journal of the american college of dentistsa publication promoting excellence, ethics, and...

Journal of the

American Collegeof Dentists

Standards

Winter 2005Volume 72Number 4

A publication promoting excellence, ethics, and professionalism in dentistry

The Journal of the American College ofDentists (ISSN 0002-7979) is publishedquarterly by the American College ofDentists, Inc., 839J Quince OrchardBoulevard, Gaithersburg, MD 20878-1614.Periodicals postage paid at Gaithersburg,MD. Copyright 2005 by the AmericanCollege of Dentists.

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

The 2005 subscription rate for members ofthe American College of Dentists is $30,and is included in the annual membershipdues. The 2005 subscription rate for non-members in the US, Canada and Mexico is$40. All other countries are $60. Foreignoptional air mail service is an additional$10. Single copy orders are $10.

All claims for undelivered/not receivedissues must be made within 90 days. Ifclaim is made after this time period, it willnot be honored.

While every effort is made by the publishersand the Editorial Board to see that no inaccurate or misleading opinions or state-ments appear in the Journal, they wish tomake it clear that the opinions expressed in the article, correspondence, etc. hereinare the responsibility of the contributor.Accordingly, the publishers and the EditorialBoard and their respective employees andofficers accept no liability whatsoever forthe consequences of any such inaccurate or misleading opinion or statement.

For bibliographic references, the Journalis abbreviated J Am Col Dent and should be followed by the year, volume, numberand page. The reference for this issue is:J Am Col Dent 2005; 72(4): 1-68

Publication Member of the American Association of Dental Editors

Mission

T he Journal of the American College of Dentists shall identify and place before the Fellows, the profession, and other parties of interest those issues that affect dentistry and oral health. All readers should be challenged by the

Journal to remain informed, inquire actively, and participate in the formulation of public policy and personal leadership to advance the purposes and objectives of the College. The Journal is not a political vehicle and does not intentionally promotespecific views at the expense of others. The views and opinions expressed herein donot necessarily represent those of the American College of Dentists or its Fellows.

Objectives of the American College of Dentists

T HE AMERICAN COLLEGE OF DENTISTS, in order to promote the highest ideals in health care, advance the standards and efficiency of dentistry, develop goodhuman relations and understanding, and extend the benefits of dental health

to the greatest number, declares and adopts the following principles and ideals as ways and means for the attainment of these goals.

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

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

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

D. To encourage, stimulate and promote research;E. To improve the public understanding and appreciation of oral health service

and its importance to the optimum health of the patient;F. To encourage the free exchange of ideas and experiences in the interest of better

service to the patient;G. To cooperate with other groups for the advancement of interprofessional

relationships in the interest of the public;H. To make visible to professional persons the extent of their responsibilities to

the community as well as to the field of health service and to urge the acceptanceof them;

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

Journal of the


aade

EditorDavid W. Chambers, EdM, MBA, PhD

Managing EditorStephen A. Ralls, DDS, EdD, MSD

Editorial BoardMaxwell H. Anderson, DDS, MS, MEDBruce J. Baum, DDS, PhDD. Gregory Chadwick, DDSJames R. Cole II, DDSStephen B. Corbin, DDS, MPHEric K. Curtis, DDSKent W. FletcherJames P. Fratzke, DMDBruce S. Graham, DDSFrank C. Grammar, DDS, PhDSteven A. Gold, DDSLaura Neumann, DDSJohn O’Keefe, DDSIan Paisley, DDSJeanne C. Sinkford, DDS, PhDDavid H. Werking, DDS

Design & ProductionAnnette Krammer, Forty-two Pacific, Inc.

Correspondence relating to the Journalshould be addressed to: Managing EditorJournal of the American College of Dentists839J Quince Orchard BoulevardGaithersburg, MD 20878-1614

Business office of the Journal of theAmerican College of Dentists:Tel. (301) 977-3223Fax. (301) 977-3330

OfficersB. Charles Kerkhove, Jr., PresidentMarcia A. Boyd, President-electH. Raymond Klein, Vice PresidentMax M. Martin, TreasurerJohn L. Haynes, Past President

RegentsThomas F. Winkler III, Regency 1Charles D. Dietrich, Regency 2J. Calvin McCulloh, Regency 3Robert L. Wanker, Regency 4W. Scott Waugh, Regency 5Harvey E. Matheny, Regency 6Jean E. Campbell , Regency 7Thomas Wickliffe, Regency 8

2005 ACD Annual Meeting4 Life After Fellowship: ACD President-elect’s Address

Marcia A. Boyd, DDS, FACD

8 National Call to Action to Promote Oral Health: Convocation AddressRichard H. Carmona, MD, MPH

11 2005 ACD Awards

16 2005 Fellowship Class

Standards20 The Legal Standard of Care

Arthur W. Curley, JD

23 The ADA’s Practice ParametersDonalda M. Ellek, PhD

28 Value of the Evidence-Based Consensus ConferenceGary C. Armitage, DDS, MS, FACD

32 What Is a Clinical Pathway?Debora Matthews, DDS

37 Evidence-Based Dentistry: Concepts and ImplementationRichard Niederman, DMD, MA, and Derek Richards, BDS

42 Are Standards and Evidence Sufficient?Kathleen T. O’Loughlin, DMD, MPH, FACD, and Robert Compton, DDS

Issues in Dental Ethics48 Restoration and Enhancement: Is Cosmetic Dentistry Ethical?

Larry Jenson, DDS, MA

Departments2 From the Editor

How Should Dentists Practice?

54 LeadershipSelf-Control

65 2005 Manuscript Review Process

66 2005 Index

This issue is supported by the American College of Dentists Foundation.

Cover Photograph: There are many professional standards to decide among, and the choices may not be obvious. ©2005 Diane Diederich, iStockphoto.

Ethics and science share a commoncharacteristic—they don’t tell dentists what to do. Dentists make

up their own minds based on their interpretations of ethics and science orby listening to intermediaries who havetheir own interests in telling dentistswhat they should do.

Ethics is the study of right andwrong or, perhaps, what is true based on reason. Philosophers do that sort ofwork. But it is quite possible to “study”this important discipline without actingin ways society will regard favorably.Socrates is a notorious example of aman who was sentenced to death by ademocratic government for thinking toomuch. Certain lawyers know more aboutstate practice acts (because they make aliving defending dentists who wanderover the line) than do members of thestate board (who are volunteers servingshort tours of duty). Most good peopleare not especially articulate about theprinciples that underlie their ethicalbehavior, even when they act admirably.The point is that the study and the prac-tice of ethics are distinct activities.

A parallel logic applies to science,which is the study of what is true basedon observation. Becoming a betterresearcher does not automatically makeone a better dentist. The disappointinghistory of the National Institute for Dentaland Craniofacial Research program totrain DDS-PhDs casts doubts on the wis-dom of trying to blend these disciplinesin the same person. (Almost all of the

government-supported dentist-scientistsare now in the private practice of den-tistry.) Scientists, per definition, areconcerned with generalizations (whatworks on average); dentists, per definition,care about unique individual patients.The point is that research and science-based practice are distinct activities.

Dentistry is better to the extent thatit is based on ethical principles andgrounded in science. Practitioners need tobe intelligent consumers of science whoare sensitive to ethical trends. But theyshould not be ethicists or researchers(unless they want to lead dual lives). Thereason for separating the disciplines goeswell beyond the obvious fact that each isa full-time job and doing one well whiledabbling in the other could be dangerous.The real reason is that each disciplinehas its own unique logic. Philosophersanalyze the logical relationships inextremely large systems in hopes ofbeing able to make the leap to universalstatements. Scientists analyze controlledcircumstances in hopes of discoveringgeneral patterns. Dentists treat patients.The issue of interest is how these disci-plines are related to each other.

The answer is that dentists becomegenerally familiar with ethics and scienceand then select those elements that workbest for them and their patients. Theyuse the logical processes of inference andsatisficing. By considering the overallpattern of evidence they select elementsthat are useful when integrated into theirpractices. This is an entirely different logic(known to the ancient Greeks as phroen-sis) than the hypothetico-deductive logic of science or the various flavors of ethical reasoning—hermeneutics,2

2005 Volume 72, Number 4

Editorial

From the Editor

How Should Dentists Practice?

casuistry, discursive, virtue, principles,or other approaches.

The relationships between ethics and science on one hand and practice on the other are seldom regarded as aproblem from the dentists’ point of view.(Probably it is a missed opportunity thatpractitioners have overlooked.) But it is a source of irritation when looked atfrom the other direction. Ethicists andresearchers do grumble that they are notappreciated. Some advocates of EBD arescornful of dentists who practice in waysthat have not been supported by “bestevidence”—even when scientists havestudied only a fraction of what dentistsdo. Ethicists sometimes sound a bit right-eous—as do those who dispute them. Inthe February 9, 2006 issue of the NewEngland Journal of Medicine, a largeclinical trial was reported showing thatsaw palmetto, a popular OTC treatmentfor benign prostatic hyperplasia, is ineffective. On February 10, a NationalPublic Radio interview with physicianswho treat patients with such symptoms,including one of the authors of thestudy, revealed that these practitionersintend to continue supporting patients’use of this unproven alternative therapy.Science considered, other factors may be more important.

The operational meaning I give theterm “should” is a second party claimingthat a first party would better serve itsown interests if it behaved in a certaindifferent fashion. Mom told me, “Youshould wear a coat if you are going outin weather like this.” The journal articlereported, “A rubber dam should always

be used when placing composite restora-tions.” The risk management lawyeradvises, “You should tighten up yourdocumentation of informed consent.”

(The term “must” can be operational-ized as a second party claiming that it isprepared to take action if its (the secondparty’s) interests are not honored. Thestate board has a regulation that dentistsmust document so many hours of CE forlicensure renewal, for example.)

Here is the irony. Those who liberallyuse “should” language are seldom ethicists, scientists, or dentists. They areintermediary groups. “Should” (whetherthe word is used or only implied) is theessential posture in codes that are devel-oped by organizations, based on ethicalthinking, for the use of their members.“Should” is also the tone of voice for CEspeakers. What gives EBD a faint smell is that its advocates, most of whom areacademic researchers, stretch pure scienceover into a “should” attitude regardingprivate dental offices. (Of course, gov-ernment, lawyers, and the insuranceindustry are intermediaries that areauthorized to go all the way to “must.”)

In recent years, dentistry has wit-nessed a blossoming of groups who arewilling to insert themselves between thepure disciplines of ethics and science inorder to tell dentists what they shoulddo. This is likely to change the relation-ships that have existed between ethicsand science and the practicing commu-nity. It is likely to make it more difficultyfor dentists to evaluate the rising cacoph-ony of claims. It may even tempt somedentists to let someone else do theirthinking for them. That would be a disappointment to me.

The papers selected for this themeissue address various perspectives on thequestion “how should dentists practice?”As an advanced organizer, considerthese landmarks:

1. Practice Grounded in Science:Dentists are generally familiar withboth the fundamentals of the biologi-cal and social sciences and currentresearch on products and processesand apply them as part of practice;this has been the mark of the profes-sion for almost a century.

2. Standard of Care: Legal concept; “If x is or isn’t done, a colleaguemight testify in court to the effectthat the dentistry is different fromwhat his or her colleagues would do.”

3. Parameters: Desirable characteristics;“If x is performed, it should be per-formed in these ways…”; defininghow something should be done, butleaving the decision of whether itshould be done to the dentist.

4. Critical Paths (sometimes Guidelines):Prescribed action flowing from diagnostic findings; “When a, b, andc are observed, a specific sequence of procedures, x, y, and z, should beperformed”; largely a medical conceptat this point since dentistry haseschewed diagnostic codes (sometimes“best practices”).

5. Consensus: A sponsoring agency rec-ognizes a group of experts who meet

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Journal of the American College of Dentists

Editorial

to combine their opinions and all theliterature to define concepts and takepositions on which treatment shouldbe performed; “best opinion.”

6. Evidence-Based Dentistry:Formalized, structured statementsabout effectiveness of products orprocedures based on evidence thatmeets very high methodological criteria; typically this rigorouslyscreened evidence is contained inmeta-analyses and “systematicreview” articles; “best data.”

7. Policy: Permissible treatment givenidentified characteristics; insurance,AAMOS, other lists that say “whenyou see this you can do that”; somehave called this “procedure code dentistry.”

8. Outcomes-Based Practice: Systematicrecording and analysis of patterns of treatment outcomes in individualpractices with a view toward continu-ous improvement; no attempt ismade to generalize across practices;OBP can be applied regardless of therational (1–7 above) that motivatesusing the product or process in thefirst place.

David W. Chambers, EdM, MBA, PhD, FACDEditor

Dentistry is better to theextent that it is based on ethical principles andgrounded in science…But [dentists] should not be ethicists orresearchers (unless they want to lead duallives).

Marcia A. Boyd, DDS, FACD

ACD President-elect’sAddressOctober 6, 2005Philadelphia, Pennsylvania

The year Julianne Bluitt was presidentwas 1994-94. That was the year Iwas inducted into the College.

Please let me begin by welcoming you all to Philadelphia and extending myheartiest congratulations to the newFellows who will be joining the AmericanCollege of Dentists this afternoon. Youshould be proud of your individualaccomplishments and your recognitionfor these accomplishments by nominationfrom your peers. In one’s professionallife, it doesn’t get any better than this! Iam confident that you will be proud to bea Fellow of the College and that you willcontinue in your leadership endeavors.

“Old” Fellows should remember theirday of convocation and feel proud too.

It was just four years ago that ACDPresident Richard Bradley spoke about thetragedy of 9/11. Only last year in Florida,we saw the aftermath of HurricaneJeanne at our Convocation. And today weare overwhelmed by the images of flood-ing and devastation on so many fronts,horrific loss of life, pain and sufferingfor so many families that has resultedfrom Hurricanes Katrina and Rita. Indeed,we see and understand that there are somany individuals and families, both hereand around the world, that know all toowell of loss and suffering. They are inour thoughts and prayers.

Another serious and important matter that is before us is the lack ofaccess to dental care in North America.Obviously there needs to be a concertedand funded effort to begin to addressthis problem. However we should neverforget that one person CAN indeed make

a difference. Beginning a communityeffort on the local level can do even more.Although not the ultimate solution, it isan opportunity to give back and make adifference. Please think about it; we havethe skill and talent to help those who areless fortunate and are in need.

I am so very proud to be the incom-ing President of the American College ofDentists. I am also proud to be a Canadianand proud to be a woman. The AmericanCollege of Dentists has always been anegalitarian organization, so let me set thehistorical record straight by saying that,in fact, there have been two CanadianPresidents, both men, and both fromToronto, the last one forty years ago. In1994 Dr. Juliann Bluitt became the firstwoman President of the College. And wehave seen our current President Dr.Charles Kerkhove lead us so very wellthis past year. So I realize that I follow ingreat footsteps and have big shoes to fill.That makes me doubly challenged anddoubly proud! My only claim to fame isthat I am the first woman from theCanadian Sections to become President;but that indeed makes me extremelyhonored and filled with pride!

Obviously I don’t know all of you,although I look forward to meeting youtoday and over the course of the nextyear. Therefore I thought it would be a

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Life After Fellowship

2005 ACD Annual Meetting

Dr. Boyd is an internationalconsultant on dental educationand professional policy. Shemaintains a private practice inVancouver, British Columbia.

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good idea to take a moment to personalizethis opportunity and introduce myself—to give you a brief “thumbnail” of who I amand then share with you what my lead-ership goals are for the Board of Regentsand the College in the upcoming year.

We’ll “fast forward” from dentalschool in Edmonton, Alberta, Canada.After graduation I took a job in publichealth with the Federal Government andtraveled north (and I do mean NORTH!)to the eastern Arctic, above of the ArcticCircle. I flew into small Inuit Eskimocommunities to deliver dental treatment,landing on ice, then arriving by dog team,complete with portable equipment, castaluminum dental chair, head lamp, coldsterilization and nothing else—all as afreshly minted graduate! Can you picturethat? I call that the “more guts thanbrains” part of my career! In truth it wasa fabulous opportunity—both as a dentallearning experience and as a chance todevelop an appreciation for a communitythat was very different from my own.

From there I went to Vancouver,British Columbia, to be a public healthdentist who delivered treatment to three-to-five-year-olds. Now that was a toughjob! God bless our pediatric dentists!After that I joined the University ofBritish Columbia, Faculty of Dentistry. I remained there as a full-time facultymember for thirty years doing almostevery job, including serving as dean.

Four years ago I did what I call a “lateral arabesque” and left the faculty,taking so called “early retirement.”However, I seem now to be busier thanever with contract work in Canada, theU.S., Hong Kong, Thailand—all that fittedbetween serving as workshop leader andtest developer for the National DentalExamining Board of Canada as well ascontinuing with my private practice inVancouver, BC. Needless to say, I haveenjoyed my career in dentistry thus farand I am extremely grateful.

I became a Fellow in 1988—Las Vegas!What a coincidence that I should bePresident during a year that ends withthe ACD annual meeting in Las Vegas!

It was during the presidency of Dr.Prem Sharma that the Canadian Sectionswere born. They have continued to growand thrive since then while keeping contact with Sections in the U.S. as wellas worldwide. The College has alwaysbeen willing to support and make changesand again we have evidence of that nowwith the redistribution of Sections withinour eight regencies.

It is the confidence that you, my colleagues have vested in me, and thementoring of my former Regent, Dr. KenFollmar, that have provided me with thishonor and privilege to serve you now as President.

An Active CollegeOver the past six years of my involvementat the national level, I have witnessedyour board take a proactive stance onmany things. Here are some examples:

• Partnering with various organiza-tions to spearhead national summitsto probe ethics issues. There havebeen three to date, with anotherplanned for February 2006.

• Supporting our outstanding Journaland it Editor, Dr. David Chambers,through collaborating with theAmerican Society for Dental Ethics toinclude an article on ethics in everyissue of the Journal—the only dentaljournal to do so.

• Supporting Dr. Chambers in undertaking theme issues, whichsometimes create controversy by presenting alternative perspectivesthat broaden our understanding andadvance our profession.

• Promoting leadership opportunitiesby encouraging Sections and Fellowsto participate in ethics programs inour dental schools and by providingfiscal support for the White Coat

Ceremonies that have now becomean integral part of most dental programs and some dental hygieneprograms as well.

• Taking the lead, spearheaded byExecutive Director, Dr. Steve Ralls, insecuring financial support for theprograms of the College. A special“thank you” to GC America, for theproduction of the dental history CD-ROM distributed to every first-yeardental student in the U.S. and Canada.

• Creating new honors and awards. A new award recognizes individuals,not necessarily ACD Fellows, ororganizations for their significantcontribution to our profession andwho share and uphold the ACD mission of leading in excellence,ethics, professionalism, and leader-ship. The award will be presented for the first time at this meeting andwe are very pleased to recognize theAmerican Dental Association as thefirst recipient.

• Building modules for your onlineethics course, again under the leader-ship of our Executive Director, Dr.Steve Ralls. There are three now andI encourage you to visit them. Theyhave been recognized for continuingeducation credit.

It is the Sections and their dedication to personifying the mission of the American College that are the life blood of our organization.

These are just a few of the leadershipinitiatives that your College has beenengaged in, and of course will continue tomove forward with in the coming year.

Now, over the next year the team of your Board of Regents and ACD staffwill also be committed to providing occasions for you to grow professionallythrough participating in LeaderSkillsworkshops at the annual meeting andcontinuing education through our cruiseand summer conference programs.Consider seriously these occasions forlearning and fellowship. Funding forthese continuing education opportunitiescomes through your American College of Dentists Foundation, the ACDF.

Active SectionsOur focus on the support of and partici-pation in educational programs forstudents in dental schools should certainly continue. It has been welldeveloped and is generally strong.However, during my presidential year I would like to guide our initiativestoward the individual practitioner andthe profession at large. There has beenan emerging concern over the focus ofnew, young colleagues who are enteringthe profession. The emphasis on “cosme-tology,” if you will, the potential for thedebt of young practitioners to influencetreatment decisions, extreme advertising,and possible fraudulent activity all havethe potential to affect our profession in a significant way. Dentistry has, over therecent past, fallen from a position ofhigh public esteem, and, until we makeour goal maintaining professionalismand service to the public a priority, wewill lose even more ground. To reinforcethe goals and ideals of the College, Iwould like Sections to lead by considering

programs that bring our mission, andthe behaviors in which we believe, to the fore. For example:

• Encouraging programs sponsored bySections at state or local meetings,perhaps selecting topics that wouldtarget the young practitioner who hasbeen in practice fewer than ten years

• Having Fellows become mentors fornew colleagues

• Sponsoring an ethics retreat

• Furthering the state-by-state endorsement of mandatory continu-ing education courses in ethics forlicensure renewal

• Growing the diversity of our membership that moves us towardreflecting the demographic profile of those practicing dentistry today

These initiatives would complimentnicely what we currently have in placein dental schools by following throughwith programs after graduation, therebypromoting and reinforcing what webelieve our profession should be. I wouldlike to propose a continuum of AmericanCollege activities that begins in dentalschool and continues throughout a dentist’s professional life as the goal forSections and ACD.

In addition I feel very strongly thatthe Regents and Executive Staff need to bepresent at Section Meetings. Oftentimes,the financial support for this has come,at least in the part, from the individualRegent. However, it is my belief that youin the Sections need and want to have a “face” on the organization and havepersonal contact with your College lead-ership. In this way information can bebrought to the Section, support and networking of individuals and activitiescan occur, concerns or issues can be conveyed through the Regent back to theBoard, and the lines of communicationwill become more frequent and stronger.A four-year tenure as Regent is not along time, and two visits in the four

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I would like to propose a continuum of American College activities that begins in dental school and continues throughout a dentist’s professional life as the goal for Sections and ACD.

years is just not enough. On the otherhand, we do have to appreciate that withthe extent of the geographical areainvolved in some Regencies, this maycreate logistical difficulties or conflicts inscheduling. But I do believe the leader-ship should be committed to being at the“grass roots” level as much as possible. It is the Sections and their dedication topersonifying the mission of the AmericanCollege that are the life blood of ourorganization. The wealth of brainpower,innovation, experience, and dedication is vested in the Sections and therein laysthe tremendous potential to do good and to advance our profession.

We need to continue to further ourpartnerships with other organizations to produce “win-win” situations for dentistry. The Ethics Summits have beenan excellent example of the sum beinggreater than the total of the parts. Thisyear we will again engage with a host of organizations and players when wegather to discuss the topic of commer-cialism. Again the ACD has been thecatalyst for this important activity.

Active FellowsMy mantra is that “there is life afterFellowship.” We all respect the honor ofbeing nominated by our colleagues forFellowship but we need to pledge here,today, that we will do just ONE THINGover the next year that supports ourCollege and pays tribute to those individ-uals who knew we were worthy and tookthe time to nominate us. There are threehundred and sixty-five days ahead—justone thing is all I ask. If we all did that,our College would be even stronger andwe would all benefit from these contri-butions. And it really isn’t difficult. Thereare so many things that you could do:

• Bring a Fellow to the next Sectionmeeting—perhaps someone you nominated or someone who has notattended for some time.

• Volunteer to be a member of theExecutive or Section Committee.

• Contribute a piece of the Sectionnewsletter—or become the editor ifyour Section does not have a newsletter.

• Be the “official photographer” foryour Section.

• Nominate a worthy colleague forFellowship (it is even easier nowwith electronic forms).

• Be philanthropic—donate to the ACD Foundation. Your gift is taxdeductible and is also tax exempt forthe Foundation making this a win allthe way around that will help ourfinancial base grow and allow us tosupport projects and opportunitiesfor Fellows.

• Along that same line, become a GiesFellow—that is easy, too, and can bepledged over a number of years.

• Be a tutor in the ethics program atyour dental or dental hygiene school.

• Participate in the summer conferencesor cruises sponsored by the College.

• Attend the annual meeting next yearin Las Vegas.

As you can tell, I could go on. Sufficeit to say, there are many ways and oppor-tunities to enjoy being a Fellow andcontributing to “life after Fellowship.”None of us should leave here today with-out making that personal commitmentand then go back to your Section andshare the message with others.

We all know that any organization isonly as strong as the involvement of itsmembers, and members only get fromthe organization what they put into it.It’s a promise and a partnership shared.

In summary, there are three things I believe we should devote our energy tothis year:

First, I want there to be a “face” tothe organization. Your national leadersat the “grass roots” should be there tofacilitate and increase communicationand Section support. Invite your Regent

or other members of the Board to be atyour Section meeting.

Second, the ACD should begin aninitiative that focuses on the practicingprofession, thereby providing a continuumin ethics and professionalism educationthat starts in dental school and continuesthrough one’s professional career. Thisshould always be the ACD’s contributionto our profession.

And third, we each should promiseto do “just one thing,” or perhaps at leastone thing, for our College this year.

So I pose the question. Why did youdo those things you did that providedthe basis for your nomination forFellowship? I ask you to consider whatpart you play in the responsibility youshare to maintain and promote the dental profession. I challenge you to continue to do so—to do even more. I’dlike to suggest that you go home and go“MAD.” That is go, Make A Difference!

I look forward to being your Presidentand leading such an exceptional groupof individual leaders in our great profes-sion. Please join in and help me to go“MAD” as well—to Make A Difference!

The American College of Dentists has a distinguished past and a dynamicfuture. Commit yourself to be a dedicatedpart of that future in recognition of thehonor of your Fellowship.

Thank you, and I look forward to seeing you in Las Vegas or sooner! ■

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Richard H. Carmona, MD, MPH

Convocation AddressOctober 6, 2005Philadelphia, Pennsylvania

It is a tremendous honor to serve asthe U.S. Surgeon General and to travelthe world speaking with people who

are shaping the future of health care and education. The American College of Dentists’ leadership in the areas ofdental education and health services and your extensive efforts in the area ofethics and professional conduct havebrought the oral health professionalcommunity to a higher level. It is thededication and accomplishments of yourorganization that continues to providethe momentum for us to reach all thosein need with the highest caliber of healthcare available worldwide. Although Istand before you today as the U.S. SurgeonGeneral, I remember that just threeyears ago I was just a guy in Arizona,working as a trauma surgeon, a collegeprofessor, and a law enforcement officer.

Being the Nation’s Doctor is a tremen-dous responsibility, one that I could notdo without a great support team. Luckily,one of my duties as Surgeon General isto lead the United States Public HealthService Commissioned Corps on behalfof the Secretary of Health and HumanServices, and I could not do my job without them.

