Business Ethics and Dental Professionalism

Kenneth Jacobs, DDS

ABSTRACT The distinctions between business ethics and dental professional ethics have become less clear due to intrinsic and extrinsic factors influencing the dental profession. Although these influences are powerful and pervasive, dentists’ special relationships with patients and underlying values set dentistry apart from the typical business endeavor and help to establish a means for ethical decision-making. These influences and characteristics will set the tone for dental professionalism going forward.

Patient or consumer? In 2013, the Dental Board of California mandated that all dental offices conspicuously display new signage, in addition to the already cumbersome messages currently required, which states the following: [1]

Notice to Consumers: Dentists are licensed and regulated by the Dental Board of California 877.729.7789 www.dbc.ca.gov

There are similar postings required by the Department of Consumer Affairs in other professional settings such as for podiatrists, physicians and hospitals. These signs are meant for individuals receiving care or their representatives to be better able to report an incident of concern to the proper licensing board for possible investigation. Empowering people by giving them such contact information is a valuable tool, but there is a subtle yet profound point that was overlooked in the language used in the posting. How and when did the receiver of health care services become a “consumer” instead of a “patient?” This insidious transformation is more than just semantics and is seen in other examples throughout the health care environment. Several dental plan carriers refer to the “customer” portion of payment instead of “patient” in their estimate-of-benefits language. Even while attending organized dentistry meetings and practice management seminars, references are made to “consumer” as opposed to “patient” in regard to those we care for in the dental setting. The two terms are not interchangeable, but may be, at best, complimentary in certain contexts. Being a patient implies a sense of passivity, yet along with it, there are protections that a consumer may not be able to claim. The term “doctor” does grant a degree of power, but with this power comes great responsibility in the care for the patient. Despite the nuanced wording, several studies demonstrate the preference by the receivers of care to be called “patient” rather than “consumer” or “customer.” [2,3] Fortunately, a few astute members within organized dentistry identified this subtle shift in terminology such that the Dental Board of California revised the posting to delete the “consumer” portion so that only “notice” appears in the header. It is interesting to note that the similar displays in other professional settings such as hospitals, physician and podiatrist offices still refer to “consumers.” So what is the origin of this shift in perception? How did we get here? Since when did the state of the doctor-patient relationship resemble a retail transaction rather than the trusted professional connection? What is in a name anyway? In a broader sense, is the patient versus consumer designation an indication that the lines of business ethics and dental professional ethics have blurred to the point where they are becoming practically indistinguishable?

Business Ethics and Dental Professionals

The acclaimed Nobel Prize-winning economist Milton Friedman concludes in his Friedman Doctrine regarding the social responsibility of business that “there is one and only one social responsibility of business, to use its resources and engage in activities designed to increase its profits so long as it stays within the rules of the game, which is to say, engages in open and free competition without deception or fraud.” [4] In other words, Freidman contends that a company has no social responsibility to the public or society, but only to its employer shareholders as long as they play within loosely defined parameters. Contrast Freidman’s notion of business purpose and ethics from the early 1970s with the purportedly more socially conscious business model of today’s environment. As described recently in the Los Angeles Times, [5] currently there has been a move toward a warmer, fuzzier business model in which capitalism is no longer that of the single-minded, make-money-at-all-costs endeavor, but rather one that seeks to include social consciousness in dealing with its stakeholders. In a seemingly significant shift in philosophy, Business Roundtable released an updated statement in August 2019 on the purpose of a corporation. [6] Within the confines of the free-market system, 181 CEOs from a vast array of business sectors committed to lead their companies for the benefit of all stakeholders including customers, employees, suppliers, communities and shareholders. By delivering value to customers, investing in employees, dealing fairly with suppliers, supporting communities, embracing sustainable environmental practices and generating long-term value for shareholder investment, each company pledged all of these attributes for the future of their businesses, communities and country.

Business Roundtable’s current platform sounds worthy and plausible, but will there be actual change beyond rhetoric? Are these changes a defensive move to ward off further government regulation in the future or a genuine shift in business policy? Will the changes become part of the fabric of each of the 181 signers’ companies? Or once there is a major economic downturn will stock buybacks and cost-cutting measures take precedence over the commitment to all of the stakeholders? Freidman’s model and the latest iteration of Business Roundtable may aspire to the level of trust and integrity intrinsic to that of professional ethics, but only time will tell which priorities are sustainable.

