American College of Dentists Gaithersburg, MD 20878-1614 ... · Spring 2014 Volume 81 Number 2 537943 Cover_Layout 1 7/11/14 10:13 AM Page 2. ... Evidence-based dentistry is the integration

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

Periodicals PostagePAID

at Gaithersburg, MD Journal of the

American Collegeof Dentists

The Ethics of Charity at Home

Spring 2014Volume 81Number 2

537943 Cover_Layout 1 7/11/14 10:13 AM Page 2

A publication advancing excellence, ethics, professionalism,and leadership 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 2014 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 2014 subscription rate for members of the American College of Dentists is $30,and is included in the annual membershipdues. The 2014 subscription rate for non-members in the United States, Canada, and Mexico is $40. All other countries are$60. Foreign optional airmail service is an additional $10. Single-copy orders are $10.

All claims for undelivered/not receivedissues must be made within 90 days. If claim is made after this time period, itwill not 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 articles, 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 opinions or statements.

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 2014; 81 (2): 1-36.

Journal of the


Communication Policy

It is the communication policy of the American College of Dentists to identifyand place before the Fellows, the profession, and other parties of interest thoseissues that affect dentistry and oral health. The goal is to stimulate this community

to remain informed, inquire actively, and participate in the formation of public policy and personal leadership to advance the purpose and objectives of the College. The College is not a political organization and does not intentionally promote specificviews at the expense of others. The positions and opinions expressed in College publications do not 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.

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

Managing EditorStephen A. Ralls, DDS, EdD, MSD

Editorial BoardDavid A. Anderson, DDS, MDS, MAVidal Balderas, DDSDavid F. Boden, DDSHerb Borsuk, DDSKerry Carney, DDS David A. Chernin, DMD, MLSDonald A. Curtis, DMDAllan Formicola, DDS, MSRichard Galeone, DDSPeter Meyerhof, PhD, DDSDaniel L. Orr II, DDS, PhD, JD, MDAlvin B. Rosenblum, DDSCarl L. Sebelius, DDSH. Clifton Simmons, DDSWilliam A. van Dyk, DDSJim Willey, DDS

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

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

Letters from readers concerning any materialappearing in this journal are welcome [email protected]. They should be no longer than 500 words and will not be considered after other letters have already been published on the same topic. The editorreserves the right to refer submitted letters to the editorial board for review.

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

OfficersKenneth L. Kalkwarf, PresidentJerome B. Miller, President-electSteven D. Chan, Vice PresidentBert W. Oettmeier, Jr., TreasurerW. Scott Waugh, Past President

RegentsThomas J. Connolly, Regency 1Thomas A. Howley, Jr., Regency 2Geraldine M. Ferris, Regency 3Richard F. Stilwill, Regency 4Joseph F. Hagenbruch, Regency 5Robert M. Lamb, Regency 6George J. Stratigopoulos, Regency 7Rickland G. Asai, Regency 8

Elizabeth Roberts, At LargeRonald L. Tankersley, At LargeRichard C. Vinci, At LargeStephen K. Young, At Large

Lawrence P. Garetto, ASDE LiaisonBrooke Loftis Elmore, Regent Intern

The Ethics of Charity at Home4 Dental School VolunteerismAmy Blake, Peter March, and Christine Miller, BS, MHS

12 Mission of MercyMark Humenik, DDS, FACD

16 The Ethics of Charity Dental ClinicsGary Miller and Keith Kirshner

19 What Are FQHCs and How Do They Affect Dental Services? Ann Marie Silvestri, DDS, MPA

22 The Potential for Telehealth Technologies to Facilitate Charity Care:Creating Virtual Dental HomesPaul Glassman, DDS, MA, MBA, FACD, Maureen Harrington, MPH, Maysa Namakian, MPH, and Jesse Harrison-Noonan

Issues in Dental Ethics26 Dental Ethics and Emotional Intelligence

Alvin B. Rosenblum DDS, FACD, and Steve Wolf, PhD

Departments2 From the EditorTQM or EBD

36 Submitting Manuscripts for Potential Publication in JACD

Cover photograph: ©2014 Stockphoto.com/William Howell(clinic) & Zargon Design (chair). All rights reserved.

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matter of reading the literature or atleast summaries of the “best” parts of it.

The computer, promotion and tenure requirements at universities, andcommercial funding of “applied science”have changed research dramatically overthe past half century. When I first taughtstatistics, the focus was on what insightcould be gained from reading a single,well-conducted study. Today, we readabstracts and look for trends innumerous related studies. Study designshave to be standardized in order tofacilitate computer searching andextraction of common features. Protocol—following the rules—is now the thing,and one cannot be published unlesscomputer-ready.

Clinical guidelines have proliferated.A panel of experts is convened for aconference, usually under the auspicesof a professional organization. Evidence-based clinical guidelines are agreed andpublished. There are clearing houses forclinical guidelines. In fact, this verymoment I did a Google search on“clinical guidelines” and found 139,000of them. A common research paper nowis for investigators to survey practitionersin a field to find out whether theypractice consistent with the guidelinesor even know that they exist. Fiftypercent awareness is generally the highend. The conclusion of such studies istypically that more education andresearch are needed.

Why does evidence-baseddentistry still have a cachet,but quality never quite

managed to catch on?We could blame John Gies, a biochem-

ist, who authored a 1926 report blastingdentistry and dental education for lackingthe proper scientific foundations to callthemselves professions and followed sixyears later with an ACD report notingwith embarrassment the role ofcommercialism in dental journalism.

Good progress has been made on the first concern. Dental educationfound new homes in research-intensiveuniversities where science was one ofthe languages spoken. This has enhanceddentistry’s reputation among theprofessions and given it credibility in the eyes of the public, to say nothing ofsupporting specular enhancements inthe techniques available to fix problemsin the mouth. Dentistry took on theprestige of the academy.

Gies was realistic in forecasting thatoral diseases are complex and it wouldtake several decades to move from a “fix-it” approach to prevention and cure, buthe certainly expected the latter to be theproper focus for inquiry. I can imaginehe would give a wrinkled grimace tofind that 80 years later, the EBD label is

primarily reserved for horse racesbetween competing reparative techno-logies. I fantasize that he would bewriting letters to the editors of journalspointing out that science and evidenceare not the same things.

By contrast, little has come of Gies’splea to escape the grip of commercialism.There was an initial period of perhaps20 or 30 years when proprietaryinterests were pushed aside. Somepractice acts at that time prohibitedcommercial exhibitors from attendingscientific sessions of dental associations,while schools were scrupulous aboutprotecting students from exposure todetail men and faculty appointmentswere terminated if conflicts of interestwere found. Dental Cosmos, Gies’s bad boy of commercial journalism,carried about the same ratio of scientificcopy to ads as does today’s JADA (4/1),although both articles and ads are ofbetter quality now.

Evidence-based dentistry is theintegration (by practitioners, notresearchers) of patient values, the bestoutcomes of research, and clinician’spractical wisdom. That is an ambitiousproject. Patient values are sometimesoverlooked or assumed to be the same asthe dentists’. It is a bit of an epithet to saythat practitioners are justified in placingfaith in what “works in their hands.”Integration of diverse values andevidence at chairside is a fantasticallycomplex art. It has received virtually noscientific study. That sometimes leavesthe impression that EBD is essentially a

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2014 Volume 81, Number 2

Editorial

From the Editor

TQM or EBD

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There is much less to say regardingTQM. The goal there is to identify whatis needed and work to raise the level oforal health; reduce unwanted variation;and reduce cost, time, and dangeroussurprises for practitioners. TQM can beperformed in individual offices, or betterin groups of offices. It depends on goodrecord keeping. In the place of statisticaltests that editors like to see forpublications, TQM works when dentalpractices thrive by improving theoutcomes they are focused on. TQMlooks to results (the dependent variable);EBD looks to materials and methods(the independent variable).

The ADA has invested heavily in EBDwith training programs, study groups,and a Web site. TQM has received lessattention, and that not always favorable.I can only speculate that EBD offers theadvantage of associating dentistry withthe positive reputation of science whileleaving the choice of how to use theevidence to individual practitioners. That is less risky than publically settingquality outcome targets. The focus inEBD on materials and methods ratherthan oral health outcomes has certainlyopened the door for commercialism toreenter the profession.

At present, the champions of TQM area few closed panels, large group practices,and even insurance companies.

Gies became interested in dentistryin 1909 when members of the FirstDistrict Dental Society of New York

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Journal of the American College of Dentists

Editorial

Integration of diverse values

and evidence at chairside

is a fantastically complex art.

It has received virtually no

scientific study.

visited his lab and offered to fund hisinquiries into stopping caries. That is aTQM question defined by results ratherthan methods. John Gies would bedisappointed, I think, that we havepermitted such a wide gap to emergebetween science and practice. The gaphas not always been filled by individualswhose first goal is to improve oral health.Fancy trappings of science bring rigor tothe protocol of that enterprise but theydo not bend its purpose to finding thebest way to make mouths healthy.

An advocate for TQM would start byasking what barriers exist to optimizingoral health and how those barriers couldbe reduced. That is a bold move, as itwould require an upfront recognitionthat professionals are not the only oneswith some legitimate claim to opinionsabout what constitutes good oral health.Touting scientific methods is safer thanpursuing quality results.

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Amy BlakePeter MarchChristine Miller, BS, MHS

AbstractStudent Community Outreach for Public Education, SCOPE, is a student-led community outreach program at the University of the Pacific thatprovides leadership opportunities,service experiences, and a chance to understand the oral needs of allAmericans. The organization andactivities of the program are detailed,along with a description of the type of individuals served. The complexrange of motives for community serviceand the relationship between theprivate system and the safety-netsystem are explored.

My responsibility is to promote thehealth of the community and thepersons I serve. I will not discriminateagainst any person in my decisionsand care. I am responsible for contri-buting to an improved community. I will strive to prevent disease and tocorrect adverse social conditions. I will serve as both a teacher and arole model for my patients, mysuccessors, and the public.

—Excerpts from the University of the PacificArthur A. Dugoni School of Dentistry

Professional Oath

At the start of second year, everyUniversity of the Pacific dentalstudent recites these words at the

White Coat Ceremony. As specializedproviders of oral health care, we bear atremendous obligation to contribute tothe well-being of our respective com-munities. What are the clinical careexamples and lessons taught in schoolabout upholding that responsibility?What are we to glean from our educationabout the ethics of charity care? Whilewe are in school, we see a wide varietyof patients in our clinics, but certainlynot a representation of all the membersand age range of a community. Peoplewho are the working poor, infirm,destitute, incapacitated, or the very frailelderly are all essentially excluded fromreceiving care at the dental school,despite the school clinics being a moreaffordable option in a cutting-edgefacility. How, then, are dental studentsable to gain experience with these mar-

ginalized groups that so desperately needthe attention of the dental profession?

For about three weeks in our finalyear of dental school, we will have theopportunity to do extramural clinicalrotations in community clinics andhospitals that will allow us to diversifyour patient experiences. Another waythat we gain experience with a cross-section of the community and exposureto challenges with access to dental careis through projects sponsored by on-campus committees like SCOPE, whichstands for Student Community Outreachfor Public Education.

The three authors of this article areheavily involved leaders of this group.Professor Christine Miller is the founderand has been the faculty advisor foryears, Peter March and Amy Blake arethe current presidents, a position held by junior-year students. SCOPE is aleadership development, peer mentoring,and student-directed volunteer com-munity oral health organization.Designed and initiated over 20 years

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Dental School Volunteerism


Amy Blake and PeterMarch are now third-year(senior) dental students andMs. Miller is AssociateProfessor and Director ofCommunity Programs at theUniversity of the Pacific,Arthur A. Dugoni School ofDentistry in San Francisco;[email protected].

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ago by a core group of students andfaculty, the mission is to develop dentalprofessionals engaged and committed toimproving the oral health of all people.

SCOPE officers coordinate projectsand events throughout the Bay Area inmany different venues, such as healthfairs, community centers, dental clinics,and hospitals, and make volunteeringopportunities available to the studentbody. As SCOPE leaders and dentalstudents, we see various reactions: theeagerness with which our fellow studentsjump at the chance to volunteer andsometimes the apathy of students.