Hurricanes Katrina and RitaWe continue to be stunned and saddenedby the devastation brought by HurricanesKatrina and Rita. I know you have beenfollowing the media reports regarding theresponse by federal, state, and local

agencies and thousands of volunteers.Their efforts have been heroic and com-mendable. Included among theseresponders are the men and womenwhom I lead in the U.S. Public HealthService Commissioned Corps. They arefully engaged, carrying out our mission,demonstrating each day an enthusiasticpublic health competence tempered withempathy and compassion for the peopleof the Gulf region.

We have dentists in Louisiana,Mississippi, and Texas caring for evacuees,as well as forensic dentists who areworking to identify those who lost theirlives during the hurricanes. Our dentistshave performed admirably no matterwhere assigned across the Gulf StatesRegion. We are most proud of theiraccomplishments.

PrioritiesWhen President Bush nominated me tobe Surgeon General, he asked me tofocus on three priorities.

First is prevention. This is the begin-ning of what each of us can do in ourown lives and communities to make ourfamilies and ourselves healthier. Rightnow, we are a treatment-oriented society.We wait for people to get sick, and then

8


National Call to Action to Promote Oral Health


Vice Admiral Carmona is the United States SurgeonGeneral, U.S. Department ofHealth and Human Services.

we spend top dollar to make themhealthy again instead of working to prevent disease from occurring in thefirst place. Today, tooth decay is the single most common chronic childhooddisease, and more than one in five adultshave reported some form of oral-facialpain in the past six months. Poor oralhealth can adversely affect all aspects oflife. Yet in many cases the pain caused by poor oral health could have been prevented through brushing, flossing,the use of fluoride rinse or toothpaste,and regular visits to the dentist.

My second priority, and new to theOffice of the Surgeon General, is publichealth preparedness. We are investingresources at the federal, state, and locallevels to prevent, mitigate, and respondto all-hazards emergencies. For decadesour nation’s public health infrastructuredeteriorated through neglect. Now, withthe nearly $5 billion investment over thepast three years to our nation’s hospitalsand state public health systems, we arefinally catching up to where we shouldbe. Not only have we increased thenational pharmaceutical stockpile andincreased our response mechanisms, wehave improved communications, health-care education, laboratory capabilities,and hospital capacity.

The third priority I am focusing onrelentlessly is eliminating healthcare disparities, an issue that is very near tomy heart and the president’s. I am sohappy and proud that President Bush

and Secretary Leavitt charged me withworking with them and all of you toeliminate health disparities. Notice thatthey did not just charge me with reducinghealth disparities. They said we willeliminate health disparities.

America suffers from racial and ethnic disparities in oral health. Oral diseases are found primarily among thepoor, people of color, and the homelessand migrant populations. I was one ofthose kids who never saw a dentist. Poor children are more than three times lesslikely to access dental care than theirclassmates. Unfortunately, children withpoor oral health grow into adults withpoor oral health. This has very little todo with genetics, but it has a lot to dowith certain aspects of culture and a lotto do with access to health care.

We obviously have a lot of work to do.To close the gap, we must:

• Increase the racial and ethic diversityof the oral health workforce to reflectthe nation’s diversity

• Improve health literacy outreach tocommunities of color

• Expand and strengthen the capacityof the safety net system to provideoral health services

The Bush Administration recognizesthese needs. This year, the Departmentof Health and Human Services, underthe leadership of the President and HHSSecretary Leavitt, increased funding tocommunity health centers to increase

their capacity to provide oral health careto those in need. I want to thank all ofyou whose efforts have helped to addressthe disparity in access to oral health care.

Health LiteracyWoven through these three priorities ishealth literacy. Health literacy is the abilityof an individual to access, understand,and use health-related information andservices to make appropriate health decisions. Even the seemingly simplethings that we can all do to stay healthyand safe, such as getting regular dentalcheckups and eating healthy foods, canbe struggles for people who do not haveaccess to information that is presentedin a way that they can understand.

Right now low health literacy is athreat to the health and well-being ofAmericans and to the health and well-being of the American healthcare system.Low health literacy has gone largelyunrecognized and untreated for too long.

Dentistry was making strides and,let’s face it, making waves in improvinghealth literacy before other professionsever heard of it. You did not always callit health literacy because it was part ofyour overall effort to help patients andtheir families. But you are some of theoriginal health literacy advocates. Asdentists, you are on the front lines ofimproving health literacy. I am askingyou to find ways to ensure that your

9



America suffers fromracial and ethnic disparities in oral health.Oral diseases are foundprimarily among the poor, people of color, and homeless andmigrant populations.

patients understand what they can do to stay healthy. You should offer theinformation even if your patients do not ask the questions.

Surgeon General’s Report: Oral Health in AmericaTwo years ago, I joined with partners to release a National Call to Action toPromote Oral Health. It builds on theobjectives outlined by former SurgeonGeneral Satcher in the Report on OralHealth. It was no surprise to any of you, I’m sure, that the report found that oral health means far more thanhealthy teeth:

• We know that oral diseases and disorders affect health and well-beingthroughout life.

• We know that safe and effectivemeasures exist to prevent the mostcommon dental diseases: dentalcaries and periodontal diseases.

• We know that lifestyle behaviors thataffect general health and well-being,such as tobacco and alcohol use andpoor dietary choices, affect oral health.

• We know that associations betweenchronic oral infections and otherhealth problems such as diabetes,heart disease, and adverse pregnancyoutcomes have been reported.

• We know that there are profoundand consequential oral health dispar-ities within the U.S. population.

Coming from that report, we recog-nized the need to change perceptionsregarding oral health so that it becamean accepted component of generalhealth. My “Call to Action” seeks toexpand current efforts by enlisting the

expertise of individuals, healthcare professionals, academia, communities,and policymakers at all levels of society. I want to thank the Fellows of the ACDfor their support of the Call to Action toPromote Oral Health, particularly theircommitment to improving Americans’oral health literacy.

Charge and ClosingAt the Department of Health and HumanServices, we are committed to improvinghealth promotion and disease prevention,but the government cannot do it alone.You are in a perfect position to act as arole model to your students and yourpatients and to teach healthy behaviors.People will listen to you because youhave the information they need andbecause you are a respected member ofthe community and the dental profession.

In the spirit of the National Call toAction to Promote Oral Health, and inthe great tradition of the AmericanCollege of Dentists, I ask you to continueproviding services to the underserved, to continue reaching out to the peoplewho need you the most, and to findways to contribute your time and expertise to your communities.

The American College was one of the earliest dental organizations chargedwith the promotion and expansion ofthe dental profession while maintainingthe highest standards for ethical conductand professional standing for Fellowship.Looking around this room; I know thatthrough your individual efforts, yourwork with the ACD nationally and inyour communities we can make all thisa reality.

I want to thank you very much foryour vision and dedication. I stand readyto work with you on any effort that isimportant to you and to dentistry. ■

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You are in a perfect position to act as a rolemodel to your students and your patients and toteach healthy behaviors.People will listen to youbecause you have the information they need and because you are arespected member of the community and the dental profession.

Biological and Agricultural Sciences atBrigham Young University. In addition,he has served as Professor and Chair ofthe Rehabilitative Dentistry Department,University of Colorado.

Dr. Christensen has presented overforty thousand hours of continuing education throughout the world on alarge number of subjects. His prowess as a speaker has been acclaimed innumerous circles. Dr. Christensen hasauthored over three hundred seventyarticles for periodicals and journals; overeighty abstracts; numerous interviews;authored or co-authored twenty-sixbooks or chapters; and produced nearlytwo hundred continuing educationaudio and video resources. He has servedon a vast number of editorial boards andeditorships, and numerous high-levelpositions of leadership with universitiesand organizations alike. Dr. Christensenhas had a longstanding interest inresearch, specifically preventive dentistry,dental caries, dental materials, clinicalinvestigations, health administration,tooth development and morphology,education, psychology, and prosthodontics.He and his wife Rella are co-founders ofthe nonprofit Clinical Research Associates,which has conducted research in manyareas and publishes the findings to theprofession. Dr. Christensen is also thefounder and director of Practical ClinicalCourses, an international continuingeducation organization for dental profes-sionals established in 1981.

William John Gies AwardThe highest honor the College can bestowupon a Fellow is the William John GiesAward. This award recognizes Fellowswho have made exceptional contributionsto advancing the profession and society.This year there are two recipients of theWilliam John Gies Award.

The first recipient of theGies Award for 2005 is Dr.Gordon J. Christensen.Dr. Christensen is a distin-guished dentist who has

demonstrated broad, significant contribu-tions to the dental profession, continuallyexhibiting outstanding leadership anduncompromising professionalism. Hehas been a preeminent force in education,research, quality of care delivery systems,advancement of dental issues, andhumanitarian causes.

After completing his undergraduatestudies at Utah State University, Dr.Christensen received his DDS degreefrom the University of Southern California,where he was student body president. He later received an MSD degree fromthe University of Washington and a PhDfrom Denver University. He has a privatepractice in Provo, Utah, and he specializedin fixed, removable, and maxillofacialprosthodontics. He is a diplomate of theAmerican Board of Prosthodontics.

Over the years, Dr. Christensen hasheld many teaching positions. He is cur-rently Visiting Professor at the EastmanDental Center in Rochester, New York;Professor of Pathology at the Universityof Utah; and Adjunct Professor of

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2005 ACD Awards


Dr. Christensen has been the recipientof numerous awards, including theCharles Pincus Award for EstheticDentistry, the Thomas P. HinmanDistinguished Service Medal, theCallahan Memorial Award, the USCSchool of Dentistry Hall of Fame, and the Fauchard Gold Medal, among manyothers. He was awarded an honoraryDoctor of Science degree from UtahState University.

In his personal life, Dr. Christensen iskept busy with nine grandchildren andhis love for the outdoors, whether ridingan ATV or horse or fly-fishing in Alaska.If that was not enough, he rides hisHarley-Davidson on CE courses with hislovely wife Rella.

Dr. Christensen’s leadership, achieve-ments, and exceptional contributionshave had a significant and positive impacton dentistry, ethical dental practice, hiscommunity, and his country. He hasbeen an extremely valued resource indentistry.

The second recipient ofthe Gies Award for 2005 isDr. Richard V. Tucker. Dr.Tucker is a 1946 graduateof Washington University

School of Dentistry in St. Louis, wherehe was named Distinguished Alumnus in 1996. Following graduation he servedin the U.S. Navy for two years beforeopening a private practice in Ferndale,Washington, in 1948.

Early in his practice career, Dr. Tuckerbecame involved in the activities oforganized dentistry, serving as Presidentof the Mt. Baker District Dental Society

and eventually President of the WashingtonState Dental Association in 1963. In 1964he become a member of the VancouverFerrier Gold Foil Study Club, unleashinghis interest and talent in the area of castand direct gold restorative dentistry.

Dr. Tucker made it his mission todevelop a cast gold technique that wouldenable the finished margins to gold cast-ings to equal those of gold foilrestorations – and he succeeded. As thiseffort progressed, he was called upon toteach these techniques to other dentists.In 1972 Dr. Tucker became mentor of astudy club for the first time. In 1976 thefirst Richard V. Tucker Cast Gold StudyClub was formed in Vancouver, BritishColumbia. The number of these clubssteadily increased throughout the 1970s,1980s, and 1990s to where there arenow forty-nine Tucker Cast Gold StudyClubs all over the United States andCanada, as well as in Germany and Italy.These clubs comprise the Academy ofthe R. V. Tucker Study Club, with a membership of six hundred members. A meeting is held annually at one of theforty-nine clubs. Dr. Tucker has present-ed more than two hundred fifty lecturesand graduate courses on cast goldrestorations in dental schools, institutes,and other dental organizations aroundthe world.

Besides his contributions to restora-tive techniques, Dr. Tucker hasimpressed on his members a philosophyof excellence and the highest ethicalstandards in both the practice of den-tistry and in everyday relationships.

Dr. Tucker is the recipient of manyawards related to his activities in teach-ing his cast gold techniques, includingthe Biagi Gold Medal from the XXIIIItalian Congress, Remini, Italy, as well asAwards of Service and Excellence fromthe Academy of Operative Dentistry andthe College of Dental Surgeons of BritishColumbia, among others. Dr. Tucker is amember of the American Academy of

Restorative Dentistry.Dr. Tucker has four children and ten

grandchildren, two of whom are den-tists. He loves sailing Puget Sound on hissailboat, the Line Angle, which is namedfor a sailing term, not a dental term.When not sailing, he enjoys spendingtime at this cabin. Dr. Tucker has tried toretire three times, but is still working, tothe chagrin of his lovely wife of sixtyyears, Elaine.

Dr. Tucker has contributed greatly toelevating the standards of dentistry andgreatly contributed to improving oralhealth care. The impact of his leader-ship, professionalism, and distinguishedcontributions is felt worldwide—farbeyond his loyal following. His achieve-ments and remarkable career haveupheld the highest traditions of dentistryand public service.

Honorary FellowshipHonorary Fellowship is awarded to indi-viduals who do not hold a dental degree,but have significantly advanced the profession of dentistry, and have shownexceptional leadership in areas such as education, research, public healthadministration, or related fields ofhealth care. This year there are tworecipients of Honorary Fellowship.

The first recipient ofHonorary Fellowship isMs. Gerry J. Barker. Ms.Barker received aBachelor of Science in

dental hygiene in 1965 form theUniversity of Michigan. In 1981 Ms.Barker became associated with theUniversity of Missouri—Kansas City asManager of Special Projects, Departmentof Oral Diagnosis. She soon becameimmersed in oral oncology, nicotineaddiction, tobacco use prevention and

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cessation, dental management of themedically compromised patient, andgeriatric oral health. She found time toearn her Master of Arts in Educationfrom the university in 1989. Ms. Barkeris a Professor Emerita of the Universityof Missouri—Kansas City. She has recentlyfinished serving as Professor in theDepartment of Dental Public Health andBehavioral Sciences, and she wasCoordinator of the Oncology Educationand Oncology Dental Support Clinic.

Ms. Barker has earned a national andinternational reputation as a leader inthe field of tobacco cessation and treat-ment or oral cancer. She has presentednumerous, significant invited lecturesaround the world. Ms. Barker has alsoauthored or co-authored more thaneighty publications, including journalarticles, textbook chapters, and brochures.

Ms. Barker also serves in positions of leadership on a large number of local, state, and national organizations.She has served as Vice President andExecutive Committee member of theInternational Society for Oral Oncologyfor nine years. She also helped initiativeand coordinate two other projects,“Students Take Action” and “Pouringfrom the Heart.”

“Students Take Action” is a programfor undergraduate dental students toprovide services to the poor, disabled,homeless, and disadvantaged. Through-out the academic year, students performscreenings at schools; conduct clothingdrives and food collections; and providefree dental services to indigent dentalpatients, at retirement homes and otherlocations. Students and faculty membersalso participate in “Sheer Madness”where participants agree to have theirheads shaved for particular monetarydonations. Certain faculty members andthe dean are prime targets. This year$13,000 was raised to send children withcancer to a summer camp designed especially for them. “Pouring from the

Heart” is an annual black-tie dinner with a silent auction that raises funds tosupport the Special Patient Clinic of thedental school. This has grown to wheremore then three hundred people attend.For the past several years, proceeds havesurpassed $100,000.

Ms. Barker is the recipient of numer-ous honors and awards, including theNational American Cancer SocietyProfessional Education Award; AmericanDental Hygienists’ Association/WarnerLambert Award for Innovations in DentalHygiene Service Delivery; OutstandingDental Hygienist of the Year, Universityof Michigan; Susan Brockman-BellHumanitarian Award; and numerousDistinguished Teacher Awards from theUniversity of Missouri—Kansas City.

Ms. Barker is an avid gardener, espe-cially of flowers, and she loves being agrandmother. She is very active in herchurch and looks forward to vacationtime in Colorado. Ms. Barker is an activemember of the FAT COWS, meaning theFun and Travel Club of OutrageousWomen—a group primarily for hygienists.

Ms. Barker has demonstrated a heartand passion for highly important publichealth issues. Her leadership and recordof accomplishments are exceptional, andshe is motivated by a sense of serviceand selfless devotion to duty.

The second recipient ofHonorary Fellowship isDr. Lawrence P. Garetto.Dr. Garetto received hisbachelor’s degree from

the University of California, followed bya Master of Science and PhD in physiolo-gy from Boston University. He began hiscareer at Indiana University School ofDentistry in 1988 as an AssociateProfessor of Orthodontics and Director

of the Bone Research Laboratory. As thecurriculum at Indiana shifted to a moreproblem-based format, he became veryinvolved in the university’s problem-based learning program. He was soonrecognized internationally as a leader instudent-centered learning. Dr. Garettohas been instrumental in incorporatingethical and professional componentsinto all of the problem-based learningcases that the dental students address intheir first two years. His interest in theoverall dental curriculum, especially theethical and professionalism aspects, ledhim in 2004 to be appointed AssociateDean for Dental Education.

Besides strong affiliations with phys-iology and research organizations, hehas been a member of the AmericanSociety for Dental Ethics (formerly PED-NET) since 1999 and is currently thatorganization’s President-elect. He waselected an honorary member ofOmicron Kappa Upsilon in 2002, and hereceived an Indiana University School ofDentistry Teaching Award in 1998. Dr.Garetto has been instrumental in devel-oping a Professional Conduct Code forstudents at Indiana University School ofDentistry. This is a code that all studentssign and swear to uphold as they enterthe profession as first-year students. Healso chairs the Professional ConductCommittee, which is composed of repre-sentatives from all classes and whichhears cases of student conduct that maybe unethical or unprofessional. The com-

13



mittee spends many hours investigatingcases, and with Dr. Garetto’s guidance,provides appropriate judgments.

Dr. Garetto has earned a reputationas an outstanding teacher. He is directorof courses and modules for several keycomponents of the curriculum. He hasmade countless contributions to thecases for the problem-based learningprogram. Further, Dr. Garetto continuesto be active in masters and doctoral programs as a thesis or dissertationcommittee member. He consistentlyreceives excellent reviews from both students and faculty members for theseefforts.

Dr. Garetto’s research record is outstanding. He has served as a revieweron five national journals and has servedas a grant reviewer for six agencies,including NIH and NASA. He has authoredor co-authored more than fifty articlesand more than fifty abstracts. He haspresented a wide variety of venues,including at a workshop on ethics at this year’s American Dental EducationAssociation meeting.

An avid woodworker, Dr. Garettoenjoys making fine furniture and turn-ing bowls, and he participates inmasters’ workshops. He also fully sup-ports his daughter’s love for volleyball,attending all the breakfasts and games.Dr. Garetto also finds time for bird hunt-ing and he has even restored an oldMercedes he found on a farm with

chickens living in it, driving it to schoolwhen the weather cooperates. Dr.Garetto is also an active member of theKnights of Columbus.

Dr. Garetto has an exemplary recordin teaching, service, and research, allhighlighting his passion for ethics andprofessionalism.

Ethics and ProfessionalismAwardThe Ethics and Professionalism Awardrecognizes exceptional contributions byindividuals or organizations in the pro-motion of ethics and professionalism indentistry. The award is given for effectivelypromoting ethics and professionalism indentistry through leadership, education,training, journalism, or research.

It is an honor and privilegefor the American Collegeof Dentists to recognizethe American Dental

Association as the first recipient of theEthics and Professionalism Award, andthis is the highest such honor afforded by the College.

Since 1866 the ADA has been thearchitect, the steward, and the championof dentistry’s code of ethics. The ADACode has been historically, and is nowpremised on the benefit of the patient asthe primary goal of the profession. ItsPrinciples of Ethics and Code ofProfessional Conduct is recognized asone of the hallmarks that distinguishesdentistry as a true profession. The ADA’smembership, over 152,000 strong, volun-tarily agrees to abide by the ADA Code asa condition of that membership. ADA

members recognize that continued pub-lic trust in the dental profession is basedon the commitment of individual dentistto high ethical standards of conduct.

The direct responsibility for ensuringthat the ADA Code remains strong andrelevant and is enforced through a uni-form and fair disciplinary processentrusted to the ADA Council on Ethics,Bylaws and Judicial Affairs (CEBJA). The ADA established CEBJA in 1913 toadvise on matters of interpretation onthe application of the principles ofethics. CEBJA is composed of volunteermember-dentists from across the UnitedStates who are appointed by the ADAHouse of Delegates and serve four-yearterms.

CEBJA maintains significant profes-sional functions, including:• Promulgating advisory opinions

that apply the ADA Code to specificsituation as guidance to the member-ship. The current ADA Code containstwenty-eight advisory opinions.

• Serving as the appellate tribunal inthe tripartite member disciplinarysystem for the ADA, its fifty-threeconstituent (state) and five hundredand forty-six component (local) dental societies.

• Supervising the annual publicationof the ADA Code, in print and elec-tronically, which is disseminated todental societies, dental students, newmembers, and others.

• Providing, since 1995, a nationalethics program for junior and seniordental students titled “SUCCESS: AnEthical Perspective to Starting YourDental Practice.”

• Serving, since 1995, as the sole judgeof the ADA Golden Apple Award forDental Ethics, recognizing the out-standing activities of a dental society.

14



• Developing, since 2004 and in coop-eration with the Journal of theAmerican Dental Association, a regu-lar feature titled “Ethical Moments”to promote awareness and educatemembers about the ADA Code.

• Providing education, information,and assistance on ethics and profes-sional matters for state and localdental societies.

Ethics and professionalism are thecornerstones of the ADA’s major policiesand programs impacting the public andthe profession, such as peer review,reporting suspected cases of patientabuse and neglect, impaired dentists andwell-being issues, treatment of patientswith HIV and other bloodbornepathogens, and evidence-based dentistry.

In 2002, in order to highlight theneeds of underserved children and whatdental professionals are dong to improvethe well-being of these children, the ADAcreated the Give Kids A Smile program.Held each February, this program providesfree oral health education, screening,and treatment services to children fromlow-income families across the country.This event has been recognized bynumerous organizations, including theU. S. House of Representatives.

The ADA has a long-standing, comprehensive, and consistent record of improving the ethical climate of dentistry. Its leadership and benefit tothe profession are immense.

This award is made possible by thegenerosity of The Jerome B. MillerFamily Foundation. Dr. Richard Haught,President of the American DentalAssociation, will accept the award.

Section Achievement AwardThe Section Achievement Award recog-nizes ACD Sections for effective projectsand activities in areas such as profes-sional education, public education, orcommunity service.

The Hudson-Mohawk Section is therecipient of the 2005 SectionAchievement Award.

The Hudson-Mohawk Section is honored for developing “Finding Our Way:Dental Ethics in 2004” as part of theSaratoga Dental Congress. This programwas considered under the professionaleducation category. The purpose of thishalf-day program was to present a com-prehensive program in ethics to dentistsand their staffs on the specific issuesinvolving the dentist-patient relationship.The program also covered broader ethicalconcepts inherent in the delivery of oralhealth care. The program was extremelywell received and future full-day programsare planned.

Section Newsletter AwardThe Section Newsletter Award is presented to an ACD Section in recogni-tion of outstanding achievement in thepublication of a Section newsletter. Theaward is based on overall quality, design,content, and technical excellence of thenewsletter. This year’s recipient is theIndiana Section.

Lifetime Achievement AwardThe Lifetime Achievement Award is presented to Fellows who have beenmembers of the College for fifty years.This recognition is supported by the Dr. Samuel D. Harris Fund of the ACDFoundation. This year’s recipients are:

Dr. Henry M. BarnhartDr. Horace A. BrayshawDr. A. Ian HamiltonDr. William B. IrbyDr. Jean-Paul LussierDr. Ralph E. McDonaldDr. Harold R. OrtmanDr. John E. RhoadsDr. Erwin M. SchafferDr. Charles T. Smith, Sr.Dr. Vincent A. TagliarinoDr. William ThemannDr. Walter S. Warpha

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The Fellows of the American College of Dentists represent the creative force of today and the promise of tomorrow. They are leaders in both their profession and their communities. Welcome the 2005 Class of Fellows.

