Is dentistry facing an ethical dilemma?

Scandals, lawsuits, a growing focus on commercialization and self-promotion, and dentists who prescribe excessive treatments are tarnishing the profession's image, according to a presentation on ethics at the recent ADA annual session in Las Vegas.

Most dentists may be surprised that a Google search on ethical scandals among health professions shows that dentistry now gets more hits than medicine, nursing, chiropractics, and pharmacology, according to Ann Boyle, DMD, interim provost and vice chancellor for academic affairs at Southern Illinois University.

Some of the public's changing perceptions toward dentistry can undoubtedly be traced to ubiquitous media coverage of scandals and malpractice lawsuits involving medical professionals, Dr. Boyle noted.

Gordon Christensen, DDS, MSD, PhD, discussed the decline of dentists' credibility in a 2001 article, noting a Gallup poll showed that their ranking among professions had fallen below nurses, physicians, and veterinarians (Journal of the American Dental Association, August 2001, Vol. 132:8, pp. 1163-1165).

Dentists were ranked third among the most trusted professionals in 1995 but slipped to ninth in 2001, according to Gallup poll rankings; they ranked sixth in 2009.

Negative influences, according to Dr. Christensen, included commercialization and self-promotion, excessive treatment and fees, providing service only when it's convenient, and refusing to accept responsibility when treatment fails prematurely.

Dr. Boyle pointed to a 1997 Reader's Digest article about dentists' honesty. In it, the author visited 50 dentists in 28 states to see how many different treatment plans he would get.

Before the survey, the author had exams and plans from his own dentist and three others who participated in the investigation. All determined that one tooth needed a crown. But the 50 treatment plans he received ranged from three dentists who said he needed no treatment to a recommendation for 21 crowns and six veneers at a cost of nearly $30,000.

"Whether we like it or not, this article clearly left the impression that some of us were planning excessive care and could not be trusted," Dr. Boyle said.

Dentists who charge high fees without justification were also excoriated by Dr. Christensen. "It is our professional responsibility to provide oral care services at a level of efficiency that allows us to treat most of the patients who request our services, including some patients without the ability to pay," he said. "If all of us treated only those who could pay high fees, we would not fulfill our responsibility as members of a profession."

Dr. Boyle recalled hearing from frustrated emergency room doctors who complained that they cannot adequately treat dental emergencies and said many patients come to them because no dentist will see them.

"We know there are reasons for this that MDs don't understand," she said, "but we must also realize that these front-line physicians consider us uncaring, selfish, and greedy and unprofessional and will tell anyone who will listen, including politicians."

Cheating in dental schools

Dr. Boyle also discussed the growing prevalence of cheating among dental students. In 2006 and 2007, cheating incidents at five dental schools became public, including instances involving patient care. And a 2007 survey in the Journal of Dental Education found that 75% of dental students admitted to cheating on exams, she said (August 2007, Vol. 71:8, pp. 1027-1039).

Cheating methods range from using new technology -- using smartphones to look up answers, texting, and using cellphone cameras to capture exams for later reconstruction -- to old tricks such as crib sheets hidden on thighs, the underside of caps, and on oversized erasers, Dr. Boyle said. One imaginative cheater peeled off the label of a water bottle, wrote answers on it, then replaced it on the bottle. The result was a magnified version of the information he was able to read during the test.

"Everybody has to empty their pockets before tests now, like airport security," Dr. Boyle told the gathering.

Students have even performed unnecessary procedures, including root canals, to fulfill requirements, she noted. Forging faculty signatures for clinical work is another ploy. Online sites sell admission essays, including papers on dental ethics, Dr. Boyle wryly added.

A recent survey of ethics instructors at 56 U.S. dental schools revealed that "little time is devoted to ethics instruction in the formal curriculum" (Journal of Dental Education, October 2011, Vol. 75:10, pp. 1295-1309).

While the amount of time devoted to ethics instruction appears not to have changed much over the past 30 years, "what has changed are what qualifies as ethics instruction, the pedagogies used, and the development and availability of norm-referenced learning outcomes assessments, which are currently used by a number of schools," wrote the study authors, from the University of Michigan.

Ethics need to be more fully integrated across the dental school curriculum, including carryover into the clinical years, and assessing and ensuring competence also is needed, the researchers concluded.