In the second year, the curriculumofficially presents 18 community healthmodules that provide the “meat andpotatoes” of what we need to knowwhen we work with underserved groups.When the modules were introduced to us, they were met by a chorus ofgrumbling. Further, there is almost noconversation about improving thesystem of providing care to includedisadvantaged groups. The majority ofstudents want to become private practicedentists or specialists serving patientswho have insurance or the means to payfor services, not to work in communityhealth or address healthcare policiesthat have left vulnerable populationswith little or no access to dental care. At the same time, when we post eventsfor volunteer sign-up, we are usuallyinundated by a flood of responses andoften need to turn students away.

An example of our school’s interestin volunteering has been our participa-tion at the Bay Area CDA Cares events. In2013, there were 165 Pacific volunteers,and in May 2014, 180 students out of astudent population of about 420 studentsvolunteered. Big events held on Saturdaysallow more students to volunteer with-out clinic conflicts or limits on attendees.

Why Participate?This dichotomy in attitude is difficult to make sense of, and its implicationsregarding charity care and the upcomingcrop of dentists is unclear. We wonderwhat exactly motivates students tovolunteer, and we have identified whatwe think are some key reasons.

For one, it has become a routine and often “required” part of educationgenerally for students to volunteer. Manyhigh schools and colleges now have acommunity service requirement, andthus students are not only accustomed tovolunteering, but actually expect it aspart of their education. This contributesto creating a culture of volunteerism, itis something people do to socialize, andthey do it because their friends are doing it. Another aspect is the increasedawareness dental students, along withthe general public, have about the dentalcare crisis in America. For example,“Dollars to Dentists,” a 2012 programproduced by PBS’s Frontline, exposed theinequities in dental care in the UnitedStates. Huge free dental events like CDACares, Missions of Mercy, California CareForce, and Remote Area Medical, always

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The goal should be to

eliminate the need for

charity care.

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draw media attention and have donetheir part to raise awareness of theaccess problem.

In 2009, California curtailed itsMedicaid insurance program, which led to a spike in demand for low-costdental services and emergency roomdental visits. The situation at hand isboth heartbreaking and overwhelming,and dental students are motivated toaddress it.

On the other hand, we believe that there are other motivations forvolunteering that are not so philanthro-pic. The job prospects for new dentalschool graduates look very different thanthey did two decades ago. The market is extremely competitive, and somestudents are saddled with enormousdebt. Further, postdoctoral residenciesare now sought out by the majority ofdental students. For example, in ourschool alone, the number of studentsaccepted into GPR/AEGD in 2009 was 23. In 2013, the number was 51. Forthose of us applying for jobs, associatepositions in private practice, GPRs,AEGD, or specialty schools, it is anecessity to have extracurricularactivities like volunteering and studentleadership on our résumés to even havea chance for an interview.

In other words, students are some-times more motivated to volunteer inorder to propel their own self-intereststhan to help needy communities.Regardless of their motivation forshowing up to volunteer, we hope that the experiences students have willopen their eyes to the problems theprofession faces in providing services to all Americans.

Adapting to an Ever-changingLandscapeStarting over 20 years ago, communityoral health projects have been availableto volunteer students through SCOPE.Decades ago, five dental students andthe Director of Community Programslaunched the student-directed programto benefit students and the underservedpublic. A hallmark of SCOPE is the peer-mentorship design. Today, the programexpanded by student recommendations,is known as Community CampusPartnership Projects [CCPP], which nowincludes, SCOPE, Project HomelessConnect, major events, and selectivecourse options in the curriculum.

Prior to dental school, many CCPP-SCOPE officers directed or volunteeredin community health service projects in college. Each year more studentsarrive to dental school anticipatingcontinued engagement with under-served people and with health projectsin the community.

Some of the professionally proposedand current solutions on access promptlively discussions among students.Additionally, in regard to practiceoptions after graduation, studentsenvision and discuss potentialalterations in the current healthcaredelivery system, including changes infinancing of dental services andincentives to providers to promoteprevention and other health outcomes.These environmental changes, plus thehealth policy recommendations todiversify and expand the dental work-force, weigh on the minds of students.

SCOPE and CCPP communityprojects are strategically designed tomeet both the community oral healthneeds as well as the professional andclinical preparation of tomorrow’sdental practitioners. The SCOPE-CCPPcommunity health projects form thefoundation and bridge between the dental school and underserved

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Regardless of their motivation for showing up to volunteer, we hopethat the experiences students have will opentheir eyes to the problemsthe profession faces inproviding services to all Americans.

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communities. Public health reports anddental health profession shortage areasare used to target specific low-incomeneighborhoods, school and preschools,and senior centers. The program isgoverned by about 12 leadership councilofficers under the supervision of theDirector of Community Programs.

The mission of SCOPE is related toone of the elements in the school’smission: to develop dental professionalscommitted to and engaged in improvingthe health of all people. Major objectivesof SCOPE include:

• Provide students community-basedexperiences for risk assessment,screening, triage, and referral to“health homes” in a wide variety oforal health community serviceprojects.

• Expand experience for oral healthprevention education and preventivedental services for the underservedmembers of the San Francisco BayArea and Central Valleycommunities.

• Use “best practices” for datacollection and analysis and reportrisk and disease status, servicesutilized, the number of participantsserved, and other demographicinformation.

• Collaborate with professionals, suchas nursing, medical, and socialservices, and students, residents,community dentists, and hygienists.

• Refine the peer-mentoring systemwhile in school for students toactively lead, design, implement, and assess outreach projects yearafter year.

• Communicate with the public,agency staff, health professionals,and others in an empathetic andculturally competent manner.

• Promote leadership while in schooland lifelong professionalengagement directly withunderserved community members.

In the next decade, dental educationprograms must make availableopportunities that engage students incommunity-based experiences or servicelearning experiences. Significantchanges, challenges, and innovativesolutions to address the underservedpopulations surround the profession.Dental disease is increasingly beingviewed by medical and dentalprofessionals as a chronic disease.Community settings such as school-based health programs, preschoolprograms, and senior centers willincreasingly be used as sites to deliverspecific preventive and restorativeservices. With these changes and otherhealthcare system changes, dentalprofessionals and graduates will likelyinteract with a broader group of socialand health professionals in more diversepractice settings.

Provision of community-based“practice ready” experiences has becomean important component of highereducation. Integrating communityservice-learning into dental curriculafosters graduates who are betterprepared to work effectively amongdiverse populations and to functiondynamically with related health andsocial service professionals. Dentaleducation can apply the concepts ofexperiential education for developingstudents’ skills in understanding humandiversity, critical thinking, and thedynamics of integrated professionaleducation and promotion of communityoral health.

Lessons on the Ethics of Charity Care An example of one of the majoroutreach events in San Francisco isProject Homeless Connect, a one-dayevent that happens about every threemonths to provide a number of servicesto the homeless population. One of the most demanded and popularservices is dental care. SCOPE has had a relationship with Project HomelessConnect for over five years. We providedstudent volunteers and faculty membersto screen patients at a community center and then refer them to receivehygiene, restorations, or extractions.During the December 2013 event we saw 44 patients, extracted 255 teeth, andprovided more than $33,000 worth oftreatment. One senior faculty memberstated that participation in ProjectHomeless Connect and SCOPE is one ofthe most enriching clinical experiencesfor students and strongly encouragesparticipation. He facilitated courseflexibility in the regular curriculum toallow alternative sessions so studentscould attend the Project HomelessConnect events.

One of the questions that comes up about large events is whether or not these outreach events raise ethicalquestions for the students about thecontinuity and nature of the care beingprovided. When we posed this questionto students who frequent these events,the general consensus is that it is just not something they think about.

Some large events strive to link theunderserved public to dental healthhomes. Others are designed in a way to highlight and praise what appears to the public as heroic dentistry withabundant media attention. This gives the impression that all of the care andvolunteerism is positive and the focus is

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more on what was done and not theneeds after the event. As a first-yearstudent, I was very impressed with theresults from single-day dentures, which Iassumed would be too difficult to do fastin a normal clinic setting. After gainingmore experience in school, I came torealize that almost all dental care shouldbe given in a comprehensive, continualcare setting where dentures aremonitored for fit and restorationsperiodically examined. It was not untilgoing to several events that I began toconsider the ethics of this kind ofsporadic dental intervention in whichcontinuing care is treated as an after-thought and the treatment is still focusedon single, high-priority treatments.

Is it fair or beneficial to the patientswho show up at these events but do nothave a dental home for follow-up care?Where does the denture recipient go forthe inevitable adjustments they willneed? What about the indirect pulp capsthat are often placed at these events ifthey turn into pulpitis?

And the biggest questions of all: Isthe fee-for-service business model ethicalwhen a disproportionate burden ofdisease is borne by poor and vulnerablepopulations? Is it fair to practice adifferent standard of care in charitysettings despite the good intentions onbehalf of the volunteer practitioner?

The standard and continuity of carefor large event charity work is quitedifferent from private practice.Continuity of care starts with referringand directing the individuals attendinglarge events to realistic nearby “healthhomes or dental homes.”

As already mentioned, inconsistentand episodic treatment without follow-uppushes the boundaries of the standard of care. I have personally been to eventswhere fillings and extractions were

performed without any radiographs. Is this considered to be acceptable,because of the dire circumstances? Then there is the matter of internationaldental missions, which are even moreconfusing from an ethical standpoint.Dentists and dental students alikeparticipate in these trips that often takeplace in exotic destinations with vaca-tion appeal. The clients or patients seenin these circumstances are at an evengreater disadvantage than theirAmerican counterparts because there isno safety net system for them to turn to.It is a wonderful thing to provide dentalservices to these patients, but the down-side is that there is seldom adequatefollow-up provided and very littleregulation of these makeshift clinics.

As students, the ethical considerationsof charity care are as complicated as thesystem that has created such extremeneediness in certain popultions. Whateverthe “right” answers are to these questions,what does seem perfectly clear is that itwill require a coordinated effort amongmany professionals and agencies withinand outside dentistry to provide a moreinclusive, comprehensive system of care. The goal should be to eliminate the need for charity care.

As student leaders, we encourage our peers and community practitionerparticipants to reflect about these issues.Now is the time, as we develop intodental professionals, to engage ourselvesin the challenges and solutions to accessto care. We challenge our peers to strivetoward making access to critical healthservices more equitable. �

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Is it fair or beneficial to the patients who showup at these events but do not a have a dentalhome for follow-up care?Where does the denturerecipient go for theinevitable adjustmentsthey will need?

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Quarter Event Patronage Service provided Ethnicities Approximate numbers served

Summer Quarter

San Francisco PHC Family Connect

Low-income families

Oral health information and screening

African American/Asian/Latin American/White 200 adults

San Francisco VN Cares Free Health Screening Families



San Francisco Western AdditionHealth Fair

Low-income families

Oral health information and education

African American/Latin American

200-500 adults, some children

Daly City Seton Medical Center Adult



San Francisco PHC–Screening

Adult and family


African American/Latin American/White 200 adults

San Francisco PHC–Oral Surgery

Low-income families


African American/White 200 adults

San FranciscoLatin American Food and HealthWellness

Youth and families

Oral health information Latin American/White 200 adults

and children

San Francisco SFGH Low-income families

Oral health information


San Francisco Larkin StreetYouth Program

Foster care children


African American/Latin American/White 100 youth

San FranciscoChinatownCommunity Health Fair

Youth and adults


Asian 200–300 adults, seniors, and children

San MateoSan Mateo Senior Health Fair

SeniorsOral health information and screening

African American/Asian/White

150 adultsand seniors

San Francisco SF Pride Low-income families



San Francisco Screening at BillGraham Center Adults


African American/Latin American/White 200 adults

San Francisco Tenderloin Health Fair

Low-income families



SCOPE and Community Campus Partnership ProjectsAnnual Outreach Activities & Projects, University of the Pacific Arthur A. Dugoni School of Dentistry

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San Francisco Carver Elementary Youth Oral health

information Latin American/White 100 children

Autumn Quarter

San FranciscoFoster Care Children’s Health and Wellness

Children Oral health information

African American/Asian/Latin American/White 100 children

Oakland Harbor HouseTeens and low-income families


African American 100 adults

San Francisco Kenko No-Hi Health Fair Children Oral health

information Asian/White 100 adults

San FranciscoYMCA and SFPD CommunityHealth Fair

Adults and families


African American/Asian/Latin American/White

50 adults and50 children

San FranciscoSoutheastCommunityCommission’s

FamiliesOral health information and screening



Concord Diabetes Health Fair Public


African American/Asian/Latin American/White 300-500 adults

San Francisco O-Positive Festival Families



San Mateo Speier Health Care and ACA

Families and seniors


Asian/Latin American/White 300 adults

San Francisco Compass Family Shelter

Low-income families


Various 30 adults and30 children

San Diego CDA Cares–San Diego

Low-income families


African American/Asian/Latin American/White 200–500 adults

San Francisco PHC Low-income families


African American/Latin American 200 adults

Winter Quarter

San Francisco MLK Red Cross SeniorsOral health information and screening


200 seniors—adults and somegrandchildren

San Francisco FIDM Health Fair Low-income families



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San Francisco SF Dept of Public Health

