Adopted by the California Dental Association House of Delegates November 2012
The privilege of being a dentist comes with a responsibility to society and to fellow members of the profession to conduct one’s professional activities in a highly ethical manner. California Dental Association (CDA) members agree to abide by the tenets embodied in the American Dental Association (ADA) Principles of Ethics and Code of Professional Conduct (ADA Code) and the CDA Code of Ethics. The CDA Code of Ethics, in general, pertains to 1) service to the public, 2) conduct in a dental office and between dental practitioners, and 3) how dental practices and services are promoted. By following the Code of Ethics, dentists build public trust and maintain high ethical standards for the benefit of all.
The CDA Code of Ethics consists of values and behavioral principles that serve as guidelines for the ethical practice of dentistry. The CDA Judicial Council may, from time to time, issue advisory opinions setting forth the council’s interpretations of the principles set forth in this code. Such advisory opinions are meant to be consultative in nature and are designed to aid in the resolution of specific ethical dilemmas. They are not binding interpretations and do not become a part of this code, but they may be considered as persuasive by the trial body and any disciplinary proceedings under the CDA Bylaws should a dentist be charged with a violation of the ADA Code or the CDA Code of Ethics.
As health care professionals, dentists assume publicly-entrusted responsibilities founded on the principle of non-maleficence—first do no harm. Some of the many characteristics of being an ethical dental professional are presented in the American College of Dentists’ Core Values and are hereby adopted by the California Dental Association as its core ethical principles:
Autonomy: Patients have the right to determine what should be done with their own bodies. Because patients are moral entities they are capable of autonomous decision-making. Respect for patient autonomy affirms this dynamic in the doctor-patient relationship and forms the foundation for informed consent, for protecting patient confidentiality, and for upholding veracity. The patient’s right to self-determination is not, however, absolute. The dentist must also weigh benefits and harms and inform the patient of contemporary standards of oral health care.
Beneficence: Beneficence, often cited as a fundamental principle of ethics, is the obligation to benefit others or to seek their good. While balancing harms and benefits, the dentist seeks to minimize harms and maximize benefits for the patient. The dentist refrains from harming the patient by referring to those with specialized expertise when the dentist’s own skills are insufficient.
Compassion: Compassion requires caring and the ability to identify with the patient’s overall well-being. Relieving pain and suffering is a common attribute of dental practice. Acts of kindness and a sympathetic ear for the patient are all qualities of a caring, compassionate dentist.
Competence: The competent dentist is able to diagnose and treat the patient’s oral health needs and to refer when it is in the patient’s best interest. Maintaining competence requires continual self-assessment about the outcome of patient care and involves a commitment to lifelong learning. Competence is the just expectation of the patient.
Integrity: Integrity requires the dentist to behave with honor and decency. The dentist who practices with a sense of integrity affirms the core values and recognizes when words, actions or intentions are in conflict with one’s values and conscience. Professional integrity commits the dentist to upholding the professions’ Codes of Ethics and to safeguarding, influencing and promoting the highest professional standards.
Justice: Justice is often associated with fairness or giving to each his or her own due. Issues of fairness are pervasive in dental practice and range from elemental procedural issues such as who shall receive treatment first, to complex questions of who shall receive treatment at all. The just dentist must be aware of these complexities when balancing the distribution of benefits and burdens in practice.
Professionalism: Self-governance is a hallmark of a profession and dentistry will thrive as long as its members are committed to actively support and promote the profession and its service to the public. The commitment to promoting oral health initiatives and protecting the public requires that the profession work together for the collective best interest of society.
Tolerance: Dentists are challenged to practice within an increasingly complex cultural and ethnically diverse community. Conventional attitudes regarding pain, appropriate function, and esthetics may be confounded by these differences. Tolerance to diversity requires dentists to recognize that these differences exist and challenges dentists to understand how these differences may affect patient choices and treatment.