Randy AdamsRichmond, VA

Jay C. AdkinsLubbock, TX

Mary E. Aichelmann-ReidyBaltimore, MD

George E. AnastassovNew York, NY

Craig S. ArmstrongHouston, TX

James K. BahcallMilwaukee, WI

Lance E. BanwellWoodbury, CT

Bradley W. BarnesNormal, IL

Bruce R. BarnhardWest Orange, NJ

Steven M. BaumNewark, NJ

David A. BehrmanNew York, NY

Richard A. BerrymanConcord, NH

David S. BinderNew York, NY

Dan L. BlackwellLee’s Summit, MO

Bruce BlasbergVancouver, BC

Michael M. Blicher,Washington, DC

Meredith C. BogertPhiladelphia, PA

Catherine A. BoosBlackwood, NJ

William H. BragdonGreenville, SC

Robert M. BrandjordBurnsville, MN

Warren A. BrillBaltimore, MD

Donna M. BrodeWindsor, ON

James C. BroomeBirmingham, AL

Thad L. Brown IIIJonesboro, AR

William C. BrownGreenville, SC

Lysette L. BrueggemanWest Bend, WI

Cavan M. BrunsdenOld Bridge, NJ

John A. BuistEnglewood, CO

Roy N. BurkLittlefield, TX

Jill M. BurnsRichmond, IN

Gary D. CarlsenHuntington Beach, CA

Brian R. CarpenterCumming, GA

William CatalanoVancouver, BC

Noel K. ChildersBirmingham, AL

Bryan ChrzPerry, OK

Patrick T. ClearyDublin, Ireland

Dean G. CloutierNew Haven, CT

Thomas E. CondronClarksburg, WV

Manuel A. CorderoSewell, NJ

Santos CortezLong Beach, CA

Bernard J. CostelloPittsburgh, PA

Lawrence K. Cox IIAdrian, MI

Delbert A. CroweNanaimo, BC

Mary E. CuccaroPittsburgh, PA

Richard H. CutlerFort Washington, PA

Peter C. DamianoIowa City, IA

Joseph P. Davis, Jr.Temple, TX

Paul G. Davis, Jr.Bedford, TX

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2005 Fellowship CLass


Salvatore P. De RiccoWhite Plains, NY

Matthew G. DelbridgeGoldsboro, NC

Matthew J. DennisGainesville, FL

Louis F. DeSantisStaten Island, NY

Bruce A. DollPittsburgh, PA

John M. Douglass, Jr.Nashville, TN

Benson C. DuffGrand Blanc, MI

James D. DuncanJackson, MS

Gerald L. DushkinMontreal, QU

Michael A. DzitzerSomers Point, NJ

David G. EdwardsWellsburg, WV

Robert J. EisenbergBoca Raton, FL

Roger L. EldridgeBaltimore, MD

Arthur C. EliasNew York, NY

Orin W. EllweinSioux Falls, SD

Shahrbanoo FadaviSkokie, IL

Egidio A. FaroneNew York, NY

Scott J. FarrellBinghamton, NY

Barry A. FederIssaquah, WA

Ralph B. FerianiAnchorage, AK

Bonnie C. FerrellDenver, CO

Laurence J. FieldsGaithersburg, MD

Steven R. FinkHamburg, NJ

Barry P. FlemingRed Deer, AB

Steven C. FongFremont, CA

Charles L. Ford IIISt. Petersburg, FL

Stanley B. FoxmanRockville, MD

Lily T. GarciaSan Antonio, TX

Gregory J. GardnerIndianapolis, IN

Gary D. GardnerLawton, OK

Steven G. GarrettWinchester, VA

David L. GeorgeBaltimore, MD

C. Richard GerberSt. Marys, WV

Daniel J. Gesek, Jr.Jacksonville, FL

Nicolaas C. GeursBirmingham, AL

Graziano D. GiglioNew York, NY

Burton H. GoldsteinVancouver, BC

Douglas J. GordonPinole, CA

C. Bruce GordyOrlando, FL

Michael J. GouldingFort Worth, TX

Michael R. GradelessFishers, IN

Edward J. GreenAlbany, GA

Richard V. GrubbHavre de Grace, MD

Betty A. HaberkampChicago, IL

John M. HagopianNiles, IL

Martin J. HalburCarroll, IA

Robert B. Hall, Jr.Winchester, VA

Robert S. HallFarmington, CT

Jerry L. HalpernNew York, NY

John J. HanckFort Collins, CO

Hayley L. HarveyDes Moines, IA

Joseph A. HerbstSilver Spring, MD

Gary E. HeyamotoBothell, WA

Kenji W. HiguchiSpokane, WA

Kenneth L. HilsenRidgewood, NJ

Brent L. HolmanFargo, ND

Kenneth E. HornowskiAshville, NC

Arlen R. HorsewoodHoagland, IN

Berta I. HowardHamilton, OH

Ralph L. Howell, Jr.Suffolk, VA

Richard F. HunterToronto, ON

Peter R. HupfauVancouver, BC

Michael A. Ignelzi, Jr.Ann Arbor, MI

Ronald S. JacobsonChicago, IL

Robert A. JaffinHackensack, NJ

Daniel L. JonesDallas, TX

James R. JorgensenPhoenix, AZ

Richard B. KahnNew Brunswick, NJ

Mark I. KampfeSioux City, IA

Liza KaramardianSunnyvale, CA

Jerry P. KatzAustin, TX

Stanley M. KaufmanOakland Park, FL

Kevin M. KeatingSacramento, CA

Richard M. KelleyFrederick, MD

John W. KillipKansas City, MO

Betty D. KlementOrange Park, FL

Kirk B. KollmannChicago, IL

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Michael S. KopeckyWest Bend, WI

David KusovitskyNew Haven, CT

Robert M. LambEdmond, OK

Timothy R. LangguthDuluth, MN

Marilyn S. LantzAnn Arbor, MI

David M. LebsackSt. Joseph, MO

David A. LedermanLakewood, NJ

Gabriela N. LeeNew York, NY

James E. LeeConway, SC

Thomas B. LeflerHot Springs Village, AR

Steven M. LepowskyFarmington, CT

Claudio M. Levato,Bloomingdale, IL

Rudolph T. LiddellBrandon, FL

Alexander A. LieblichSt. Vancouver, BC

Barry E. LiptonLargo, FL

Perng-Ru LiuBirmingham, AL

Patrick M. LloydMinneapolis, MN

William A. LobelSaugus, MA

John B. LoeffelholzFort Worth, TX

Richard M. Lofthouse, Sr.Fennimore, WI

Melanie R. LoveFalls Church, VA

Amy L. LudwigNew York, NY

John L. LytleLa Canada, CA

Stanley M. Mahan, Jr.Brierfield, AL

Hans S. MalmstromRochester, NY

Edward A. MarcusYardley, PA

Stanley MarkmanFort Lee, NJ

Rodney M. MarshallTuscaloosa, AL

James P. McLemore IIIJackson, TN

Alston J. McCaslin VISavannah, GA

Richard E. McClungLewisburg, WV

Dorothy McCombToronto, ON

Neville J. McDonaldAnn Arbor, MI

Joseph M. McManus, Jr.New York, NY

Stanley J. McNemeFort McPherson, GA

M. Gary McRaeCourtenay, BC

Phyllis G. MerlinoStaten Island, NY

Jon S. MichaelWest Lafayette, IN

Dennis M. MillsDeadwood, SD

Daniel T. MiyasakiSacramento, CA

David R. MlnarikWest Point, NE

Robert N. ModlinLafayette, IN

Joseph F. MoralesNew York, NY

Carol S. MoralesNew York, NY

Laura J. MurckoLittleton, CO

Stephen C. MyersPanama City Beach, FL

Ronnie MyersNew York, NY

Patrick M. NearingLa Grande, OR

Thomas E. O’BrienVancouver, BC

Donald R. OliverSt. Louis, MO

John H. PaulLakeland, FL

James L. PavelkaDenton, TX

William L. PearceDes Moines, IA

Ivy D. PeltzNew York, NY

Gregory E. PhillipsColumbus, IN

Randy J. PhillipsLos Angeles, CA

Mervyn F. PinermanColumbia, MD

Thomas R. PixleyFort Collins, CO

LeeAnn G. PodruchShelburne, VT

Stephen J. PueriniCramston, RI

William L. PurifoyFort Worth, TX

Fred C. QuarnstromSeattle, WA

Donald L. RastedeRock Falls, IL

J. Steven RatcliffKey Biscayne, FL

Craig S. RatnerStaten Island, NY

Edward T. ReidySantee, CA

Jeffrey H. RempellClifton, NJ

Colin R. RendellBrisbane, Australia

Elizabeth C. ReynoldsRichmond, VA

James L. RibaryGig Harbor, WA

Neal B. RichterMerrillville, IN

Enrique A. RiggsNew York, NY

O. H. RigsbeeCarmel, IN

Donald L. RobertsBillings, MT

Leslie B. RoederHouston, TX

Kenneth B. RowanJefferson City, MO

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David L. Russell, Sr.Fort Walton Beach, FL

William A. RussellLittle Rock, AR

Alex C. SalinasSan Antonio, TX

Jeffrey B. SameroffPottstown, PA

David A. SchimmelState College, PA

Willis L. SchlenkerLoma Linda, CA

Eugene J. SchmidtFountain Valley, CA

Adam T. SchneiderGaithersburg, MD

Murray SchwartzNew York, NY

Steven S. SchwartzStaten Island, NY

Adriana SeguraSan Antonio, TX

Ronald R. SepicUniontown, PA

Timothy J. ShambaughFort Wayne, IN

Jay H. SherLivingston, NJ

Bhavna ShroffRichmond, VA

James Randall SmithTullahoma, TN

Lee E. SnelsonWarren, OH

James M. SobermanNew York, NY

Robert S. SorochanNanaimo, BC

Meropi N. SpyropoulosAthens, Greece

J. Michael SteffenEdmond, OK

Jeffrey I. SteinWhite Plains, NY

James D. StephensPalo Alto, CA

Mark D. StevensonConcord, CA

Christian S. StohlerBaltimore, MD

Howard E. StrasslerBaltimore, MD

Judith M. StrutzSan Bernardino, CA

Steven B. SyropNew York, NY

Russell S. TabataHonolulu, HI

Donald N. Taylor, Jr.Alliance, NE

Leslie Z. TaynorNew York, NY

Bruce R. TerryWayne, PA

John H. TheeSouth Pasadena, FL

James M. TinninFayetteville, AR

Steven H. TinsworthBradenton, FL

Bruce R. TrefzGastonia, NC

Robert M. TromblyDenver, CO

Timothy S. TruloveMontgomery, AL

Steven J. TunickNew York, NY

David A. VarnerSouth Bend, IN

Nancy L. VillaOld Bridge, NJ

Joel M. WagonerChapel Hill, NC

Marshall Lynn WallaceSumter, SC

Douglas P. WalshSeattle, WA

James A. WeddellIndianapolis, IN

Robert E. WegerConvent Station, NJ

L. Thomas WeirCharleston, SC

Frederick W. WetzelSchenectady, NY

Bruce L. WhitcherSan Luis Obispo, CA

Eli E. WhiteMelbourne, FL

William D. WhiteDecatur, AL

Scott C. WietechaWest Columbia, SC

Charles W. WikleTupelo, MS

W. Craig Wilcox, Jr.Wheeling, WV

David H. WilhitePlano, TX

David S. WilliamsColumbia, TN

David A. WilliamsSmithsburg, MD

Terrence M. WilwerdingOmaha, NE

Henry C. WindellGresham, OR

Shari A. WitkoffCoral Gables, FL

Steven C. WoodWeatherford, TX

Johnson C.S. YipMacau, China

John J. Young, Jr.New York, NY

David J. ZaparinukVictoria, BC

Daniel L. ZedekerNew York, NY

James K. ZenkMontevideo, MN

19



Arthur W. Curley, JD

AbstractStandard of care is a legal concept ofestablishing, on a case by case basis, theminimal quality of care that must be met to defend against a claim of negligence in a lawsuit. Unlike other “standards,” it is not prescriptive, but it does encompassdiagnosis and overall management ofpatients, not just treatment. The standardis determined by assessment of the credibility of expert witnesses, the appropriateness of written evidence, andpertinent laws and regulations. Althoughthe burden of proof rests with the plaintiff,only a preponderance of the evidence, not certainty beyond doubt, is required.Practice, especially diagnosis and informedconsent, must be updated continuously.

It has been estimated by the AmericanDental Association that every year oneout of every ten dentists is involved in

a legal dispute concerning his or herpractice. This author has been defendingdentists for over thirty years and hasobserved that many legal claims arise asthe result of a practitioner’s failure toappreciate the required legal standard ofcare, rather than careless treatment.Nationwide, professional liability carriersroutinely offer dental risk managementcourses that include discussions of thelegal standard of care, with the view inmind of stemming the tide of malprac-tice claims.

During the education and training of prospective dental professionals, students are taught criteria for the diagnosis and treatment of a dental condition. However, the legal standard of care is broader and more dynamic.The prudent practitioner, hoping toavoid being drawn into the legal system,needs to have an appreciation of thelegal standard of care, and to implementthat knowledge in practice protocols.

Standard of Care DefinedLegal standards of care are generallydetermined by the laws of the state inwhich the dental professional practicesand is licensed. However those laws areseldom specific as to any method of diagnosis, plan, or required treatment.Rather, the laws are very general as tothe definition of the legal standards ofcare. In addition, there are Federal Lawsthat can affect practice, such as HIPAAand OSHA.

Although state statutes vary to somedegree, there is a basic universal defini-tion of the legal standard of care:

A dentist is negligent if he or she failsto use the level of skill, knowledge, andcare in diagnosis and treatment thatother reasonably careful dentist woulduse in the same or similar circumstances.This level of skill, knowledge, and care is sometimes referred to as “the standardof care.” (Calif. Civ. Jury Instructions‘501. Standard of Care for HealthcareProfessionals)

The legal standard of care in not justthe very best care, or treatment by onlythe best healthcare provider. It is alsonot the average care in the community.Rather it is that minimum level of careto which a patient is entitled that is safeand reasonable.

Failure to provide the legal standardof care is considered professional negli-gence or what is commonly referred toas malpractice. For a patient to prevail ina malpractice claim, they must provethree elements: that injury occurred,that the dental practitioner failed to meetthe legal standard of care, and that thefailure was the legal cause of the injury.Only upon proving those three elements

20


The Legal Standard of Care

Standards

Mr. Curley practices law in Northern California, emphasizing risk managementand defense of healthcareproviders against malpracticecharged. He teaches jurispru-dence at the University of the Pacific, Arthur A. DugoniSchool of Dentistry. He may be contacted at [email protected].

can they be awarded damages (money).(Calif. Civ. Jury Instructions ‘400Essential Factual Elements)

Source of the Standard of CareGenerally the law provides that there canbe multiple sources for the legal standardof care, and they are not limited to orsolely defined by the specific training ofthe defendant in a legal dispute. Thosesources include: 1) the opinion of expertwitnesses; 2) recognized or authoritativetexts, journals, or treatises; and 3) statutesand/or regulations. In a malpractice suit,a jury of mostly lay persons will generallydetermine whether or not a dental practitioner violated the standard of care by comparing and contrasting theevidence provided by each side (plaintiffvs. defendant) in a trial. In the case of an accusation before a licensing board,an administrative law judge sitting with-out a jury will make the determinationas to any violation of the legal standardof care.

Expert WitnessesThe primary source for the determinationof the legal standard of care is the opin-ions and testimony by expert witnesses.The legal qualifications for such expertwitnesses include being licensed to perform the treatment in question orhaving expertise in the area of one of theissues in dispute. Therefore an expert maybe a general practitioner or a specialistin the area of the treatment in question,or an expert in heart values and post-dental infections, such as a cardiologist

or infectious disease physician in casesof postoperative septicemia. Experts have to be able to describe and justifytheir opinion as to the standard of carein the community of the defendant’spractice. The jury’s role is to determinethe relative credibility and/or believabilityof each expert’s opinions. In order to justify their opinions on the standard ofcare, experts generally will review therecords, x-rays, and depositions.

Expert witnesses typically come from two sources: treating dentists andretained experts. Most often they aresubsequent treating dental care providerswho have expressed some criticisms ofthe care of another dentist. The othersource of experts, those who are retainedon behalf of the plaintiff or defendant,are those who have not seen the patientfor treatment and instead evaluate thestandard of care by reviewing recordsand testimony. Therefore understandingand maintaining the general standard of care in one’s community is critical for a dentist striving to avoid claims ofsubstandard care.

Experts can also render opinions asto the management of dental auxiliaries,such as hygienists, assistants, etc. andtheir impact on the dentist’s performancewithin the standard of care. Exampleswould include transmission of referralinformation, scheduling follow-upappointments or recalls, and maintainingOSHA standards.

21


Standards

Many legal claims arise as the result of a practitioner’s failure to appreciate the required legal standard of care, rather than careless treatment.…The legal standard of care [is the] minimum level of care to which a patient is entitled that is safe and reasonable.

Authoritative/Recognized Texts The legal standard of care can also bedefined by way of authoritative or wellrecognized texts, peer review journals,or treatises. However, whether or not awriting is considered authoritative orwell recognized is determined by a judgewho considers expert witness testimonyas to the qualifications of the text orjournal at issue.

In addition, if the defendant hasreferred to or relied upon a particulardocument in order to perform a diagnosisor treatment, then that writing may beadmitted as evidence of a standard ofcare. Or, if the defendant is a member of a dental society that promulgatesstandards or follows well accepted guidelines, such as the American HeartAssociation, these documents may alsobe considered evidence of the standardof care.

Statutes and CodesMost states have laws providing that any violation of a statute is presumptiveevidence of a violation of the standard of care or professional negligence, andin such cases expert testimony is notrequired. A typical case might be the failure to adhere to OSHA regulations for the management of potential blood-borne pathogens. For example, should a patient develop a post-treatment infection, an OSHA violation would beconsidered evidence of substandard careand the defendant’s only defense wouldbe to prove the lack of a causation of theinfection by the OSHA violation. But inany case, expert testimony would not berequired on the issue of a breach of thestandard of care when there is evidenceof a violation of a code or statute.

Informed Consent and Refusal Most states also have statutes thatrequire dental care providers to obtain

informed consent before providing treat-ment. However the laws are not specificas that the details that must be part ofthe informed consent discussion, onlythat the patient must be told the signifi-cant risks, benefits and alternatives torecommended treatments, therapies ormedications. With a few exceptions (IVsedation: California Code of Regulations,‘1685) the law does not require that theinformed consent be in writing. However,risk managers urge their use as a deterrentto claims of lack of informed consentbecause studies have shown that patientsdo not recall pre-treatment discussionsand insist, with credibility, that theywere not warned. Therefore written documentation, by way of a signed consent form, can be powerful evidencein the defense of a malpractice claim.

As dentistry has become more complex and involves more treatmentoptions, a new standard of care has arisen, namely the obligation to provideinformed refusal, including the risks ofthe patient’s declining a recommendedtreatment, therapy, or medication. Anexample would be the offering to apatient the option of dental implants versus a partial denture. These new standards for consent have been codifiedin some states (Calif. Jury Inst. ‘535).Therefore, it is recommended thatinform consent forms be used routinelyand updated regularly.

Burden of Proof The patient in a typical malpractice suit, or the attorney general in a boardhearing, has the burden of proving (convincing a jury or administrative lawjudge) that a violation of the standard ofcare has occurred. Unlike criminal caseswhere the evidentiary level is “beyond a reasonable doubt,” the plaintiff needonly provide evidence of a probability(not a certainty) of a breach of the standard of care. A probability in the lawmeans greater than 50%, meaning ajury can have 49% doubt and still find

that the defendant failed the standard of care.

The Dynamic Legal Standard of Care Because of the speed of communicationand information distribution via theInternet, the legal standard of care hasbecome dynamic, subject to rapid andsignificant changes in a short period oftime. For example, just a few years ago,health histories had to be modified toadd a question regarding a patient’s useof the medications known as Fen-Phen.Today histories need to updated toinclude questions about patient’s use ofbisphosphinates prior to performing anydental surgery. Therefore the prudentpractitioner must stay current with con-tinuing education and communicationsfrom dental societies such as the ADAand AGD, as well as governmental agencies such as the CDC and OSHA.

Health history forms should berevised annually, staff protocols andmanagement regularly reviewed, con-sent forms used and frequently updated,and record-keeping methods periodicallyevaluated for content, detail, accuracy,and thoroughness.

With the increasing availability ofdigital systems for the dental office(records, x-rays, and communications)the standard of care requires more detailedrecord keeping because of the ease ofrecording and compiling information.Combined with an understanding thatthe standard of care is a communitystandard, as well as an appreciation ofsome of the codes controlling the practiceof dentistry, the prudent practitioner canavoid claims of substandard care thathave more to do with the practice ofdentistry rather than actual provision of treatment. ■

22


Standards

Donalda M. Ellek, PhD

AbstractThe ADA parameters of care have servedthe needs of practicing dentists for fifteenyears. Their purpose is to describe a rangeof treatment options that dentists willwant to consider, in combination with particular clinical conditions and patientpreferences. These options have beendeveloped based on available evidence and a consensus of professional judgment. The ADA has exercised concern thatparameters not be used, out of the contextof individual professional judgment, forpolicy purposes.

In the early 1990s, the healthcare system’s development of parameters,guidelines, and standards stirred much

debate and controversy, which focusedlargely on terminology, definitions ofthose terms, and ohow they were different from each other. Underlying thisdebate, however, was the contentiousissue of how parameters, guidelines, andstandards were intended to be used andhow appropriate use of them could bemanaged. Definitions and terminologywere formulated by the developers of theparameters approach primarily to clarifyand support the developers’ intended use.

Today, there is still no authoritativedefinition of parameters and, in fact, theneed to draw tight divisions betweenguidelines, standards, and parametershas virtually disappeared in the eyes ofsome. The terms are often used inter-changeably. Some organizations use theterm “parameters” as an umbrella underwhich to include practice options, prac-tice guidelines, practice policies, andpractice standards. And the debate overtheir use continues unabated. This paperwill describe how parameters haveevolved over the last fifteen years, theissues surrounding terminology, theirbasis in scientific evidence and profes-sional consensus, and the concernsabout how they are used. The experienceof the American Dental Association(ADA), when it began the developmentof dental practice parameters in 1994-1997, can illustrate some of the concernsand considerations that underlie thedevelopment of parameters in general.

TerminologyWhen the ADA formulated the plan forparameters development, there waslengthy discussion of the terminologythat would most accurately capture theADA’s intent in developing them. TheADA discussed the meaning and inter-pretation of the terms “standards,”“guidelines,” and “parameters.” Theterm “parameters” was finally chosenand was defined as describing the fullrange of appropriate treatment for agiven condition. In comparison to stan-dards or guidelines, parameters woulddescribe all appropriate options for treat-ment and offered the greatest latitudefor exercising professional judgment inchoosing among appropriate options.The ADA interpreted standards as intending to be applied rigidly with littlejustification for deviation from them.Standards, in essence, prescribed whatthe practitioner must do. Althoughguidelines were considered more flexiblethan standards and allowed for deviationbased on individual patient needs, theywere thought to be more prescriptivethan parameters, and thus the ADAopted to develop parameters.

23


The ADA’s Practice Parameters

Standards

Dr. Ellek is manager of theOffice of Quality Assessmentand Improvement in theAmerican Dental Association’sCouncil on Dental BenefitPrograms. She may be reachedat [email protected].

The American Dental Association, in 1993, defined parameters as follows,and this definition remains current:

Parameters describe the range ofappropriate treatment for a givencondition. In comparison to stan-dards or guidelines, parametersbroaden the range of professionaljudgment for the practitioner. Theystrengthen the ability of the providerto evaluate options and arrive atappropriate treatment.

The ADA parameters are intended asan aid to clinical decision making andthus describe the clinical considerationsin the diagnosis and treatment of oralhealth conditions. As the ADA parameterswere developed to aid clinical decisionmaking, there was at the same time aneffort to avoid prescriptive, “cookbook”instructions to practitioners. Like mostother health professional associations,its perspective is that dentistry, like somuch of direct healthcare delivery,includes an art and clinical experiencethat is invaluable to delivering care andis indispensable for tailoring care to theindividual needs of patients. Parameters,as opposed to guidelines and standards,seemed to explicitly highlight professionaljudgment and allow for the possibility of considering not only the clinical circumstances of the individual patient,but the patient’s social, cognitive, anddemographic characteristics. Equallyimportant, it permitted the patient beable to express his or her own preferenceswhen weighing the costs and benefits of one treatment option over another.Explicit statements regarding the importance and need for professional

judgment appear in parameters, and theterminology used in parameters state-ments (or recommendations) supportsprofessional judgment as well.

When reading the dental practiceparameters, it is apparent that the state-ments vary in the degree to which theyare prescriptive. Some statements in theparameters say the dentist “may,” whileother statements say the dentist “should.”In the ADA’s parameters, on the topic ofdental caries, one parameter statementsays “Pulpal tissue should be protectedwhen indicated.” Another statement says“Chemotherapeutic agents may be usedfor caries prevention and the treatmentof incipient caries.” The word “should”suggests stronger direction than theword “may.” The ADA comments on thispoint in its preamble to the parameters,saying that considerable thought wasgiven to the use of the verbs “may,”“should,” and “must.” The verb “may”clearly allows the practitioner to decidewhether to act. The verb “should” indi-cates a degree of preference and differsin meaning from “must” or “shall”(which require the practitioner to act).Similar use of the verbs “may” and“should” are also used in both parametersand guidelines developed by some of theother dental professional organizations.Thus, the language within parameterscan differ in the degree to which it isprescriptive.

The measured degree of prescriptiveterminology not only supports profes-sional judgment, but varies with thedevelopers’ perceived reliability of theparameters statement, whether the statement is based on the consensus ofprofessional opinion or the scientific evidence supporting the parameters. Alesser degree of variation in the normregarding a certain parameter statementmay prompt the developers to use theword “should,” but a greater degree ofvariation might prompt the word “may.”

Scientific EvidenceAnother distinction sometimes madebetween standards, guidelines, andparameters is the degree to which eachis based on sound evidence of the out-comes of care. This distinction was madeeven in 1990, when David Eddy specifiedthree types of “practice policies” eachbased on a different level of clarity of theevidence about the outcomes of care and the importance of the outcomes topatients (Designing a Practice Policy—Standards, Guidelines, and Options.Journal of the American MedicalAssociation, 263:3077-3084, 1990).Eddy’s concept was as follows: Standardswere based on very strong evidence andexceptions to following the standardwould be rarely justified. Guidelineswere based on less strong evidence andexceptions were more likely than forstandards. The term “options” wasapplied when several treatment optionsexisted, but the evidence was weak ornonexistent and so the evidence did notwarrant a specific recommendation.Thus, the degree of scientific strengthbehind recommendations is anotherdimension by which a distinction couldtheoretically be made between parametersand other types of recommendations.

Parameters, then and now, are developed on the basis of scientific evidence to the extent that it is available.But, the methodology used to developparameters in the early and mid-1990srelied heavily on developing a consensusof professional opinion. The ADA statesin the preamble to its parameters that“Balancing individual patient needs withscientific soundness is a necessary step inproviding care.” The ADA was not uniquein focusing on consensus building. Otherprovider groups and public agenciesstressed the importance of professionalconsensus as well. In part, it may have

24


Standards

reflected a relative dearth of strong evidence on clinical topics at the time,especially if an organization’s objectivewas to develop a comprehensive set ofrecommendations for practitioners. And, it may have reflected a genuineregard for the consensus of professionalopinion, especially for its importance toindividual patient-centered care and for prudently examining the limits ofappropriate care. Equally importantly, it may have reflected the health profes-sions’ need to carefully adapt to a newlevel of transparency or accountability in healthcare delivery.

Health professionals have always dis-seminated new technology and scientificinformation among themselves; it hadalways been a part of the professions’responsibility for the quality of care. Theunsettling change for practitioners thatcame about in the late 1980s and the1990s was that those outside the profes-sion—policymakers and payers—becameinterested in quality of care. Policymakersand payers began to view quality of care as a factor by which to stimulatecompetition within the healthcare market and to so control the costs ofcare. As a result, policymakers and payers were interested in measuring orevaluating the quality of care; parameterswould likely provide the very informationfrom which such evaluations could be created. Practitioners, in general,were uneasy with information being available to payers, patients, and othernon-clinicians who might not under-stand how recommendations should beapplied in individual cases, could incor-rectly apply parameters in developingquality evaluation criteria, and wouldignore the importance of professionaljudgment in providing care.

If practitioners are going to be heldpublicly accountable for adhering toparameters, it is essential for them tohave a hands-on role in their develop-ment. In addition, public accessibility of

parameters and other recommendationsplaces pressure on developers to be surethat the recommendations are valid andreliable. Professional consensus becamea methodology in itself for developingparameters. Well-conducted consensusbuilding provided the profession with a politically sound mechanism for devel-oping parameters and also providedvalidity and reliability that the parametersrepresented practice norms, especiallywhere scientific evidence was lacking. It also served to increase the acceptanceof parameters by practitioners. Thedrawback to using professional consensuswas that third-party payers and othersoutside the health profession could perceive a very narrow line between professional consensus and professionalinterest and gain and so might feel freeto draw those boundaries to suit theirpurposes. Similarly, practitioners perceived a very narrow line betweenappropriate use of parameters by thoseoutside the health professions and distortion of parameters for the sake ofcost containment or expedient policydecisions. This problem has yet to beresolved, but the advent of evidence–based methods of developing professionalrecommendations may bring someobjectivity to the issue.