Childrenand parents



100 adults and children

San Francisco Give Kids a Smile–SFGH

Childrenand parents



San Francisco SF Dept of Public Health

Childrenand parents


200 children

Stockton Give Kids a Smile–Stockton Children Oral Health

InformationAfrican American/Asian/Latin American/White 200 children

Union City Give Kids a Smile–Union City

Low-income families



Reno Give Kids a Smile–Reno Children Oral Health

InformationAfrican American/Asian/Latin American/White 100 children

Oakland Harbor House Oral Health Fair

Low-income families



San Francisco AIDS Game Night Ryan Whiteclients


African American/Asian/Latin American/Whiten 50 adults

San FranciscoIda B. Wells Health and Wellness Fair

Youth, teens and families




San Francisco Women Vet Connect

Female veteransand children




Spring Quarter

San Francisco3rd AnnualCommunity andFamily Resource Fair

FamiliesOral health information and education


100–150 adults and children

San Francisco Western AdditionCommunity Fair Families



San Francisco6th Annual JCC Art of AgingGracefully

Adults andseniors



SausalitoFather’s Day Kick Ball Tournament

YouthOral health information and education


50 children and parents

San Francisco Senior Smiles Event Seniors



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Mark Humenik, DDS, FACD

AbstractSome dentists prefer solo charity work, but there is much to be said forcollaboration within the profession inreaching out to those who are dentallyunderserved. Mission of Mercy (MOM)programs are regularly organized acrossthe country for this purpose. This articledescribes the structure, reach, andpersonal satisfaction to be gained fromsuch missions.

Do good work; treat the patientswell.” That was my response to ayoung dental associate who

recently asked how he might thank mefor my help and guidance. It is aprinciple that has guided me throughdental school, advanced training, andprivate practice. And now, like a growingnumber of my dental colleagues, I canfully express this conviction, in its purestsense, by caring for the underserved.

As dental professionals, we strive toprovide assistance and promote healing.We also recognize that the access-to-care issues are critical. Thanks to theinitiative and enthusiasm of practicingdental professionals successfullypartnering with like-minded friends ofdentistry, there has never been a bettertime to make a significant contribution.Volunteer opportunities are increasingin both number and scope in an effort to reach and treat more patients. With minimal time and financial commit-ment, those keen to share their skillswill gain immeasurable rewards. Also, by volunteering in our field, we combineour eagerness to give back with ourgreatest strength, our expertise.

As the president of America’sDentists Care Foundation (ADCF) boardof directors (the nonprofit parentorganization of Mission of Mercy), I have had the privilege of witnessingthe growing participation of dentalprofessionals and dental societies todevelop, promote, and host successfulMission of Mercy events. Since the first

event was held in Virginia in 2000,Mission of Mercy clinics have improvedand expanded every year. The first ADA-sponsored event was held in conjunctionwith the 2013 meeting in New Orleans,and the next clinic is scheduled to takeplace this fall in San Antonio. At theconclusion of 2014, the Mission of Mercyfamily will include 26 states.

Each Mission of Mercy event, or“MOM,” is a two-day dental clinicproviding approximately $1 million incharitable dental treatment for 1,600 or more people. Our patients seekassistance because they lack access todental care. This issue occurs due tolimited or nonexistent financialresources, no dental insurance, or thelack of a dental home. All ages arewelcome, although pediatric servicesaccount for under 15% of event patienttreatment—parents will prioritize theirchildren’s needs, and more state-fundedprograms are available to serve them. A MOM event is hosted by the statedental society and its foundation inpartnership with ADCF. The benefit of a state partnering with ADCF is thatthe infrastructure and support are in

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Mission of Mercy


Dr. Humenik is president of the board of Dentists Care Foundation, the parent organization for Missions of Mercy. He practices inNorthbrook, Illinois; [email protected].

“

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place to host a large, high-profile, veryproductive clinic on a weekend.

A typical MOM event features a 100-chair portable dental clinic,complete with central compressed air,vacuum and water, instruments, andsterilization. ADCF provides, services,and maintains the equipment inaddition to offering guidance andtechnical support prior to and through-out every event. Dental treatment at aMOM event includes cleanings, basicrestorative services, oral surgery, andlimited endodontics. Oftentimes an on-site lab provides treatment partialsand in some states, prefabricated fulldentures. Patient educators andassistance from local social serviceorganizations reinforce and supportclinical treatment.

Patients are seen on a first-come,first-served basis and are not required toshow proof of need or citizenship. Everypatient receives at least one treatmentafter passing a preliminary medicalscreening (i.e., blood pressure/bloodglucose). The goals of a MOM event are:• Provide free, critical dental care

with a high priority on treatingpatients in pain and with infection.

• Raise public awareness of thebarriers to dental care faced byindividuals with limited financialresources.

• Challenge patients, policymakers,and dental professionals to worktogether to make viable andbipartisan “healthy choices” that will improve the oral health ofUnited States citizens.

What is necessary to host a MOM? It is important that a passionate group of individuals guide and advance theprogram in active collaboration withdedicated state dental society or founda-tion staff. Approval and support at thestate level is critical to establish a “MOMheadquarters” and to ensure the tax-deductible status of all donations. Inaddition, strong support from the localhost community and local dental societyfor pre-event assistance, on-site assist-ance, and follow-up care are required.

A MOM event is typically scheduled12-18 months in advance. This allowsthe member states adequate time toobtain funding (approximately $150,000in financial and in-kind donations), seek and secure an appropriate venue,coordinate volunteers, and work withADCF staff to assess and configure clinicneeds. Staffing for a standard MOMevent is significant: approximately 250dentists (general and specialists), 100hygienists, and 650-700 lay volunteersare required.

Nationwide, Mission of Mercy eventshave had a positive impact, treating over146,000 patients and providing $84million in free dental care since 2000.For every donated dollar, dentists andother MOM volunteers provide $6-8 ofcare. It has been observed that followingMOM events, dental emergency room

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It is impossible for an

individual to successfully

volunteer without a

network of support.

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visits are seen to decrease, often by asmuch as 40-50%.

A free, bustling clinic allows us toheighten political awareness by invitinglegislators, community leaders, and themedia to witness the “human face” ofour dental access problem. A MOM clinic can prompt productive discussionsthat we hope and believe will lead tobetter solutions to meet the risingdemand for oral healthcare services for those individuals with limitedfinancial resources.

Collaboration is intrinsic to ADCFand Mission of Mercy. The philosophybehind MOM and ADCF is “see one, doone, teach one.” It is a terrific model forgrowth and illustrates a culture thatmandates collective sharing. State dentalsocieties and program directors areencouraged to share clinic protocols,volunteer recruitment suggestions,fundraising methods, promotiontechniques, etc. Guests visiting anotherstate’s MOM events are enthusiasticallywelcomed and are encouraged to remainin close contact to ensure that ideas are shared, questions and concerns are addressed by those with greaterexperience, and assistance is madeavailable upon request. The same is truewith ADCF. Home-office personnel aswell as foundation board memberswelcome e-mails, phone calls, andopportunities to volunteer on-site.

The esprit de corps that resonatesthrough Mission of Mercy is also anessential component of organizeddentistry, dental societies, and studyclubs. Through our involvement in thesegroups, we benefit from and areenriched by the friendships that develop,the knowledge and insights that areshared, and the support that is offeredwhen challenges arise. In addition weare afforded opportunities to developcommon goals and celebrate individualand group successes. Participating in

a MOM experience provides theopportunity to give back through ourprofession in a meaningful way.

Dental friends have remarked that,though they may have volunteered in their communities, at church andschool functions, and at larger, nationallyorganized events, no experience quitecompares to a MOM event. Thedifference lies in the pleasure of usingtheir skills creatively while working side-by-side with colleagues outside thecomfort of private practice. Many haveconveyed that they have never felt astronger sense of solidarity withindentistry or more pride in their fellowcaregivers. Great satisfaction comes from committing to one another andcontributing to the team’s commonvision to transform lives.

A Mission of Mercy event absolutelytransforms lives in a direct and tangibleway. Inevitably one of the first patientsin line will present with active infectioninvolving a front tooth or missing frontteeth. These individuals are always self-conscious and confide that they are embarrassed to apply for jobs. Later in the “clinic day,” followingtreatment, the dental team is able todeliver a transitional partial that restoresthe patient’s smile and dignity andprovides a confidence boost that willallow him or her to seek employment.Nothing compares to the joy shared bythe patient and many caregivers. It isreally remarkable!

Amelia Earhart observed that, “asingle act of kindness throws out rootsin all directions, and the roots spring upand make new trees,” thus illustratingthe power and expansive nature ofvolunteerism. When we choose toactively contribute to and promote ourcause to staff, patients in our practices,

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As dental professionalswe strive to provide assistance and promotehealing. We also recognize that the access-to-care issues are critical.

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family, and friends, our enthusiasm hasthe capacity to influence and inspire.Many a dental office has committed, as a team, to participate at a MOM eventand have found that in addition toaccomplishing a great deal of good work and good will in a weekend, theyhave gained a better appreciation oftheir colleagues’ talents, improved their communication techniques, andreturned to the office as a stronger unit.

As critical as practitioners are to the success of a MOM event, the supportroles undertaken by general volunteersare invaluable. Dental supply representa-tives, technicians, plumbers, electricians,local and national business associates,friends of dentistry, family, and personalfriends step up and embrace incrediblechallenges to set up, maintain, anddismantle a clinic. For their dedicatedefforts, this enthusiastic group earns the gratitude of both the patients and clinicians.

It is impossible for an individual tosuccessfully volunteer without a networkof support. Time away from practice and family shifts our concerns to otherswho willingly commit themselves to ourcause. I contend that every individualclose to the on-site volunteer, personallyor professionally, contributes as anactive member of the volunteer team. At a minimum, the “at-home”’ teamoffers necessary personal support,accepts increased responsibilities athome or office, and often is involved in fundraising and securing necessarysupplies and equipment. I alwaysrespond to every gesture of support with,“Thanks for being part of this mission!”

For me there is no experience morethrilling than watching the clinic humwith an energetic, productive rhythm asdental students, hygienists, assistants,and general volunteers, together withyounger and more senior dentists work

in concert to treat deserving people. Ourpatients benefit enormously and so doesevery volunteer.

The countless “MOM Moments” weexperience through volunteering aredeeply satisfying. However, we recognizethat regardless of an event’s success orhow worthwhile the experience is for itsparticipants (patients and volunteers),we are limited by the nature of ourclinic. We are equipped only to delivercritical care, and a MOM clinic is notintended to function as a patient’s dentalhome. A great need remains to be filledand until better programs are in place tooffer complete treatment to individualswith limited financial resources, MOMand other outreach ventures are crucial.

As a skilled team of dentalprofessionals sharing our expertise, we send a genuine and explicit messageto the general public and our state andnational politicians that our attempts to provide access to care are diligent and innovative.

I guarantee that a MOM experiencewill enrich you and invigorate yourcareer commitment. If the challenge of a lead role sounds too ambitious, I encourage you to volunteer on-site at a MOM event. Your involvement (as aclinic set-up or tear down volunteer or as a two-day, one-day, or half-daytreatment provider) is always genuinelyappreciated. If a time conflict preventsyour clinical participation, I ask that youconsider making a financial donation insupport of an event at www.adcfmom.orgor through your state dental society.

By the simple gesture of offeringyour skills, enthusiasm, and support,you will positively impact other lives, as well as your own. �

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No experience quite

compares to a MOM event.

The difference lies in the

pleasure of using their skills

creatively, while working

side-by-side with colleagues

outside the comfort of

private practice.

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Gary MillerKeith Kirshner

AbstractThe Ben Massell Dental Clinic is part ofthe Jewish Family & Career Services inAtlanta, Georgia, which provides a widerange of health and social services on asliding-fee basis. A fixed location,comprehensive service, and a clinic withfull regular hours is an obvious benefit topatients. This structure also providesadvantages to dentists who wish to donatetheir professional expertise withoutdisrupting their offices and without theneed to create a new logistic andmanagement structure. Such a regularclinic also provides continuity of care in acharity setting.