Veracity: Veracity, often known as honesty or truth telling, is the bedrock of a trusting doctor-patient relationship. The dentist relies on the honesty of the patient to gather the facts necessary to form a proper diagnosis. The patient relies on the dentist to be truthful so that truly informed decision-making can occur. Honesty in dealing with the public, colleagues and self are equally important.
Section 1. Service to the Public
Service to the public is the primary obligation of the dentist as a professional person. Service to the public includes the delivery of quality, competent, and timely care within the bounds of the clinical circumstances presented by the patient.
1A. Professional Esteem
While serving the public, a dentist has the obligation to act in a manner that maintains or elevates the esteem of the profession.
1B. Accepting Patients Into the Dental Practice
In serving the public, a dentist may exercise reasonable discretion in accepting patients into the dental practice. However, in keeping with the core value of justice, it is unethical for a dentist to refuse to accept a patient into the practice, deny dental service to a patient, or otherwise discriminate against a patient because of the patient’s gender, sexual, racial, religious, or ethnic characteristics.
1.B.1. Patient Abandonment: Once a dentist has undertaken a course of treatment, the dentist should not discontinue that treatment without giving the patient adequate notice and the opportunity to obtain the services of another dentist. Care should be taken that the patient’s oral health is not jeopardized in the process.
1.B.2. Notice of Provider Relocation: Patients treated by a dentist who leaves a dental practice have the right to be informed of the dentist’s new contact information. It is unethical to withhold this information, if known, upon the request of a patient or to provide misleading information to patients. If the responsibility for notifying the patients falls to the departing dentist rather than the dental practice, the practice should not interfere with the discharge of these duties by withholding patient lists or other necessary information.
1C. Standards of Care
Wherever “standards of care” or “quality services” are undefined by law, such standards or services shall be defined by the California Dental Association or such agency as designated by the association. It is unethical for a dentist to render, or cause to be rendered, substandard care.
1D. Informed Consent
Fully informed consent is essential to the ethical practice of dentistry and reflects the patient’s right of self-decision. Except as exempted by state law, a dentist has the obligation to obtain the fully informed consent of the patient or the patient’s legal guardian prior to treatment, or the use of any identifiable artifacts (such as photographs, X-rays, study models, etc.) for any purpose other than treatment. Informed consent is also required when using a human subject for research.
1.D.1. Explanation of Treatment: A dentist has the obligation to fully explain proposed treatment, reasonable alternatives, and the risks of not performing treatment to the patient. The dentist shall explain treatment in a manner that is accurate, easily understood, and allows patients to be involved in decisions affecting their oral health or their participation in a research project.
1.D.2. Reporting Abuse: When a dentist suspects abuse, the dentist is not legally required to obtain informed consent prior to taking photographs, impressions or x-rays on a minor or dependent adult.
1E. Patient Confidentiality
Dentists are obliged to safeguard the confidentiality of patient records. Dentists shall maintain patient records in a manner consistent with the protection of the welfare of the patient. Upon request of a patient or another dental practitioner, dentists shall provide any information in accordance with applicable law that will be beneficial for the future treatment of that patient.
1F. Obligation to Inform
A dentist has the obligation to inform patients of their present oral health status.
1.F.1. It is the duty of a dentist to report instances of gross and/or continual faulty treatment. When informing patients of the status of their oral health, the dentist shall exercise care that the comments made are justifiable. This would include finding out from the previous treating dentist under what circumstances and conditions the treatment was performed. A difference of opinion as to preferred treatment shall not be communicated to the patient in a disparaging manner which implies mistreatment.
1G. Health Education of the Public
A dentist may participate in a program of health education of the public, involving such media as the press, radio, television, and lecture, provided that such programs are in keeping with the dignity of the profession.
1.G.1. Solicitation of Children: Solicitation of children on any private or public school grounds by the use of dental health programs (e.g., dental screening, mouth guards, sealants, etc.) for the purpose of generating referrals or for the financial benefit of the dentists participating in such programs is deemed not to elevate the esteem of the dental profession. For purposes of this advisory opinion, solicitation includes, but is not limited to, dissemination of business cards or any other materials intended to promote the dentist’s practice.
