research and specialty training need to be enhanced with sufficient funds21.allocated to dental applicants.

Specialty organizations should be encouraged to continue efforts dedicated to funding teaching22.scholarships and fellowships.

Dental educators should be encouraged to test alternative, less faculty-dependent models for educating23.dental students.

The dental profession should support the establishment of centers for research excellence that provide24.research training and opportunities for organized research for dental faculty within a defined geographic area.

The dental profession should develop lobbying efforts directed towards the development of new25.assistance programs for the improvement of the physical facilities of dental schools.

Well-funded, innovative recruitment programs to identify and enroll quality candidates for dental hygiene,26.dental assisting, and laboratory technology education should be developed.

The development of additional training programs for allied dental personnel, which employ both traditional27.and innovative educational programs, needs to be encouraged. This could be accomplished through thecombined efforts of national, state, and local dental societies, working with various allied communities ofinterest.

Credit against educational debt should be sought for dental team members who work with dentists in28.designated underserved locales.

Continuing education programs, designed to provide upward mobility for dental team members, need to29.be developed and offered.

The dental profession should continue its efforts to ensure quality control, educational counseling, and30.appropriate recognition for achievement.

Research RecommendationsProfessional organizations and patient advocate groups should form a coalition to support the long-term1.maintenance of National Institute of Dental and Craniofacial Research as a separate institute within theNational Institutes of Health.

The dental profession should be an active member of the National Health Profession Coalition for the Human2.Genome. Research on pathogenesis, prevention, etiology, diagnosis, and treatment is necessary for all oraldiseases. Future research will form an improved definition of genetic, environmental, and microbial riskfactors for oral disease that will lead to development of a profile for patients at risk for advanced disease.

Additional studies should be undertaken to develop new approaches to the non-invasive diagnosis and3.genetic assessments of patients at risk for caries, periodontal diseases, oral cancer, craniofacial anomalies,and other oral conditions. Clearly accepted criteria for the diagnosis of oral diseases should be developed.

Controlled clinical trials must be conducted to assure the safety, efficacy and appropriateness of new and4.emerging approaches to the treatment of oral diseases.


Standards: Part I


Federal agencies, the insurance industry, private foundations and the dental profession should establish5.partnerships to fund the development of systems that can model future oral diseases or conditions in thecontext of rapidly changing demographics, increased co-morbidities associated with aging, and enhancedunderstanding of complex oral diseases.

The research community should establish as a goal the refinement and improvement of biomaterials and6.bioappliances with the aim of increasing their efficacy and longevity and minimizing their iatrogenic effects.

The scope of clinical research should be expanded to incorporate tissue engineering and biomimetic7.approaches.

Health promotion activities should be undertaken to educate the public of the continued presence of dental8.caries and the need to engage in preventive and diagnostic regimens to assure optimum oral health. Themouth has been called the mirror of the body, reflecting signs and symptoms of health and disease. Recentresearch reveals findings that relate oral infections to systemic conditions. Specifically, emerging evidenceindicates that chronic oral infections such as periodontal diseases may contribute to the risk for pre-termbirth, diabetes, stroke, and cardiovascular disease.

If it is demonstrated that oral infections are related to one or more systemic diseases, coalitions within the9.health professions should encourage national and international clinical trials to establish optimal dentaltreatment protocols.

If clinical trials confirm the existence of links between oral and systemic diseases, health promotion activities10.will need to be targeted to high-risk groups.

The research community should establish as a priority goal the identification of patients at risk for oral11.cancers.

The dental profession should educate legislators about the need for economic support for individuals who12.wish to follow a career track into research.

Professional organizations should develop mechanisms to provide financial support for research projects13.and/or training for dental school faculty in their fields of interest.

Together with nonprofit organizations and industry, the dental profession should consider creating and14.supporting fellowship programs for research.

The dental profession, in concert with federal agencies and the private sector, should work for enhanced15.resources for clinical research.

Building upon the ADA’s Research Agenda for the Practicing Dentist, the dental profession should convene16.a clinical research consortium to develop and oversee the implementation of this agenda.