Do dentists have a moral duty to provide charity care? That is a valid question. We can go

further: Does anyone have a moral dutyto provide charity? Maybe people do nothave an obligation to give charitably. But turn the question around. If some-one has the means to give, perhaps theyshould. We believe the answer is yes—especially when it comes to healthcareservices. Helping those in need is centralto the mission of healthcare providers.

We do not mean they must donatemoney. While we do believe they should if they have the means, we arereferring specifically to volunteeringtime and talents.

Across the country, there are somany people in so many communitieswho have no access to quality dentalcare. In Atlanta, hundreds of thousandsof people cannot afford a dentist. Yes,they have many other needs as well,such as affordable housing, food andclothes, and transportation. And thereare many worthwhile charities that offer support in those areas. But unlikean organization such as Habitat forHumanity, where volunteers do not needto have a certain level of education tobuild a house, dentistry is specific. It canbe provided only by a limited number ofhighly trained individuals in any com-munity. Perhaps the privilege dentistshave earned places them in a differentposition with respect to helping others.

The Ben Massell Dental ClinicAt the Ben Massell Dental Clinic (BMDC)in midtown Atlanta, we believe everyonedeserves quality dental care regardless of the ability to pay. And while that idealmight be universal, it is the responsi-bility of the dental community andpublic policy to find viable and sustain-able solutions. Many individualscontribute by doing pro bono work intheir offices; what we have done is tosystemize that charitable effort to sharethe burden and, in doing so, assure thehigh quality of care we provide.

BMDC began more than 100 yearsago in order to address the inequalitiesin society and to provide care to thosewho could not get it otherwise. AlphaOmega, the Jewish dental fraternity, hadbeen looking for an avenue to providecharitable care and was excluded frommost groups. So the members under-stood what injustice felt like. The clinicwas one of the first nonsegregatedprograms in Atlanta.

The clinic would not be in business if not for the roughly 150 dentists whovolunteer their time each month. Andthe more than 4,000 patients who comethrough our doors each year would be in much different situations.

We do not do it alone. We arethankful for our providers and

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The Ethics of Charity Dental Clinics


Gary Miller is CEO and Keith Kirshner is Director ofthe Ben Massell Dental Clinicand Jewish Family & CareerServices of Atlanta, Georgia;[email protected].

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supporters who share the challenge oftreating this population but recognizeour limitations. Once our volunteerdentists restore stable oral health, wehave reached our primary goal ofoffering a helping hand to individuals.But they still have other needs, andusing a patient-centric approach, we tryto help them navigate and advocate forthose needs. To do this we have twosocial workers to help patients withmental health and social servicesconcerns and then identify resources for primary health, vision services, andother needs including food, shelter,energy assistance, job training andplacement, clothing, substance abuseand recovery, domestic violence, and the like. If dental health is truly a part of overall health, it should not be offeredin isolation.

The clinic itself is part of JewishFamily & Career Services (JF&CS), anorganization that provides programs,services, and support to the entirecommunity, regardless of race, religion,or age. JF&CS depends on both donorsand volunteers to operate.

Ethical Standards in CharityClinical CareThe American Dental Association spellsout what it expects from its members in its Principles of Ethics and Code ofProfessional Conduct:

Since dentists have an obligation touse their skills, knowledge, and experience

for the improvement of the dental healthof the public and are encouraged to beleaders in their community, dentists insuch service shall conduct themselves insuch a manner as to maintain or elevatethe esteem of the profession.

Giving back is important but whereethics enters into the equation is ingiving the same level of quality as inprivate practice. Dentists have anobligation to do good, high-qualitywork—no matter where they are doing itand who the patient is. We might evenplace volunteer work on a higher ethicallevel, because one is not getting compen-sated for doing it. For dentists whovolunteer their time through pro bonotreatment or even at Mission of Mercy-type of events, it can be challenging tomaintain that level of commitment.

One of the great things about BMDC is our ability to provide idealtreatment, which is not always possiblefor charity patients treated in a privateoffice. We do not frequently havepatients who ask why they need thisroot canal or that other procedure. They have confidence that because with no cost involved, they are gettingwhat they actually need. Special, once-a-year charity events have theirplace—principally to sensitize patientsand practitioners regarding the need forcare. Charity clinics in fixed locations

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Dentistry can be provided

only by a limited number

of highly trained individuals

in any community. Perhaps

the privilege dentists have

earned places them in a

different position with

respect to helping others.

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gap for those who cannot afford medicalcare. The oral health field will notchange any time soon. Nationally, theACA does not require oral health. Insome states, there is public access for it.

Our ability as dentists to literally heal the community is enormous. Byaddressing people’s dental needs, we arenot just addressing their medical needs.We are doing something much greater.By helping them physically, we arehelping them emotionally, and they aremore likely to end up in a better place. If they are unemployed, they may beable to reenter the workforce or focustheir energy on improving their lives inother ways and contributing to society.

Ben Massell’s legacy is built ongetting people back on their feet, givingthem back their dignity, and helpingthem to improve their lives. For morethan a century, we have been changingthousands of lives every year. We haveevolved into a training center forstudents and residents, and we arefostering a commitment by this nextgeneration to quality volunteer work.Public health is a critical piece of theoverall education of the next generationof dental professionals.

The decision to volunteer or not is an individual one. What we have foundoverwhelmingly is a generosity andcompassion from most dentists. Is therea moral obligation? We are uncertain.Neither of us is that authority. But whatwe do know is that many dentists dobelieve there is. Many come to uslooking for a way to give back to theircommunity. That is a good thing,because if they did not want to giveback, where would we be? And moreimportant, where would our patients be?�

large-hearted dentists to pool resources.BMDC, for example, serves as ascreening and coordination mechanismfor patients. We provide a venue fordentists to focus on what they are goodat it—delivering treatment. We take those difficult or awkward situationsthey might face out of their hands.

Another barrier to private-officecharity care might be the potentialforliability. Community clinics have sur-mounted that by using the laws of thestate to offer our providers sovereignimmunity coverage.

Multiple Standards of Care The question of quality of care receivedin private fee-for-service offices andcommunity clinics depends entirely onhow the question is framed. One senseof quality has to do with the standardsfor the treatment that is delivered. Theissues here are informed consent,sterilization, technique and materails,freedom from iatrogenic effects, andservice life of the procedure. Communityclinics have an advantage over healthfairs and other occasional events intemporary locations and are on a parwith private offices. There should be onlyone standard for treatment rendered.There is an additional definition ofquality of dentistry, and that has to dowith whether patients receive thetreatment they need. There is a sense inwhich patients who cannot afford fee-for-service dental care experience alower quality of oral health. Communitydental clinics that accept all patientsregardless of ability to pay play a criticalrole in meeting this standard of quality.

While the need for public oral healthvaries from state to state, there alwayswill be patients without access. Thatremains true in the general medical fieldas well, and laws like the Affordable CareAct (ACA) are intended to help close the

open year-round fill a different need, one that includes comprehensive andcontinuous care.

When you think about it, quality careis not only what the patients deserve; itis what makes sense. If we do not do ourbest work, the results will suffer. If we donot take responsibility for our patients’care and if the work is done poorly, weare simply kicking the can down thestreet and we will see the patient in ourchair again soon. If we strive forexcellence, if we do it right the first time,we can better ensure success, whichmeans we can address the needs ofadditional patients.

While the labor is free, we have the expenses of running a business—staff, facilities, materials, and so forth.Correcting for poor quality directly costsus and hinders our ability to provideservices to more people. Continuouscharity care programs such as BMDC are especially sensitive to this becausewe know we will be seeing the samepatients throughout their lifetimes.

The best part about working andvolunteering at the clinic is the appre-ciation and gratitude of the patients. Itgoes beyond words. Every day we hear “I can’t thank you enough,” or “I don’tknow how to say thank you.” Youcannot put a price on that.

Reluctance to Do Charity in One’s Neighborhood It can appear easier to do charityepisodically or in remote areas. Localservices can interfere with a profes-sional’s business. People might hear of a practitioner who provides care forthe underserved and this may lead toexcessive or unreasonable requests.Perhaps the best response to that is for

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Ann Marie Silvestri, DDS, MPA

AbstractFederally Qualified Health Centers serve,on a “cost-to-provide-care basis,” low-income and other patients who cannot useprivate pay facilities. This is a safety-netcare system that is much more comprehen-sive and less expensive than emergencyroom visits. The existence of an FQHC in a community partially removes thepressure on fee-for-service providers tomake arrangements for treating dentallydisadvantaged individuals. Increases infederal spending for dental services have recently outpaced declines in out-of-pocket private pay spending and sluggishimprovements in insurance coverage.

An FQHC is a Federally QualifiedHealth Center. FQHCs are the“safety-net” facilities for

underserved communities. “Medicallyunderserved population” refers to thosein urban or rural areas designated ashaving a shortage of personal healthservices. This includes the homeless,migrant workers, and patients with theinability to pay for their own healthcare. FQHC facilities can be communityhealth centers, Indian Health Services,or programs serving migrant workersand the homeless population. The main purpose of an FQHC is to provideprimary care services. These facilitiesreceive enhanced reimbursement fromMedicare and Medicaid in exchange for providing services to the low-income population.

This low-income population isgenerally medically underserved,meaning having no insurance orinsurance of limited value, where thereare few providers that are willing to takepatients’ coverage. When the dentalservices ceased to exist for adults inCalifornia in July 2009, patients oftensought care at FQHC clinics. More oftenthan not, this treatment was done in the emergency department of hospitalsor in primary-care physician offices.

There are certain required primaryhealth services that must be provided byan FQHC clinic. These services include:1. Health services related to family

medicine for all age groups2. Diagnostic laboratory and

radiology services

3. Preventive health services includingprenatal and perinatal services,cancer screening, well-child services,and immunizations

4. Dental screenings to determine theneed for dental care, and delivery ofpreventive dental services

5. Emergency medical services6. Pharmaceutical services7. Hospital and specialty care

Additional health services, whichinclude behavioral and mental health,recuperative care, environmental healthservices, and others, are also provided in several of these community clinics. A reduced-cost program must be in placefor non-emergency services that thefacility is not required to provide.

There are benefits associated withbeing an FQHC provider. These includereceiving cost-based reimbursement forservices provided under Medicare,reimbursement under state-approvedpayment for services provided underMedicaid, medical malpractice coveragethrough the Federal Tort Claims Act,eligibility to purchase prescription and nonprescription medication foroutpatients at a reduced cost, access to national health services, access tovaccines for children program, andeligibility for various other federal grants and programs.

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What Are FQHCs and How Do They Affect Dental Services?


Dr. Silvestri is Chief of DentalServices and Dental ProgramManager, San Mateo MedicalCenter, California;[email protected]

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Authorization and FundingAs background, the FQHC benefit underMedicare was added October 1, 1991,when section 1861 of the Social SecurityAct was amended by section 4161 of theOminous Budget Reconciliation Act of1990. The main purpose of the FQHCprogram is to enhance the provision ofprimary-care services in underservedurban and rural communities. There area few ways that an entity may qualify asan FQHC. These include receiving agrant under section 330 of the PublicHealth Service Act or by being contractedwith the recipient of such a grant, beingtreated by the federal Department ofHealth and Human Services for purposesof Medicare Part B as a comprehensivefederally funded health center in January1990, operating as an outpatient healthprogram of a tribe or tribal organizationunder the Indian Self-Determination Act, or as an urban Indian organizationreceiving Title V funding under theIndian Health Care Improvement Act asof October 1991. San Mateo MedicalCenter, the facility in which I work, is anFQHC facility as it receives grant fundingunder section 330 for San MateoCounty’s Health Care for the Homelessand Farm Worker Health Program(HCH/FH).

With the 2014 implementation of the Affordable Care Act of 2010, theFederally Qualified Health CenterProspective Payment System (FQHC PPS)is soon scheduled for implementation.The Centers for Medicare and MedicaidServices (CMS) are collecting andanalyzing data that are required todevelop and implement the newpayment system. Since January 1, 2011,all services provided by the FQHC shouldhave been listed with the correctrevenue and healthcare system code in

order for the data to be analyzed. AnFQHC facility is paid an all-inclusive pervisit payment based on reasonable costsas reported in their annual cost report.The patient pays no Part B deductible,but is required to pay the co-insuranceand for services not covered within theFQHC guidelines. The FQHC all-inclusivevisit rate is generally calculated bydividing FQHC’s total allowable costs bythe number of visits for all FQHCpatients. This visit rate is reconciled atthe end of each cost-reporting period.