Section 2. Government of a Profession
Every profession receives from society the right and obligation to regulate itself, to determine and judge its own members. Such regulation is achieved largely through the influence of the professional societies, and a dentist has the dual obligation of becoming part of a professional society and of observing its rules of ethics.
2A. False Statements
It is unethical for a dentist to make a statement in any document filed with the California Dental Association, its component societies, or the American Dental Association, which is fraudulent or false in a material respect, or which omits to disclose any material fact or matter. For the purpose of this section, the word “material” means “not insubstantial” or “of significance” with respect to reasons for which the document is filed.
Section 3. Cooperation with Duly Constituted Committees
A dentist has the obligation to comply with the reasonable requests of a duly constituted committee, council or other body of the component society or of this association necessary or convenient to enable such a body to perform its functions and to abide by the decisions of such body.
Section 4. Violation of State and Federal Laws
A dentist has the obligation to comply with all state and federal laws and regulations. It is unethical for a dentist to violate any law of the state of California relating to the practice of dentistry or to engage in activity for which the dentist may be reprimanded, disciplined, or sentenced by final action of any court or other authority of competent jurisdiction, when such action reflects unfavorably on dentists or the dental profession. It is also unethical for a dentist to engage in unprofessional conduct as it is defined by the Dental Practice Act.
Section 5. Continuing Education
The right of dentists to professional status rests in the knowledge, skill and experience with which they serve their patients and society. Dentists have the obligation to advance their knowledge and keep their skills freshened by continuing education throughout their professional lives.
Section 6. Representations and Claims
In order to properly serve the public, dentists have the obligation to represent themselves in a manner that contributes to the esteem of the profession.
6A. False and Misleading Advertising and Solicitations
It is unethical for a dentist to mislead a patient or misrepresent in any material respect either directly or indirectly the dentist’s identity, training, competence, services, or fees. Likewise, it is unethical for a dentist to advertise or solicit patients in any form of communication in a manner that is false or misleading in any material respect.
6.A.1. False Advertising: A dentist shall not disseminate, permit or cause to be disseminated, or participate in the benefits from any form of advertising containing a statement or claim which is false or misleading in any material respect, for the purpose of, directly or indirectly, soliciting patients or inducing the rendering of dental services.
A statement or claim is false or misleading when it:
a. Contains a material misrepresentation of fact;
b. Is materially misleading because the statement as a whole makes only a partial disclosure of relevant facts; or
c. Is intended or is likely to create false or unjustified expectations of favorable results.
6.A.2. Publicity: A dentist who compensates or gives anything of value to a representative of the press, radio, television or other communication medium in anticipation of, or in return for, professional publicity must make known the fact of such compensation in such publicity.
6.A.3. Public Statements: A dentist shall not issue or cause to be issued through any medium, a public statement expressing or implying official sanction of the ADA, CDA, or any of its component societies, without due consent of the governing body of said organization. Upon receiving such authorization, the dentist shall ascertain that any public statement is scientifically correct and complies with the Code of Ethics.
6.A.4. Subjective statements about the quality of dental services can raise ethical concerns. In particular, statements of opinion may be misleading if they are not honestly held, if they misrepresent the qualifications of the holder, or the basis of the opinion, or if the patient reasonably interprets them as implied statements of fact. Such statements will be evaluated on a case by case basis, considering how patients are likely to respond to the impression made by the advertisement as a whole. The fundamental issue is whether the advertisement, taken as a whole, is false or misleading in a material respect.
6B. Professional Titles and Degrees
Dentists may use the degrees conferred upon them by diploma from recognized dental colleges or schools legally empowered to confer the same, the letters “D.D.S.” as permitted by state law, and/or the titles, “Doctor” or “Dentist” and any additional advanced academic degrees earned in health service areas. It is unethical for a dentist to use a title or degree in connection with the promotion of any dental or other commercial endeavor when such usage is false or misleading in any material respect.