The dental profession should support the development of oral health research centers of excellence that17.would facilitate collaborative and clinical research.

To improve the research capabilities of dental schools, funding programs for enhancement and18.modernization of their facilities should be developed and promoted.

A plan to ensure the effective and accelerated transfer of research findings and new technology into19.practice and into the dental curriculum should be established.

The dental profession should take the lead in convening all members of the healthcare community in20.developing a plan to incorporate appropriate oral and systemic healthcare concepts into the respectivecurricula.


Standards: Part I


Global Health RecommendationsThe American dental profession should be an active partner and leader in the global environment. 1.

International collaborative networks should be established to facilitate funding and implementing of2.research, education, and practice-related activities.

The American dental profession should work to restore and perpetuate the presence and effectiveness of3.oral health programs at the World Health Organization.

The dental profession should emphasize the importance of addressing global oral health and general4.health issues to its members and to other health professions.

National and global health policies, particularly those promoting primary preventive strategies, should be5.developed.

The international dental profession should work to establish and maintain a strong global data bank that6.would capture information that helps to prevent the spread of diseases and promote the best clinicalpractices.

The international dental community should ensure that there are sufficient individuals trained in7.epidemiology, dental informatics, and health services research.

The international dental community should foster the development of exchange programs and fellowships8.to ensure that basic principles of ethics, competencies, and sensitivity to cultural differences are maintained.

The international dental community should foster research training for investigators from developing9.countries.

International standards for dental products and equipment should be fostered.10.

The international dental community should support the emerging development of standards for dental11.education and clinical practice.

The global dental community should foster the expansion of international volunteer activities to include12.educational components for local practitioners and populations.


Standards: Part I


William van Dyk, DDS, FACD

Abstract

What separates the dentist who mistreatedso many patients described in the AtlanticMonthly article from the vast majority of excellent dentists was not the lack ofstandards for appropriate dental care. It was the absence, in this case, of aninternal standard. Profit or some othermotive nullified the widely held and well-documented norms of good dentistry. Inthe end, it is the individual practitioner’sconscience that is the ultimate standard.

Every so often someone takes acrack at dentistry. Reader’s Digest

had a field day a few years back as areporter submitted his mouth to aseries of widely different diagnosesand treatment plans by a variety ofdentists. Recently an article in AtlanticMonthly caused quite a stir in theoffices of the profession. Variousdental organizations, including theAmerican College of Dentists, reactedwith advice and instructions tocounter potential negative reactionsamong patients.

Individual dentists as alwaysreturned to their practices themorning after and continued to treattheir patients according to thestandards they had developed overtime and learned through experience.The standards that these dentistsfollow are first formed by theinstitutions that support them, butultimately become their individualphilosophy of practice.

Dentistry is a curious profession. Itsranks grew out of itinerant self-taughtpractitioners and coalesced into agroup of independent members of thehealthcare establishment, separatefrom medicine, but a part of themedical treatment of patients. It alsostayed out of the operating room andthe benefits of general anesthesia forthe most part. The result has been thedevelopment of a very effective andefficient system of oral care deliveredby highly trained practitioners inisolated practice settings.

To combat the potential foruncontrolled activity in this type of

environment, a system of intenseeducation, coupled with a testingprogram designed to ensure higheducational standards, and a mandateof continuing education throughout adentist’s career slowly developed. Inaddition, the profession created for itself a vigorous researchestablishment that not only tests anddevelops new and improved productsand services, but also connects thedots between dentistry and the rest of the medical world. Numerousexamples of connection between oral health and overall health arecontinually being established. All thisactivity plays a significant role in thestandards that dentists follow, but,because of their isolation, theinterpretation of those standards can vary widely. It is this individualinterpretation that leads to theopportunity for many inside andoutside the profession to question the capability and honesty of its professionals.