To understand the importance ofFQHC facilities in a community, onemust recognize the role of the HealthResources and Services Administration(HRSA) and its importance in improvingaccess to health care in the United States.HRSA is the primary federal agency forimproving access to healthcare bystrengthening the healthcare workforce,building healthy communities, andachieving health equity. HRSA’s goal is to provide health care to people who aregeographically isolated, economicallychallenged, or medically vulnerable. Thispopulation includes pregnant women,patients with HIV/AIDS, and families inneed of high-quality primary healthcare. HRSA achieves this goal by offeringloans, scholarships, and grants toencourage and enable clinicians to workin underserved areas.

Loan repayment programs includethe National Health Service Corps(NHSC) for primary-care medical,dental, and mental health cliniciansworking at approved NHSC facilities inHealth Professional shortage areas; theNurse Corps Loan Repayment Programfor professional registered nurses,including advanced practice registerednurses, working in a critical shortagefacility; and the Faculty Loan RepaymentProgram for degree-trained healthprofessionals from disadvantagedbackgrounds serving on the faculty ataccredited health professions colleges

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The main purpose of an FQHC is to enhance the provision of primarycare services in under-served urban and ruralcommunities. These facilities receiveenhanced reimbursementfrom Medicare andMedicaid in exchange forproviding services to thelow income population.

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or universities. Scholarship programsinclude the NHSC for studentscommitted to primary care and enrolledin allopathic, osteopathic, medical,dental, physician assistant, nursepractitioner, or certified nurse midwifetraining programs; the Nurse CorpsScholarship Program for studentsenrolled or accepted for enroll-ment inaccredited RN or graduate nursingtraining programs located in the UnitedStates; and the Scholarships for Disad-vantaged Students, which is need-based,for students enrolled in participatinghealth profession programs. Loanprograms are all need-based competitiveprograms. They include Loans forDisadvantaged Students who are enrolledin participating schools of allopathic,osteopathic, podiatric medicine, veterin-ary medicine, dentistry, optometry, orpharmacy; Health Professions StudentLoans for students pursuing a degree in dentistry, optometry, pharmacy,podiatric medicine, or veterinarymedicine; Nursing Student Loans forstudents pursuing a diploma, associate,baccalaureate, or graduate degree innursing; and Primary Care Loans forstudents pursuing a degree in allopathicor osteopathic medicine. HRSA providesgrants to organizations to both improveand expand healthcare services.Focusing on the underserved, HRSAprovides grant opportunities to buildclinics and enhance programs formaternal and child health, HIV/AIDS,primary health care, behavioral health,oral health, and rural health, to name afew of their focus areas. It was throughHRSA grants that the building of SanMateo Medical Center’s CoastsideMedical and Dental Clinic and theMobile Dental Clinic became a reality.

On September 26, 2013, the UnitedStates Court of Appeals for the Ninth

Circuit issued a mandate based on thecourt’s September 17, 2013 decision,stating that three California Medicaid(Medi-Cal) services that had beenexcluded July 2009—namely adult dental,chiropractic, and podiatric services—would now be covered by Medi-Cal whenprovided by FQHC and Rural HealthClinics (RHC). This mandate was issuedbased on the decision in the case ofCalifornia Association of Rural Clinics,et al. v. the California Department ofHealth Care Services. In accordancewith this decision, dental servicesprovided on and after September 26,2013, were now reimbursable throughMedi-Cal, but only when provided in anFQHC or RHC. This mandate has allowedFQHC and RHC clinics to provide neededdental services to adults seeking care at their clinics. This is a great enhance-ment for FQHCs and RHCs and atremendous help to their patients

OperationAn FQHC facility offers comprehensivehealth care much the same as a closedpanel health system or Health Mainten-ance Organization (HMO) does. Thestandard of care offered is usually high,as there are several quality measures inplace that are constantly being reviewed,monitored, and enhanced. Continuedreimbursement for services provided isdependent on the quality and extent ofcare being administered. FQHC facilitiesdo not treat patients other than low-income patients that qualify for financialassistance in regard to their medicalcare. Providers, both medical and dental,are either employees of the FQHC or oncontract with it. They do not bill their“pro fee” to any patient for the servicesthey provide, as all billing is done by theFQHC facility. In such a system, privatepatients are not obligated to take on thefinancial burden of allowing theprovider the opportunity to treat lowincome patients. Between 2008 and

2001 the amount of money enteringdentistry from private pay fell by almost7% in constant dollars. At the same timeinsurance contributions rose by 2.6%,but the amount of cash entering thedental market from federal sources grewby 36% and now stands at about 10% of all funding.

Since FQHCs are an all-inclusivehealth system, low income patients,attached to an FQHC, have the benefit of receiving all of their health serviceswithin the same facility. This can beconsidered a benefit not available to theprivate-paying public. An importantthing to note is that patients treated inan FQHC are patients that the privatemedical and dental providers do notusually want to treat due to lowreimbursement for services provided. To give an example, when San MateoMedical Center opened the dental clinicat Coastside, the dental-practice com-munity was concerned about the clinic,until they realized that no private-payingpatients could be seen there, and thatthe patients that would be treated therewere patients for whom they weretrying to find placement. One mustrealize that patients that go to thesefacilities have little access to health care anywhere else.

Presently there are approximately118 FQHC clinics in California. Many, but not all, of these clinics offercomprehensive dental services. In theend, it is important to note that thesefederally funded health centers care forall patients, even if they have no healthinsurance. They are the “safety net” for all patients in need of medical anddental care. Without these clinics low-income, noninsured and underinsuredpatients would have nowhere to go for their healthcare needs. �

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Paul Glassman, DDS, MA, MBA, FACDMaureen Harrington, MPHMaysa Namakian MPH Jesse Harrison-Noonan

AbstractThe dramatic increase in broadbandconnectivity is opening up the possibilityfor using telehealth-connected teams in an improved system for charity care. TheVirtual Dental Home demonstration takingplace in California provides a model for thedevelopment and deployment of suchteams. Teams using telehealth connectionsto provide oral health care can transformepisodic or one-time visits into an ongoingsystem of care with a much greateremphasis on prevention and earlyintervention techniques and a greaterlikelihood of improved oral health for the population.

The traditional office and clinic-based oral health delivery system is failing to reach an increasingly

large segment of the United Statespopulation. The disparities in access and the resulting health disparities havebeen well documented in the 2000Report of the U.S. Surgeon General, andin the 2011 reports Advancing OralHealth in America and ImprovingAccess to Oral Health Care for Vulner-able and Underserved Populations bythe Institute of Medicine of the NationalAcademies of Science. One solutionbeing used is charity care where teamsof dentists provide screening and limitedcare to individuals who self-select toattend a one-time event without follow-up. While these programs do help thetargeted population by eliminating themost advanced disease, often throughextraction of teeth, there is limitedability to create and foster a system ofongoing preventive activities and follow-up monitoring and care.

Welcome to a Connected WorldRecent advances in the use of telehealthtechnologies may allow dental care forthose who do not regularly see theirown dentist to include pre-visit and postvisit triage, prevention, and monitoringactivities. The last decade has broughtrapid expansion in the availability ofinternet connectivity and the developmentof telehealth systems that can be used tofacilitate care for those in greatest need.

Telehealth technologies coulddramatically alter the delivery of care byfacilitating engagement with the targetpopulation prior to and after an in-person visit. If a team of health workersalready working with groups of at-riskindividuals could be identified andprovided training, perhaps throughonline videoconferencing and otherdistance education methodology, thislocal team could gather health records tobe used by the visiting team for pre-visittriage and planning. The local teamcould also be empowered to beginpreventive education and interventionprograms with supervision andcoaching from the visiting team.

If oral health records could bereviewed prior to a visit, this could allowthe visiting team to better prioritize thework that needs to be done. It might bepossible to provide instructions andcoaching so that some procedures thatwould have otherwise been performedby the visiting team can be performed bylocal workers prior to the visit. Such asystem could also allow the visiting teamto spend less time on diagnostic andpreventive procedures, concentrating

22


The Potential for Telehealth Technologies to Facilitate Charity Care

Creating Virtual Dental Homes


Dr. Glassman is Professor and Director of the PacificCenter for Special Care,University of the Pacific,Arthur A. Dugoni School ofDentistry; Ms. Harrington isDirector of Grant Operationsand Community Education; Ms. Namakian is ProgramManager; and Ms. JesseHarrison-Noonan is AssistantProgram Manager at the center. [email protected]

537943 Text_jacd 7/11/14 9:28 AM Page 22

Recent advances in the use

of telehealth technologies

may allow dental care for

those who do not regularly

see their own dentist to

include pre-visit and post

visit triage, prevention, and

monitoring activities.



23

connected charity-care system. ThePacific Center for Special Care at the University of the Pacific, Arthur A. Dugoni School of Dentistry (Pacific)has created a Virtual Dental Home insites throughout California (Glassman et al, 2012). Pacific is using this model todeliver oral health services in locationswhere people live, work, play, go toschool, and receive social services. Theindividuals receiving these services rangefrom children in Head Start Centers andelementary schools to older or disabledadults in residential care settings ornursing homes.

The Virtual Dental Home is acommunity-based oral health deliverysystem in which people receive preventiveand early intervention therapeuticservices in community settings wherethey live or receive educational, social, or general health services. It uses allieddental personnel who work in a teamlead by geographically distant dentistsand can keep many people healthy incommunity settings by providingeducation, triage, case management,preventive procedures, and earlyintervention therapeutic services. Thesystem promotes collaboration betweendentists in dental offices and clinics andthese community-based allied dentalpersonnel. This project redefines the use of the term “dental home” to includethe entire geographically distributed,collaborative, telehealth-facilitated

their efforts on performing advancedprocedures that cannot be performed by local health workers.

In association with any care given by dentists, the local team couldcontinue to monitor and providepreventive and other procedures for the population, again with supervisionand coaching from the visiting team.These interventions could turn a one-time visit into an ongoing system ofcare, focused on preventive activities.

The Virtual Dental HomeWith the advent of teams connected by telehealth systems, a fragmented orone-time delivery of care could betransformed into a “dental home” or“health home” for the target population.There has been considerable interest and an expanding body of literature onimproving health care provided tounderserved populations through a“medical home” or “health home” model (American Academy of Pediatrics,2007; Edwards, 2004). In general thehealth home model encompassessystems that provide:• Care management over time • Health promotion activities• Access to technical medical services

when needed• In pediatric medical home models,

there is also an emphasis on earlyintervention services

There is a system of oral healthdelivery currently operating in the UnitedStates that could serve as a model for a

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system of care. The Virtual Dental Home provides all the ingredients of thehealth home, keeps dentists at the headof the distributed team, and mostimportantly, it brings much-neededservices to individuals who mightotherwise receive no care.

Equipped with portable imagingequipment and an Internet-based dentalrecord system, the allied dentalpersonnel collect electronic dentalrecords including radiographs,photographs, charts of dental findings,and dental and medical histories, andupload the information to a secure Web site where the records are reviewedby a collaborating dentist. The dentistreviews the patient’s information andcreates a plan for dental treatment. Theallied dental personnel then carry out

the aspects of the plan under generalsupervision of the dentist that can beconducted in the community setting.These services include:• Health promotion and prevention

education • Dental disease risk assessment • Preventive procedures, such as

application of fluoride varnish ordental sealants, and for dentalhygienists, dental prophylaxis, andperiodontal scaling

• Placing carious teeth in a holdingpattern using interim therapeuticrestorations (ITR) to stabilizepatients until they can be seen by a dentist for definitive care andtracking and supporting the indivi-dual’s need for and compliance withrecommendations for additional and follow-up dental services

The accompanying figure is adiagram illustrating the Virtual DentalHome Concept Model that illustrateshow the emphasis of the Virtual Dental

Home system is the delivery of diagnostic,preventive, and early interventionservices by allied dental personnel incommunity settings under generalsupervision of dentists who havereviewed patient records and determineda plan of treatment for that patient.