Methods for evaluating evidencehave become more refined, yieldingmore valid and reliable results, and sothe reliance on scientific evidence hasgained much credibility. The NationalGuideline Clearinghouse (NGC) exempli-fies the current effort to establishparameters and other types of recom-mendations on scientific evidence. TheNGC is a public database of (what istermed) “guidelines.” The term “guide-lines,” as used by the NGC, serves as anumbrella term to include parameters,

25


Standards

Health professionals have always disseminatednew technology and scientific informationamong themselves; it hasalways been a part of theprofessions’ responsibilityfor the quality of care.

guidelines, and standards. For example,the American Academy of Periodon-tology publishes its parameters and theAmerican Academy of Pediatric Dentistrypublishes its guidelines in the NGC. The common denominator is that theparameters, guidelines, and other recommendations submitted to the NCGmust be evidence-based and shouldinclude an assessment of the level of evidence supporting them. The NGC ismaintained by the Agency for HealthcareResearch and Quality, but it began as ajoint partnership with the AmericanMedical Association and the America’sHealth Insurance Plans. Such an unex-pected confluence of parties (those of agovernmental agency, a provider group,and a third-party-payer group) suggeststhat a diverse group of stakeholders inthe health care system has signed on tothe idea that the scientific strength ofparameters and other types of recom-mendations is now a key feature uponwhich all can agree. This is not to say,however, that provider groups have dis-missed the importance of professionalconsensus; provider groups maintainthat parameters or any set of recommen-dations should allow for professionaljudgment as appropriate.

Use of ParametersA very serious concern, and one that continues to create controversy, is theintended use of parameters. In an intro-ductory section of the ADA’s dentalpractice parameters, the importance ofthe intended use of parameters is clear.It is pointed out in the introduction that:

these parameters are distinct fromthe standards that are developed bypayers and regulatory agencies. Thestandards of payers and regulatory

agencies address more narrow con-cerns such as financial obligations or the contractual agreements of abenefit plan.

This excerpted statement describesconcerns about the intended use ofparameters and suggests that the term“parameters” connotes a differentintended use than does the word “standards.”

Parameters developed by professionalorganizations are intended primarily forpractitioners. Not only can practitionerssort through the latest scientific researchresults efficiently, the use of parameterscan support the practitioner in risk management. Anecdotal commentsabout how practitioners use parameterssuggests that practitioners reviewparameters especially when they are in need of support for treatment thatthey have provided, such as when apractitioner is involved in a dispute with another practitioner, a payer, or apatient about some aspect of care.

Although parameters are usually notwritten particularly for patients, patientsalso seek them out to learn more abouttheir health conditions and diagnosticand treatment options. The fact thatparameters allow for professional judg-ment supports the principle that patientpreferences should be considered and so supports patient participation in treatment. This principle is coincidentalwith the current thinking in the health-care policy arena that patients should be educated to become savvy consumersof health care, improving the healthcaresystem’s ability to function in the com-petitive economic market.

However, parameters do not addressthe many complex questions on thehealth policy agenda, such as fundingand allocation decisions. The ADA, in itspreamble to the dental practice parame-ters states that:

26


Standards

The degree of scientific strength behindrecommendations is another dimension by which a distinction couldtheoretically be madebetween parameters and other types of recommendations.

The American Dental Association recognizes that other interested parties, such as payers, courts, legislators, and regulators may alsoopt to use these parameters. TheAssociation encourages users tobecome familiar with these parame-ters as the profession’s statement ofthe scope of clinical oral health care.However, these parameters are notdesigned to address considerationsoutside of the clinical arena and,therefore, may not be directly appli-cable to all health policy issues.

The statement suggests that parame-ters are intended to be separate from the benefits, plan designs, and coveragepolicies developed by third-party payers.Insurance plans and other third-partypayers have a legitimate business inter-est in developing the quality of theirproduct—their benefit packages—andparameters can serve as reference forthis. But, insurance plans and otherthird-party payers must also considerrisks and allocation issues in designingbenefit plans and coverage policies andmake decisions that are unrelated to theappropriateness of care. The ADA param-eters are not intended to consider thesefactors of risks and allocation issues. Thestatements made in parameters are notintended to justify financially based deci-sions. Parameters describe the full rangeof appropriate treatment without attach-ing judgments on the relative financialcosts and benefits of each of the options.

Policy questions regarding the distribution and allocation of health careare another area that may require information about clinical care or thequality of care. For example, the pay-for-performance programs that are currently emerging in the healthcaresystem are one example of how theassessment of the quality of care cancontribute to answering a larger policyquestion. Parameters can serve as a reference for developing quality evalua-

tion and measurement tools. However, apolicy question may be related to meas-uring the quality of care in order tosupport a policy objective that is relatedto financing or allocation of care.Although a parameters statement mightbe excerpted from its context and a quality measure developed from it, theparameters cannot necessarily be said tojustify the policy objective. The prioritiesimplicit in the policy objective might beunrelated, or even opposite, thoseimplicit in the parameters.

Possible DevelopmentsAside from serving as a resource forpractitioners in clinical decision making,parameters will likely continue to serveas a reference for developing qualityassessment tools—such as the criteriathat are use in pay-for-performance programs and other reimbursementstructures—and to address policy questions. Although a distinction shouldbe made between assessments aimed atevaluating the quality of care and theassessments that are made to makefinancial or policy decisions, this can be a genuine hurdle, first to make thedistinction and then to ask the rightquestions to address the financial andsocial issues.

There have been several examples in the recent two or three years that may indicate this hurdle is starting to be approached. The examples involvehaving the diverse stakeholders in anissue working together to develop qualityassessment instruments or in other ways applying parameters. The pay-for-performance program, recentlyimplemented as a demonstration by theCenters for Medicare and Medicaid(CMS), is one example where physicianorganizations, the National Committeefor Quality Assurance, and the CMS

joined together to develop the measures.The measures were then submitted tothe National Quality Forum for comment.There was then further work betweenthe CMS and physician groups to developconsensus agreement on how the dataon the measures would be collected andused to assess the quality of care andthen implement pay for performance.

Other such joint efforts can be seen in the healthcare system, withaccrediting bodies, professional associa-tions, payers, and consumer groupscoming together to develop criteria toguide and evaluate financial and socialissues. This approach does not guaranteethat the final product will be satisfactoryor effective, but it may allow all partiesto comment on the appropriate use oftheir documents as the process proceeds.Doing so may spur more deliberate identification where questions on thequality of clinical care are separate fromsocial and financial questions. ■

27


Standards

Gary C. Armitage, DDS, MS, FACD

AbstractThe purpose of this paper is to describehow the inherent strengths of an evidence-based (EB) workshop can be combined with the conventional wisdom generatedby a group of experts participating in aconsensus conference. A traditional consensus conference is an appropriateway to arrive at the best current way to do something if the knowledge base isinsufficient to make a scientifically rigorousEB analysis of the clinical problem. Theresult is the best opinion of experts in thefield. The EB approach is the application of a repeatable review process to an existing knowledge base that is relevant to a focused question of clinical importance.It is a powerful tool that can help dentistsin clinical decision-making processes. A combination of the EB approach with a consensus conference provides the highest level of evaluation and thestrongest level of evidence upon which to make clinical decisions. Application ofany of these sources of information can be used in the development of healthcarestandards. However, standards are complicated statements that blend currentscientific knowledge and clinical judgmentwith cultural, societal, and economic issues.When healthcare standards are beingdeveloped or revised, it is important that all sources of information be consideredand the target population and purposes ofthe standards be identified.

There are several forces that drivethe development and application ofstandards in dentistry. Standards in

a healthcare setting should be directedtoward the best possible care for patientswithin the constraints or limits of thecurrent knowledge base. Healthcarestandards are complicated statementsthat blend current scientific knowledgeand clinical judgment with cultural, societal, and economic issues.

The purpose of this paper is todescribe how the inherent strengths ofan evidence-based (EB) workshop canbe combined with the conventional wisdom generated by a group of expertsor thought leaders participating in aconsensus conference. I have had theprivilege of participating in a consensusconference on disease classification(American Academy of Periodontology,1999) and a consensus conference com-bined with an evidence-based workshopon clinical periodontics (AmericanAcademy of Periodontology, 2003). Iserved as editor of the proceedings forboth meetings. It is from this perspectivethat this paper was written.

Goals of Consensus Conferences & EB WorkshopsThe overall goals of each type of meetingare very similar. One of the commongoals of a consensus conference or anEB workshop is to accurately summarizea body of information and present it topractitioners in a way that will be usefulto them in the treatment of patients.

Information is sought that will help guideclinicians as they go through the difficultdecision-making process in providinghealthcare services for their patients.

Consensus ConferenceThe genesis of a consensus conferenceusually begins with a clinical problemthat has no clear-cut solution widelyaccepted by the practicing community. A recognized governmental agency (e.g., the National Institutes of Health)or professional society (e.g., the AmericanAcademy of Periodontology, AAP) usuallytakes on the task of identifying a groupof experts in the field and asks them todevelop a consensus on what is the bestway to solve a specific group of clinicalproblems. Prior to the conference certainindividuals are assigned subtopics relatedto the overall clinical problem. They are asked to write a comprehensive literature review on their subtopic thatwill serve as a basis for discussion by the other experts participating in theconsensus conference. At the conferenceall issues associated with the clinicalproblem are thoroughly discussedagainst the backdrop of relevant scientificinformation, clinical experience, and

28


Value of the Evidence-Based Consensus Conference

Standards

Dr. Armitage is the R. EarlRobinson DistinguishedProfessor, Division ofPeriodontology, Department of Orofacial Sciences, UCSFSchool of Dentistry, 521Parnassus Avenue, C-628, San Francisco, CA 94143-0650;[email protected].

clinical judgment. What emerges from asuccessful consensus conference is astatement such as, “It is the consensus of experts in the field that an ‘x’ type ofproblem is best managed by ‘y’ proce-dures.” The result is simply the bestopinion of thought leaders in the field.

An example of such a conference wasthe AAP 1999 International Workshopfor a Classification of PeriodontalDiseases and Conditions. Prior to thismeeting, twelve participants were askedto prepare comprehensive literaturereviews of separate topics related to theclassification of periodontal diseases.The papers were peer-reviewed prior todistribution to the over sixty internationalexperts who were invited to the confer-ence. At the conference the problemsassociated with disease classificationwere discussed in small working groupsand several plenary sessions. The working groups wrote consensus reportsdealing with the best classification forthe assigned subgroup of periodontaldiseases. At open sessions, all participantswere asked to comment on and suggestrevisions to the consensus reports. After the revisions were made, the entiregroup was asked to approve of the con-sensus reports and the revised diseaseclassification. What emerged was a classification that represented the bestopinion of the experts who attended that meeting (Armitage, 1999).

A consensus conference is an appro-priate way to arrive at the best currentway to do something if the knowledgebase is insufficient to make a scientificallyrigorous and evidence-based analysis ofthe clinical problem. The problem withclinical decisions based solely on the collective opinion of a group of experts isthat they might be wrong. Nevertheless,if there is no scientific evidence to thecontrary, one needs to rely on the opinionsof experts and one’s own experience.

Evidence-Based WorkshopThe EB approach is the application of arepeatable review process to an existingknowledge base that is relevant to afocused question of clinical importance.The EB approach is necessary because thesheer volume of information concerningthe diagnosis, prevention, and treatmentof oral diseases has become overwhelm-ing. Evidence-based dentistry (EBD) isthe application of the EB approach toclinical issues related to the practice ofdentistry. When properly applied andunderstood, EBD is a powerful tool thatcan help the practicing dentist in clinicaldecision-making processes.

The first step in the EBD approach isto develop a focused question that hasclinical relevance. Such questions areoften called “PICO” questions since theyspecify a population (P), an intervention(I), a comparison or control group (C),and an outcome (O). An example of sucha question is the one used by Haffajee et al. (2003) at the AAP Workshop onContemporary Science in ClinicalPeriodontics: “In patients with periodon-titis, what is the effect of systemicallyadministered antibiotics as compared to controls on clinical measures ofattachment level?” The next step is tosystematically conduct a literaturesearch of all available databases that arerelevant to the PICO question. Thesearch process must be clearly describedso it can be repeated by others if they so desire. Usually the search process isconducted by two independent reviewerswho reach an agreement on whatpapers need to be included in the finalsystematic review. Importantly, papersare scored or graded from the strongestto weakest forms of evidence. In mostsystems, the strongest form of evidence

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Standards in a healthcaresetting should be directedtoward the best possiblecare for patients within theconstraints or limits of thecurrent knowledge base.Healthcare standards arecomplicated statementsthat blend current scientificknowledge and clinicaljudgment with cultural,societal, and economicissues.

is a meta-analysis of similarly designedrandomized controlled clinical trials(RCTs), whereas the weakest form of evidence is information gained from laboratory studies or expert opinion. Theoverall result can be a powerful analysisthat is useful in helping practitioners iden-tify the best available evidence regardingthe benefits of a specific intervention.

Some zealots of the EB approachcontend that procedures or interventionsnot based on well-conducted RCTsshould not be performed. The fallacy ofsuch a view has been pointed out in apaper in the British Medical Journalentitled, “Parachute use to prevent deathand major trauma related to gravitationalchallenge: systematic review of random-ised controlled trials” (Smith & Pell,2003). In their search, these authors wereunable to identify any RCTs dealing withparachute intervention. They concludedthat radical advocates of evidence-basedmedicine who declare that no interven-tions should be adopted until supportedby RCTs should volunteer as participantsin a double-blind RCT dealing with thehealth benefits of using parachutes whenjumping out of airplanes at 33,000 feet.

It has been pointed out that althoughevidence provided by a properly conductedRCT is quite strong, for some types ofclinical questions RCTs have serious limitations. For example, an RCT designedto determine if periodontitis causes coronary heart disease or stroke is notpossible since periodontitis cannot berandomly assigned to human subjects(Dietrich & Garcia, 2005).

It is important to point out thatalthough the EB approach is a powerfulsource of information for clinical decisionmaking, it is not the only source

of information upon which clinical decisions are made. It is neither a substitute for clinical experience nor areplacement for clinical judgment. Finally,it does not replace the need to stay currentsince healthcare professionals should routinely read the literature in an attemptto stay abreast of new developments.

Application of the EB Approach to a Consensus ConferenceIn 2002 and 2003 there were twonotable periodontal consensus confer-ences that utilized the power of the EBapproach. One was held in Switzerlandand organized by the European Federationof Periodontology (Lang, et al., 2002).The other was held in the United Statesand organized by the American Academyof Periodontology (AAP, 2003). Both ofthese meetings combined the expertiseand experience of multiple thought lead-ers with well-conducted EB systematicreviews. This combination provides thehighest level of evaluation and thestrongest level of evidence upon whichto make clinical decisions. Combiningthe conventional wisdom of experts withthe EB approach is better than othermethods of assessment because themethod is thorough and comprehensive,objective, scientifically sound, andpatient focused. It incorporates clinicalexperience, stresses good judgment, anduses transparent methodology(Newman, Caton & Gunsolley, 2003).

Holding an EB consensus conferenceis not a trivial undertaking. It is animmense task to organize, find fundingfor, recruit reviewers and participants,hold the conference, and publish theproceedings. For the 2003 AAP EB consensus conference an organizingcommittee spent over two years planningthe event since they needed to select topics for systematic review, identifyreviewers and participants, develop theworkshop format, and find sources offunding. An important step prior to theconference was the training of content

experts in the EB process during whichPICO questions were written andapproved by the group. A critically impor-tant component of the entire processwas enlisting the aid of a statisticianwith expertise in the EB process. Well in advance of the meeting designatedparticipants conducted systematic reviewsof assigned topics. These papers werepeer-reviewed by journal referees andwere then sent to all participants inadvance of the meeting. For the 2003AAP conference fifteen systematicreviews were written. At the conferenceconsensus statements were written usingthe relevant EB systematic reviews asguides. The final step was editing andpublishing the proceedings. The entireprocess took over three years to complete.

Some of the valuable things that cancome out of EB consensus conferences arethe identification of clinical interventionsthat have strong evidence compared tothose that have hardly been studied.Both findings are important. This is onlypossible at a conference that follows the EB process, since the strength of theevidence is formally assessed or graded.This is not the situation at a conventionalconsensus conference, where expertopinions and traditional literature reviewsgovern the proceedings. Traditional literature reviews are usually a crediblesource of information, but they have theinherent weakness of an unconsciousarticle selection bias by the authors.

Even though EB consensus confer-ences provide the strongest availableevidence to assist the clinician in decision-making processes, informationgenerated by such conferences rarelyprovides an unequivocal rationale formaking patient-care decisions. For example, one of the systematic reviewsat the 2003 AAP EB consensus conferencefound that based on the data from over

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twenty RCTs, administration of systemicantibiotics resulted in statistically significant gains in clinical attachmentfor patients with periodontitis (Haffajee,Socransky, & Gunsolley, 2003).Compared to controls, the adjunctive useof antibiotics resulted in an averagemean gain in clinical attachment inaggressive periodontitis of 0.72 mm, andfor chronic periodontitis patients theaverage gain was 0.24 mm (P < 0.0001).These findings do not, however, establisha standard of practice that dictates theuse of antibiotics in all patients withperiodontitis. Part of the problem is thatuse of an antibiotic carries with it somerisk of developing untoward effects suchas an allergic reaction and emergence of resistant strains. In addition the systematic review with its meta-analysisdid not establish, “…which agent(s)should be used for which infection, whatis the optimum dosage and duration ofthese agents, which subjects would mostbenefit from systemic antibiotics, whenshould subjects receive antibiotics inrelation to mechanical debridement…”and how long should the medications beadministered to get the maximum effect(Haffajee, Socransky, & Gunsolley, 2003).

Development of HealthcareStandardsIt should be clear from the above discus-sion that development of healthcarestandards cannot be simply derived from a single source of information orevidence. This is true even in situationswhere the information source is verystrong, such as an EB consensus confer-ence. Healthcare standards might beviewed within the context of a simplequestion, “What type of intervention will result in a clinically meaningful out-

come?” However, a clinically importantoutcome often depends on the opinionor perspective of those deciding what is,and is not, important.

For example, in a study of throm-bolytic strategies after acute myocardialinfarction (MI) in forty-one thousandpatients, conventional treatment (i.e.,streptokinase + intravenous heparin)was compared with a more expensiveregimen (i.e., “accelerated” administra-tion of tissue plasminogen activator[t-PA] + intravenous heparin). This RCTdemonstrated that the t-PA regimen pro-vided a 0.9% higher chance of recoverythan the streptokinase treatment (TheGUSTO Investigators, 1993). On a popu-lation basis, the cost of using the moreexpensive t-PA on all patients who needthrombolytic therapy after an MI wouldbe $188,000 for each additional survivor(Chelluri, Sirio, & Angus, 1994). At thepatient level, there is little doubt that anindividual would prefer to have the t-PAtreatment if it increased their chances of survival, even by only 0.9%. However,at a societal level the issue becomesmore complex. Who is going to bear theadditional cost of the more expensive t-PA treatment? If the overall health ofthe entire population is the principalconcern, is it better to save more lives by making less costly treatments morewidely available (Hujoel, Armitage, &Garcia, 2000)?

The message is clear: when health-care standards are being developed orrevised, it is important that all availablesources of information and evidence be taken into account. In addition, thetarget population and purposes of thestandards need to be clearly articulated.When it comes to standards, one sizedoes not fit all. ■

References American Academy of Periodontology(1999). International Workshop for aClassification of Periodontal Diseases andConditions. Annals of Periodontology, 4 (1),1-112. American Academy of Periodontology(2003). Workshop on Contemporary Sciencein Clinical Periodontics. Annals ofPeriodontology, 8 (1), 1-352.Armitage, G. C. (1999). Development of a classification system for periodontal diseases and conditions. Annals ofPeriodontology, 4 (1), 1-6.Chelluri, L., Sirio, C. A., & Angus, D. C.(1994). Thrombolytic therapy for acutemyocardial infarction: GUSTO criticized[Correspondence]. New England Journal ofMedicine, 330, 505.Dietrich, T., & Garcia, R. I. (2005).Associations between periodontal diseaseand systemic disease: Evaluating thestrength of the evidence. Journal ofPeriodontology, 76 (11, Suppl.), 2175-2184. The GUSTO Investigators (1993). An international randomized trial comparingfour thrombolytic strategies for acutemyocardial infarction. New EnglandJournal of Medicine, 329, 673-682.Haffajee, A. D., Socransky, S. S., &Gunsolley, J. C. (2003). Systemic anti-infective periodontal therapy. A systematicreview. Annals of Periodontology, 8 (1),115-181.Hujoel, P. P., Armitage, G. C., & Garcia, R. I.(2000). A perspective on clinical signifi-cance. Journal of Periodontology, 71(9),1515-1519.Lang, N. P., Karring, T., Lindhe, J., Kinane,D. F., Sanz, M., & Tonetti, M. S. (2002).Fourth European Workshop onPeriodontology, Charterhouse at Ittingen,Thurgau, Switzerland. Journal of ClinicalPeriodontology, 29 (Suppl. 3), 1-233.Newman, M. G., Caton, J., & Gunsolley, J.C. (2003). The use of the evidence-basedapproach in a periodontal therapy contem-porary science workshop. Annals ofPeriodontology, 8 (1), 1-11.Smith, G. C. S., & Pell, J. P. (2003).Parachute use to prevent death and majortrauma related to gravitational challenge:Systematic review of randomised controlledtrials. British Medical Journal, 327, 1459-1461.

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When it comes to standards, one size does not fit all.

Debora Matthews, DDS

AbstractClinical pathways are patient care algo-rithms based on best evidence. They areintended to minimize variance in treatmentand thus reduce cost, increase efficiency,and ultimately improve patient care out-comes. Clinical paths are more commonlyused in the United Kingdom, and there isevidence that they are effective in themedical context. Some limitations thatdentists may want to keep in mind regard-ing critical paths are that they may not beappropriate for all patient especially thosewith complex conditions); they present thepotential for being misunderstood or mis-applied; and practitioners often find themtime-consuming, restrictive, and intrusive.

As clinicians, we are always (consciously or not) makingdecisions about the best possible

care for each of our patients. It would be nice if we had a “cookbook” withstep-by-step “recipes” for each possibleclinical situation. In a manner of speaking, we do. Standards of care,parameters of care, clinical practiceguidelines, clinical care pathways, andintegrated care pathways—the literatureabounds with recipes, but differentiationamong them is not entirely clear. Thispaper will outline some of those differ-ences, focusing on the role of clinicalpathways (CPs).

Standards of care are generally mandated by government legislation orlicensing bodies, as interpreted throughthe legal system. They tend to be rigidprescriptions for care or observance of previous precedence and are usuallyminimally accepted standards. Parametersof care, as used by the American Academyof Periodontology, have been based onboth narrative (the traditional literaturereview) and systematic reviews of the literature, and may or may not involveconsensus of clinical or content experts.Clinical practice guidelines are based onthe best available evidence (generally asystematic review) and use rigorous and explicit methods to search for andcritically apprise the entire body of clinical research evidence related to thequestion. This evidence is then integratedwith clinical expertise from practitionersand patients to develop workable clinicalrecommendations. Each guideline is

intended for use in specific conditions orcircumstances. The individual clinicianis expected to take into account eachpatient’s history and preferences, togetherwith his or her clinical experience andjudgment, when applying a guideline.Unfortunately, research on the organiza-tional, behavioral, and cost implicationsof applying a particular guideline is rare.As a result, the uptake of guidelines hasbeen less than ideal (Grol & Grimshaw,1999; Stephens, 1998).

Clinical pathways (CPs) or criticalpaths, or treatment protocols, have beenlikened to manufacturing guides used in industry. There may be many ways ofassembling a Volvo station wagon, forinstance, but each one is put together thesame way on the assembly line becauseit is the most efficient and cheapest way to do so. CPs are multidisciplinaryhealthcare algorithms, intended to reducevariability and cost, increase efficiency,and ultimately improve patient care.Clinical pathways also provide a meansof ongoing audit into clinical practice. As with standards of care and clinicalpractice guidelines, their aim is to improvepatient care, as well as continuity andcoordination of care across different disciplines and sectors. Regardless ofwhether or not these efforts are effectivein achieving such goals, many institutionsand managed-care programs have developed such pathways.

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What Is a Clinical Pathway?

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Dr. Matthews is Chair ofPeriodontics at DalhousieUniversity School of Dentistryin Nova Scotia. She may bereached at [email protected]

CPs should have four main compo-nents (Hill, 1995; 1998): 1) a timeline; 2) the categories of care or activities andtheir interventions; 3) outcome criteria;and 4) a record of variances between thecare that is planned and the actual careprovided. The latter allows for audit andanalysis at an organizational level. Thetreatment algorithms included in path-ways are built on “best practices” and thebest available evidence (ranging from asystematic review to expert opinion) andoffer clinicians reproducible methodologyfor managing difficult problems.

Limitations of Care PathwaysWoolf et al. (1999) present an in-depthlook at the limitations of care pathwaysand practice guidelines. If not carefullyand thoughtfully developed they canharm the very groups they are intendedto benefit—namely, patients, cliniciansand organizations. The most importantlimitation of CPs (and clinical practiceguidelines) from a patient perspective isthat the recommendations may be wrong,or at least wrong for individual patients.Because of their structured format, CPsmake it easy to apply the cookbookapproach to patient care. It is much easierto rely on an algorithm than it is tothink about each patient and theirunique situation. And, more often thannot, good quality evidence on which CPsare based is lacking, misleading, or misinterpreted. Even when the data arecertain, recommendations for or against

interventions involve subjective valuejudgments, made by members of theguideline group, when the benefits areweighed against the risks.

Because of their nature, CPs do notrespond well to unexpected changes in apatient’s condition. CPs are better suitedto standard conditions than rare orunpredictable ones. There inflexibilitydoes not always allow clinicians to tailorhealth care to each patients’ personalcircumstances and medical history.Blanket recommendations, such as arefound in CPs, ignore patients’ preferences(Woolf, 1997). Thus, the frequently toutedbenefit of pathways—more consistentpractice patterns and reduced variation—may come at the expense of reducingindividualized care. Lay versions ofguidelines, if improperly constructed andworded, may mislead or confuse patients and disrupt the doctor-patientrelationship. In short, practices that aresuboptimal from the patient’s perspectivemay be recommended to help controlcosts, serve societal needs, or protect special interests (those of dentists, dentalhygienists, program administrators, orpolicymakers).