6.B.1. Volunteer Position Titles and Experience: A dentist using volunteer position titles and association and/or component society connected experience in any commercial endeavor may be making a representation which is false or misleading in a material respect. Such use of volunteer position titles and association and/or component society connected experience may be misleading because of the likelihood that it will suggest that the dentist using such is claiming superior skills. However, when such usage does not conflict with state law, volunteer position titles and association and/or component society connected experience may be indicated in scientific papers and curriculum vitae which are not used for any commercial endeavor. In any review by the council of the use of volunteer position titles and association and/or component society connected experience, the council will apply the standard of whether the use of such is false or misleading in a material respect.
6.B.2. Additional Advanced Academic Degrees: The phrase “any additional advanced academic degrees earned in health service areas” is interpreted to mean only those degrees that are earned after a dentist graduates from dental or medical school. Use of a degree earned prior thereto may be misleading in a material respect because of the likelihood that it will indicate to the public the attainment of specialty status or advanced dental education. A dentist may list degrees only in the order received. A certificate or license is not a degree and shall not be listed with professional titles or degrees.
6.B.3. Letter Abbreviations: A dentist may append either the letters “D.D.S.” as permitted by state law, or the letter abbreviation(s) representing the degree(s) conferred upon the dentist by a recognized dental college or school legally empowered to confer the same, when indicating successful completion of a dental educational program. The simultaneous use of these abbreviations, however, may be making a representation which is false or misleading in a material respect as it implies completion of an increased level of dental education. In any review by the council of the use of letter abbreviations, the council will apply the standard of whether the use of such is false or misleading in a material respect.
6C. Name of Practice
As the name under which a dentist conducts a dental practice may be a factor in the selection process of the patient, it is unethical for a dentist to use a trade name or an assumed name that is false or misleading in any material respect. Use of the name of a dentist no longer actively associated with the practice may be continued for a period not to exceed one year.
Section 7. Billing Practices
A dentist has the obligation to submit any billing for services rendered or to be rendered in a manner which is not fraudulent, deceitful, or misleading.
7.A.1. Third Party1 Benefits: A dentist shall avoid any representation that causes patients to believe the dentist is a provider for the patient’s third party payer if, in fact, the dentist is not.
7.A.2. Waiver of Copayment: A dentist who accepts a third party payment under a copayment plan as payment in full, without disclosing to the third party payer that the patient’s payment portion will not be collected, may be engaged in overbilling. The essence of this ethical impropriety is deception and misrepresentation; an overbilling dentist makes it appear to the third party1 payer that the charge to the patient for the services rendered is higher than it actually is.
7.A.3. Billing For Services Not Rendered: A dentist shall avoid billing for services not rendered. If payment has been received for a service that is ultimately never rendered, the dentist shall arrange to refund any overpayment immediately.
Section 8. Emergency Service
A dentist has the obligation to make reasonable arrangements for the emergency care of his or her patients of record. A dentist has the obligation, when consulted in an emergency by a patient not of record, to make reasonable arrangements for emergency care of that patient.
8.A.1. Continuity of Care: In the interest of preserving the patient’s continuity of care, a dentist who treats a patient not of record shall recommend to the patient to continue treatment with the original treating dentist unless the patient expressly reveals a different preference.
Section 9. Consultation and Referral
Whenever the delivery of care to a patient requires diagnostic and therapeutic modalities that are beyond a dentist’s scope of services, the dentist has the obligation to inform the patient of all available treatment options and to refer the patient to a provider who is qualified to provide consultation or necessary care.
Some third party1 payer contracts restrict a contracting dentist’s scope of referral to specialists who have contractual arrangements with the payer. Some third party1 payers also restrict the circumstances under which referrals may be made to contracting specialists. If a dentist believes a patient’s condition requires services beyond a third party1 payer’s contracted services or providers, a dentist has the obligation to inform the patient of all available options in order that the patient may decide whether to seek services available within the contracted plan or to accept an outside referral at his or her own expense.