The Virtual Dental Home system of care has been operating in California for more than three years. Over 2,000patients have been cared for in almost5,000 visits. The project has clearlydemonstrated the ability to connectdentists with allied personnel operatingin community settings. The project hasalso demonstrated the ability of allieddental personnel, after review of records by dentists, to apply prevention,education, and early interventiontechniques in populations of people who traditionally do not seek dental care until they have advanced disease.

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The Virtual Dental Home Concept Model Pacific Center for Special Care, University of the Pacific Arthur A. Dugoni School of Dentistry, ©2012

537943 Text_jacd 7/18/14 4:57 PM Page 24

Scaling the Virtual Dental Home ModelWhile the Virtual Dental Home system in California has demonstrated theability to use telehealth technologies to connect providers in geographicallydistributed sites, there are clearlychallenges to be faced in translating this experience to other areas. Thesechallenges include the cost and deploy-ment of equipment, identifying orrecruiting teams of local health workers,and creating a system of care that canfunction on an ongoing basis.

Fortunately, the cost of equipmentneeded to create telehealth system hasbeen decreasing dramatically. The“technology kit” that is being used in the Virtual Dental Home system inCalifornia is under $20,000. While thismay be a significant expense in a globalcharity-care system, the amortized costover thousands of patient encountersmight amount to only a few dollars per visit.

Identifying and recruiting teams of local health workers to participate ina distributed, telehealth system of caremay be challenging. As has been thecase in the Virtual Dental Home systemin California, it would be necessary totrain these individuals to use the tech-nology equipment to collect oral healthrecords and transmit them to a cloud-based server. These workers would alsoneed to be trained to provide preventiveeducation and perform basic preventiveprocedures for the population they areserving. None of these challenges isinsurmountable, however.

Finally, if equipment is available andlocal teams can be recruited and trained,it is still necessary to develop a system forcoordinating the activities of the localteam with the visiting team. Developingsuch a system has the potential totransform episodic or one-time visitsinto an ongoing system of care.

ConclusionThe dramatic increase in broadbandconnectivity is opening up the possibilityfor using telehealth-connected teams in improved systems for reachingpopulations that are not well adapted to the traditional dental care deliverysystem. The Virtual Dental Homedemonstration taking place in Californiaprovides a model for the developmentand deployment of such teams. Teamsusing telehealth connections to augmentoral health care for difficult-to-reachpopulations can transform episodic orone-time visits into an ongoing systemof care with a much greater emphasison prevention and early interventiontechniques and a greater likelihood ofimproved oral health for the population.�

ReferencesAmerican Academy of Pediatrics, Councilon Children with Disabilities (2007). Role of the medical home in family-centeredearly intervention services. Pediatrics, 120(5), 1153-1158.Edwards, E. S. (2004). Forward.Supplement on the Medical Home.Pediatrics, 113 (5), 1471.Glassman, P., Harrington, M., Namakian,M., & Subar, P. (2012). The virtual dentalhome: Bringing oral health to vulnerableand underserved populations. CDA Journal,40 (7), 569-577.Institute of Medicine of the NationalAcademies (2011). Advancing Oral Healthin America. Washington, DC: The NationalAcademies Press. Institute of Medicine of the NationalAcademies (2011). Improving access tooral health care for vulnerable andunderserved populations. Washington, DC:The National Academies Press. U.S. Department of Health and HumanServices (2000). Oral Health in America: A Report of the Surgeon General. Rockville,MD: U.S. Department of Health and HumanServices, National Institute of Dental andCraniofacial Research, National Institutesof Health.

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The Virtual Dental Home

system of care has been

operating in California for

more than three years. Over

2,000 patients have been

cared for in almost 5,000

visits. The project has clearly

demonstrated the ability to

connect dentists with allied

personnel operating in

community settings.

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Alvin B. Rosenblum DDS, FACDSteve Wolf, PhD

AbstractDental ethics is often taught, viewed, and conducted as an intellectualenterprise, uninformed by emotional orother noncognitive factors. Emotionalintelligence (EQ) is defined here anddistinguished from the cognitive intelli-gence measured by Intelligence Quotient(IQ). This essay recommends moreinclusion of emotional, noncognitive input to the ethical decision process indental education and dental practice.

Ethics is the systematic study of humanconduct examined in the light of moralvalues and principles. It is the mostimportant competency in dentistry, in business, and in life. Competencyin ethics requires an understanding of its accepted principles, and suchcompetency is the obligation of everydental professional.

—Alvin Rosenblum (2001)

This article explores the relationshipbetween the disciplines of appliedprofessional ethics and emotional

intelligence (EQ). Although the affectivedimensions of applied ethics have beenaddressed in the professional ethicsliterature, even as they apply to dentalpractice (1989 Curriculum Guidelines),the 2010 CODA (accreditation) standards

Dental Ethics and Emotional IntelligenceIssues in DentalEthicsAmerican Society for Dental Ethics

EditorBruce Peltier, PhD, MBA

Editorial BoardMuriel J. Bebeau, PhDPhyllis L. Beemsterboer, RDH, EdDEric K. Curtis, DDS, MALola Giusti, DDSPeter M. Greco, DMDLarry Jenson, DDS, MAAnne Koerber, DDS, PhDLou Matz, PhDDonald Patthoff, Jr., DDSAlvin Rosenblum, DDSToni Roucka, DDS, MAAnthony Vernillo, DDS, PhD, MBE Gerald Winslow, PhDPamela Zarkowski, JD, MPH

Correspondence relating to the Issues in Dental Ethics section of theJournal of the American College ofDentists should be addressed to: Bruce [email protected]

for ethics in dentistry direct the educator’sattention to the cognitive and philo-sophical and seem to ignore a necessarypsychological, noncognitive, emotionalcomponent. The paradigm of emotionalintelligence presented in the popularpress offers a viable way to redirectattention to a need the authors see ascritical for effective ethics education and for professional practice.

The authors view professionalism as a social contract requiring altruism,caring, community, commitment toexcellence, and service to others.Professionalism includes service overprofit. It is not something one can puton and take off like a white coat; it mustexist deeply as a part of personality andidentity. The goals of ethics are based on a commitment to a purpose higherthan our own self-serving ends. As such,it is much more than the absence ofunprofessional behavior, or even anunderstanding of normative principlesand decision models.

A challenge the authors (one dentistand one psychologist) faced in integra-ting professional ethics with emotionalintelligence was in defining their owndiscipline for each other. Having done

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Issues in Dental Ethics

Dr. Rosenblum leads the consulting firm DentalRealities, and Dr. Wolf is aprivate practice psychologist in Los Angeles, California;[email protected].

The authors wish to acknowl-edge the helpful comments ofDrs. Muriel Bebeau and BrucePeltier on an earlier draft ofthis article.

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that to their satisfaction the task has beento provide the reader with definitions forboth ethics and emotional intelligence(EQ) and to subsequently clarify theimportance of the relationship betweenthose two disciplines. We believe that by highlighting the importance ofemotional intelligence as it applies toprofessional ethics we will refine thedefinition of both, especially as theypertain to dental education and practice.

Applied Professional Dental EthicsThis analysis necessarily begins with a bit of a history lesson. As recently as1980 the literature about ethics indentistry was scant. With the exceptionof the Journal of Dental Education,the Journal of the American College ofDentists, and the occasional editorial,little was written that had the disciplineof ethics as its focus. Much of the early literature could reasonably becharacterized as a professional “scold.”Rather than addressing the moral valuesand ideals that might guide the dentist’sinteraction—and there may not have beenwidespread agreement on these—thewriting focused primarily on negative orquestionable behavior in the profession,much of which could be categorized as“dental-professional etiquette.”

In the early 1980s two highlyregarded academicians began to focuson ethics in the profession of dentistry.Muriel Bebeau of the University ofMinnesota is a psychologist whoseresearch interests include the processes(sensitivity, reasoning, motivation, andimplementation) that give rise to ethicaldecision-making and their role as deter-

minants of ethical behavior (Bebeau &Monson, 2008). David Ozar is professorof philosophy at Loyola University ofChicago, formerly director of Loyola’sCenter for Ethics, and author of a populardental ethics text (Ozar & Sokel, 1994).These two non-dentist educators becamethe prime movers in what became acollaboration of interested teachers indental schools across the country.

With that collaboration and Dr.Ozar’s leadership, the Professional Ethicsin Dentistry Network (PEDNET) wasfounded in 1986. The organization,which included a small number ofdental school faculty and a handful ofpracticing dentists, ultimately becamethe American Society of Dental Ethics,now a section of the American College of Dentists. That organization and thework of Drs. Ozar, “Pat” Odom, andBebeau became a stimulus for a growingbody of literature about ethics in thedental profession. They and a number of other dental educators have helped toclarify what the discipline of ethics isand how it can be taught.

The 1989 model curriculumguidelines (mentioned above) resultedfrom a tripartite arrangement amongthe American Association of DentalSchools (AADS, now ADEA) the AmericanCollege of Dentists (ACD), and the ADACounsel on Dental Education (CDE).Even before the guidelines were published,the ADA Commission on Dental Accredi-tation (CODA) revised its standards torequire mandatory instruction in ethics

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The paradigm of emotional

intelligence presented in

the popular press offers

a viable way to redirect

attention to a need the

authors see as critical for

effective ethics education

and for professional practice.

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(Commission on Dental Accreditation,1988, p. 19). This action quickly resultedin greater emphasis on the need forformal instruction in ethics as anindependent subject in dental schools. A survey of all 56 United States dentalschools operating in 2008 indicated that80% offered formal instruction in dentalethics, with the rest offering ethicsinstruction integrated with other courses.Reflecting on changes over the past 30years, Lantz, Bebeau, and Zarkowki(2011) noted that whereas the relativelysmall amount of time devoted to ethicsinstruction (an average of 26.5 clockhours) is unchanged over the past 30years, there was substantial change inwhat was classified “ethics” instruction.Instead of classifying courses in practicemanagement, jurisprudence, andavoidance of malpractice as constitutingethics instruction, curricula today focuson topics such as the social contract,priority of needs (dentists and thoseserved), obligations and central values,and with normative principles(expressed as virtues such as integrity,trust, justice, and compassion). Mostschools include information about ethicscodes and many, about 40%, address theguild, agent, commercial, and interactivecareer models described by Ozar, andreflected in the Professional RoleOrientation Inventory, designed by

Bebeau, Born, and Ozar (1993). Mostschools present models for resolvingethical dilemmas (Rule & Veatch, 2005)along with material on topics such asaccess to care, managed care, delegationand supervision, standard of care,impaired colleagues, child and elderabuse, advertising, and commercialism.

The shift in content reflects growthin the discipline, yet it appears fromthese descriptions that the study ofethics is often perceived by dentaleducators to be a fundamentallycognitive activity. Even when formalethics education programs include caseanalysis and discussions, those discussionstend to focus on the decision process: an intellectual task. Rather thanbroadening the focus to include theaffective dimensions of ethical compe-tence, the CODA standard, revised in2010, directs attention exclusively to thecognitive dimension of decision-making:“Graduates must be competent in theapplication of the principles of ethicaldecision making and professionalresponsibility” (Commission on DentalAccreditation, 2010, p. 25).

There have been efforts on the partof thought leaders in dental ethics toacknowledge the influence of noncogni-tive elements, to be sure. For example,the interdisciplinary team that formulatedthe 1989 curriculum guidelines usedRest’s (1983) Four Component Model ofMorality as an organizing framework for describing curriculum objectives.Rest’s model includes factors such asawareness of self and others, thecapacity to code social situations, and

how one’s actions might impact others.It also includes empathy and perspective-taking. Several of these are clearlycomponents of EQ. When describingmoral sensitivity, the first of Rest’scomponents, empathy and affectivearousal (anger, apathy, anxiety, empathy,and revulsion), together with recognitionof the professional’s ethical duties, areseen as key elements in the interpretiveprocess. To test the importance of moralsensitivity to ethical decision making,Bebeau and her dental colleagues(Bebeau et al, 1983) designed a series of cases (the Dental Ethical SensitivityTest [DEST]), to see whether the dentist(or student dentist) could diagnose theaffective dimensions of an ethicalproblem—often from ambiguous clues,while simultaneously recognizing whatwas ethically expected of the dentist.