Dentists practicing in an isolatedenvironment can give their patientssome concern. In every aspect ofmedicine and dentistry, there is a fearby patients that they do not have theknowledge to choose a competentpractitioner. Patients just cannot knowall there is to know about the variousailments, infections, and operationsthat might be needed to get themhealthy or at least to stay alive. Inmedicine, patients receive some


Standards: Part I

Conscience, Training, and Professionalism

Dr. van Dyk recently retiredfrom practice in the SanFrancisco Bay Area. He has heldnumerous leadership positionsin California dentistry, includingas the editor of the Newsletter ofthe Northern California sectionof ACD; [email protected].


solace in the fact that medicine ispracticed in hospitals and large clinics where physicians and nursescontinually evaluate and observe eachother in practice.

Little of that exists in dentistry. Thegreat majority of dentists practice soloor in very small groups without anyoversight even by other professionalsin the practice. Individual patients arecaught in the conundrum of “buyerbeware” in a system where they knowlittle or nothing about the treatmentthey will receive. Their sole defense is the confidence they have in thepractitioner in front of them. They can receive reassurance from otherpatients about the practitioner’scompetence. Sometimes they can even receive assurances from a fellowpractitioner. And they can read thedocuments on the wall verifyinggraduation and licensing to showinstitutional and government approval.But ultimately patients have to look adentist or hygienist in the eye anddecide that they can trust that person.

Where Does the Problem Lie?

Very likely, as long as there are casessuch as the one described in theAtlantic article patients will havedoubts about the trustworthiness of all dentists. Diagnosis is based on avariety of factors: the clinical skills ofthe dentist, the materials available, andthe desire by the patient to maintain orimprove their oral environment. Thestandard of care in a community is nota thin line, but rather a pathway with

many options that can be different butstill acceptable. Decay in a tooth couldbe watched to see if it worsens,replaced with amalgam or acomposite, or treated with a gold inlay.All of them are acceptable and withinthe standard of care. Putting a pricetag on each possibility makes themseem ridiculously varied. If the publiconly sees the dollar signs, the choicesseem unbalanced.

Likewise, the Atlantic articledescribed a case where a dentist didnot follow the information available inthe world of research and expertise.Research is very often coupled withexperience to provide the mosteffective treatment possible. But to justcompare the day-to-day knowledge of the individual with the volumes ofmaterial being published in the fielddaily gives the impression of ignoranceand inadequate treatment. In medicine,physicians often use drugs “off label”due to observation in the field ofpositive effects outside the testedrecommendations. Were the publicmade aware in an investigative fashionthat physicians were circumventingthe Food and Drug Administrationto treat without research and testingprotocols, there might be a slightuproar. But the fact that they workclosely in hospital and clinic settingsgives the public some confidence thattheir recommendations have been


Standards: Part I

All this activity plays a

significant role in the

standards that dentists

follow, but, because of their

isolation, the interpretation

of those standards can

vary widely.


vetted if not by the FDA, then at leastby fellow professionals.

In dentistry, there is no clearpattern of consultation about the valueof experience.

Some parts of dentistry are clearlyeffective and proven through years ofresearch. Good studies show thatstopping decay before it reaches thepulp of the tooth saves money, pain,and the need for more complextreatment. Excellent studies show thatendodontics saves dying teeth in anatural fashion that allows forcontinuous use and function, often for the rest of the patient’s life. Andimplants work in a vast majority ofpatients based on studies of placementand longevity. The list is long andinclusive. There are parts of dentalcare, however, that can be the subjectof debate. Has the profession everdone double-blind studies on thebenefits of flossing or the effectivenessof fluoride varnishes? Does instructionin preventive care make a difference inthe ultimate number of teeth lost inlife? Sure, there are anecdotal reports(some of them often repeated) ofimprovements in populations, evenmeasureable results against populationswhere treatment was not provided, but the variables involved make theinformation less than perfect.

In addition, in dental practice manytreatment techniques have developedthrough experience in individualoffices. How long should a tooth beetched? What kind of base or lack ofbase or chemical treatment results inthe least post-operative sensitivity?What temporary cement works thebest to calm a tooth and keeps

a temporary in place for the time ittakes to make a permanent crown?No matter what standards and studiessay, what works best in each office isoften the individual decision of thedentist. Because this creates variety in the field, dentistry is subject todoubts sown by media and consumergroups about the validity of the overallstandards. And if the public demandsonly treatment that has been tested touniversal standards, it is difficult fordentistry to stand the scrutiny.