Even when CPs are appropriate, clinicians often find them inconvenientand time consuming to use. Outdatedrecommendations may perpetuate out-moded practices and technologies. As anaudit is a major component of CPs, clini-cians may feel the quality of their care isbeing unfairly judged. CPs are designedto be explicit; they may include injudi-cious words (“should” vs. “may”),arbitrary numbers (such as months of

treatment, intervals between recallexaminations), and simplistic algo-rithms when supporting evidence islacking. Algorithms that reduce patientcare into a sequence of yes/no decisionsdo not take into account the complexityof clinical decisions. Words, numbers,and simplistic algorithms can be used bythose who judge clinicians to repudiateunfairly those who, for legitimate rea-sons, follow different practice policies.This may prompt providers to withdrawavailability or coverage. A theoreticalconcern is that clinicians may be sued fornot adhering to guidelines. Fortunately,this has not yet become an importantreality. However, the use of flawed orinappropriate care pathways by dentalprofessionals, third-party payers, ororganizations can do more harm thangood, entrenching the delivery of ineffec-tive, harmful, or wasteful interventions.

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Algorithms that reducepatient care into a sequenceof yes/no decisions do nottake into account the com-plexity of clinical decisions.

Figure 1. National Health Service England Algorithm for Oral Health Assessment and Recall.

Clinical Pathways in DentistryCPs are most useful in large organiza-tional settings, where a multidisciplinaryteam is responsible for various aspects ofthe care of a patient. In the managementof a patient with a fractured hip, forexample, lab technicians, radiologists,nurses, orthopedic surgeons, and physiotherapists may be involved. This israrely the case with dentistry, where themajority of general dentists are, in effect,small business owners, and are presentthroughout, or directly oversee, the management of each patient.

Unlike North America, dentistry inthe United Kingdom is often practicedwithin a hospital. As well, rather than anentrepreneurial system, reimbursementfor services is provided through theNational Health Service (NHS). Not surprisingly, all care pathways appear to

come from the NHS either directly orthrough individual hospitals. A protocolexists for the management of head andneck malignancies in which the dentalteam is one of many (University of YorkCentre for Reviews and Dissemination,2004). Many hospitals have developedcare pathways for minor (and major)oral surgery. These usually includechecklists of everything from health history to clinical assessment to swaband instrument counts and length of stay.They are rarely in the form of algorithmsfor the management of a patient with aparticular disease or condition.

In 2004, under the auspices of theNHS, the Dental Health Services ResearchUnit at the University of Dundee publisheda CP to determine intervals between oralhealth recalls (National CollaboratingCentre for Acute Care, 2004). This is acomprehensive, well-designed CP. It is

based on the best available evidence andthe process of development is clearlydocumented. The recommendations takeinto account the impact of dental checkson patients’ well-being, general healthand preventive habits, caries incidence,periodontal health, and avoidance ofpain and anxiety. In addition to providingan algorithm for care (Figure 1), the CPdocument contains a quick referenceguide with clear step-by-step clinicalguidelines, procedures for implementa-tion, a checklist for risk assessment, anda patient guide.

Do CPs Result in Better PatientCare?In spite of the sound principles underly-ing CPs, few evaluations have been doneexamining the cost of developing andimplementing them and their effective-ness in changing practice and improving

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Full patienthistoriesrecorded

Thoroughdental, headand neckexaminations

Initial dentaldiseasepreventionadvice

Patient anddentist agreeon care plan

Dental report:findings,agreedprovisionalplan and ‘journeydestination’

New NHSdental patient

Oral health review

NHS primary oral health care

Oral health maintenance and agreed recall interval (NICE)

Private dentistry

Entry toNHSprimarycare

Personalcare plancompleted

Dental teamand patientwork throughpersonal care plancomponents

Updatepatienthistories

Updateexaminations

Assess ifpreventionadvice working andre-advise

Patient anddentist agreeon care plan

Dental report:findings, refine planand ‘journey’ destination’

patient outcomes. An article on Bandolier,an evidence-based medicine site, examined fifteen randomized controlledclinical trials that measured the impactof care pathways on patient outcomes.All but one led to improvements in diseasemanagement. These improvementsincluded shorter hospital stays, fewercomplications, and lower mortality.Three of the papers did not include costsor resource allocation as an outcomemeasure. One study found no differencein the quality of care, thus an increasedcost of implementing the CP; anotherfound no difference in the cost, but animprovement in patient outcomes. Theremaining ten showed that costs werereduced, while improving quality of care.In fact, three of the studies reexaminedoutcomes up to two years later, findingeven more cost savings over time.

A clinical guideline or care pathwaymay be shown to be effective, but that isonly true insomuch as they are actuallyused. A major hurdle in the use of carepathways is changing clinicians’ behav-ior (Eccles et al. 2005; Grimshaw et al.2001; Grol, 1997). Several qualitativereviews have described the effects ofinterventions such as educational pro-grams, feedback to healthcare providers,provider reminders and financial incentives. Oxman et al. (1995) reviewedone hundred two trials and concludedthat a wide range of interventions mayimprove practice but that there are no“magic bullets.” Davis et al. (1997)showed that educational interventionsimproved physician performance andpossibly patient outcomes. Mugford(1991) found provider feedback effectivewhen part of an overall implementationstrategy. In a systematic review byWeingarten et al. (2002), one hundredtwo studies evaluating one hundredeighteen discrete care pathways forpatients with chronic illnesses wereexamined. The majority of disease man-agement programs used two or more

interventions, possibly because multipleinterventions are thought to be morelikely to be successful than single interventions. Overall, 30-40% of theprograms made small but significantimprovement in patient outcomes.

Because of the promise that diseasemanagement holds for improving patientcare, about $1 billion is invested in clini-cal care pathways in the United Stateseach year. The National Committee onQuality Assurance (NCQA) in the UnitedStates requires health plans to submitdata on two disease management programs each year for consideration ofaccreditation. However, this investmentin CPs should be guided by information

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Figure 2. Care Pathway for Determining Oral Health Recall Intervals.

Step 1

Step 2

Step 3

Step 4

Step 5

Children/young peopleIf the patient is younger

than 18 years

AdultsIf the patient is

18 years or older

Overview of how the interval between oral health reviews is set

Consider the patient’s age; this setsthe range of recall intervals.

Consider modifying factors in light of the patient’s medical, social, anddental histories and findings of theclinical examination.

Integrate all diagnostic and prognosticinformation, considering advice fromother members of the dental teamwhere appropriate.Use clinical judgement to recommendthe interval before the next oralhealth review.

Discuss recommended interval withthe patient.Record agreed interval or any reasonfor disagreement.

At next oral health review, considerwhether the interval was appropriate.Adjust the interval depending on thepatient’s ability to maintain oralhealth between reviews.

3months

12months

3months

24months

3months

12months

3months

24months

3months

12months

3months

24months

Discussion

Reassessment

Discussion

Reassessment

on how to optimize the benefits of theseprograms for the patient and the system.In medicine CP developers have had limited qualitative or quantitative information about which interventionsachieve the greatest benefits; in dentistry,no such studies have been done.

Evidence-based health care, qualityassurance, clinical guidelines, care pathways—whatever we call it—we mustremember that as health care professionalsour goal is to treat the right patient rightin the right way and at the right time.■

ReferencesEccles, M., Grimshaw, J., Walker, A.,Johnston, M., & Pitts, N. (2005). Changingthe behavior of healthcare professionals:The use of theory in promoting the uptakeof research findings. Journal of ClinicalEpidemiology, 58 (2), 107-112.Davis, D. A., & Taylor-Vaisey, A. (1997).Translating guidelines into practice. A systematic review of theoretic concepts,practical experience and research evidencein the adoption of clinical practice guide-lines. Canadian Medical AssociationJournal, 157, 408-416.Grimshaw, J. M., Shirran, L., Thomas, R.,Mowatt, G., Fraser, C., Bero, L., et al.(2001). Changing provider behavior: An overview of systematic reviews of interventions. Medical Care, 39 (8 Suppl 2),II 2-45.Grol, R. (1997). Beliefs and evidence inchanging clinical practice. British MedicalJournal, 215, 418-421.Grol, R., & Grimshaw, J. (1999). Evidence-based implementation of evidence-basedmedicine. Joint Committee of the Journalof Quality Improvement, 25 (10), 503-513Hill, M. (1995). CareMap and case management systems: Evolving modelsdesigned to enhance direct patient care. In: S. Blancett & D. Flarey (Eds).Reengineering nursing and health care:Handbook for organizational transformation.

Hill, M. (1998). The development of caremanagement systems to achieve clinicalintegration. Advances in Practical NursingQuality, 4 (1), 33-39.Mugford, M., Banfield, P., & O’Hanlon M.(1991). Effects of feedback of informationon clinical practice: a review. BritishMedical Journal, 303, 392-402.National Collaborating Centre for AcuteCare (2004). Clinical guideline 19. Dentalrecall. Recall interval between routine dental examinations. London: The Center.Oxman, A. D., Thomson, M. A., Davis, D.A., & Haynes, R. B. (1995). No magic bullets: A systematic review of 102 trials of interventions to improve professionalpractice. Canadian Medical AssociationJournal, 153, 1423-1431.Service, N. H. (Ed). Care pathways know-how zone. London: National ElectronicLibrary for Health. Stephens, R. G. (1998). A lesson to belearned. The Ontario experience with legislated quality assurance should be awarning to other provinces. Oral Health,88 (5), 51-52.University of York Centre for Reviews andDissemination (2004). Management ofhead and neck cancer. Plymouth, UK:Latimer Trend & Company Ltd.Weingarten, S. R., Henning, J. M.,Badamgarav, E., Knight, K., Hasselblad, V.,Anacleto Gano, A., Jr., et al. (2002).Interventions used in disease managementprogrammes for patients with chronic illness—which ones work? Meta-analysisof published reports. British MedicalJournal, 325.Woolf, S. H. (1997). Shared decision-making: The case for letting patientsdecide which choice is best. Journal ofFamily Practice, 45, 205-208.Woolf, S. H., Grol, R., Hutchinson, A.,Eccles, M., & Grimshaw, J. (1999). Clinicalguidelines: Potential benefits, limitations,and harms of clinical guidelines. BritishMedical Journal, 318 (7182), 527-530.

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Because of their structuredformat, CPs make it easy to apply the cookbookapproach to patient care. It is much easier to rely onan algorithm than it is tothink about each patient and their unique situation.

Richard Niederman, DMD, MADerek Richards, BDS

AbstractEvidence-based dentistry is the use by dentists of best research evidence, clinicaljudgment and patient values to guide practice. This article focuses on methodsdentists can use to collect the best relevant evidence. Using the examples of systemic fluoridation and fluoridateddentifrices, the authors illustrate a five-step process of: 1) asking answerablequestions; 2) conducting a systematicsearch; 3) critically appraising the literature; 4) applying results to practice;and 5) evaluating outcomes.

Evidence-based health care, and evidence-based dentistry (EBD) asa subset, is the “…integration of

the best research evidence, with clinicaljudgment, and patient values” toimprove health care (Sackett et al. 2000).Essentially, EBD is a set of methods forrapidly aggregating, distilling, andimplementing the best clinical informa-tion in clinical practice. While mostclinicians will not engage in developingevidence, they can relatively easilybecome effective evidence users. Thismanuscript introduces the concepts ofEBD and provides a mechanism for theirimplementation in practice.

Water fluoridation is a good exampleof the conundrum that surrounds evidence-based health care and EBD. Thecurrent best evidence is the systematicreview published by the Centre forReviews and Dissemination, YorkUniversity in 2000 (www.york.ac.uk/inst/crd/fluorid.htm). After a two-year,open -access process evaluating theworld’s literature, the editorial groupconcluded that water fluoridation waseffective in preventing dental caries.Further, it had only one demonstrateddownside, fluorosis in a small percentageof people. Clinical judgment is representedby the more than one hundred interna-tional healthcare organizations thatsupport water fluoridation. Former U.S. President Kennedy best articulatesvalues when he said: “…our most basiccommon link…is that…we all cherish

our children’s future. And we are allmortal.” Supporters of water fluoridationdo so to protect their children’s future.

Conversely, opponents of waterfluoridation, based on their value system, argue that water fluoridation isa violation of freedom of choice, that it is mass medication, that it is toxic, andmost potently that the data are biased.The claim of data bias is based on theobservation that most of the studiesresulting in high quality data were funded by government agencies thatsupport water fluoridation.

The EBD MethodThe EBD approach has five steps:1. Ask answerable questions2. Systematically search for the

best evidence3. Critically appraise the evidence4. Apply the evidence in practice5. Evaluate the outcome

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Evidence-Based Dentistry: Concepts and Implementation

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Dr. Niederman is the directorof the Forsyth Center forEvidence-Based Dentistry, The Forsyth Institute, 140 The Fenway, Boston, MA; and Health Policy & HealthServices Research, BostonUniversity Goldman School ofDental Medicine, Boston, MA;[email protected].

Dr. Richards is at the Centrefor Evidence-Based Dentistry,Oxford University, Oxford, UK.

A clinical scenario might best exemplify the method, and Internet references to each of the steps are avail-able (Niederman et al. 2004).

Scenario: A new ten-year-old patient,who lives in a fluoridated community,comes to see you with his mother. Hehas interproximal carious lesions onboth mandibular first molars. The mother, who has been using non-fluori-dated toothpaste asks: “Should we usefluoridated toothpaste?”

Ask Answerable Questions:Using an EBD approach, the mother’squestion would be reframed in a questionwith four parts: Problem (P), Intervention(I), Comparison (C), Outcome (O). Anexample of this “PICO” question formatfollows:

Problem: “In children from fluoridatedcommunities with caries…”

Intervention: “…would using a fluoridated toothpaste…”

Comparison: “…when compared tonon-fluoridated toothpaste…”

Outcome: “…reduce the incidence of caries?”

Search for the Best Evidence:Finding the answer to a key question

and keeping up with the current literaturecan be a profound task. A recent studyfound that for each of the dental special-ties (Niederman et al. 2002): 1) morethan five hundred clinical trials werepublished per year; 2) clinical trial publi-cation is increasing by 10% per year; and 3) trials are published in more thatthirty different journals. Thus, to staycurrent, one would need to identify,obtain, read, appraise, implement, andevaluate more than one article per day,seven days a week, three hundred andsixty-five days per year. This is an impos-sible task, if one also expects to have anactive practice.

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Table 1. Levels of Evidence Demonstrating Causality in Humans

Evidence Level Study Type

1 Systematic review & Review of randomized controlled trialsRandomized controlled trials Experimental + control, randomization

2 Cohort trial Experimental + control, no randomization

3 Case-Control trial Experimental + control, retrospective

4 Case series Experimental only, prospective

5 Narrative review, Editorial

N/A Case report, Epidemiology, Animal studies, In vitro studies

Adapted from: Centre for Evidence-Based Medicinewww.cebm.net/levels_of_evidence.asp

Table 2. Comparison of Clinical Trials and Systematic Reviews

Clinical Trial Systematic Review

Stated hypothesis Stated hypothesis

Protocol specifying: Protocol specifying:

Patient recruitment Search strategy

Patient inclusion/exclusion Study inclusion/exclusion

Intervention comparison Intervention comparison

Data analysis Data analysis

Adapted from: Needleman (2002)

Table 3. Comparison of Systematic and Traditional Narrative Reviews

Systematic Review Narrative Review

Methods stated Method not stated

Focused question Broad issue

All studies located Biased study selection

Critical appraisal No critical appraisal

Data-based conclusion Opinion-based conclusions

Continuous results Dichotomous results

Adapted from: Needleman (2002)

One can use EBD search methods,however, to reduce this time. The methoddescribed below takes about five minutesto identify from some fifty-five thousandarticles, the twenty evidence-based systematic reviews.

Returning to the fluoride toothpastescenario, one can search the NationalLibrary of Medicine’s free access database,www.PubMed.gov, for “toothpaste” and“caries” and “fluorides.” Individually,each topic identifies approximately fivethousand, twenty-six thousand, andtwenty-five thousand articles, respectively.Using PubMed’s utilities, the searches,when they are grouped together, identifyapproximately one thousand articlesthat simultaneously include all three topics. Applying more of PubMed’s utilities the number of articles is reducedto one hundred and thirty narrativereviews, of which twenty are evidence-based systematic reviews.

Examining the twenty identified systematic reviews; the second review on the list distills seventy studies thatinclude forty-two thousand children(Marinho et al. 2004). The results indicatethat fluoride toothpaste reduces cariesby 25% in children when children haveone carious lesion per year, and is twiceas effective in children with a greaterincidence of caries. Furthermore, thebenefit was not influenced by waterfluoridation.

Critically Appraise the Evidence:Clinical evidence comes in multiple, and often conflicting forms, or evidencelevels (Table 1). From an EBD perspec-tive the central element is the ability todemonstrate cause-effect relationships in humans in as unbiased a way as possible. To accomplish this, the searchresults are first stratified by evidencelevel, and then evaluated from three perspectives: is the study valid; are theresults clinically important; and can theybe applied to my patient? (Centre for

Evidence-Based Medicine, www.cebm.net/critical_appraisal.asp). Interestingly, this is the same evidence pyramid independently identified by the U.S.Supreme Court in Daubert v. Merrill-Dow (1993).

The best example of this rules-basedapproach to critical appraisal is the contrast between a systematic reviewand a narrative review (evidence level 1and level 5, respectively). A narrativereview is a traditional literature reviewwhere a content expert articulates his orher version of the historical evidence,based on his or her reading of the litera-ture. In marked contrast, a systematicreview is based on rules, much like aclinical trial, using the five-step methodarticulated in this manuscript (Table 2).In using this rules-based approach, a systematic review is less biased than atraditional narrative review (Table 3).

Apply the Evidence in Practice:Evidence application is a two-step“process”. The first step is a determina-tion of values, and the second step isactual implementation. In the U.S.health system there are at least fourcompeting value systems for a patient,with dental insurance, sitting in a dentalchair (Table 4). These value systems orvalue equations for clinical care high-light contrasting economic perspectivesof four stakeholder groups. The valueequations all incorporate the same fourelements: clinical effectiveness, need,time, and fees. Further, the clinical effec-tiveness is identical for all stakeholdergroups. This highlights the consistencyof “clinical evidence” use among thestakeholder groups.

However, the groups whose needsare addressed change, and the fee andtime are variable. For example, at theextremes, from a patient’s perspective,

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EBD is a set of methods for rapidly aggregating, distilling, and implementingthe best clinical informationin clinical practice.

dental care is most valuable when it iseffective, meets their needs, takes verylittle time, and fees are modest.Conversely, from a dentist’s perspectivedental care is most valuable when it iseffective, meets the patient’s needs, takesvery little time, and fees are high. Theclinician’s challenge, then, is to integratethese sometimes-conflicting value systems. In short, integrating clinicalevidence with clinical judgment and thepatient’s values.

The second step is actual implemen-tation. Knowing what works in clinicaltrials and knowing how to implementthis information in clinical practice:“know what” and “know how,” respec-tively (Niederman & Leitch, in press).Connecting them requires knowledgecreation, and effective knowledge creation in practice is experimentallybased (Table 5) (adapted from Langleyet al. 1996).

Developing clinical know how typically takes multiple iterations withbefore-after comparisons. The numberof comparisons, time frame for compar-isons, and the number of iterations willdepend on the complexity of the newintervention. As a trivial example, consider the first successful amalgamplaced on an ivorine tooth in dentalschool. The comparisons to ideal, timeframe, and number of iterations dependedon individual talent. Similarly, translating

this “know what” to clinical “know how”in a patient took additional work.

Evaluate the Outcome:Methods for evaluating outcomes dependon the complexity of the intervention. At the extremes one can consider a newprophylaxis paste and a new implantsystem. The first might require sixtyminutes to evaluate with several patients.The latter might require multiple intensivetraining sessions, followed by treatmentof multiple patients over multiple years.

At baseline, however, the four evaluative elements are similar: is thereexperimental evidence of efficacy; isthere a clinical advantage for the newproduct or procedure; is it simple to use; and most importantly, can it be evaluated in practice? Practice evaluationrequires a systematic determination of a pre-implementation measure onmultiple patients, followed by a system-atic determination of the same measurepost-implementation.

The marketing of a new prophylaxispaste provides a simple example. A newpaste is marketed to obviate the adverseattributes of current pastes: splattering,sandy texture, and patient’s dislike. On a3x5 card one could evaluate the currentpaste in the three categories on a scaleof 1 to 5 for one-half dozen patients inthe morning. Then in the afternoon, onanother 3x5 card, one could similarlyevaluate the new paste. At the end of theday, one could total the categories on both

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Table 4. Competing Value Systems

Stakeholder Value Numerator Denominator

Patient V = Clinical Effectiveness x Needs (Patient) / Fee (Dentist) x Time Employer V = Clinical Effectiveness x Needs (Employees) / Fee (Insurer) x Time Dentist V = Clinical Effectiveness x Needs (Patient) x Fee (Dentist) / Time Insurer V = Clinical Effectiveness x Needs (Employer + Dentist) x Time / Fee (Clinician)

The value systems for each of the stakeholder groups all incorporate four elements: treatment effectiveness, needs, fees, and time.However, the stakeholder whose needs are addressed varies. As well, the fee and time move between the numerator and denominator,depending on the stakeholder. Finally, depending on the stakeholder, the value may be determined on an individual (e.g., for the patient and dentist) or a population (e.g., for an employer and insurer) basis.

cards and systematically identify the better paste for use in clinical practice.

ResourcesOf the five-step approach to EBD, thefirst three are core skills that are nowtaught in some dental schools and postgraduate courses. There are alsomultiple resources that clinicians canrapidly access for high quality validatedevidence-based information. These rangefrom clinical guidelines, to systematicreviews, to search engines, to journals,to courses. Table 6 provides a samplingof several resources available. In particular, the Centre for Evidence-BasedDentistry, Oxford, has a comprehensivelist of resources. ■

ReferencesDaubert v. Merrill Dow Pharmaceuticals,Inc. (1993). 509 U.S. 579, 595. Langley, G. J., Nolan, K. M., Nolan, T. W.,Norman, G. L., & Provost, L. P. (1996). TheImprovement Guide. A practical approachto enhancing organizational performance.Jossey-Bass, San Francisco.Marinho, V. C., Higgins, J. P., Logan, S., &Sheiham, A. (2003). Topical fluoride (tooth-pastes, mouthrinses, gels or varnishes) for preventing dental caries in children andadolescents. Cochrane DatabaseSystematic Reviews, 4.Needleman, I. G. (2002). A guide to systematic reviews. Journal of ClinicalPeriodontology, 29 Suppl 3, 6-9.Niederman, R., Chen, L., Murzyn, L., &Conway, S. (2002). Benchmarking the dental randomized controlled literature onMEDLINE. Evidence-Based Dentistry, 3, 5-9.Niederman, R., & Leitch, J. (in press).Know-what and know-how: Knowledge creation in practice. Journal of DentalResearch.Niederman, R., Richards, D., Matthews, D.,Shugars, D., Worthington, H., & Shaw, W.(2003). International standards for clinicaltrial conduct and reporting. Journal ofDental Research, 82, 415-416.Sackett, D. L, Straus, S. D., Richardson, W.S., Rosenberg, W., & Haynes, R. B. (2000).Evidence-Based Medicine: How to practiceand teach EBM. Churchill.

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Table 5. Clinical Knowledge Creation

Clinical Knowledge Clinical Trial Clinical Practice

Goal Know what Know-howHypothesis Fixed FlexibleSample Large Small, iterativeTrial type Controlled Case seriesMeasure Blind ObservableBias Eliminate Accept

Clinical knowledge creation takes two forms, clinical trials and clinical practice. Becauseof the knowledge goals of each, the method for obtaining the highest level of evidencevaries slightly for hypothesis framing, sample size, trial type, blinding, and bias.

Adapted from: Niederman and Leitch, in press.

Table 6. Selected Clinical Resources

Resource Publisher, URL

Clinical Agency for Healthcare Research and Quality, Guidelines U.S. Department of Health and Human Services

www.guidelines.gov

Scottish Intercollegiate Guideline Networkwww.sign.ac.uk/

Systematic The Cochrane CollaborationReviews www.cochrane.org

Center for Reviews and Dissemination, University of York, UKhttp://144.32.150.197/scripts/WEBC.EXE/NHSCRD/start

Search National Library of Medicine, U.S. National Institutes of HealthEngines www.pubmed.gov

The Forsyth Institutewww.evidents.org

Web site Centre for Evidence-Based Dentistry, Oxford Universitywww.cebd.org

EBD Journal Nature Publishingwww.nature.com/ebd/index.html

Training Oxford Universitywww.conted.ox.ac.uk/cpd/healthsciences/courses/short_courses/Dentistry/

Kathleen T. O’Loughlin, DMD, MPH, FACDRobert Compton, DDS

AbstractThe origins of standards and guidelines in medicine are traced from work in the1970s showing that treatment variationscould not be accounted for by objective differences in the disease or other conditions of patients. Guidelines based on evidence can be effective in reducingsuch variation and in reducing costs.However, population disparities in diseaseand access, as well as dramatically rising insurance costs, pose challenges.Standards based entirely on efficacy ofprocedures will leave unanswered important questions about diagnosis and effective allocation of resourcesthroughout population groups.

Standards of care for dentistry havebeen discussed for decades as away to improve quality of care in

the oral healthcare delivery system. TheAmerican Dental Association, in thePreamble to Dental Practice Parameters,distinguishes among “standards of care,”“parameters of care,” and “guidelines.”Specifically, they state that standards ofdental care “are rigid and inflexible andrepresent what must be done”; parame-ters are intended as “an aid to clinicaldecision making and thus they describeclinical considerations in the diagnosisand treatment of oral health conditions”;and guidelines are “less rigid, but repre-sent what should be done.” Although all three have important places in theprofession and for the public, attentionis increasing focused on guidelines.

Standards of care seem to applymore in the legal realm. J. P. Graskemper(2004), a dentist and an attorney, provides an excellent review of standardsof care in dentistry. He notes that thestandard of care actually is found in thedefinition of negligence, which is said tohave four elements, all of which must bemet to allow negligence to be found in amalpractice lawsuit. Those four elementsare as follows:

1. That a duty of care was owed by thedentist to the patient;

2. That the dentist violated the applica-ble standard of care;

3. That the plaintiff suffered a compen-sable injury; and

4. That such injury was caused in factand proximately caused by the sub-standard conduct.

Graskemper further states that thebest definition can be found in Blair v.Eblen: “[A dentist is] under a duty to usethat degree of care and skill which isexpected of a reasonably competent[dentist] acting in the same or similarcircumstances.” While standards of careare certainly important to any dentistfacing a malpractice lawsuit, from theperspective of improving the quality ofcare, parameters of care and clinicalguidelines are more important.