For those of us in the health professions and in dentistry in particular, it is interesting to witness the narrowing of the divide between business and professional ethics. That is not to say companies are any less willing to make profits or that dental practices should abandon their core ethical principles to become more like retail establishments. Even though the American Dental Association (ADA) publishes numerous volumes of material to assist its members in operating successful businesses, there are still certain basic concepts that distinguish a professional dental practice from a retail establishment. Dentistry has traditionally been a professional service business in which the products are the services provided to patients rather than to customers. This product is based on the distinct needs of those individuals performed by highly trained and skilled professionals. An NBA player may be a professional in the sense of possessing unique ability and is highly compensated as compared to an amateur “nonprofessional” athlete. In contrast, the dental professional is obligated historically by virtue of an implied contract with society and through licensure to ethical standards that the paid athlete, entertainer or, for that matter, a corporation is not. Dental professionals are expected to be trusted role models in society whereas athletes and corporations can only aspire to be as such. In fact, in some instances, professional athletes ask society not to view them as role models, but to instead look toward doctors, teachers and parents as examples. Although the business community has decided it is time to be more responsible in its actions with society, during the past century, dentists have been committed to individual patients’ needs and public service along with individual practice success. The struggle is to find the desired balance between viable dental business and the essence of an admired profession. As in the broader business community, the evolution of professional ethics in dentistry is being influenced by various intrinsic and extrinsic factors. Concurrently with this struggle, there appears to be four emerging factors influencing the current landscape within dentistry and consequently what the dental profession will resemble in the future.

Factors Influencing Dental Professionalism

As described in the soon to be published American College of Dentists report “A New Professionalism,” [7] four essential factors are concurrently influencing the practice of dentistry. The challenges of individual practice styles, pervasive commercial influences, fragmentation throughout the profession and the disruptions caused by technology of previously accepted clinical and management methods are molding the future of dental professionalism. Once perhaps an enticing reason to enter dentistry, individual practice offered great satisfaction.

Dentists take appreciable consideration to establish their own style of providing care. A dentist’s philosophy of clinical practice may consist of the employment of auxiliaries, the utilization of preferred materials and the emphasis of certain technical competencies. Furthermore, the individual dentist may emphasize various methods of practice management philosophy.

Outside finance companies, dental product manufacturers and management consultants influence desired practice methods. With the convergence of these elements and in conjunction with burdensome regulations, a prolific scientific knowledge base and ever-present personal demands, there is a tendency to inhibit rather than encourage engagement between practitioners. An individual’s ethical philosophy of practice without engagement and common understanding is difficult to assess and implement. The small ethical decision moments we each experience on a daily basis should meet the needs of the patient and dentist. Codes of ethics may be a starting point, but they can be confusing, subject to interpretation and difficult to apply. The individuality of dental practice can be an ethically confounding aspect of the currently emerging dental professionalism.

The pervasiveness of commercialism has in many circumstances transformed the process along such that dental care increasingly resembles a bundle of commoditized transactions instead of a professional service provided within a trusted relationship to improve oral health. The branding of dental practices as “institutes,” “centers” or “academies” mirrors that of retail establishments. This combined with the proliferation of claims of superiority, as exemplified by pronouncements of “best dentist,” “No. 1 dentist” and “top dentist” all ironically within close geographical proximity, shifts the emphasis from genuine collaborative patient care among colleagues to that of aggressive competition. Receivers of service become customers, which alters the nature of the dentist-patient relationship and helps to further increase the outside influences of investment bankers, management consultants and lawyers. The impact of commercial business model ethics upon dental professional ethics has the significant potential to alter the nature of rendering dental services within this landscape.

As individual practitioners have engaged less within the dental community at large, membership in the ADA has decreased, leaving less of a unified voice for dentists. Yet, special-interest groups such as ethnic dental societies, recognized specialty organizations and other specific interest groups have become more pervasive. Along with these varied groups comes unique sets of goals, philosophies and ethical standards. With such diversity among the many participants within the profession, there is an alarming lack of engagement with each other and a failure of leadership to break down barriers. The result of this fragmentation creates an opportunity for confusion as to the rules of the game along with a lack of respect and understanding of each of our differences in the approach to ethics.