Conscience: the UltimateStandard

We are at risk for imposing standardsthat are worse than the problem if weare clear about where the problem lies.It is not lack of evidence that causesovertreatment. It is lack of consciencethat ensures that all dentists use thedocumented best approaches. Thequestion then remains, will dentistryalways be the subject of investigationsinto its vulnerabilities or can theprofession right its ship without losingwhat is valuable about dental care?The answer is complex and unsettled.Some solutions would answerconcerns but create new and, in manycases, worse outcomes. Dentistrycould move closer to the medicalmodel, and patients in need oftreatment could be treated only inhospital settings with generalanesthesia. Dentistry could require thatall treatment be vetted in legitimatedouble-blind studies or dropped fromrecommended treatment. Privatepractice could be reinvented into onlylarge clinic settings where consultationand education would be continuous.

Ultimately, the solution needs tocome from the smallest part of theproblem, the individual practitioner.As was noted earlier, in each instanceof attack on the profession and in eachencounter with a patient, the solution


Standards: Part I

Individual patients are

caught in the conundrum of

“buyer beware” in a system

where they know little or

nothing about the treatment

they will receive. Their sole

defense is the confidence

they have in the practitioner

in front of them.


lies in the relationship between theindividual patient and the individualdentist. To counter the doubt and theimplication of inadequate care, apractitioner needs to do the rightthing and convey that fact to thepatient. In the case described in theAtlantic article, the dentist was doingthe wrong thing, even though patientstrusted him. Dentistry is more than anart and a science, it is a bond-buildingexperience between two individuals.How to do that?

Let’s first look at the quality ofdentistry. Every dentist knows rightfrom wrong. Every dentist has seenthe ideal (it is the basis of dentaleducation), and every dentist cancompare the actual to the ideal and tryto get as close to the ideal as possible.Ethical behavior is not a flexible rod.When patients or patient advocatesfind fault with the profession, it oftenbegins when a dentist ignores whathas been shown to be true and usessome rationale to explain thecompromise. The author of theAtlantic article described such a case.Granted, there are many instanceswhere the ideal is not achievable dueto circumstances beyond anyone’scontrol. And there are manyadditional aspects of dental practicebeyond the clinical expertise thataffect the overall quality of care. These aspects of dentistry combinedtogether often get closer to the idealthan just the clinical technique.Patient confidence, adaptation topatient limitations, and personalconnections all play a role in thequality of care. But continuouslyproviding dental care that is below thestandards of care is never a solutionand leads to justifiable attacks.

If the standard of care is being metby the members of the profession, thenext step is to build a product andservice line that can be explainedeasily and with confidence. Thenumber of patients with full denturesis plummeting. Even partial denturesare no longer a common occurrence.These facts can be a first line ofargument against attacks on theeffectiveness of the profession. Moreteeth are being saved for a longerperiod of a patient’s life than everbefore. The adage of old age “You’llget wrinkles, your hair will disappear,and your teeth will fall out” is onlytwo-thirds true. Patients are keepingtheir teeth for a lifetime. There aremultiple reasons for this very positivechange in oral health in this country,some of them due to researched anddeveloped products and services thatwork better. Some are also due to alongstanding effort by dentistry tobuild on prevention of oral problems.Many of these efforts cannot berigorously studied because it is notethical or possible to deny somepeople a lifetime of preventive care tocompare to others who receive thepreventive care for comparisonpurposes. Do not floss for 30 years and let us see where your teeth arecompared to someone who does floss.There are multiple anecdotal instancesof improvements among patients whotry certain therapies. These can be andhave been documented. All of theefforts of the profession, frominstitutional efforts to individualpractice efforts, must be documentedand disseminated to the professionand the public in easily explained andobserved fashion. Does fluoride work?What types of fluoride work and withwhom? Does an electric brush workbetter than a manual one? And whichworks best in which instance? Whatdoes toothpaste do? How does a

desensitizer work? And what cleaningtechniques work best in whatinstances? What makes endodonticssuccessful and where are implantsbeneficial, and why do they work? The list can be endless and it can beevidence based, not all in independentdouble-blind studies, but based onstudies and accumulated observationsand long-term results.