Improving Quality of CareOne of the driving forces leading to the development of clinical guidelineswas the work of the physician John E.Wennberg. In 1969, he became theregional medical director in Vermontand began collecting utilization data.Initially he collected it in Vermont butexpanded his data base by adding utilization data from Maine and Iowa. Asresearchers were analyzing the data itbecame apparent that similar diseases/conditions were treated significantly different depending on the area of thecountry that the patient resided(Wennberg & Gittelsohn, 1973). Forexample, it was found that in some

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Standards

Dr. O’Loughlin is Presidentand CEO of Dental Service ofMassachusetts. She may bereached at [email protected].

Dr. Compton is Chief DentalOfficer at Delta Dental Plan ofMassachusetts.

communities 70% of women had hys-terectomies by age seventy compared toonly 20% of similar women in othercommunities. Similarly, 70% of childrenhad tonsillectomies in some communitiescompared to only 8% in others. It appearsthat the strongest determinant of thetype of treatment a patient received was where they lived and where thephysicians received their training. SoWennberg’s team went to the medicallibraries to see which treatment modali-ties were supported by the scientificevidence. What they found was therewere no studies (Millenson, 1997).Similarly, students have shown that agreat deal of variability exists in dentaltreatment as well.

In the 1970s the focus shifted toimproving the quality of care. Donabedian(1980), in The Definition of Qualityand Approaches to Its Assessment, toldus that we needed look at structure,process and outcome. Outcome, the endresult of the care we provide—did thepatient get better? —is what ultimatelyinterests us. But few, if any, outcomestudies were being performed. So insteadwe look at structure and process.Structure is all the “things” we need inorder to provide care. We need physicalspace, medical equipment, trained qualified personnel, medical records,sterilization procedures and other suchthings. Process, is the work or care thathealthcare providers perform or provide.

In the 1980s, organizations such asthe National Committee for Quality

Improvement and the Joint Committeeon Healthcare Quality began measuringstructure as part of its credentialingprocess. They also began to look atprocess with such measures as thosefound in HEDIS standards.

Clinical GuidelinesAccording to the Library of Medicine,clinical guidelines “assist the healthcarepractitioner with patient care decisionsabout appropriate diagnostic, therapeutic,or other clinical procedures for specificclinical circumstances.” The first clinicalguideline is often attributed to theAmerican Cancer Society, which in 1980developed its guideline for the cancer-related health checkup (Eddy, 1980).Their advice is still timely today:

First, there must be good evidencethat each test or procedure recommendedis medically effective in reducing mor-bidity or mortality; second, the medicalbenefits must outweigh the risks; third,the cost of each test or procedure mustbe reasonable compared to its expectedbenefits; and finally, the recommendedactions must be practical and feasible.

By 1985 the American College ofPhysicians began publishing guidelines.The National Guideline Clearinghousewas created in 1997 by the Agency forHealthcare Research and Quality in partnership with the American MedicalAssociation and the American Associationof Health Plans (now America’s HealthInsurance Plans [AHIP]). There are over one thousand clinical guidelines,including many for dentistry, at theirwebsite (www.guideline.gov). Theclearinghouse has processes in place

to ensure that guidelines are submittedby credible organizations and gothrough a rigorous process to verify that they represent the best available scientific evidence. Systemic reviews,efficacy trials, effectiveness trials, meta-analysis, consensus of expert opinion,and other processes contribute to theirdevelopment. They are disease/conditionspecific and aim to ensure that there isconsistency in the quality of clinical care—again, to reduce the variability of carebetween similar populations with similardiseases and conditions.

The focus on quality continued intothe 1990s when the Institute of Medicine(2001) published Crossing the QualityChasm, which said that we should have six aims in improving the quality of the healthcare system. That reportestablished six quality improvement goalsfor the healthcare system. They are:• Safe: avoiding injuries to patients

from the care that is intended to help them.

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As the government andemployers struggle to absorbcontinued increases, pressure is mounting to control costs while increasing quality of care.

• Effective: providing services based on scientific knowledge to all whocould benefit, and refraining fromproviding services to those not likelyto benefit.

• Patient-centered: providing care that is respectful of and responsive toindividual patient preferences, needs,and values, and ensuring that patientvalues guide all clinical decisions.

• Timely: reducing waits and some-times harmful delays for both thosewho receive and those who give care.

• Efficient: avoiding waste, includingwaste of equipment, supplies, ideas,and energy.

• Equitable: providing care that does not vary in quality because ofpersonal characteristics such as gender, ethnicity, geographical location, and socioeconomic status.

It said we should aim to make care safe, effective, efficient, equitable,patient-centered, and timely.

They defined effective care as “providing services based on scientificknowledge to all who could benefit andrefraining from providing services tothose not likely to benefit from it.” Weoften refer to this as evidence-based care.D. A. Ebby (2005) offers perhaps the best definition of evidence-based care as“a set of principles and methods intendedto ensure that to the greatest extent possible, medical decisions, guidelines,and other types of policies (includingbenefit coverage, disease management,performance measures, quality improve-ment, medical necessity, regulations andpublic policy) are based on and consis-tent with good evidence of effectivenessand benefit.” The IOM (2001) also notedthat “care should not vary illogically

from clinician to clinician or from placeto place.”

With this background it is easy to seehow the Agency for Healthcare Researchand Quality, the American MedicalAssociation, and the American Associationof Health Plans came together to begindeveloping clinical guidelines. Accordingto the Library of Medicine clinical guide-lines “assist the health care practitionerwith patient care decisions about appro-priate, diagnostic, therapeutic, or otherclinical procedures for specific clinicalcircumstances.” A process is in place toassure that guidelines are submitted bycredible organizations and go through a rigorous process to verify that they represent the best available scientific evidence. Systematic reviews, efficacytrials, effectiveness trials, meta-analysis,consensus of expert opinions and otherprocesses go into their development.They are disease and condition specificand aim to ensure that there is consis-tency in the quality of clinical care—again to reduce the variability of care.

To ensure consistency, clinical guide-lines begin with a diagnosis to identify aspecific clinical condition. The clinicalguideline then assists the healthcareprovider by identifying which treatmentoptions have the strongest scientific evidence to support them leading to evi-dence-based care. That’s the startingpoint of treatment planning—identifyingwhat the scientific evidence says is themost effective care. To that a dentist may add patient preferences, his or herexperience, and other factors, such asinsurance coverage, to develop the treatment plan. However, the ultimatetreatment plan can be modified to thepoint where it is not supported by thebest available scientific evidence.According to Ebby’s definition, this maybe appropriate for that patient but it isnot evidence-based care. The challengefor payers of health benefits is to deter-mine at what point the actual treatmenthas insufficient scientific evidence to

support covering it as a benefit, especiallyif the evidence strongly supports analternative treatment.

The Disparities ChallengeThe 2000 Report of the Surgeon Generalon Oral Health in America concludedthat in spite of significant improvementsin the oral health of Americans over thelast fifty years, serious disparities exist.The oral health of low-income and disadvantaged populations has actuallyworsened due to a lack of access to basicoral health care. Major findings of theSurgeon General’s report include thefacts that oral disease affect health andwell-being throughout life, that safe andeffective measures exist to prevent themost common oral diseases, that lifestyle behaviors affect oral health, thatthere are profound oral health disparitieswithin the U.S. population, that moreinformation is needed to improve oralhealth, and that the mouth reflect thegeneral health. Scientific research is keyto further reduction in the burden of diseases. The Surgeon General’s reportconcluded that a “framework for action”must include five basic components if weare to improve oral health for all citizens:

• Change perceptions regarding oralhealth and disease so that oral healthbecomes an accepted component ofgeneral health.

• Accelerate the building of the scienceand evidence base and apply scienceeffectively to improve oral health.

• Build an effective health infrastruc-ture that meets the oral health needsof all Americans and integrates oralhealth effectively into overall health.

• Remove known barriers betweenpeople and oral health services.

• Use public-private partnerships toimprove the oral health of those who

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still suffer disproportionately fromoral diseases.

This “call to action” provides a broadtemplate for improving population oralhealth; however it does not address thegrowing threat to dental care access thatis a direct result of limited financialresources and unsustainable escalationof medical costs. These goals are consis-tent with improving quality in the oralhealthcare delivery system, especially inthe areas of effectiveness and efficiency.

Economic ChallengesThe National Health Statistics Group hasprojected that national health spendingwill grow at an average rate of 7.2% overthe coming decade. This compares to the projected average rate of growth inGross Domestic Product (GDP) of only1.5% over the same period. The resultwill be that healthcare costs will doublein ten years, going from $2 trillion in2005 to $4 trillion in 2015. This alsomeans that healthcare costs will grownfrom 16% of GDP in 2004 to 20% of ournation’s Gross Domestic Product by 2015.

However, this rate of growth is actually a decline from 9.8% growth inhealthy costs in 2002. The main reasonfor this decline was not moderation inmedical inflation. The main reason wasa sharp deceleration in use of services.Utilization management is being reintroduced, rising copayments anddeductibles are impacting consumerdemand, and more people are becominguninsured as employers are cutting benefits and employees. According to the Urban Institute’s Study released inNovember 2005, an analysis of the“March Current Population Surveys,2001 and 2005” reveals that the numberof Americans without health insuranceis now around forty-six million and theuninsured have increased by 2.7% fromthe year 2000 to 17% in 2004. But hiddenin the data is the fact that there is also

a shift occurring within the insured populations. That rise was mainly from5.2% more children being covered byMedicaid. The adults were not as fortu-nate; the 2.7% growth in the uninsuredpopulation was totally for adults.

The cost of dental services is projectedto grow from $87.4 billion in 2005 to$167 billion by 2015. They are expectedto grow at a 7.9% rate in 2006, but fallback to 6.0% by 2015. Approximately onehalf of the population (54%) currentlyhas some form of dental benefit, and the dental benefit market is expected togrow at approximately 2% to 3% annually.Having dental benefits significantlyimpacts the ability to access care.According to the Agency for HealthcareResearch and Quality (2004), 47.8% ofinsured individuals under the age ofsixty-five accessed care in 2000, whileonly 28.9% of those covered by Medicaidand 19.2% of the uninsured did so. Notonly did more insured people visit thedentist, but they also had more visits per person (13.6% more). In 2000 theaverage person with dental benefits paid4.1% out-of-pocket, while the uninsuredpaid 79.8%. This may account for whyso few of them accessed care and validated the assertion that out-of-pocketexpense is a significant barrier to accessing care. Overall, government contributes only around 5% of the totaldental annual costs.

What Is NeededWhy should the oral health professionbe interested in the creation of clinicalguidelines?

Despite current conventional wisdomto the contrary, establishment andacceptance of dental standards of carewill not mitigate the most urgent issuescurrently the profession today. Oral

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The challenge for payers of health benefits is todetermine at what point the actual treatment hasinsufficient scientific evidence to support covering it as a benefit,especially if the evidencestrongly supports an alternative treatment.

health disparities, continuing financialbarriers, ineffectiveness of treatments,commercialization of esthetic treatments,and inefficiency in the delivery of oralhealth care especially are immediate critical problems to be solved if thiscountry is to achieve optimum oralhealth for all. A more feasible approachmay be the development of “clinicalpractice guidelines” for common oral conditions such as caries and periodontal disease.

The development of “clinical practiceguidelines” for caries and periodontaldisease would support quality improve-ment in the oral healthcare deliverysystem. Good guidelines are grounded in science and supported by evidence of effective outcomes, clear, flexible,measurable, population-based, and areeasy to implement for the private practi-tioner. Guidelines use best availablescientific to support decision making byboth the patient and the practitioner,without creating artificial barriers foreither in accessing care. Clinical careoften suffers because of inefficient transfer of knowledge from research topractice and the natural decline in apractitioner’s knowledge over time aftertraining is completed. Consider the poorutilization of beta-blockers for heartattack victims by hospital emergencyrooms as an example of when best evidence that is easily obtained is notimplemented in the treatment of a patient.

The Agency for Healthcare Researchand Quality has taken the lead in thedevelopment of clinical practice guide-lines in medicine. A similar effort indentistry would enhance the effort toimprove quality in the oral health care

delivery system, while not increasing thecost of care. Transparency of cost andquality is essential for oral healthcarepurchase decision making. It is impor-tant to define quality not as a dentistwould in terms of technical excellence,but from the perspective of the purchaser,if oral health is to compete for its shareof the health care dollar. A purchaserwants to know that the care they obtainis effective. Satisfaction improves withtimely, safe, patient centered care. Cost iscontrolled through efficient delivery ofthe necessary care. Effectiveness requiresthat treatments are based on sound evidence and that the patient’s outcomewill be a measurable improvement intheir oral health status. The dollars thatare currently spent on ineffective oralhealth care could be redistributed toeffective treatments, thereby improvingquality and access to care with outincreasing costs.

Shrinking financial resources createan environment where cost and qualitymatter to those purchasing medical and dental services. Purchasers activelyseek to contain or reduce cost whileincreasing quality. According to theInstitute of Medicine report of March2001, Crossing the Quality Chasm: ANew Health System for the 21st Century,the U.S. healthcare system falls short inthe delivery of consistent, high-qualitycare to all people.

In order to improve oral health, andthe quality of the oral healthcare deliverysystem, one does not need dental stan-dards of care. Following a prescribed setof activities given a specific diagnosismay be part of what is needed toimprove oral health, but effectivenesscannot be achieved by exclusive focus ofefficiency or quality standards. The realissue is whether or not the appropriateset of treatment activities, as determined

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The emotional stressbrought on by a major illness precludes most individuals from appropriately researchingcost and quality in health care, even when the critical data is available.

by the best scientific evidence available,are delivered to the right patient, at theright time, and for the right cost.Currently, wide variations exist in thepractice of dentistry. Variation mayresult in either underutilization oroverutilization of effective services. Oralhealth practitioners currently have nosystematic way of determining effectiverisk-adjusted approaches toward thetreatment of even the most commonoral diseases. Providing care that meetsof exceeds standards for some patientsdoes not guarantee the optimal deliveryof resources to populations as a whole.

The complexity of the dental caredelivery system challenges all of us inconverting current available informationinto beliefs and actions in the treatmentroom. Good evidence that a treatment iseffective requires more than researchdata; patient outcomes must also be evaluated regularly and continuouslyevaluated in each specific location wherecare is delivered. Data collection, synthesis,and dissemination of patient outcomes isessential in the development of evidencerequired to support treatment decisionmaking. Outcome information is lackingin the oral healthcare delivery system forthe simple reason of a lack of diagnosticcodes necessary to perform the analytics.

The resultant gaps between what weknow and do, and what actually workscreates an array of treatments that are at best ineffective, and at worst, harmfulto the patient or the practitioner or both.Common procedures done every day,with good intentions, may have ques-tionable benefit and use up valuable,limited financial resources. For example,the routine of having dental prophylaxisevery six months, regardless of thepatient’s actual risk for developing oraldisease, is a potential waste of resources.

Standards of care, guidelines, or EBD,although they may be important forother reasons, fail to address these con-cerns. At the same time, an individual athigh risk of disease is being deprived ofa customized targeted prevention plan,critical in the management of his or herdisease. Population-based rather thanprocedure-based guidelines would helpmove oral health care from the traditionalparadigm of anecdotal, personal obser-vation, clinical intuition, and possiblebenefit, to a paradigm of decision makingbased on optimizing outcomes, withsome ability to quantify the risk andbenefit, while including patient and doc-tor values, preferences, and knowledge.

Currently, there is no way for indi-vidual or group purchasers of dentalservices to assess quality of care. Grouppurchasers often look to third-party payors for quality assurance. Utilizationdata from dental benefit claims opera-tions use treatment code patterns toidentify questionable care, which is avery poor surrogate measure at best. The patterns are relative to other practi-tioners in particular regions and noassumptions are made about the appro-priateness of the care delivered, simplywhether or not the pattern of care issimilar to other local practitioners.Patient complaints regarding care areanother source of surrogate qualitymeasures. The level of compliance withaccepted clinical practice guidelineswould provide a rational, measurablequality measure that could be used by awide array of participants in the oralhealthcare delivery system. ■

ReferencesAgency for Healthcare Research andQuality (2004). Dental services: Use,expenses, and source of payment, 1996-2000. Washington, DC: U. S. Department ofHealth and Human Services.Donabedian, A. (1980). Exploration in quality assessment and monitoring: Volume 1–The definition of quality andapproaches to its assessment. Ann Arbor,MI: Health Administration Press.Eddy, D. M. (1980). Guidelines for the cancer-related checkup: Recommendationsand rationale. CA: A Cancer Journal forClinicians, 30 (4), 193-240.Ebby, D.A.(2005). Evidence-based medicine:A unified approach. Health Affairs, 24 (1),9-17.Graskemper, J. P. (2002). A new perspec-tive on dental malpractice: Practiceenhancement through risk management.Journal of the American DentalAssociation, 133, (6), 752-757.Institute of Medicine (2001). Crossing thequality chasm: A new health system forthe 21st century. Washington, DC: NationalAcademy Press.Millenson, M. L. (1997). Demanding medical excellence. Chicago: University ofChicago Press.Wennberg, J. E., & Gittelsohn, A. (1973).Small area variations in healthcare delivery.Science, 117 (December), 1102-1108.

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Larry Jenson, DDS, MA

AbstractThe ethical ground for restoration (returning a patient to healthy form andfunction) differs from enhancement (usingmedical means to improve appearance).Physicians and dentists who argue thatenhancements improve self-esteem mustreconcile this claim with the fact that theyare not licensed to practice psychology.The extreme views are that doctors either should provide cosmetic services asrequested by patients or they should not.The middle position is that doctors mustretain their fiduciary position of trust based on professional judgment and advocating for patients’ health interests.Patient health always outweighs patients’cosmetic desires.

The rapid rise in demand for cosmeticprocedures in both medicine anddentistry has had a dramatic effect

on the practice of both professions. Bothphysicians and dentists educated in a tradition that emphasizes the use of surgical skills to help people with healthneeds are now routinely asked for proce-dures that have little or nothing to dowith illness. The unmitigated prolifera-tion of “extreme makeover” programs ontelevision and in the print media wouldgive the impression that the medical anddental communities are in full supportof this new deployment of surgical skills. Yet, it is quite possible that theintense public demand has outpaced any thorough examination of the ethics thatare relevant to this change. Perhaps it istime to take a collective breath and try to

Restoration and Enhancement: Is Cosmetic Dentistry Ethical?

Issues in DentalEthicsAmerican Society for Dental Ethics

Associate EditorsDavid T. Ozar, PhDJames T. Rule, DDS, MS

Editorial BoardPhyllis L. Beemsterboer, RDH, EdHMuriel J. Bebeau, PhDLarry Jenson, DDS, MABruce N. Peltier, PhD, MBADonald E. Patthoff, Jr., DDSGerald R. Winslow, PhDPamela Zarkowski, RDH, JD

Correspondence relating to the Dental Ethics section of the Journal of the American College of Dentistsshould be addressed to: American Society for Dental Ethicsc/o Center for EthicsLoyola University of Chicago6525 North Sheridan RoadChicago, IL 60627e-mail: [email protected]

find a way to reconcile this change inpopular opinion about what physiciansand dentists should be expected to provide and the ethical traditions ofthese professions.

This paper will examine the ethicalaspects of cosmetic procedures and try to provide an ethical basis from whichdentists can make sound treatment decisions with their patients. I will arguethat there are indeed times when theethical dentist (and physician) ought tosay no to requests for cosmetic proceduresand I will attempt to provide some practical guidelines for determining such times.

There are several terms and conceptsthat if clearly defined would help thisinvestigation greatly. Unfortunately, termssuch as “health,” “disease,” “normal,”“medically necessary,” “treatment,” “risk,”“need,” and “esthetics” all involve signifi-cant ambiguity and are often at risk ofbeing defined however the user wishes.What counts as a “risk” for one personmay not be the same for another, andwhat is considered a “need” may alsovary greatly within a given population.Nonetheless, I think it is possible to workthrough the general outlines of the

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Issues in Dental Ethics

Dr. Jenson is in private practice in San Francisco andis also Associate Professor inthe Division of Clinical GeneralDentistry at UCSF DentalSchool. He may be reached [email protected].

ethics of cosmetic procedures without adefinitive consensus on these terms. Iwill ultimately reject the thesis that sincesubjectivity plays a role in doctor-patienttreatment considerations, it is always thedeciding factor in those cases.

Restoration and EnhancementTo begin, I will take “restoration” tomean the act of returning something (in this case a person) to normal formand/or function. Things in need ofrestoration have a defect of some sortand, with regards to people, these defects go by many names, such as malady, disease, deficit, etc. I will take itas uncontroversial that, whatever theprecise definition of health may be, thetraditional goal of medical and dentalcare has been to eliminate or managedefects and restore people to health(normal form and function), howeverbroad the “normal” limits might be. This is commonly known as healing orcuring or therapy. With regard to plasticsurgery and dentistry, examples ofrestorative procedures include restoringa broken tooth with a porcelain crown,repairing a cleft lip, reconstructing abreast following a mastectomy, andreconstructing a nose following trauma.

“Enhancement,” on the other hand,seeks to take an individual who has nodefect and improve that person’s form orfunction (according to some standardother than health) through medical ordental procedure. Examples of enhance-ment include prescribing steroids orbeta-blockers to improve the perform-

ance of an athlete, surgically altering abody part to improve performance on atask, prescribing amphetamines toincrease job productivity, or any numberof cosmetic procedures (both medicaland dental) that enhance esthetics.

Some will immediately argue thatcosmetic procedures do not belong inthe category of enhancement. Cosmeticsurgeons and dentists are famous forclaiming that patients do indeed have adeficit (unattractiveness, ugliness, etc.)and that cosmetic procedures “heal” theindividual by increasing the individual’sperception of themselves (Christiansen,1989; Leibler et al. 2004). However, JosWelie has convincingly made the case inhis excellent 1999 article that “ugliness”is, on the contrary, not a medical condi-tion at all and procedures that seek to“heal” this condition are outside of medi-cine and dentistry proper (Welie, 1999).Likewise, Eileen Ringel has argued thatthe effects of aging on skin are not a disease and therefore cosmetic skinenhancement is not a therapy or treat-ment in the proper sense (Ringel, 1998).

The problem here is that the advo-cates of cosmetic procedures confusebenefit with therapy. Just because some-thing is of benefit to a patient does notnecessarily place it within the properdomain of dentistry or medicine, whichis the restoration of people to health(normal function and form), i.e., therapy.There is no doubt that people find greatbenefit in tattoos and other body art; butjust because these involve the body itdoes not logically follow that physiciansand dentists should be offering to dothese procedures or that they should be

considered examples of therapy. Manypatients no doubt desire and are madehappy by cosmetic procedures; but this isno argument for the ethical acceptanceof these procedures as appropriate com-ponents of dental or medical practice.

As Ringel states: “When happinessreplaces healing as the goal of medicine,the practice of medicine becomes a com-modity and the medical profession justanother way to make a living” (Ringel,1998). Traditionally, the goal of medicaland dental therapy has been to provide abenefit that addresses a deficit, restoringa patient as much as possible to normalform and function. The suggestion thatphysicians and dentists may provideservices that are outside of the traditionalgoals of both professions should at leastbe ethically suspect. Just because a physician or dentist has the capability toprovide a procedure does not make itethically acceptable to do so. “Therapy”and “treatment” are terms to be usedonly when discussing procedures thathave some dental or medical benefit byrestoring the patient to health or main-taining a patient’s health in the face ofsome threat to it.

Have medicine and dentistry evolvedto the point that this tradition no longerapplies? Perhaps they have. And yet, Idoubt if the subject has had sufficientformal discussion to create a consensusamong practitioners and ethicists. Onething is clear, the sheer prevalence ofcosmetic procedures performed in contemporary medicine and dentistry is

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not a sufficient argument for the inclu-sion of cosmetics within the professions.Moreover, opinion surveys showing thatproviders and patients are “comfortable”with these procedures is a poor argumentas well (Christiansen, 1994). Many mayfeel that in regards to cosmetics “thehorse is already out of the barn.” But mysense is that there is a sufficient level ofuneasiness (at least within the dentalcommunity) that a reasoned ethicalinvestigation may still recover what israpidly being lost everyday.

There is one way in which it mayseem that cosmetic surgeons and dentistsreally do have a good point in sayingthat they are actually providing therapyto their patients. They claim that the cosmetic procedures they perform are“psychotherapeutic.” Poor self-esteemand other psychological maladies areoften “cured” or at least the patient’s situation is significantly improved by giving someone a better “look.”

There are many problems with thisthesis and Eileen Ringel has done anexcellent job identifying them (Ringel,1998). Briefly summarized: There is no strong evidence that cosmetic procedures improve self-esteem. In fact,cosmetic procedures, by focusing onsuperficial attributes of the person, mayonly deflect and defer real progresstoward an authentic acceptance of theperson from which a true increase ofself-esteem will result. Moreover, physi-cians and dentists who perform cosmeticprocedures are not trained to evaluatepsychological and psychiatric disorders,so if this is their rationale for doing cosmetic procedures, they are offeringtherapy without a proper diagnosis or,in the case of dentists, practicing outsidethe scope of practice. In fact, as far asoutcomes are concerned, the evidencethat surgical therapy is an effective treatment for psychiatric disorders (withthe exceptions of body dysmorphic

syndrome and sex reassignment surgery)is thin or nonexistent. Lastly, it is reasonably argued that any patient witha serious psychological deficit requiringtreatment may not be in a position togive an informed consent, and treatingsuch a patient simply on the basis of hisor her request for treatment would beunethical for this reason alone.

The ContinuumWith these arguments in mind, I think it is reasonable to draw a distinctionbetween medical and dental proceduresand cosmetic procedures. Now we must ask ourselves whether dentists and physicians ought to be providingcosmetic procedures at all. And if theanswer to this question is yes, what are the circumstances under which aphysician or dentist is ethically justifiedin performing such services?

We can look at the possible answersto the first question as lying somewherealong a continuum. At one extreme, wehave the position that dentists and physi-cians should not perform any cosmeticprocedures. At the other extreme, wehave the position that physicians anddentists should provide any cosmeticprocedure that the patient asks for aslong as the physician or dentist is competent to provide such services.Somewhere in between these is the posi-tion that physicians and dentists mayprovide cosmetic procedures, but mustnot be merely an agent of the patient;they will sometimes decline to treat basedon their judgment of the situation.