Traditionally, technological advances in dentistry have been slowly and methodically adopted with some never being fully utilized and others pervasively incorporated into practice over time. Yet currently, as in most aspects of modern life, the disruption of processes and the tools created by technology into modern dental practice have seeped into every aspect at a never seen before pace. We can glance into the future by looking to see what is happening currently in dental school education across the country. Technology is being used to create innovative learning environments in which the digital workflow is optimizing every aspect of dental education. Course work and clinical work are video teleconferenced to remote sites. Data analytics are used to support student success and predict clinical outcomes. Electronic records and research are connected across networks to provide greater access to information in real time. Those students graduating from institutions having technology ingrained within the educational process will know little of the past analog world. These same new dentists who have grown up in the digital world will expect the seamless continuation of technology upon embarking on their careers. Technology may be the single most influential factor in changing the way dental services are distributed and performed. Along with the digital age comes great entry costs and the influence of the providers of the technology who in many instances wish to partner with dentists on an ongoing basis in the form of updates, upgrades and additional fees. The need to have the latest and greatest places pressure on dentists to keep up with the “competition” or be perceived as less competent. To proclaim possession of the newest devices can be even more powerful in some instances than the actual use of the device in practice. Unfortunately, occasionally patients unwittingly become the proving grounds for these advances in which tweaks are necessary to improve the technology’s performance. Direct-to-consumer technology is also disrupting the delivery of care. Do the receivers of the technology’s products transform into “consumers” rather than “patients” when the dentist is largely bypassed in the equation? The ethical challenge in the utilization of new technologies is to successfully integrate the touchstones of trust and integrity so that innovation will enhance not overrun basic professional values.

The Dentist-Patient Relationship

The vast array of factors affecting the practice of dentistry can be overwhelming in the context of integrating these changes into everyday practice. The desire may be for some to disengage rather than embrace the inevitable. Perhaps with useful decision-making tools to process and assimilate the information, we can work toward understanding the circumstances in which dentistry will operate in the future. Before an ethical decision-making process can be proposed, a framework for dentist-patient interaction should be considered as a foundation so that decisions can be made for the mutual benefit of the parties involved. As presented by Ozar et al., [8] the interactive model of the dentist-patient relationship seeks to describe an ideal scene that sets goals to maximize patient autonomy while the dentist contributes their abilities, expertise and protections to the patient as an ethical professional. In this model, collaboration is the foundation with the dentist and patient having equal standing within the interactions of making choices. Although the relationship is said to be equal, it originates from differing grounds. The patient brings their values and independence knowing it is their life that will be directly impacted by the interaction. Concurrently, the dentist brings the qualities of being able to apply their knowledge and skills in enhancing the patient’s ability to take control of their bodies. The exchange is far more interactional than the mere signature on a boilerplate informed-consent document. In this model, dentists and patients are seen as being on the same team, so to speak, such that each party’s unique contributions of judgments, choices and values can coalesce to produce shared actions. Within this framework, the obligation is to the patient’s autonomy through education, unbiased discussion rather than sales pitches disguised as informed consent and an overall commitment to the patient’s well-being. Care and collaboration are paramount in this model rather than competition and one-sided gains as might be seen in a typical business relationship. The ideal model can perhaps even be taken a step further as described by Chambers, [7] such that each participant will “act so that no one involved in or affected by our actions, including ourselves, would be motivated to act differently.” Thus, it can be conceived that all involved will thrive when each party grounds the relationship in ethics.

Core Values

Of course, a model of an ideal dentist-patient interaction is valuable as a concept to aspire, but also presumes both parties are willing participants. Is it possible in today’s landscape that the ideal relationship proposed here is becoming less of a likely interaction? Consumers by definition may act differently than patients. Furthermore, is an increasingly fragmented profession of individual practitioners struggling with how to deal with quantum leaps in technology sending the best messages to the public? Is society truly still interested in having the continued trusted relationships an ideal model represents or is the preference merely a series of transactions based on conveniences, potentially manipulated online reviews or third-party payer dictates?

These factors make it even more crucial for the dentist-patient relationship to have grounding in the core values of the dental profession. The combination of an ideal interaction between dentist and patient along with essential core values establishes a reference that can be communicated among fellow professionals and then ultimately utilized to serve the public.