And lastly, dentists need to realizethat they have to offset the model oftheir practice life. Their isolationneeds to be countered by the strengthof their relationship with patients.What builds that connection? First ofall, patients want to know that theirpractitioners know what they aretalking about. Time with patients forclear explanations of conditions andtreatment options with back-upinformation is essential. The days of“fill and bill” are fading fast. Patientshave become savvy consumers and are much better with questionsand demand better answers.Communication to patients of what is being learned at meetings andconventions can instill confidence inthe practitioner. There are standardsand they need to be easily used bypatients to judge their practitioners.Secondly, patients want to feel thattheir dentists are concerned aboutthem as whole people. Certainly it isessential that a dentist hear and focusfirst on the patient’s chief complaint,but overall the patient wants the


Standards: Part I


“doctor” to communicate anunderstanding of how to make thewhole patient healthier through team-work with medicine and specialties.Communication through the patientbetween various members of themedical and dental fields can expandthe feeling of confidence based onmultiple inputs. Thirdly, and part ofthe whole-patient focus, dentists needto understand and develop personalconnections to patients. Sometimesthis comes naturally and trust andconfidence come easily. But it isessential that it come implicitly forevery patient. Patients are more than aset of teeth and gums and the betterthe individual dentist gets that acrossto the patient, the better the level oftrust and confidence. Essentiallistening skills can be learned and used to give patients the belief that thedentist hears their concerns and caresfor their overall health.

Treatment Based on Trust

The essence of a strong bond betweenpatients and the profession is built onnumerous blocks. The standards ofcare, the research arm of theprofession, the various policing andguiding institutions are all there. Thecornerstone, however, is therelationship between the individualdentist and the individual patient. Thedentist needs to operate with a

conscience that is based on a true anduniversally accepted standard of care.The dentist needs to maintain thatstandard through continuous learningprovided by a profession built onresearch and the benefits ofexperience. And the dentist needs tofoster an unbreakable relationshipwith patients that speaks to theirneeds, guides them toward excellenthealth, and shows them the valuabletools available for them in theprofession that have withstood the testof time. It will take a proactive effortfrom the top to the bottom of theprofession, but it will build a level ofconfidence among the public that willnegate the efforts by investigators tofind the vulnerabilities in theprofession.

We must deserve the public’s trust.Our profession justifies it. But untilevery dentist faithfully and continuallyconsults his or her ultimate standard,it is likely that there will be anotherexposé in the media in a few years.Trust me. n


Standards: Part I

We must deserve the public’s

trust. Our profession justifies

it. But until every dentist

faithfully and continually

consults his or her ultimate

standard, it is likely that

there will be another exposé

in the media in a few years.

Trust me.



Manuscript Submission

Manuscripts for potentialpublication in the Journal

of the American College of Dentistsshould be sent as attachments via e-mail to the editor, Dr. David W.Chambers, at [email protected] transmittal message should affirmthat the manuscript or substantialportions of it or prior analyses of thedata upon which it is based have notbeen previously published and that the manuscript is not currently under review by any other journal.

Authors are strongly urged to review several recent volumes of JACD. These can be found on theACD website under “publications.” In conducting this review, authorsshould pay particular attention to the type of paper we focus on. Forexample, we normally do not publishclinical case reports or articles thatdescribe dental techniques. Thecommunication policy of the college isto “identify and place before thefellows, the profession, and otherparties of interest those issues that affect dentistry and oral health.

The goal is to stimulate this communityto remain informed, inquire actively, and participate in the formation ofpublic policy and personal leadership to advance the purpose and objectives of the college.”

There is no style sheet for the Journalof the American College of Dentists.Authors are expected to be familiarwith previously published materialand to model the style of formerpublications as nearly as possible.