Let’s consider the first extreme. Welie has made the case that cosmeticprocedures are outside of medicine anddentistry proper and thus outside theethics of those professions. People(patients) who decide to allow physiciansor dentists to perform these procedures

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Physicians and dentists who perform cosmetic procedures are not trainedto evaluate psychologicaland psychiatric disorders,so if this is their rationale for doing cosmetic procedures, they are offering therapy without a proper diagnosis or, in the case of dentists, practicing outside the scope of practice.

ought to know that the ethics of the profession do not apply and they can beno more assured of professional carethan they would be at a tattoo parlor.The ethics of the marketplace that anymuffler shop or hair salon follows is theonly ethical standard constraining therelationship at that point. Now if thiswere indeed the case, it is reasonable tosay that there is nothing special abouthaving a physician or dentist providethese services. Just as with tattoos andhair styling, anyone talented enoughand creative enough should be able toobtain a license to provide cosmetic surgery. (In that case, of course, thecosts of these procedures wouldundoubtedly drop and the benefits ofcosmetic procedures would be obtainableby a larger segment of the community.)From the standpoint of the principle of justice, this would necessarily be agood thing.

Doctors and CosmetologistsHowever, most members of society wantmore than justice, low prices, and goodtraining; they demand a certain level ofprofessional judgment and want toknow that, when it comes to surgery ontheir bodies, someone is looking out forthem. Society’s implicit contract withphysicians and dentists expects a securitythat can only come from somethingbeyond skill and training, namely profes-sional judgment in the best interest ofthe patient. It is this fiduciary responsi-bility that distinguishes medicine anddentistry as professions; they are not just businesses. Without this fiduciaryresponsibility there is no such thing asprofessional ethics.

The key aspect of the doctor-patientrelationship is that the doctor is ethicallybound to decline to “treat” a patientrequesting treatment if the risks andcosts of the procedure outweigh the benefits. It is a generally accepted ethicaltenet that patients cannot ask doctors to

hurt them (Ozar & Sokol, 2002;Beauchamp & Childress, 1983). Becauseof this, it is safe to say that people arenot ready to turn over cosmetic surgeryto tattoo artists and others in the estheticsbusiness, however gifted they may be.So, either we license anyone with theability to provide cosmetic procedures, or we bring these procedures into thedomain of medicine and dentistry alongwith the professional ethics that apply to them.

Now let’s look at the other end of thecontinuum. If all cosmetic proceduresare fully within the domains of medicineand dentistry, then patients clearly mayrequest any cosmetic procedure theywish and physicians and dentists whovalue the business may ethically providethese services if they are capable ofdoing so.

Gary Chiodo and Susan Tolle haveaddressed the issue of cosmetics proce-dures in some detail (Chiodo & Tolle,1993). They argue first that there areindeed limits to a patient’s right todemand cosmetic dental services. Brieflysummarized: Dentists have the ethicalduty to weigh the risks, costs, and bene-fits of a given procedure and decline totreat if the risks and costs outweigh thebenefits. The ethical principles of benefi-cence and non-maleficence both supportthis conclusion. But Chiodo and Tollepropose that, if the risks and costs do notoutweigh the benefits, the patient hasthe right to expect the treatment becauseit passes the benefit/harm test that thedentist is professionally obligated toapply. Chiodo and Tolle rightly empha-size the subjective nature of this type ofdeliberation and point out that the per-sonal values of the patients, and thus therationale for their treatment requests,are often different from the values of the

dentist. The significance of risks, costs,or benefits varies from patient to patient.Chiodo and Tolle argue that a dentistshould not impose his or her values onthe patient unless a clear case can bemade that the proposed treatment hasunacceptable risks or will, in fact, resultin harm to the patient. They go on to say,however, that dentists always have theright to refer to another practitioner ifthey are “uncomfortable” doing a proce-dure they would not choose for themselves.

There are two points to be madehere regarding Chiodo and Tolle’s position. First, the word “treatment” isused to describe cosmetic procedures.“Treatment” suggests that there is somedental health benefit received as a resultof the procedure. We have already estab-lished that there is no health-relateddental benefit (no goal of restoration) inenhancement procedures, so this use ofthe word “treatment” stretches its mean-ing significantly. When no health-relateddental benefit is to be had, normal considerations for balancing risks, costs,and benefits may not apply. More on this point below.

Second, as I have argued previously(Jenson, 2003), if a procedure’s risks and costs do not outweigh the benefits,the dentist must ordinarily provide thetreatment if he or she is capable.Otherwise there is no real ethical weightto patient autonomy.

Chiodo and Tolle are in alignmentwith this; and other bioethicists wouldagree that the normative picture of thedoctor-patient relationship as a paternal-istic or guild-based cannot be accurate(Ozar & Sokol, 2002; Kirkland & Tong,1996). But the fact that the doctor-patientrelationship should not be paternalisticdoes not require us to accept the otherextreme of our continuum where thedoctor is merely an agent of the patientand must do whatever the patient asks.

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With just a little reflection and a fewexamples, the case can be made that thisextreme position does not accuratelydescribe the ethics of enhancement procedures. Consider the case of a personwho would like to have his front teethfiled down to sharp points for eitheresthetic or cultural reasons. While wemight make the case that the patient values this procedure highly, we wouldbe hardpressed to find a practicing den-tist who would agree to this procedure.Similarly, we would be hardpressed tofind a physician who thinks it is a wisechoice to give an otherwise healthy athlete a prescription for steroids. Inboth cases, the harm or potential harmto the patient seems to conflict withsome deeply held sense of what it meansto be a dentist or physician. It simplydoes not make sense to create an ethicalparameter for the doctor-patient rela-tionship that has implications that nodoctor could support. We need to seeksome sort of reflective equilibrium thatis both rational and realistic.

Having looked at the extremes, let’snow consider a middle position. Thisposition states that cosmetic proceduresmay be done by dentists and physicians,yet it also holds that there are timeswhen the physician or dentist must say“no” to an enhancement request. Howare we to define this position and locateit along the continuum? While it may bedifficult to delineate this point in specificinstances, I think we can at least estab-lish some general guidelines.

The first point to stress is open com-munication between doctor and patient.Weighing risks, costs, and benefits todetermine a course of treatment in theproper sense is, by anyone’s assessment,not a mathematical process. The processalways involves the judgment and valuesof both doctor and patient. A differentoutcome from these deliberations isalmost to be expected with different doctors and different patients. However,the fact that these deliberations involvesome aspect of subjective values does notmean that they are inherently irrational;reasonable people can come to differentconclusions and parties who disagree on what is best may still agree preciselyon what is unacceptable. A judiciousconsideration of clinical experience,research studies, and patient preferencesis ethically demanded of the doctor andcan lead him or her to a reasonablygood and ethical treatment plan for aspecific patient.

This dynamic process, this interac-tive style of doctor-patient relationship is crucial to the ethical treatment ofpatients (Ozar & Sokol, 1994). And itmust be part of the relationship betweendoctor and patient when cosmetic procedures are under consideration.Ultimately, both patient and doctor have rights; neither gets to dictate thetreatment at all times and each has theright to decide not to participate in aprocedure, the patient at anytime andthe doctor under certain circumstances(Jenson, 2003).

Second, having already establishedthat enhancement procedures are not“treatments” per se, it is fair to ask thenif the same ethics apply to decisionsbetween doctors and patients about cosmetic procedures as they apply totreatments proper. I propose that in thecase of cosmetic procedures, it is simplynot important to the dentist’s ethicaldecision that the patient thinks the

procedure would be beneficial. The valuesat work in patients’ cosmetic decisions in the dental office do not differ from thevalues at work in other areas, far outsideof the domain of dentistry and medicineproper, including tattoos and hairstyling. People do, of course, place greatbenefit in some of these things; but whatsignificant difference is there betweenpeople’s valuing of cosmetic medical anddental procedures and their valuing oftattoos or hairstyles? The proposal hereis that we have to say that all cosmeticprocedures are simply a benefit to thepatient with no hierarchy of value inrelation to health, which is the focus ofdental and medical decisions in theproper sense. As such, they are irrelevantto the doctor’s deliberations as towhether or not he or she should agree todo the procedure. In practice this willmean that the threshold at which thedoctor may say “yes” to a procedure risessignificantly with a cosmetic procedurebecause it involves no health benefit tobe weighed against the possible risks andharm of the procedure. What is importantto the doctor’s deliberation, then, iswhether or not the procedure presents asignificant harm or potential for harmto the patient’s oral or general health.

For example, while it may be justifi-able to expose a patient to the risk ofdeath by general anesthesia (one in tenthousand cases) to obtain a medical benefit (e.g., removing a brain tumor), it is unjustifiable to expose them to thesame risk in order to remove the fatfrom their thighs. For a dental example,a dentist who places a gold crown on atooth that has no need for restoration,simply because the patient sees anesthetic benefit, would be practicingunethically given the fact that there is a

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risk (one in one hundred) that the pulpof the tooth would be damaged in theprocess. Another common dental exam-ple would be the placement of porcelainveneers. If the veneers are intended toovercome some defect, (say, deterioratingrestorations) the benefits of the procedureare more restorative in nature and maythen be worth the relative risks andcosts. Placing veneers to take a patientfrom a Vita shade B3 to B1 on the otherhand, is clearly an enhancement proce-dure and may be difficult to justify giventhe attendant risks and costs. As an alternative, bleaching teeth has few ifany risks and may therefore be ethicallyjustified for the patient who has stained teeth.

The proposal here is that, if there is no health-related benefit to justify it,the dentist may not ethically perform aprocedure with any significant risk ofharm to the patient. If an enhancementprocedure can be done without signifi-cant hazards, a dentist or doctor mayagree to a patient’s request. (At no time,of course, is the doctor justified in providing a procedure if it is beyond hisor her capabilities.) Patient autonomynever outweighs the patient’s health(Ozar & Sokol, 2002), and so the rangeof ethically acceptable procedures available for a patient to choose fromwill thus be significantly curtailed whenit comes to cosmetic procedures.

Is it possible to maintain this distinc-tion between these two ethics (patternsof valuing), one for regular dental proce-dures and one for cosmetic procedures?Can we really split professional ethicsand say that some procedures demandone set of behaviors and another proce-dure some other? While it may seemcounterintuitive initially, I propose thatthis is the case. Keep in mind that the onlyreason to include cosmetic procedures inthe domain of medicine and dentistry isthat the community thinks they ought to

be there for its own protection. But thecommunity cannot have it both ways: itcannot both demand that doctors makeall of these procedures available andthen not bring their professional judg-ment and professional duties to bear inspecific cases—especially the duty not toharm, and to permit harm only in theinterest of even greater health benefit.This would leave dental practitioners (at least the conscientious ones) in animpossible position. Distinguishingesthetic procedures from health relatedtreatments in this way produces a work-able compromise that is superior toeither of the extreme positions.

In the future, physicians and dentistsand the community will have to decide ifenhancement procedures will eventuallybe part of medicine and dentistry properand that health will mean more thanrestoring a person to normal functionand form. (There are signs that we maybe moving in this direction: see CarlElliott’s 2003 book, Better than Well).Until then, many of the cosmetic surgeriescurrently performed by physicians anddentistry simply cannot be supportedethically. This is not in any way a judg-ment on the values of the people whoseek these procedures. People, ultimately,have the right to decide what they dowith their bodies. They cannot, however,expect that a doctor should take part inthat choice and contribute to the harmthat these choices may bring. Peoplemust accept that there are limits to whattheir doctors can ethically provide; and if they desire more than this, theyshould seek those who are not bound byprofessional ethics. Caveat emptor. ■

ReferencesBeauchamp, T. L., & Childress, J. F. (1983).Principles of Biomedical Ethics. New York:Oxford University Press.Chiodo, G. T., & Tolle, S. W. (1993).Requests for treatment: Ethical limits oncosmetic dentistry. General Dentistry, 16-19.Christiansen, G. J. (1994). How ethical areesthetic dental procedures? Journal of theAmerican Dental Association, 125, 1498-1502.Christiansen, G. J. (1989). Esthetic dentistry and ethics. QuintessenceInternational, 20, 747-753Jenson, L. E. (2003). My way or the high-way: Do dental patients really haveautonomy? Journal of the AmericanCollege of Dentists, 70, 26-30Kirkland, A., & Tong, R. (1996). Workingwithin contradiction: The possibility of feminist cosmetic surgery. The Journal ofClinical Ethics, 7 (2), 151-159.Liebler, M., Randall R. C., Burke, F. J. T., etal. (2004). Ethics of esthetic dentistry.Quintessence International, 36 (6), 456-465.Meningaud, J-P., Servant, J-M., Herve, C.,Bertrand, J-Ch. (2000). Ethics and aims ofcosmetic surgery: A contribution from ananalysis of claims after minor damage.Medicine and Law, 19, 237-252.Ozar, D. T., & Sokol, D. J., (2002). Dentalethics at chairside: Professional principlesand practical applications, (2nd ed).Washington, DC: Georgetown UniversityPress. Ringel, E. W., (1998). The morality of cosmetic surgery for aging. Archives ofDermatology, 134, 427-431.Welie, J. V. M. (1999). Do you have ahealthy smile? Medicine, Health Care andPhilosophy, 2, 169-180.

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David W. Chambers, EdM, MBA, PhD, FACD

AbstractThere is a part of our mental functioningthat makes decisions and executes themand another part that monitors and regulates the first part. When these operations are in balance, we may be said to exercise self-control. There is evidence that these functions operate indifferent parts of the brain. Self-controlplays a vital role in performing complextasks, habit formation, and ethics. Self-control also interacts with goal setting and achievement. There are predictable differences among individualswho seek success and those who avoid failure.

Ibelieve it was Joseph Campbell whopopularized the quip, “As you scrambleup the ladder of success, it is wise to

pause occasionally to make certain it ison the right wall.” The concept is thataccomplishing one’s goals involves twoactivities: Most of it is time and energyon task; less obvious and less time consuming is managing the target andthe effort to get started.

Two-process ViewThis two-process view of goals-directedaccomplishment has become currentamong psychologists. There is one partof us that does the work and anotherthat exercises (or sometimes fails toexercise) executive oversight. In the literature, this is known as the problemof self-control. America is awash withexhortations about learning to use thelatest gadgets, mastering new skills,working hard, performance excellence,and success. Will power, trade-offs (con-sciously deciding not to do something),monitoring to ensure that circumstanceshave remained the same, and self-denialare less fashionable topics of conversa-tion and there is frank skepticism thatanything can be done to change theseaspects of “human nature.”

We do know a great deal, however,about breaking habits, scheduling pro-ductive work days, exercising vigilanceand oversight, and why people cheat. We have even identified some of regionsin the brain that are involved in these

processes. Self-control, and the responsi-bility that accompanies it, are notaccidents, mysteries, or innate haracter-istics. When I was young, I broke aceramic dish my mother kept on the cof-fee table. When caught red-handed, Iblurted out, “I didn’t do it; my hand did.”That works for a five-year-old, but not anadult. We are responsible for both ouractions and for self-control.

The basic purpose of self-control issimple, but the way it works is not.Behavior is motivated to achieve goalsand provide satisfaction. If there wereonly one feedback loop focused on goalattainment—if work were self-managing—we would converge on mindless, repetitious behavior. As long as wefocused on the unrealized gap betweenwhat we want and our not havingachieved it yet, we would remained fixated. Alternatively, if we persist inrepeating those things that lead to satis-faction, we again get stuck in mindlessidling. The challenge in understandingwhere people put their efforts is not inexplaining why we keep doing the samethings over and over again; what begsfor clarity is why we switch from onetask to another. There needs to be a second feedback loop that tells us whenit is time to switch.

Emotions Control BehaviorOne popular theory is that emotionsrather than consequences are whatcause behavior. When we succeed at atask, the emotion is relief or satisfaction.We are free to consider alternatives, tolook for new and attractive investments

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Leadership

for our time and talent. There is evensomething like a built-in discounting system for rewards. What was oncethrilling becomes satisfying and eventaken-for-granted over time because ofthe survival value in varying the goalswe put our hands to. The value ofrewards does not follow the rules ofgood arithmetic. More is not always better. It is human nature to “satisfice”;to accept good enough and then askwhether more good enough is betterthan making up some other existingdeficit. Consider, as an example, runningtwenty minutes over on a difficult crownpreparation. When it is finally workedout, does the dentist immediately lookfor another such case or, more typically,reassess the remaining schedule for theday to see how he or she might get backon schedule?

The other type of result from effort ismore complicated. It is not always easyto anticipate what will happen followingunsuccessful attempts. There are severalsections below that address themselvesto the difference between striving toachieve success and striving to avoid failure. There is a different logic in thesetwo cases. At the most general level,when the expected results are undershotby a small amount, the resulting emotionsof frustration and even annoyance stim-ulate renewed effort and close off anyconsideration for alternative activities.This is the fixation of determination. Butwhen efforts are consistently short ordramatically disappointing, the emotion

is sadness, depression, or resignationand a consequent freeing of attention toother activities.

Sometimes our interests are bestserved by carefully focusing our attentionand dedicating our effort to the task athand; sometimes they are better servedby considering alternatives—either differ-ent approaches to the task or differenttasks. It is the job of self-control to bal-ance task management, and emotionresulting from performance feedbackplays a role in this self-control.

Performance (work on the task, notdeciding which task to focus on) is afunction of capacity to do the work andeffort applied to it. Fast dental work is amatter of skill and applying one’s self.Self-control operates differently. Knowingwhen it is appropriate to work fast orwhether caution or even discretion aremore to the point requires monitoringwhat one is doing. Vigilance regardingone’s efforts is a function of personalitytype (as discussed below) and of “self-regulatory strength”—will power. A good analogy might be oxygen debt inmuscles. Regardless of whether one isrunning, climbing stairs, or engaged inother activities, when the capacity of thered blood cells to carry oxygen to themuscle tissues is exceeded for any periodof time, performance declines and thenceases. Similarly, when attention isdiverted to self-control in one area (say

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Leadership

The challenge in understanding where people put their efforts is not in explaining why we keep doing the same things over and over again; what begs for clarity is why we switch from one task to another.

managing professional responses to anunreasonable patient) it is not availablefor other purposes (say managing control of a difficult dental procedure).Fatigue, hunger, generalized emotionalstress, and other demands reduce self-control. Don’t start a diet if you are tired.

Cortical LocationIt has not been established whethercapacity for self-control can be increasedthrough exercise. It is well-established,however, that trauma to the frontalregion of the brain can result in permanent and severe decrements inself-control. The ability to attend to andshift among several tasks is associatedwith the prefrontal cortex. Lesions in the dorsolateral prefrontal cortex areassociated with difficulty in planning,making choices, processing novel situations, and initiating action. The ventromedial orbitofrontal cortex appearsto mediate social judgment, while theanterior cingulated cortex seems to beinvolved with attention switching, overcoming habitual responses, moni-toring actions, and dividing attention(multitasking).

Personality TypesThere is also evidence that individualsdiffer in their level of self-control andthat these differences are enduring personal traits. Connections have beendemonstrated between low generalizedcapacity for self-control and various self-destructive habits such as overeating,drug and alcohol addiction, and compulsive shopping. Research has alsodemonstrated some connections betweendeficits in self-control and negative socialbehavior such as sexual obsessions and a wide range of criminal and antisocialbehavior. It is important to emphasize

that there are alternative views on thesetopics, but there is a significant body ofevidence that points in the direction ofindividuals who have an extreme andsocially unacceptable inability to refrainfrom continuing to engage in behaviorsthat they actually understand to be badfor them. Ask any cigarette smoker.Consider any dentist whose lifestyle hasgotten so far out of hand that he or sheabuses the practice and his or herpatients to support a habit.

On the positive side of the matter ofindividual differences in will power,there are several well-publicized studiesshowing a relationship between cookiesand Scholastic Aptitude Test (collegeentrance examination) scores. WalterMischel and his colleagues have reportedthe best known studies. Four-year-old children are told that they will be givenmany cookies if they can wait a numberof minutes or have one now. The adult isthen called out of the room on a pretext,and the children’s will power is quantifiedin minutes. There is a clear and signifi-cant correlation between ability to delaygratification among the youngsters andtheir SAT scores when adolescents.

There is such a thing as will power.It has a neurological foundation andvaries in strength across individuals. Itappears to operate through emotionsarising from the difference between goalsand outcomes, but in a complex fashion.It also seems to be fixed in capacity, worksacross all activities, and is subject tofatigue and renewal much like muscletone. The function of self-control is to manage shifts from one activity toanother (or approaches to the same task)to maximize overall personal benefit.

HabitsHabits are patterns of circumstances and behaviors that are self-reinforcingand largely unconscious. This makesthem especially resistant to managementby self-control.

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Leadership

Don’t start a diet if you are tired…Habits are patterns of circumstances and behaviors that are self-reinforcing and largely unconscious. This makes them especially resistant to management by self-control.

It is necessary, first of all, to realizethat the vast majority of habits are bene-ficial, or at least neutral. They grow andstrengthen precisely because they areuseful and need no conscious monitoring;they free the limited reservoir of willpower for use elsewhere. As long as thechains of synchronized behaviors thatform task performance are appropriateto the circumstances, are not dominatedby some other more appropriate behaviorsequence, and produce the desired effect,they should be left alone. Where we mustenlist the good offices of self-control are where conditions have been altered(we failed to notice that our metabolismswere changed by maturity until ourpants size brought that to our attention)or where we need to make a newsequence of behaviors self-reinforcingand subconscious.

Four-step Habit ReplacementTo understand habit formation, breaking,or modification, it is necessary to realizethat the process of converting attention-controlled behavior into automaticallycontrolled behavior involves severalsteps. The dynamics, hence the role, ofself-control differs at each stage in thisprocess. One accepted version of thisstaged process involves: 1) determination;2) development; 3) maintenance; and 4) habit formation proper. Determiningto create a new habit or to break an oldone is entirely conscious and under thesway of self-control. It is a work of mental calculus: do the expected benefitsand likelihood of success outweigh theinconvenience and the probability of failure? Frequently, this involves studyand assembly of equipment and otheraccoutrements to support the habit-changing journey. The second stage,

development, begins when the individualdemonstrates for the first time that thedesired behavior can be performed at all and ends when the behavior can beperformed consistently. A new kind ofself-control is now called for. The development stage is where the collisionoccurs between the hoped-for benefitsand the unpleasant experiences and disappointments associated with lapses.This is the classic test of will power.

Consider a dentist who wants to create a new habit of working with atight modular scheduling system.Determination comes from reading orattending CE programs, discussions with consultants, and engagement of thestaff. It looks attractive on paper. Thepath through the development stage isstrewn with frustration over restrictedfreedom and responsiveness, fears aboutdecreased quality, misgivings that thestaff is controlling the office, runningover several times a day, better produc-tivity figures, novelty, and a dozen otherfactors. All of these shout for attention.Losing weight would be another example.There are very good reasons for framingthe process as one of “building the habitof eating and exercise that creates a new,more appropriate weight”—the goal of“weight loss” almost always produceseventual weight gain. The first phase isconscious and calculating, perhapsassisted by the thinly disguised disap-pointment of someone who cares aboutyou or the stern advice of a physician.Development is a tension between theactual beneficial and discouraging outcomes and is managed, or not, byself-control.

If the development stage is persistedin for a reasonable length of time, thethird stage, maintenance, is reached.The major work of the maintenancephase is to balance actual costs and benefits and to build tolerance for thetension that exists between them.

Occasionally, there are relapses to development or even determination, buteventually, maintenance becomes habit.This occurs primarily by circumstancesand normal patterns stabilizing toreplace self-control. Think of driving: ifyou keep the car pointed in the middle ofthe road, you will eventually get to yourdestination, and you may even forget tothink very much about the steeringprocess. Once a habit is created, it cannot be changed other than by aprocess of forming a new habit.

Self-control is conspicuous in all purposeful thinking and choice behavior.It is essential in selecting a habit toattempt. In habit development, traditionalwill power is needed to manage conflicting experiences of reward andpunishment. Self-control plays only asmall role in maintenance, primarily asmonitoring, and its disappearance in thefourth stage is part of the definition ofhabit formation or replacement.

Self-control and PracticeHabits are not created by will power; self-control is part of the managementprocess that allows habits that havepotential for becoming self-sustaining to take hold. That is a subtle shift of perspective and is entirely Zen. Themetaphor about driving the car is entirely apt. Habits must be thought ofin terms of responsiveness and persever-ance while natural forces work. They are not willed into existence. GeorgeLeonard’s little book, Mastery, describesthis beautifully. He conceives of masteryformation as a sequence of reasonablysharp and brief positive changes inbehavior followed by very long plateaus.

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Figure 1. Leonard’s View of Achieving Mastery Through Practice Over Time

The key issue is what individuals do during the plateaus when no behavior ischanging. Leonard’s answer is “practice.”That is a good dental term and it suitswhat happens in growing practices quitewell. There are long periods of doingone’s best with no apparent changes inoutcome. But breakthroughs do occur,and they are more likely than gradualimprovements.

The alternatives to practice are variations on things falling apart. One ofthe pretenders to mastery that Leonard

identifies is the “dabbler” (see Figure 1).This is the person who buys gadgets,embraces new systems, makes grandannouncements (or threats), andattempts to purchase improvement. Thecourse of change is predictably a briefspurt in performance until the noveltywears off and then rapid decline. The“obsessive” is driven by outcomes andsheer force of character. The actual pat-tern of performance of the obsessive ismuch like the dabbler, except that thereare brief small spikes of improvement

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“Dabbler”

“Drifter”

“Obsessive”

“Master”

followed by relapse as the obsessiveinserts his or her energy and effort intothe project and then withdraws inexhaustion. There is a fourth type thatLeonard labels the “hacker,” but one Iwould prefer to describe as a “drifter.”Once established on a plateau, the drifteris content to stay there, maintaining hisor her position with minimal effort aslong as circumstances stay the same. As circumstances and performancebegin to diverge, they drift toward weaker performance.

The only way to ensure a reasonablelevel of habit renewal is to practice. Thisshould lead to alternating short periodsof growth and long periods of stability.The irony is that practice is critical pre-cisely at the point (the plateau) wherenothing is changing. That requires selfcontrol in large doses. It also requires areframing of what is occurring. Asrenowned basketball coach Bob Knightsays, “The will to win is nothing; the will to get ready to win is everything.”Professional growth cannot be predictedor controlled, but it can be prepared for.A key role for self-control is proper inter-pretation of what is at play. For example,dieters often interpret hunger as a signthat the diet is failing. Exactly the oppo-site is true; it means the diet is working.Effective dieters reinterpret hunger awayfrom being a signal to eat to being abadge of success to be celebrated, just asa distance runner embraces and fightsthrough fatigue. There is probably nopractice innovation worth making thatdoes not cause discomfort. There is probably no attempt to improve practicethat succeeds without reinterpreting thisdiscomfort in constructive ways.