As described by Ozar et al., [8] dentistry’s central practice values are practiced by dentists but for the benefit of patients. No one dentist establishes these professional values that are received by patients, rather they evolve over time through dialogue between the dental profession and society. These values are central practice in that they represent the essence and permeate every aspect of the dentist’s professional life. In all professions, there are values that are essential to its particular practice. Within dentistry, six hierarchically ranked central values can be identified:

■ The patient’s life and general health.

■ The patient’s oral health.

■ The patient’s autonomy.

■ The dentist’s preferred patterns of practice.

■ Aesthetic values.

■ Efficiency in the use of professional resources.

This approach is designed in a preferential manner to maximize the central values so positive outcomes can be achieved over less desirable ones. The emphasis is on the process such that the goals are shared and transparent. In contrast to health care’s HIPAA protections, the lack of transparency in the multibillion-dollar business of electronic data collection and monetizing would be inconceivable and illegal. It would be safe to say that although a dentist’s primary concern would be a patient’s oral health, life and general health would typically take precedence. Of course, we realize the important relationship between the two, but it would be unwise for a dentist to act in a manner that would place a patient’s life in danger. The state of oral health as with general health is not a simple matter to define. For our purposes now, if we think in terms of a condition of being pain/infection-free along with individually tailored function/ aesthetics and the resilience to maintain such a status, we can prioritize oral health next in line as a value as long as a life-threatening circumstance does not exist. As previously discussed, patient autonomy is of primary importance in the dentist-patient collaboration. Yet, a dentist would be potentially acting unprofessionally by complying with a patient request that endangered the patient’s oral or general health. The dentist’s preferred patterns of practice include a wide range of considerations. Treatment philosophies, practice location, equipment selection, auxiliary utilization and management styles are among the many practice-pattern choices the dentist makes. In some instances, there may be small differences and in others a wide schism between patient desires and a dentist’s practice patterns. Keeping in mind the ideal interactive relationship in which it is the dentist’s role to enhance the patient’s ability to maintain control over their body, practice patterns might not be in line with patient autonomy.

In such a situation, emphasizing the goal for all parties to thrive together and to not feel a need to act otherwise, there could be several outcomes. Options might involve the complete revision of a practice pattern, patient choice shift through education or ultimately disengagement between the parties in the relationship. Aesthetic values must be considered in the dentist-patient relationship in that appearance can have a psychological connection to oral and general health. Further consideration must also be given that in many instances, perceived intraoral aesthetics vary between personal, professional and community standards. Yet, to potentially violate a practice pattern of damaging otherwise healthy oral structures to comply with a patient request for a particular perceived aesthetic procedure would be acting unprofessionally even though respecting patient autonomy. Efficiency in the use of professional resources is a component of dentistry’s central values in that time, effort, materials and expertise should be judiciously utilized, as these resources are not unlimited. This value would take a relatively lower position in the hierarchy than the other concerns that might more commonly relate directly to an individual patient’s well-being.

Ethical Decisions

This value-optimizing hierarchical method can be effectively utilized as an aid in the ethical decision-making process. In any given dentist-patient situation, the priority is given to the highest-ranking value. Thus, in considering extensive dentoalveolar surgery along with placing multiple dental implants for a medically compromised patient, the patient desire to function better (autonomy) and improve their chewing ability (oral health needs) could potentially be outweighed by the general health and life value considerations if such treatment would harm the patient’s overall health. Of course, there are many straightforward scenarios, whereas other ethical dilemmas require more intense considerations. The use of the central practice values will not necessarily make ethical decisionmaking simple but can provide a general structure to start the conversation.

As proposed by Peltier, [9] five steps are included in his discussion of how to use the central practice values to aid in an ethical decision-making process. Of course, the discourse on how to make an ethical decision is broad and deep with no one process able to satisfy all situations.

The proposed steps can be effectively used as a tool in the decision-making process though.

For most ethical decisions, these five steps can be followed as a framework while keeping in mind the interactive relationship of dentist-patient and the central practice values. Of course, in some situations the chosen path may become apparent in fewer steps.

■ Make a list of the available choices including ones that are liked and disliked.

■ Make a list of the professional values that come into play.

■ Determine the possible positive and negative outcomes of the actions on the list.

■ Rank the list of choices relative to the values involved within the hierarchy.

■ Justify the rankings with the possible outcomes or consequences and reconcile them with the values of the profession.