A “desk review” is normallyprovided within one week of receivinga manuscript to determine whether it suits the general content and qualitycriteria for publication. Papers thathold potential are often sent directlyfor peer review. Usually there are sixanonymous reviewers, representingsubject matter experts, boards of thecollege, and typical readers. In certaincases, a manuscript will be returned to the author with suggestions forimprovements and directions aboutconformity with the style of workpublished in this journal. The peer-review process typically takes four to five weeks.

Authors whose submissions are peer-reviewed receive feedback from this process. A copy of the guidelinesused by reviewers is found on theACD website under “How to Review a Manuscript for the Journal of theAmerican College of Dentists.”

An annual report of the peer reviewprocess for JACD is printed in thefourth issue of each volume. Typically,this journal accepts about a quarter of the manuscripts reviewed and theconsistency of the reviewers is in the phi = .60 to .80 range.

Letters from readers concerning any material appearing in thisjournal are welcome at [email protected]. They should be no longerthan 500 words and will not beconsidered after other letters havealready been published on the sametopic. [The editor reserves the right torefer submitted letters to the Editorial Board for review.] Where a letter tothe editor refers specifically to authorsof previously published material orother specific individuals, they aregiven an opportunity to reply.

Submitting Manuscripts for Potential Publication in JACD


A publication advancing excellence, ethics, professionalism,and leadership in dentistryThe Journal of the American College of Dentists(ISSN 0002-7979) is published quarterly by the American College of Dentists, Inc., 839JQuince Orchard Boulevard, Gaithersburg, MD20878-1614. Periodicals postage paid atGaithersburg, MD, and additional mailing offices. Copyright 2019 by the American College of Dentists.

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

The 2019 subscription rate for members of the American College of Dentists is $30 and is included in the annual membership dues. The 2019 subscription rate for nonmembers in the United States, Canada, and Mexico is $40. All other countries are $60. Foreign optional airmail service is an additional $10.Single-copy orders are $10.

All claims for undelivered/not received issues must be made within 90 days. If the claim is made after this time period, it will not be honored.

While every effort is made by the publishersand the Editorial Board to see that no inaccurateor misleading opinions or statements appear in the Journal, they wish to make it clear that the opinions expressed in the articles, correspondence, etc., herein are the responsibility of the contributor. Accordingly, the publishers and the Editorial Board and their respective employees and officers accept no liability whatsoever for the consequences of any such inaccurate or misleading opinions or statements.

For bibliographic references, the Journalis abbreviated J Am Col Dent and should be followed by the year, volume, number, and page. The reference for this issue is:J Am Col Dent 2019; 86 (3): 1-48.

Journal of the


Communication Policy

It is the communication policy of the American College of Dentists to identify andplace before the fellows, the profession, and other parties of interest those issuesthat affect dentistry and oral health. The goal is to stimulate this community toremain informed, inquire actively, and participate in the formation of public policyand personal leadership to advance the purpose and objectives of the college. The college is not a political organization and does not intentionally promotespecific views at the expense of others. The positions and opinions expressed incollege publications do not necessarily represent those of the American College of Dentists or its fellows.

Objectives of the American College of Dentists

THE AMERICAN COLLEGE OF DENTISTS, in order to promote the highest ideals in health care, advance the standards and efficiency of dentistry, develop good human relations and understanding, and extend the benefits of dental health to the greatest number, declares and adopts the following principles and ideals asways and means for the attainment of these goals.

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

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

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

D. To encourage, stimulate, and promote research;

E. To improve the public understanding and appreciation of oral health service and its importance to the optimum health of the patient;

F. To encourage the free exchange of ideas and experiences in the interest of better service to the patient;

G. To cooperate with other groups for the advancement of interprofessionalrelationships in the interest of the public;

H. To make visible to professional persons the extent of their responsibilities to the community as well as to the field of health service and to urge theacceptance of them;

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

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American College of Dentists

839J Quince Orchard Boulevard

Gaithersburg, MD 20878-1614

Periodicals Postage

PAIDat Gaithersburg, MD

and additional

mailing officesJournal of the


Standards:Part I

Summer 2019

Volume 86

Number 3

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839j quince orchard boulevard gaithersburg, md 20878-1614

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