GoalsGoals operate through self-control. Theforemost psychologist studying the rela-tionship between goals and behavior,

Edwin Locke, notes that goals serve thevaluable purpose of singling out whichfeedback matters. A dentist might focuson the speed of curing composites andwonder why case acceptance is fallingoff while patients are focused on theaggressiveness of informed consent (orvice versa). Goals direct individuals tothose aspects of self-control that matter.What is not a goal is difficult to manage.

Self-control is most critical to goalsetting. That is the moment when alternatives are considered and a level of performance is chosen that will, inconcert with future outcomes, create theemotional results of perceived success orfailure that regulate future effort or ashift of attention. It matters little to peoplewho lack self-control what goals are set.They are deprived of useful informationthat will make future self-control possible.

Some of the surprises from researchin goal setting include: higher goalsalmost always result in higher perform-ance; creating evaluation systems almostalways leads to spontaneous goal setting;people who are given realistic goals bytheir supervisors perform as well asthose who set their own goals; andgroup goal setting is no more effectivethan individual goal setting. All of theseresearch findings are in opposition toconventional wisdom and a lot of thepopular press on the topic.

The first rule—that performanceincreases as the level of goals increases—is only true within a range. Extremelylow goals are laughed off as a joke, asare ridiculously high ones. If goalsexceed the ability of the performer or ifcircumstances place a barrier on per-formance, the level achieved is limited.Still, it remains generally the case thathigher goals lead to greater effort andgreater consistency of effort than dolower goals. This is probably the case fortwo reasons: setting goals, especiallywhen they are recognized as being different from previous ones, requiresconscious effort to imagine how success

can be achieved; and, secondly, highergoals are more likely to result in a performance gap that is motivation forstronger effort on subsequent attempts.

When evaluation systems are put in place, it is natural for goals to be considered, whether they are explicitlyannounced or not. This second surprisecalls attention to the importance of the feedback—goal-gap regulation of performance. It is the gap that matters.Most people intuitively understand thisand will supply one or the other to makea matched set available. Frustration andweak performance improvements aremore likely to result from forcing a system that has mismatched goals andfeedback than from leaving eitherunspecified. Dentists and staff alwayshave reasonably clear goals for howbusy the office should be, and they knowhow to gauge this without the assistanceof an outside consultant. Just learninghow well others are doing on compara-ble tasks improves performance if thenorm group has a higher goal.

Many people are surprised by thethird rule: imposed goals are as effectivein raising performance as self-selectedgoals are—provided that they are realistic.One of the reasons dentists go to conventions and CE courses is to find out what others are setting as goals. ADA and other statistics on practice characteristics and income figures arepopular reading. But the source of thegoal is not particularly important foractivating self-control and the resultingchanges in performance.

The final rule relating goal settingand performance flies directly in the faceof most advice that dentists will read intheir non-subscription journals. We haveto be careful here: the research showsthat goals set externally are as effective in

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improving performance as are individu-ally set ones. The claim is not that goalsetters will like the process better (gener-ally they don’t care too much one way or another) or that morale will improve(it won’t when autonomy is curtailed).But performance will not be improvedby letting a group deliberate on its goals.Besides building team spirit, one of thebenefits from group goal setting is likelyto be that alternative means for achievingthe goals are discussed in groups.

Success and FailureIndividuals strive for success and individ-uals seek to avoid failure. But these arenot two ends of the same continuum. Adentist who does eight units of veneersin hopes of showing them off to his colleagues exercises a different kind ofself-control from a colleague who performseight veneers while hoping to avoidocclusal and retention problems. Thelogic of seeking success differs from thelogic of avoiding failure. It is even truethat some people orient predominantlytoward one type of self-control whileothers have the opposite personality.

The Case of Drs. AM and AFConsider the case of Drs. AM (achieve-ment motivation) and AF (avoid failure).They take a practice management coursetogether and, because their practices arevery similar, they mutually agree on agoal of $85,000 gross per month. Overcoffee after the first month, they bothreport $88,000 (no one knows whateither actually produced). Both arehappy and explain the various thingsthey did to accomplish the goal, layingheavy emphasis on personal initiative.AM, the success-oriented dentist, evensuggests that the target for next monthhas been raised to $86,000; but AF willstay pat.

Next month at coffee, AM reports$84,000 ($2,000 under the new goal)and the more risk-averse AF also reports$2,000 under goal, or $83,000. This outcome is consistent with goal theory—higher goals result in better performance—and with the laws of nature that requiresome degree of random variation.

But the table conversation is differentthis month. Dr. AM mentions that thehygienist just hasn’t bought into the newsystem. Dr. AF follows suit, noting thatthere were some strange and unantici-pated cancellations on some large cases.Both agree that dentistry is just veryunpredictable from month to month.Neither even hints at having as muchinvolvement with the disappointingresult as they had with the previousmonth’s success. Hence the old sayingthat success has many parents and failure is an orphan. Hence also the well-established fundamental attributiontheory in psychology.

The differences go further. Now it isthe success-oriented Dr. AM who says thegoals are fine and there is no need forchange. Perhaps surprisingly, the dentistoriented toward avoiding failureannounces a new goal—$87,000, a largeraise in the stakes. It has been docu-mented repeatedly that following initialdisappointing results, those who striveto avoid failure will raise their goals. Thereasons are unclear, but they may includea desire to negate the failure (“that wasonly a random result and there shouldhave been an increase”), a need to self-handicap to achieve a compensatorysuccess (“it is clear I will have to domuch better to make up for the slip”), or simply a lack of realism and wishfulthinking. The latter alternative has someweight behind it. It is generally the casethat following initial failures, peoplewith avoidance orientations set unrealis-tically high or unrealistically low goals(or even swing back and forth betweenthe two). The changes they make in

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Some of the surprises fromresearch in goal settinginclude: higher goals almostalways result in higher performance; creating evaluation systems almostalways leads to sponta-neous goal setting; peoplewho are given realisticgoals by their supervisorsperform as well as thosewho set their own goals;and group goal setting is no more effective thanindividual goal setting.

goals following failure are more extreme than the goal changes made by achievement-oriented individuals. It is as though initial failure disorients the self-control mechanism of those tryingto avoid failure.

But that is not all. Drs. AM and AFcontinue to meet for lunch and exchangereports revealing apparently large randomswings in gross productivity, with a generally stable performance followingsome early gains for AM and a cleardownward trend for AF. AM still complainsabout forces that cannot be controlledand the tedium of having to work at thenew methods. AF is excited by occasionalup months and crushed by the downmonths and is beginning to question thewisdom of the approach generally. He isfinding it difficult to continue to makethe effort. Eventually, AF begins to findconflicts that prevent meeting with hiscolleague. The rule here is simply thatthose with an orientation to achieve success persist longer in the face of disappointing outcomes than do thosewho seek to avoid failure.

Orientation MattersThis example is not meant to suggestthat people who are oriented toward success always or even generally do betterin life than those whose orientation istoward avoiding failure (although I suspect this might be true). Perhaps thesystem really is wrong, or maybe circum-stances in the offices are not the same,or perhaps AM is a better dentist than AF.The example is intended only to illustratethat it is human nature to credit ourselvesfor success and blame circumstances for failure and that people with an orientation to avoid failure tend to setunrealistic goals and do not persist aslong in the face of failure as do thosestriving for success.

The research establishing these ruleswas performed more than forty yearsago and it is further significant becauseit has been repeatedly demonstrated thatthese differences in orientation towardsuccess and failure are personality traitsformed early in life and abiding there-after. Dr. AM is the one who delayedgratification for the cookies as a child,while Dr. AF filched one as soon as theadult left—“just to make sure.” There area number of variations on this dichotomy,including a recent theory by Carol Dweckdistinguishing between individuals wholearn for the sake of giving correctanswers from those who learn to under-stand the material. The patterns areroughly the same as those reportedabove. The answer-oriented individuals(seek to avoid failure) get As and Ds andgive up on learning quickly. An applica-tion in dentistry would be the differencebetween a practitioner who attends a CE course to get credits and one whoattends to learn how to make a specificchange in the office.

Promotion vs. PreventionA psychologist at Columbia University, E.Troy Higgins, has proposed yet anotherwrinkle on the dichotomy. He divides theworld into folks who are focused on pro-motion and those focused on prevention.Promotion-oriented people are concernedwith ideals, advancement, aspiration,and accomplishment (including removalof unwanted or damaging conditions).They are easy to spot because they areeager and positive. Prevention-orientedpeople are concerned with security, conformance with rules (even when theybitterly complain about them), safety,responsibility, protection, and the pre-vention of unwanted outcomes. They are cautious. The distinction Higgins ismaking is not exactly the same as strivingfor success versus avoidance of failure. Itis preoccupation with positive outcomes(getting the good ones and getting rid ofthe bad ones) versus preoccupation with

negative outcomes (minimizing them).Ethicists often make a similar distinctionbetween beneficence and maleficence.

Because this is an important, butperhaps slippery, notion, it can benefitfrom further explanation in graphicterms. Refer to the accompanying Figure2. The two columns represent outcomes,simplified for our purposes as successand failure; the rows are actions thatprecede the outcomes that are character-ized as high involvement or invasiveversus low involvement or passive. TheXs represent actual combinations of outcomes reflecting a combined effect ofeffort (the rows) and chance factors.Four results are possible: 1) true positives—promotion effort resulting in success; 2) false positives—promotion effortresulting in failure; 3) false negatives—prevention effort resulting in failure; and4) true negatives—prevention effortresulting in success.

This is actually a favorite questionnow on Part II of the National BoardDental Examinations, wherein studentsare asked to select the correct name ofthe ratio of true positives to total posi-tives and the name of the ratio of truenegatives to total negatives (“selectivity”and “specificity”). Higgin’s point is thatpromotion-oriented personalities focuson the left-hand side of the table; theystrive to maximize the positives withoutpaying too much attention to the negatives, “selectivity.” Those with a prevention orientation concentrate onmaximizing “specificity,” keeping downthe false negatives without much regardfor the positives.

Promotion pride leads to postmortems of failures where the individualsays, “If only I had done x, the resultmight have been different.” The Endothat blows up on a promotion-oriented

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dentist might be explained in terms suchas needing to take additional radiographsor changed the working length. A dentistwith prevention pride would speak interms like “I shouldn’t have been soaggressive (or conservative); I shouldhave referred the case.” Promotionanalysis of failure stresses that morecould have been done or done differently;a prevention analysis stresses what wasnot done. Promotion orientation is associated with seeing many potentialalternatives in a situation; prevention orientation is more narrowly rule driven—there is one best way. Promotion orientation is characterized by strongeremotions—eagerness in the approachand excitement or disappointment in the outcome. By contrast, prevention orientation is subdued. The approach is accompanied by feelings of “dignityand properness” and the outcomes byconcern or satisfaction. Speed is preferredby promotion-pride people, accuracy byprevention-pride people. The former areopen to changing tasks regularly; the latter prefer to stay put. The “sunk-costtrap” involves continued investments is failing strategies. The vigilance orientation of the prevention personalityreduces the likelihood of this trap, whilepromotion-minded people are orientatedto finding the next success and over-looking their failures (thus continuingto feed them). Promotion-minded indi-viduals feel especially bad about errorsof omission—missed opportunities. Theprevention personality regrets errors ofcommission.

It would be nice if we could combinethe benefits of both personality types.That is not possible, as can be seen bylooking at Figure 2 again. Consider thedashed horizontal line across the middleof the graph. The best strategy for theeager, promotion-minded individual is to

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Figure 2. Promotion Pride vs. Prevention Pride

Act

Don’t

Act

Success Failure

Promotion Pride

Prevention Pride

Act

Don’tAct

Success Failure

XX

X X

X

XX

X

X

X

X

X

X

XX

X

XX

X

X

lower the line. Bold steps will increasethe number of hits; a more open strategywill increase the ratio of true positives tototal positive outcomes. But lowering theline will have exactly the opposite effectfor prevention-minded individuals: itincreases the likelihood of false failures.Adjusting the world to benefit preventionorientated people will bring disadvantageto their promotion-minded peers.Optimizing standards for individuals oriented toward promotion will create a disadvantage those oriented towardprevention and vice versa. This tensionis currently being played out with regardto national security and personal privacy.The National Security Administrationwould like to lower the horizontal line tocatch more terrorists; the American CivilLiberties Union would like to raise it toprotect the privacy of more Americans.(Congress is currently playing a strangecard—make the line wider and let us, the Congress, decide cases on an individ-ual basis).

There is actually one way in whichthe differences in personal preferencesbetween promotion and prevention orientation matter less. Consider theright-hand part of the figure. The boundaries that define true positives and true negatives remains the same(the personality preferences of thoseinvolved are held constant), but thereare fewer “errors.” This represents a casewhere the skill in converting effort intooutcome is improved. If the NSA wereextremely accurate in collecting intelli-gence on only actual terrorists, theAmerican public would not care too muchabout the principles of privacy involved.If dentists were enormously successfulwith all procedures, the line betweenhigh levels of success and patient protec-tion would cease to matter much. Thus,the personality preferences surroundingpromotion and prevention grow in significance in areas where chanceintrudes on performance.

Dentistry Is Prevention-OrientedHiggins presents his concept of promo-tion versus prevention orientation as a matter of the personality types ofindividuals. I would argue that there arepersonalities in whole segments of societyand especially in whole professions.Dentistry is—by self selection, by training,and by norms of professional conduct—a prevention-oriented profession. It isconservative, concerned over makingmistakes, and cautious. Every year, thereare several editorials written with thetitle, “Primum, non nocere.” This is aLatin phrase meaning “first, do noharm.” It is believed to come from theHippocratic Code, but that is a mistakethat seriously challenges its own premiseof not making mistakes. The sentencethat the phrase is thought to appear inthe Hippocratic Code is (in Greek, notLatin) “I will use my Art for the better-ment of mankind and not for its harm.”This is certainly a more balanced blendof the promotional and the preventiveorientation, and, if anything, a slightnod in favor of promoting health.

Anyone who has read through tothis point has demonstrated substantialself-control. Such a reader understandsthe importance of balancing attention tothe task at hand while scanning theenvironment to make certain it is theright task. It is known that habits cannotbe broken—only replaced by better ones—and that goals drive performance. Such an individual also likely has some insight into whether he or she is motivated to seek success or avoid failure and has grown accustomed toresponding accordingly. ■

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There is probably no practice innovation worth making that does not cause discomfort. There is probably no attempt to improve practice that succeeds without reinter-preting this discomfort in constructive ways.

Recommended Reading

Summaries are available for the threerecommended readings preceded byasterisks. Each is about eight pageslong and conveys both the tone andcontent of the original source throughextensive quotations. These summariesare designed for busy readers whowant the essence of these references infifteen minutes rather than five hours.Summaries are available from theACD Executive Offices in Gaithersburg.A donation of $15 to the ACD Foundationis suggested for the set of summaries ongenerations; a donation of $50 wouldbring you summaries for all the 2005leadership topics.

Roy F. Baumeister and Kathleen D. Vohs (Eds). Handbook of Self-Regulation:Research, Theory, andApplications.* New York: The Guilford Press, 2004.ISBN 1-57230-991-1; 573 pages; priceunknown.

Self-regulation is the appropriate bal-ance of dominant and current activitieswith potential alternatives for the long-

term benefit of individuals and society.This book is designed as a comprehen-sive summary of current research andtheory on self-regulation. There aretwenty-eight chapters ranging frombrain physiology to control of impulsebuying. This is a scholarly publication,with extensive references.

Carol S. Dweck (1986). Motivational processes affectinglearning. American Psychologist, 41 (10), 1040-1048.

Performance goals link success and fail-ure to publicly observable results. Forlearners who naturally have this orienta-tion or where circumstances are createdfavoring this approach, individuals shyaway from risky activities such asattempting new tasks. Learning goalslink success and failure to long-termacquisition of enhanced skills. When thisorientation prevails, learners performbetter on related but slightly differenttasks, persist longer in learning, andgain deeper understanding of the struc-ture of the situation.

Leonard, George (1991). Mastery.* New York: Plume. ISBN 9-780452-267565; 176 pages; about $13.

Leonard warns against the prevailingbottom-line mentality that puts quick,easy results ahead of long-term dedica-tion to the journey itself. He advocatesinstead an essentially goalless process ofmastery where practice at a plateaubecomes enjoyable in its own right untilit is a habit. This is a quick and positiveread. Leonard appears to have come outof the Esalen movement of the hippiesand he draws heavily on Zen teachings.

Edwin A. Locke and Gary P. Latham. A Theory of Goal Setting TaskPerformance.*Englewood Cliffs, NJ: Prentice Hall, 1990.ISBN 0-13-913138-8; 412 pages; priceunknown.

“The results with respect to goals andperformance are quite clear: given goalcommitment, feedback, self-efficacy, suitable strategies, and so on, the higher,harder, or more difficult the goal, thebetter the performance” (246). Exhaustive,detailed clinical research evidence build-ing up a compact theory of the influenceof goals on performance, including thecollateral effects of self-esteem, task complexity, commitment, etc. Some ofthe surprises in Locke’s theory are thatthere is no negative effect in setting toohigh goals that imposed goals are aseffective as self-set goals, and that participation in goal setting probablyhelps by creating better understandingof the task rather than higher motiva-tion. Straightforward presentation, butlots of references and jargon.

Charles P. Smith (Ed). Achievement-Related Motives inChildren.* New York: Russell Sage Foundation,1969. N0 ISBN; 264 pages; priceunknown.

Classic collection of early researchpapers establishing achievement motiva-tion as a stable personality characteristicincluding realistic goal setting and per-sistence toward success. By contrast, fearof failure, or as it was originally called,test anxiety, leads to unrealistically highor low goals and lack of persistent per-formance. Both are learned early in life.

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Five unsolicited manuscripts wereconsidered for possible publicationin the Journal of the American

College of Dentistry during 2005. Threemanuscripts were returned to theirauthors as being inappropriate in topicor format for the journal. Of the twosent for full review, one was acceptedimmediately and the other was acceptedfollowing substantial rewriting.

Ten reviews were received for thetwo reviewed manuscripts, an average of5.0 per manuscript. Eighty-six percent ofthe reviews that expressed a clear viewwere consistent with the final decisionregarding publication. Cramer’s V statis-tic, a measure of consistency of ratings,was .714, showing very high consistencyamong reviewers. There is no way ofcomparing the consistency of thereviews for this journal with agreementamong other publications, because it isnot customary for other dental journalsto report these statistics. The Collegefeels that authors are entitled to knowthe consistency of the review process.The Editor also follows the practice ofsharing all reviews among the reviewersas a means of improving calibration.

The Editor is aware of nine requeststo reprint articles appearing in the journal and four requests to copy articlesfor educational use received and grantedduring the year.

In collaboration with the AmericanAssociation of Dental Editors, the Collegesponsors a prize for a publication in anyformat presented in an AADE journalthat promotes excellence, ethics, andprofessionalism in dentistry. Twenty-seven manuscripts were nominated forconsideration. The winner was an essayby Dr. Charles Bertolami, “Why ourethics curricula don’t work,” whichappeared in the April 2004 issue of theJournal of Dental Education. Fifteenjudges participated in the reviewprocess. Their names are listed amongthe Journal reviewers below. TheCronbach alpha for consistency amongthe judges was an extremely high .947.

The College thanks the followingprofessionals for their contributions,sometimes as multiple efforts, to thedental literature as reviewers for theJournal of the American College ofDentists during 2005.

Marcia A. Boyd, DDS, FACDVancouver, BC

John A. Breza, DDS, FACDFraser, MI

D. Gregory Chadwick, DDS, FACDCharlotte, NC

James R. Cole, II, DDS, FACDAlbuquerque, NM

Stephen B. Corbin. DDS, FACDRockville, MD

Bruce Corsino, PhDReston, VA

Eric Curtis, DDS, FACDSafford, AZ

Caswell A. Evans, DDSChicago, IL

Geraldine M. Ferris, DDS, FACDWinter Park, FL

Kent W. FletcherAlsip, IL

Lawrence Garetto, PhD, MS, FACDIndianapolis, IN

Steven A. Gold, DDSSanta Monica, CA

Bruce S. Graham, DDS, FACDChicago, IL

Frank C. Grammer, DDS, PhD, FACDSpringdale, AR

Detlef B. MooreMilwaukee, WI

Laura Neumann, DDSChicago, IL

John O’Keefe, DDS, FACDOttawa, ON

Stephen A. Ralls, DDS, FACDGaithersburg, MD

Harriet F. Seldin, DDS, FACDEncinitas, CA

Thomas J. Wickliffe, DDS, FACDBillings, MT

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2005 Manuscript Review Process

2005 Manuscript Review Process

Editorials:Distributive Justice in Dentistry ....................................................................................................................................................Number 1, page 2

David W. ChambersHow Should Dentists Practice? .....................................................................................................................................................Number 4, page 2

David W. ChambersOpen Leadership ............................................................................................................................................................................Number 3, page 2

David W. ChambersRetributive Justice and Dentistry ..................................................................................................................................................Number 2, page 2

David W. ChambersLetters [M. Holder; R. B. Stevenson] .............................................................................................................................................Number 3, page 4

College Matters:Life After Fellowship [President-elect’s address]..........................................................................................................................Number 4, page 4

Marcia A. BoydNational Call to Action to Promote Oral Health [Convocation address].......................................................................................Number 4, page 8

Richard H. CarmonaACD Awards, 2005.......................................................................................................................................................................Number 4, page 11Manuscript Review Process, 2005 ..............................................................................................................................................Number 4, page 65Fellowship Class, 2005 ................................................................................................................................................................Number 4, page 16

Theme Papers:The ADA’s Practice Parameters ...................................................................................................................................................Number 4, page 23

Donalda M. EllekAn Accidental Career in Dental Journalism................................................................................................................................Number 1, page 17

John P. O’KeefeAdvice for a Young Editor—The Appeal .......................................................................................................................................Number 1, page 4

Deepinder NijjarAre Standards and Evidence Sufficient? .....................................................................................................................................Number 4, page 42

Katherine T. O’Loughlin & Robert ComptonThe Buy or Lease Decision in Dental Curricula...........................................................................................................................Number 2, page 15

William K. LobbClinical Licensure Exams: The Unruly Gatekeepers ....................................................................................................................Number 3, page 16

Timothy W. OhEntrepreneurialism in Dentistry: Commercialism versus Opportunity .......................................................................................Number 2, page 18

Robert A. UchinEntrepreneurship in Continuing Dental Education: A Dental School Perspective......................................................................Number 2, page 10

Vincent N. LibertoEvidence-Based Dentistry: Concepts and Implementation .........................................................................................................Number 4, page 37

Richard Niederman & Derek RichardsIndustry Support for Dental Education ........................................................................................................................................Number 2, page 12

Michael R. SudzinaThe Legal Standard of Care .........................................................................................................................................................Number 4, page 20

Arthur W. Curley66


2005 Article Index

Journal of the American College of Dentists, 2005, Volume 72

2005 Index

A Long and Satisfying Relationship ............................................................................................................................................Number 1, page 12Norman Becker

Managing Financial Conflicts of Interest in Research ..................................................................................................................Number 2, page 4Lisa A. Bero

Mentor Says Learning Is a Two-Way Street ...............................................................................................................................Number 3, page 14Karen Burgess

My Journey in Dental Journalism .................................................................................................................................................Number 1, page 5Eric K. Curtis

New Dentist Shows Commitment to Community and Profession ..............................................................................................Number 3, page 12Karen Burgess

A Path to Professional Growth ....................................................................................................................................................Number 1, page 14Phillip Bonner

Reframing Diversity: Young Dentists and the Numbers Game.................................................................................................... Number 3, page 9Ivan Lugo

Risks and Rewards of Dental Journalism ...................................................................................................................................Number 1, page 24Harriet Seldin

The Scientific Publication ............................................................................................................................................................Number 1, page 21David L. Turpin

Today’s New Dentists Face Professional Challenges and Opportunities .....................................................................................Number 3, page 6Teri Barichello

Value of the Evidence-Based Consensus Conference.................................................................................................................Number 4, page 28Gary C. Armitage

What Is a Clinical Pathway?........................................................................................................................................................Number 4, page 32Debora Matthews

You Gotta Love the Details ............................................................................................................................................................Number 1, page 9Richard J. Galeone

Manuscripts:Founders of a Profession: The Original Subscribers to the First Dental Journal in the World..................................................Number 2, page 20

Malvin E. RingVisions and Viewpoints: Promises and Realities ........................................................................................................................Number 3, page 19

Kenneth D. Jones, Jr.

Issues in Dental Ethics:Changing Perspectives on Dental Advertising ........................................................................................................................... Number 3, page 24

Senior Class Essay Winners, Columbia UniversityErrors in Dentistry: A Call for Apology ........................................................................................................................................Number 2, page 26

Barry SchwartzRestoration and Enhancement: Is Cosmetic Dentistry Ethical? ..................................................................................................Number 4, page 48

Larry JensonWhat Does the Fact of Advertising Convey to Patients?............................................................................................................Number 3, page 22

Junior Class Essay Winners, Columbia UniversityWhen Nobody’s Looking [Ethics Prize Winner]............................................................................................................................Number 1, page 32

Steven A. Gold

Leadership Essay: Generations..................................................................................................................................................................................Number 3, page 27

David W. ChambersThe Progressive Era .....................................................................................................................................................................Number 2, page 33

David W. ChambersReflection .....................................................................................................................................................................................Number 1, page 34

David W. ChambersSelf-Control ..................................................................................................................................................................................Number 4, page 54

David W. Chambers67


2005 Index

Journal of the


2005 Statement of Ownership and CirculationThe Journal of the American College of Dentists is published quarterly by the American College of Dentists, 839J Quince Orchard Boulevard,Gaithersburg, Maryland 20878-1614.Editor: David W. Chambers, EdM, MBA, PhD.

The American College of Dentists is anonprofit organization with no capitalstock and no known bondholders, mortgages, or other security holders. The average number of readers of eachissue produced during the past twelvemonths was 5,486, none sold throughdealers or carriers, street vendors, orcounter sales; 5,426 copies distributedthrough mail subscriptions; 5,277 total paid circulation; 149 distributed as complimentary copies. Statementfiled with the U.S. Postal Service,October 18, 2005.

American College of Dentists839J Quince Orchard BoulevardGaithersburg, MD 20878-1614

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journal of the american college of dentistsa publication promoting excellence, ethics, and...

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