The DEST has been used to assessethical sensitivity of dental students (You& Bebeau, 2011) and as a way to assessshortcoming in both ethical sensitivityand ethical implementation of practicingdentists referred for assessment by alicensing board (Bebeau, 2009a; 2009b).Groups tested reveal significant variabilityboth within and between groups. Further,the eight cases of the DEST that aredevised to assess ethical sensitivity havebeen used as a stimulus to teach whatwe refer to in this article as “emotionalintelligence.” DEST cases specificallyaddress ethical considerations in thedentist-patient relationship. Because thecases require respondents to construct a

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dialog in response to an unstructuredproblem and then to respond to anumber of open-ended questions, thecases and method lend themselves toself-assessment and peer-assessment, aswell as an opportunity to engage therespondent in discussions with dentistswho have expertise in professionalethics and emotional intelligence.

In contrast to the DEST, the widelyused Defining Issues Test (DIT) (Rest,1979; Thoma, 2006) measures thecognitive schema that individuals use tomake moral decisions—the competencedescribed by the 2010 CODA standards.Although not a measure of EQ, DIT resultscan be used to show the respondent theextent to which affective responsesmight override cognitive judgments. Forexample, if a respondent says “Heinzshould steal the drug to save his dyingwife,” then argues that community lawsmust be upheld, this inconsistencybetween reasoning and judgment mayhelp him or her see the disconnectbetween affective and cognitive responses.In fact, Bebeau (2009a; 2009b) recom-mends giving respondents feedback on their DIT profile, including theirconsistency index, as part of an educa-tional experience. In other words whilethe DIT indices attempt to explore therelative influence of noncognitive factorsin ethical decision-making, there was noattempt on the part of the test developersto directly assess emotional reactivity.

In addition, while the DIT isfrequently referred to as a valid tool forassessing the status of dental ethicscompetence, it may in fact also serve as

a teaching tool. Unfortunately, data fromLantz, Bebeau, and Zarkowski (2011) on the current state of dental educationindicate that only 15 or fewer of the 56dental schools used tests such as theDefining Issues Test, the Dental EthicalSensitivity Test, or the Professional RoleOrientation Inventory (a measure ofRest’s third component) to assessstudent development.

In sum, a review of the status ofethics education in United States dentalschools, together with research findingsfrom the study of ethical sensitivity,supports inclusion of the affectiveelements of EQ into ethics education.Also arguing for broader inclusion of theaffective dimensions of ethical decisionmaking, David Nash (2010) directlyaddresses emotional intelligence asrecently as 2010, saying, “The thesis ofthis essay is that emotional empathy, as it has evolved in human evolutionand developed existentially in thesocialization of children, is an importantdeterminant of moral behavior” (p. 575).

To date, the potential influences ofnoncognitive factors related to EQ havenot yet been adequately integrated intodental ethics curricula. The recentlyrevised 2010 CODA standards ignore thebroader concerns of ethical development,suggesting that it is sufficient to focussolely on the cognitive or intellectualapplication of principles.

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The shift in content reflects

growth in the discipline,

yet it appears from these

descriptions that the study

of ethics is often perceived

by dental educators to

be a fundamentally

cognitive activity.

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Defining EthicsThere is, at this point in time, no settleddiscussion or agreement about theappropriate content of ethics courses,nor is there total agreement on teachingmethods or curriculum. There are evendisagreements about the very meaningof the term “ethics.” Confusion about thenature of dental ethics has resulted inhistoric arguments about whether or notethics can even be taught.

A recent essay by Chambers (2011)in this journal provides a genericdefinition of ethics. “In its pure form,ethics is the study of right and wrong,good and bad. This is an academicpursuit, largely confined to departmentsof philosophy in universities.... It isabout reflecting on principles and learn-ing to give good reasons for behavior”(p. 42). He goes on to write that “Ethicseducation is generally understood astraining in how to apply principles.” (p. 45). This is, in fact, the competencyrequired by CODA standards. But hedistinguished between ethical reasoningas an isolated cognitive skill and moralityas the way moral agents act based on thefull use of thinking, feeling, and valuing.The problem, as Rest (1983) articulatesit, is that to apply principles in real-lifesettings one must first code the situationas ethical. Having done so and arrived ata defensible reason for action, one mustcommit to acting in accord with one’sjudgment and then effectively act upon

it. A moral failing can result from adeficit in any of the four processes.

In contrast to the narrow definitionof ethics, the Hastings Center offers abroader definition. They state, “Ethics isthe study of right and wrong, good andevil, duty and obligation in humanconduct and of reasoning and choiceabout them.” They define ethics as thediscipline of moral philosophy. And intheir book Ethics Teaching in HigherEducation Daniel Callahan and SisselaBok (1980) suggest that in teachingethics, “The emotional side of studentsmust first be elicited or evoked—empathy,feeling, caring, sensibility” (p. 65). Evenhere though, the cognitive must quicklyenter to discern hidden assumptions, tonotice consequences of thought andbehavior, to see that pain or pleasure donot merely happen.

Defining Emotional Intelligence Ethical practice necessarily involvesethical behavior, not just case analysisand decision-making. Few can deny thepowerful influence emotions andpersonality have on how we behave andmanifest our decisions. Emotionalintelligence is therefore a keycomponent in the practice of normativeethics, in which case the authors arguethat competency in dental ethics mustinclude an understanding of emotionalintelligence. This is obviously not anoriginal idea. While not employing theterm “emotional intelligence” directly,Bebeau’s application of Rest’s FourComponent Model attempted to bothmeasure effects of emotion on ethical

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In sum, a review of thestatus of ethics educationin United States dentalschools, together withresearch findings from thestudy of ethical sensitivity,supports inclusion of theaffective elements of EQinto ethics education.

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decision-making and assist participantsto explore and develop it.

When discussing intelligence it ismost often assumed that the referencebeing made is to IQ, the intelligencequotient. IQ is a measure of intelligencedescribing cognitive (thinking) abilities.(Dentists have been known to describepatients in terms of their “dental IQ,”their knowledge of dental facts andconcepts.) IQ includes the demonstratedability to complete math problems, toremember things, to understand abstractconcepts, to navigate mazes, to definevocabulary words, to complete designsof blocks, to recite basic scientific facts,and to complete puzzles. Emotionalintelligence, a more recent development,describes emotional abilities. The historyof EQ is embedded in the history of IQ,which dates from 1905 (Kamin, 1995).At that time Alfred Binet and TheodoreSimon published the first intelligencetest for children. Subsequently, in 1916,the Binet-Simon test was updated byLewis Terman, a Stanford psychologistwho renamed it the Stanford-Binet IQTest for Children (Terman, 1916).Psychologist David Wechsler, whileworking for the United States military in 1939, developed and published theWechsler Adult Intelligence Scale(WAIS). Over the past 75 years theWechsler tests (WISC, WAIS, and WPPSI)have become the standard instrumentsfor measuring IQ. Scores on thesestandardized tests have defined theabstract concept of intelligence for

practical applications in professionalpsychology. Wechsler himself, however,acknowledged that there were dimen-sions of “intelligence” which had notbeen addressed in the tests that he had developed. Here is a sample of his thinking about the limitations ofintellect (1981): “Intelligence is afunction of the personality as a wholeand is responsive to other factors besidesthose included under the concept ofcognitive abilities. Evidence…stronglyimplies the influence of personality traitsand other non-intellective components,such as anxiety, persistence, goal aware-ness, and other conative dispositions” (p. 8). (Conation is an archaic term forthe force of drive or will or striving toaction. It could be thought of as one’scapacity to make something happen.)

Psychologist Howard Gardner later expanded the study of intelligence(1993) with a theory of multiple intelli-gences. He identified 14 “problem solving”intelligences which included intrapersonal(within a person) and interpersonal(between people) social skills.

Daniel Goleman, a psychologistbuilding upon the work of Mayer andSalovey (1997), successfully launchedthe concept of emotional intelligence—EI or EQ—into the American mainstreamwith his bestselling book EmotionalIntelligence (1995). The book and

concept were a smash, and TimeMagazine put “Emotional Intelligence”on its cover in huge red letters. For acomprehensive critical review ofemotional intelligence see Peltier (2010).

Emotional intelligence might be bestunderstood as “the mind of the limbicsystem,” which at its most primitive levelhas been informing us as to whether wefeel safe or unsafe since the origin of our species. The limbic brain producesemotions in the way that the reptilianbrain produces heartbeats or the urge to flee. We cannot help it; we experiencepowerful emotions that influence ourbehavior, for better and sometimes forworse. EQ includes the ability to identify,understand, and communicate limbic,emotional experiences.

While there are now several modelsof emotional intelligence, the most impor-tant and useful idea is that noncognitiveaspects of life and decision-making areat least as important as the intellectualone, if not more important in theexecution of real life. The core componentof Goleman’s EQ is a four-part modelthat includes: • Self-awareness• Self-management• Social awareness (awareness of

others)• Relationship management

(management of others)

The relationship between these fourfactors has been summarized in tableform by Cherniss and Goleman (2002).

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A Framework of Emotional Competencies

According to Golman and Chernissemotional intelligence involves the fourfacets identified above. However, Bebeau,in a personal communication, remindsus that, “This has no relationship toprofessional ethics unless one ties it tothe responsibilities the professional hasto put the interests of other before theself. Unless this is tied to ethical responsi-bilities, it is nothing more than managingothers. The salesman who is able to talkyou into purchasing a product may havewell-developed emotional intelligence,but that does not make him or her avirtuous professional.”

Wolf (2009) adjusted Goleman’sfour-part model to emphasize the impor-tance of understanding of emotions. His model includes:• Self-awareness (and the ability to

communicate and to feel understood)• Other awareness (awareness

of others and the capacity forsympathy and empathy)

• Self-management• Understanding emotions

There is general agreement thatemotional intelligence involvesawareness and understanding feelings,management of those feelings, empathy,awareness of the thoughts and feelingsof others, and effective responses toother people. While Cherniss andGoleman (2002) place emphasis onmanagement skills, Wolf emphasizes the understanding of emotions.

The implications of these ideas fordental ethics are profound. Emotions,both conscious and unconscious, oftenplay an important role in ethicaldecision-making. Reflecting on the factsafter problem identification, questions of whose interests are at stake, andreflection on ultimate decisions can allbe impacted by feelings. Our feelings can help us distinguish between rightand wrong as well as influence us torationalize and act otherwise. Rational-ization occurs when we make a decisionand subsequently marshal support for it.

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Self (Personal Competence)

Self-awareness

• Emotional self-awareness• Accurate self-assessment• Self-confidence

Self-management

• Emotional self-control• Trustworthiness• Conscientiousness• Adaptability• Achievement drive• Initiative

Other (Social Competence)

Social-awareness

• Empathy• Service orientation• Organizational awareness

Relationship Management

• Developing others• Influence• Communication• Conflict management• Visionary leadership• Catalyzing change• Building bonds• Teamwork & collaboration

Recognition

Regulation

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Emotional reactions are certainly animportant component of real-life ethicaldecision-making.

The application of the normativeprinciples found in the ADA’s Principlesof Ethics and Code of Conduct is animportant starting point, but it is notenough. Emotional, non-rational forceshave a powerful influence on humandecision-making. The most obviousexamples include the fear involved withdoing the right thing (especially when it runs against majority opinion or aboss’s scowl) or the embarrassment that accompanies admission of an error.You can know the right thing to do but experience powerful feelings thatprevent you from actually doing what isright. These feelings rarely make it intodiscussions of dental ethics, and anembrace of emotional intelligence mightopen the door to them. Try to recall aformal discussion of a case wheredecision-makers considered the weightof emotional factors such as fear (andlack of assertiveness) or embarrassmentor even revenge. A proper ethical deliber-ation should include an assessment ofthe emotional components of thesituation, as they are just as important in the end as the cogntive analysis.

Imagine yourself (or someone else)saying or doing something that does notfeel right. What feelings are evokedwhen you imagine such a circumstance?How do you know what “feels” right ornot right? Answering these questionsrequires emotional intelligence. You

must first be able to identify qualities ofemotional experience, then translatethem in a way that guides action, thenapply them to the task at hand. Somefeelings must be taken more seriouslythan others. For example, a vague andabiding sense of discomfort—difficult toshake—should be taken more seriouslythan a sense of embarrassment.

Understanding our own emotionalreactions can help to keep us honest. Ifethical behavior were determined solelyby ideas of right and wrong—which arethemselves based on cognitive beliefsand philosophical principles—then EQwould provide little if any value indetermining what is ethical. However,knowing “the right thing to do” does notnecessarily determine whether one actsethically or not. Dentists often note that“I know what the right thing is; it’s justhard to do under the circumstances.”Emotions can influence behavior bytrumping ideology, influencing one toviolate valued ethical principles, or bycausing internal conflict and cognitivedissonance. In those circumstances EQ can provide an internal feedbackmechanism, an emotion-based earlywarning system which can inform uswhen a contemplated action threatens to violate an ethical code or principle,providing invaluable information,perhaps challenging one’s integrity withregard to abiding by an ethical principle.