When a patient visits or is referred to a specialist or consulting dentist for consultation:
1. A dentist has the obligation to make a reasonable inquiry to determine whether a prospective patient is currently under the care of another dentist.
2. In the interest of preserving the continuity of care, a specialist or consulting dentist has the obligation to inform the patient of the need to continue care with the referring dentist, unless the patient expressly reveals a different preference.
3. When there is no referring dentist and upon completion of the treatment, a specialist or consulting dentist has the obligation to inform the patient when there is a need for further dental care.
Section 10. Expert Testimony
A dentist may provide expert testimony when that testimony is essential to a just and fair disposition of a judicial or administrative action.
10A. Conflict of Interest
It is unethical for a dentist to engage in activities where personal or professional interests may conflict with the dentist’s duties as an expert witness. It is unethical for a dentist to use information learned as expert witness for personal gain or advantage. If a dentist accepts a request from an attorney to provide an expert opinion about a person who is not a patient of the dentist, the dentist shall not accept that person as a patient into his or her practice until the litigation or other proceeding, if any, involving that person has concluded.
10B. Statements on Policies
A dentist has the right to speak out against any policies espoused by organized dentistry, provided the dentist does not misrepresent such policies. It is unethical, however, for a dentist to represent his or her views as those of the dental society or as those of the majority of the dentists of the community when, in fact, those views are opposed to those of the society or the majority of dentists in the community.
10C. Fair and Reasonable Comments
A dentist has the right to make fair comments with respect to dental health subjects, including dentists and the quality of dental care delivered and costs related thereto. However, it is unethical to publish, cause to be published or encourage the publication of comments on such subjects if the dentist does so without having sufficient information that would justify a reasonable dentist to believe the comments to be true. The burden shall be on the commenting dentist to produce the evidence upon which the comments were based and to establish there from that a reasonable dentist would be justified in believing the comments to be true. For the purposes of this section, the word “publication” means any form of communication, including, without limitation, the press, radio, television and lecture.
Section 11. Rebates, Split Fees and Other Fee Arrangements
It is unethical for a dentist to accept or tender “rebates” or “split fees.” Other fee arrangements between dentists or other persons or entities of the healing arts which are not disclosed to the patient are unethical.
11.A.1. Split Fees in Advertising and Marketing Services: The prohibition against a dentist’s accepting or tendering rebates or split fees applies to business dealings between dentists and any third party, not just other dentists. Thus, a dentist who pays for advertising or marketing services by sharing a specified portion of the professional fees collected from prospective or actual patients with the vendor providing the advertising or marketing services is engaged in fee splitting. The prohibition against fee splitting is also applicable to the marketing of dental treatments or procedures via “social coupons” if the business arrangement between the dentist and the concern providing the marketing services for that treatment or those procedures allows the issuing company to collect the fee from the prospective patient, retain a defined percentage or portion of the revenue collected as payment for the coupon marketing service provided to the dentist and remit to the dentist the remainder of the amount collected. The prohibition against fee splitting is not applicable to marketing via group advertising or referral services that do not base their fees on the number of referrals or amount of professional fees paid by the patient to the dentist.
1A third party is any party to a dental prepayment contract that may collect premiums, assume financial risks, pay claims, and/or provide administrative services.
The association’s Code of Ethics, although presented in the form of general guidelines, clearly suggests the conduct that a dentist is expected to follow in carrying out professional activities whether they are related to patients or to fellow practitioners.
Problems involving questions of ethics should be solved within the broad boundaries established in this Code of Ethics and within the meaning and interpretation of the Code of Ethics and Bylaws of the constituent and component societies. If a satisfactory decision cannot be reached, the question should be referred, on appeal, to the Council on Ethics, Bylaws and Judicial Affairs of the American Dental Association, as provided in Chapter XII of the Bylaws of the American Dental Association, and also in Chapter XI of the Bylaws of the California Dental Association.
American Dental Association Principles of Ethics and Code of Professional Conduct
American Dental Association Constitution and Bylaws
State of California Department of Consumer Affairs Dental Practice Act
California Dental Association Bylaws