The ethical decision-making process can sometimes seem somewhat mysterious rather than a thoughtful consideration of information and possible outcomes. There is no one absolute method. Sometimes even engaging friends, family, colleagues, mentors, educators, religious leaders or even a gut check can be helpful in the process. Using as many of the five suggested steps as applicable along with a firm footing of interactive relationships and central practice values, let’s take a look at the multifaceted example of developing a professionally ethical advertising and marketing campaign for a dental practice to clarify the process.

1. Available choices: Advertise now? Delay to another time? Never endeavor into the advertising realm? If so, in what or how many different media — print, online, radio, television, sky writing? Hire a media manager to handle the project or do it without experienced help? How much exposure is needed? What will be the cost of the campaign? If the choice is to not develop a program, how else will it be possible to reach potential patients?

2–5. Professional values to consider and possible consequences/ justifications to consider:

● Use of professional resources is not an overwhelming factor in this scenario, but certainly spending an overabundance of effort on the advertising campaign may or may not be a wise use of more patient-oriented time. Typically, an advertising and marketing effort requires repeated exposure to be effective. Financial resources could be wasted if not used wisely, thus leaving less resources available for other practice operations.

● Aesthetic values could be relevant in that some prospective patients may be interested in these services and a well-conceived truthful advertisement could aid in matching dentists and prospective patients. Yet, an overblown ad campaign could give a patient unrealistic expectations of results damaging the dentist-patient relationship from the onset. Conflicts could arise between dentistry’s traditional values regarding aesthetics and more fashionable market-based trends.

● A dentist’s preferred pattern of practice would weigh significantly on the decision of whether to or how to advertise. Heavily advertising on the radio or a television campaign may suit some dentists whereas others may be more comfortable with an informative newsletter periodically distributed to existing patients. Others may prefer to use no external marketing, relying solely on internal word-of-mouth practice promotion. Each of these choices could be well-suited to achieve a dentist’s particular style of practice.

● Patient autonomy as discussed previously is central to the interactive relationship such that the dentist’s primary contribution is to provide the patient with trusted assistance necessary to make choices pertaining to their oral and overall health. Yet, unlike a business-model marketing campaign in which a business-customer relationship might be described as “buyer beware,” the dentist-patient relationship is steeped in the professional responsibility of the dentist to respect and support the patient’s ability to make autonomous decisions. Thus, a positive outcome of marketing in a manner that is truthful and patient-benefit centric enhances patient autonomy through its motivational and educational effects. Conversely, pursuing a marketing campaign that is filled with exaggerated claims demonstrated by perfect-smile, tooth-model images rather than actual patients, confusing fee offers and claims of superiority such as “top dentist,” “No. 1 dentist” or “best dentist” would have a negative effect on patient autonomy. A patient would have no objective means to decipher which dentist is top or best or which procedures were actually performed by the dentist in a particular timeframe with fees that are not relatable to a specific procedure. Dissemination of such claims in which there is no supportive verifiable criteria would not aid the patient’s ability to make informed autonomous choices. Perhaps the process would even be hindered by overstated assertions, as these stray from the principles of truly ethical interactive relationships and central values. As a natural extension, a claim by a dentist to be “top,” “best” or “No. 1” would necessarily mean that all other dentists are none of those things. Strangely, within the same geographical location, it is not uncommon to find dentists making those claims. The potential message to the public in such a campaign is one of competition in an aggressive marketplace in which trust and integrity are diminished.

● Oral and general health values can be well served when marketing and advertising efforts are supported by the other underlying central values in dentistry. A well-crafted and thoughtful campaign based with its origins in the professional ethical values of truth and integrity can help stimulate patients of various levels of sophistication to realize the importance of oral health care and its relationship to overall health. Conversely, advertising containing mixed messages and unsupported information could repel patients who are truly in need of what dentistry has to offer. Of course, there are other methods and individual conclusions that can be reached, but as demonstrated using a combination of central values and interactive relationships in a thoughtful format, an individual dentist’s decision on a host of issues can be broken down into more straightforward components. The goal of this uncoercive process is to yield what is professionally desirable for the mutual benefit of the parties concerned.