For example, a dentist might yearnto help a patient by charging a reducedprice for a procedure while billing theinsurance company for the full fee(waiver of co-payment). If dentists areaware of their emotions, they might

notice an uneasy feeling or some anxietyor even a vague sensation of dread about that idea. Some people call thisfeeling “conscience.”

The feeling can be understood as anemotional signal that the dentist is aboutto engage in unethical behavior, eventhough the process of decision-makingor rationalization had previouslyindicated that the behavior was “okay.”Ignoring an emotional signal subjectsthe dentist to the possibility of proceed-ing with what is sensed as an unethicalact concurrent with the conflictingintention of “doing the right thing.” Thiscreates a type of cognitive dissonance, astate that psychological research hasshown to be difficult to bear. Once thesignals the conscience is sending arenoticed, the dentist has the opportunityto take another look at the situation andto reevaluate. The inclusion of emotionalinformation into the decision process isan essential component of ethical action.

Since emotional intelligence includesboth awareness and understanding ofemotional experience, it can providevaluable information for addressingthose conscious and subconsciouscontributors to potentially unethicalactions. It can affect judgment when afeeling is present and can help determine

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whether or not a feeling should even beallowed to influence a particular decision.

There are other advantages todevelopment of emotional intelligence. A case in point is the alleged highincidence of suicide and divorce ratesamong dentists. (The actual suicide rateof dentists, or of any group of profes-sionals is impossible to accuratelydetermine, for various reasons.) Dentistryis a challenging profession and practi-tioners experience considerable stressand strain over the days, weeks, andyears of practice. Many dentists wouldbenefit from developing greater emotionalintelligence to allow for better under-standing and integration of emotions to prevent an escalation of emotionalpressure and the associated problemsand dangers, which may manifest inother non-professional domains of theirlives. The reality in ethics is evidentwhen we see public disclosures ofpractitioners’ wrongdoing. There is a lotat stake for both dentists and patients.Just as a rope comprises interwovenstrands, emotional intelligence is astrand within dental ethics, and itspresence or absence will continue toinfluence attitudes, decisions, and actionsof oral healthcare providers. The goodnews is that EQ—unlike IQ which typicallyremains relatively stable throughoutadult life—can be nurtured and developed.We can get “emotionally smarter” and

become more able to identify, understand,express, and regulate emotionalexperience and increase our capacity for sympathy, empathy, and intimacy in chosen relationships.

ConclusionsAt the time of the most recent CODArevision, many believed as CharlesBertolami did, that dental ethics coursecontent is typically inadequate, “becauseit does not foster an introspective basisfor true behavioral change.” He argued(2004) that dental education in ethics isboring and ineffective because it focuseson principles and ethics codes ratherthan on self-awareness of a student’sown existing moral instincts. Hesuggested implementing a precurriculumvery early in the dental educationalexperience to address the disconnectbetween knowledge and action.

The integration of emotionalintelligence into mainstream ethicalconversations has significant potential to enhance moral decision-making indental practice. Additionally, the use ofthe Dental Ethical Sensitivity Test andthe Defining Issues Test appear to bevaluable means of assessing theeffectiveness of teaching that addressesboth ethics and emotional intelligence. A validated, self-scoring, short test for all four of Rest’s components in moralaction has been prepared by theAmerican College of Dentists and isavailable at www.dentalethics.org/pead/exercise-A3.htm. The authors believe it is incumbent upon those invested inachieving and maintaining high ethical

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Charles Bertolami suggested implementing a precurriculum very earlyin the dental educationalexperience to address the disconnect betweenknowledge and action.

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standards in the profession to exploreemotional intelligence and to considerhow to best include it within the dentalschool curriculum. �

ReferencesBebeau, M. J. (2009a). Enhancing profes-sionalism using ethics education as part of a dental licensing board’s disciplinaryaction: Part 1–An evidence-based process.Journal of the American College ofDentists, 76 (2), 38-50. Bebeau, M. J. (2009b). Enhancing profes-sionalism using ethics education as part of a dental licensing board’s disciplinaryaction: Part 2–Evidence the process works.Journal of the American College ofDentists, 76 (3), 32-45. Bebeau, M. J., Born, D. O., & Ozar, D. T.(1993). The development of a professionalrole orientation inventory. Journal of theAmerican College of Dentists, 60 (2), 27–33.Bebeau, M. J. & Monson, V. E. (2008).Guided by theory, grounded in evidence: A way forward for professional ethicseducation. In D. Narvaez & L. Nucci (Eds.),Handbook on moral and charactereducation. Hillsdale, NJ: Routledge, pp.557-582.Bebeau, M. J., Rest, J. R., & Yamoor, C. M.(1985). Measuring dental students’ ethicalsensitivity. Journal of Dental Education, 49 (4), 225-235.Bernstein, D. A., Penner, L. A., Clarke-Stewart, A., & Roy, E.J. (2003). Psychology(6th ed). Boston, MA: Houghton-Mifflin.Bertolami, C. N. (2004). Why our ethicscurricula don’t work. Journal of DentalEducation, 68 (4), 414-425.Callahan D. & Bok S. (1980). Ethicsteaching in higher education. New York,NY: Plenum Press.

Chambers, D. W. (2011). Ethics fundamentals.Journal of the American College ofDentists, 78 (3), 41-46.Cherniss, C. & Goleman, D. (Eds.). (2002).The emotionally intelligent workplace.San Francisco, CA: Jossey-Bass.Commission on Dental Accreditation,American Dental Association (1988).Accreditation standards for dental educationprograms. Chicago, IL: The Association.Commission on Dental Accreditation,American Dental Association (2010).Accreditation standards for dental educationprograms. Chicago, IL: The Association.American Assocaition for Dental Education(1989). Curriculum guidelines on ethics andprofessionalism in dentistry. Journal ofDental Education, 53 (2), 144-148Gardner, H. (1993). Multiple intelligences.Far Hills, NJ: New Horizons Press.Goleman, D. (1995). Emotional intelligence:Why it can matter more than IQ. New York,NY: Bantam Books.Kamin, L. J. (1995). The pioneers of IQtesting. In R. Jacoby, & N. Glauberman(Eds.), The bell curve debate: History,documents, opinions. New York, NY: Times Books.Kohlberg, L. (1981a). Essays on moraldevelopment. Vol 1. The philosophy ofmoral development. San Francisco, CA:Harper & Row.Kohlberg, L. (1981b). The meaning andmeasurement of moral development.Worcester, MA: Clark University Press.Lantz, M. S., Bebeau, M. J., & Zarkowski,P. (2011). The status of ethics teaching andlearning in U. S. dental schools. Journal of Dental Education, 75 (10), 1295-1309.Mayer, J. D. & Salovey, P. (1997). What isemotional intelligence? In P. Salovey & D.Sluyter (Eds.), Emotional development andemotional intelligence: Implications foreducators. New York, NY: Basic Books, pp. 3-31.Nash, D. (2010). Ethics, empathy, and theeducation of dentists. Journal of DentalEducation, 74 (6), 567-587.

Ozar, D. T. & Sokel, (1994). Dental ethics at chairside: Professional principles andpractical applications. St. Louis, MO: Mosby.Peltier, B. (2010). Emotional intelligence. In The psychology of executive coaching:Theory and application. New York, NY:Routledge Press, Chapter 11. Rest, J. (1979). Development in judgingmoral issues. Minneapolis, MN: Universityof Minnesota Press.Rest, J. R. (1983). Morality. In P. H. Mussen(ed.), Manual of child psychology, Vol. 3,Cognitive Development. New York, NY:Wiley, pp. 556-629.Rosenblum, A. B. (2001). Ethicscompetencies in the business of dentistry.Journal of the California DentalAssociation, 29 (3), 235-240.Thoma, S. J. (2006). Research on theDefining Issues Test. In M. Killen & J. G.Smetana (Eds.), Handbook of moraldevelopment. Mahwah, N.J.: ErlbaumAssociates, pp. 67-92.Terman, L. M. (1916). The Measurement ofIntelligence. Boston, MA: Houghton Mifflin.Wechsler, D. (1981). WAIS-R manual(Wechsler Adult Intelligence Scale–Revised). Cleveland, OH: The PsychologicalCorporation.Wolf, S. (2009). EQ-101: Building blocks foremotional intelligence. Los Angeles, CA:Universal Psychology Press. You, D., & Bebeau, M. J. (2012) Genderdifferences in the ethical competence ofprofessional school students. Journal ofDental Education, 76 (9), 1137-1149.

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Manuscripts for potentialpublication in the Journal of the American College of

Dentists should be sent as attachmentsvia e-mail to the editor, Dr. David W.Chambers, at [email protected] transmittal message should affirmthat the manuscript or substantialportions of it or prior analyses of thedata upon which it is based have notbeen previous published and that themanuscript is not currently underreview by any other journal.

Authors are strongly urged to review several recently volumes of JACD. These can be found on the ACDWeb page under “publications.” Inconducting this review, authors shouldpay particular attention to the type ofpaper we focus on. For example, wenormally do not publish clinical casereports or articles that describe dentaltechniques. The communication policyof the College is to “identify and place

before the Fellows, the profession, andother parties of interest those issues that affect dentistry and oral health. The goal is to stimulate this communityto remain informed, inquire actively, and participate in the formation ofpublic policy and personal leadership to advance the purpose and objectives of the College.”

There is no style sheet for theJournal of the American College ofDentists. Authors are expected to befamiliar with previously publishedmaterial and to model the style of formerpublications as nearly as possible.

A “desk review” is normally providedwithin one week of receiving a manu-script to determine whether it suits the general content and quality criteriafor publication. Papers that holdpotential are often sent directly for peer review. Usually there are sixanonymous reviewers, representingsubject matter experts, boards of theCollege, and typical readers. In certaincases, a manuscript will be returned to the authors with suggestions forimprovements and directions aboutconformity with the style of workpublished in this journal. The peerreview process typically takes four to five weeks.

Authors whose submissions are peer reviewed receive feedback from this process. A copy of the guidelinesused by reviewers is found on this site

and is labeled “How to Review a Manu-script for the Journal of the AmericanCollege of Dentists.” An annual report of the peer review process for JACD isprinted in the fourth issue of eachvolume. Typically, this journal acceptsabout a quarter of the manuscriptsreviewed and the consistency of thereviewers is in the phi = .60 to .80 range.

Letters from readers concerning any material appearing in this journalare welcome at [email protected] should be no longer than 500words and will not be considered afterother letters have already been publishedon the same topic. [The editor reservesthe right to refer submitted letters to theeditorial board for review.]

This journal has a regular sectiondevoted to papers in ethical and profes-sional aspects of dentistry. Manuscriptswith this focus may be sent directly to Dr. Bruce Peltier, the editor of theIssues in Dental Ethics section of JACD,at [email protected]. If it is not clearwhether a manuscript best fits thecriteria of Issues in Dental Ethics, itshould be sent to Dr. Chambers at the e-mail address given above and adetermination will be made.

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Submitting Manuscripts

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A publication advancing excellence, ethics, professionalism,and leadership 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 2014 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 2014 subscription rate for members of the American College of Dentists is $30,and is included in the annual membershipdues. The 2014 subscription rate for non-members in the United States, Canada, and Mexico is $40. All other countries are$60. Foreign optional airmail service is an additional $10. Single-copy orders are $10.

All claims for undelivered/not receivedissues must be made within 90 days. If claim is made after this time period, itwill not 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 articles, 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 opinions or statements.

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 2014; 81 (2): 1-36.

Journal of the


Communication Policy

It is the communication policy of the American College of Dentists to identifyand place before the Fellows, the profession, and other parties of interest thoseissues that affect dentistry and oral health. The goal is to stimulate this community

to remain informed, inquire actively, and participate in the formation of public policy and personal leadership to advance the purpose and objectives of the College. The College is not a political organization and does not intentionally promote specificviews at the expense of others. The positions and opinions expressed in College publications do not 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.

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American College of Dentists Gaithersburg, MD 20878-1614 ... · Spring 2014 Volume 81 Number 2 537943 Cover_Layout 1 7/11/14 10:13 AM Page 2. ... Evidence-based dentistry is the integration