Summary

In a world of multiple conflicting considerations, what does the future hold for professionalism in dentistry? Of course, there is no one simple, clear answer with so many at the table and so much at stake. Considering the average educational indebtedness incurred by new graduates is approaching $300,000, 10 third-party payer dominance in setting reimbursement structures and government regulatory intrusion, the actual undertaking of performing dentistry almost seems mundane. This in combination with the challenges of patient procurement, rising operational expenses and staffing all packaged up as the cost of doing “business,” it is a wonder that there are still willing entrants to the profession. It is inconceivable that the trajectory of these trends will be slowed as time passes. As described by Chambers, [7] the emerging professional tide is being shaped by several crucial factors.

Individual dentists are practicing in relative isolation with great leeway regarding ethical values. There is a trend of replacing trusted ongoing relationships with bundles of commercial transactions. Fragmentation amongst organizations exists creating less engagement along with mixed interpretations of ethical behavior. Management of technological advances will be increasingly necessary to preserve the primary professional obligation of appropriate care versus service over utilization. Dentistry’s destiny will not be determined in isolation. Individual practitioners and organizations need to understand the value of a professional community engaged with the public in order to positively shape the future. Ethnic, recognized specialty, public health, special interest, dental schools, government and commercial enterprises must be willing to engage with full understanding that society is rapidly evolving. This should not be attempted on a large-scale effort only, but by each party in conjunction with small daily ethical changes in once otherwise routine behavior. Although there are great expectations placed on individual dentists and the profession in its entirety, we must remember that dentists are merely human and their organizations are the same with all of the trappings that come along. Yet, dentistry’s ace-inthe-hole superpower is its foundation of ethical interactive relationships combined with core values in ethical decision-making, which traditional business still struggles to integrate. Among the present essential tasks is the call to interested leaders throughout the profession to show the way through engagement at every level that ethics is not only a means of judgement and punishment, but a mutually beneficial attribute on par with technical acumen and business prowess that can be uniquely merged for the shared betterment of dentists and patients alike.

REFERENCES

1. Dental Board of California. Adopt Section 1065 of Division 10 of Title 16 of the California Code of Regulations. www.dbc.ca.gov/ formspubs/1065mt.pdf.

2. Deber RB, Kraetschmer N, Urowitz S, Sharpe N. Patient, consumer, client or customer: What do people want to be called? Health Expect 2005 Dec;8(4):345–51. doi: 10.1111/j.1369- 7625.2005.00352.x.

3. Deber RB, Kraetschmer N, Urowitz S, Sharpe N. Do people want to be autonomous patients? Preferred roles in treatment decision-making in several patient populations. Health Expect 2007 Sep;10(3):248–58. doi: 10.1111/j.1369-7625.2007.00441.x.

4. Friedman M. The social responsibility of business is to increase its profits. The New York Times Magazine Sept. 13, 1970. umich.edu/~thecore/doc/Friedman.pdf.

5. Edgecliffe-Johnson A, Mooney A. Touting kinder gentler values in business. Los Angeles Times Dec. 26, 2019. www.pressreader.com/ usa/los-angeles-times/20191226/281840055578687.

6. Business Roundtable. Business Roundtable redefines the purpose of a corporation to promote ‘an economy that serves all Americans.’ www.businessroundtable.org/business-roundtable-redefines-the-purpose-of-acorporation-to-promote-an-economy-that-serves-all-americans.

7. Chambers DW. Ethics Report: New Professionalism. 4th draft. Gaithersburg, Md.: American College of Dentists; June 2019.

8. Ozar DT, Sokol DJ, Patthoff DE. Dental Ethics at Chairside: Professional Obligations and Practical Applications. 3rd ed. Washington, D.C.: Georgetown University Press; 2018.

9. Peltier B, Jenson L. Dental Ethics Primer. Gaithersburg, Md.: American College of Dentists; 2017.

10. American Dental Association Health Policy Institute. Health Policy Institute: Educational debt in numbers, 2019 graduating class. www.ada.org/en/publications/new-dentist-news/2020-archive/ february/health-policy-institute-educational-debt-in-numbers.

THE AUTHOR, Kenneth Jacobs, DDS, can be reached at kjjdds@msn.com.

AUTHOR Kenneth Jacobs, DDS, has practiced general dentistry for over 30 years in Beverly Hills, Calif. He is an adjunct clinical instructor at the Herman Ostrow School of Dentistry of USC where he teaches ethics and professionalism. He is a fellow of the American College of Dentistry and served on the CDA Judicial Council. Conflict of Interest Disclosure: None reported.