Journal of the American College of Dentists

Journal of the

American Collegeof Dentists

Electronic Dental Records

Winter 2010Volume 77Number 1

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 2010 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 2010 subscription rate for members of the American College of Dentists is $30,and is included in the annual membershipdues. The 2010 subscription rate for non-members in the United States, Canada, andMexico 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. Ifclaim is made after this time period, it willnot be honored.

While every effort is made by the publishersand the Editorial Board to see that no inaccurate or misleading opinions or state-ments appear in the Journal, they wish tomake it clear that the opinions expressed in the 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 2010; 77 (1): 1-44.

Mission

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

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

Objectives of the American College of Dentists

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

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

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

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

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

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

F. To encourage the free exchange of ideas and experiences in the interest of betterservice to the patient;

G. To cooperate with other groups for the advancement of interprofessional relationships in the interest of the public;

H. To make visible to professional persons the extent of their responsibilities to the community as well as to the field of health service and to urge the acceptanceof them;

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

Journal of the

American Collegeof Dentists

EditorDavid W. Chambers, EdM, MBA, PhD

Managing EditorStephen A. Ralls, DDS, EdD, MSD

Editorial BoardNorman Becker, DMDLaura Bishop, PhDSusan Bishop, DDSMarcia Boyd, DDSFred Bremner, DMDTheresa Gonzales, DMD, MS, MSS Donna Hurowitz, DDSWilliam Leffler, DDS, JDMichael MeruFrank Mirada, DDS, MEd, MBAKirk Norbo, DDSDon Patthoff, DDSMartha S. PhillipsMarcia Pyle, DDSCherlyn Sheets, DDSPhilip E. Smith, DMD

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

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

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

OfficersThomas Wickliffe, PresidentThomas F. Winkler III, President-electPatricia L. Blanton, Vice PresidentW. Scott Waugh, TreasurerMax M. Martin, Jr., Past President

RegentsHerb H. Borsuk, Regency 1Robert A. Shekitka, Regency 2T. Carroll Player, Jr., Regency 3Robert L. Wanker, Regency 4Bert W. Oettmeier, Jr., Regency 5Carl L. Sebelius, Jr., Regency 6Steven D. Chan, Regency 7R. Terry Grubb, Regency 8

Kenneth L. Kalkwarf, At LargeJerome B. Miller, At LargeLinda C. Niessen, At LargeEugene Sekiguchi, At Large

Lawrence P. Garetto, ASDE Liaison

Dental Editors Prize for Journalism4 Following Your Moral Compass: Ethics in Dental School

Michael Meru, DDS

Electronic Dental Records10 Electronic Dental Records in Dentistry

Larry Emmott, DDS

13 Converting to Electronic Dental RecordsStephen I. Hudis, DDS

16 Electronic Health Record Conversion in a Private Dental SchoolRichard Fredekind, DMD, MA

Issues in Dental Ethics21 The Dental Patient Who Is “High:”

Ethical and Scientific Recommendations for the Standard of CareBruce Peltier, PhD, MBA; Lola Giusti, DDS; Terry Hoover, DDS; Jennifer Fountain; Jared Persinger, DDS; and Scott Sutter

Departments2 From the Editor

The Right Fight

35 LeadershipEvil Games

Cover photograph:

© 2010 malerapaso, istockphoto.com. All rights reserved.

This editorial is about the old chest-nut “Politics is too important to beleft to the politicians.” Ditto: health

care. My primary text is the U.S. Army,Marine Corps Counterinsurgency Field Manual, written by GeneralsDavid Petraeus and James Amos. This isnot a how-to manual for defusing IEDsguide to killing people; it is the best book on American democracy I haveread in decades. It is 400 pages long andavailable from Amazon for about $10.

Health care is certainly as complexas war. The former accounts for 18% of our country’s GDP; the latter 6%(including about 10% of that amount formilitary health care). Metaphors aboundenlisting us to fight birth defects, wipeout obesity, attach the causes of cariesand periodontal disease. The idea is thathealth can be achieved by wiping out thecauses of disease and the soldiers andgenerals in this campaign are the healthprofessionals. The patient is literally the host, just as in insurgencies wherearmies intervene on behalf of host countries. On this view, healthcare professionals and generals are heroes in charge and body counts, includingantibody counts, are a good way to keepscore. In the Gallup surveys of trust forvarious American professions, nurseslead the pack, followed by pharmacists,physicians, and dentists. Consistently, however, officers in the armed forcesscore higher on public trust than do all

healthcare providers except nurses whenthey are included on the survey. Whereis Hot Lips Houlihan when we need her?

But the metaphor is flawed. It isspecifically rejected in the Counterin-surgency Field Manual. It is only one ofseveral views of health care, and the onethat is beginning to slip in popularity.

In the Golden Age of Greece, therewere three schools claiming to be thecorrect way to promote health. TheAsclepian School (from which we takethe caduceus as a symbol for medicine)was popular at Delphi. Rich patientschecked in at a resort-like environmentfor baths and divinations of theirdreams. On what is now the Turkishcoast, the Cnydian School (pronouncedNII-dee-in) argued that ill health iscaused by pathogens or other externalforces. Cure consisted of diagnosing anddestroying the unhealthy influence. Onthe Island of Cos, just across from theCnydians, the School of Hippocrates feltthat disease was the manifestation of animbalance in the natural condition ofthe patient. The task of the healthcareprofessional was to help the patientregain control of his or her life—thephysician stabilized the condition; thepatient provided the cure.

Strains of all three traditions are evident in current-day health care,including dentistry. The currently domi-nant view is surgical, in the Cnydiantradition. But spa and esthetic dentistrywould be recognized by the Asclepians,and Hippocrates would applaud cariesmanagement and preventive care as thetrue calling of professionals.

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2010 Volume 77, Number 1

Editorial

From the Editor

The Right Fight

The term “hero” somehow does not fit wellon those who pick fightsso they can demonstratetheir prowess.

Surely, however, war is the businessof the Cnydians. Find the bad guys andtake them out. But evidently not accord-ing to Generals Prateous and Amos.There are perhaps three references in the400 pages of the manual to necessity ofkilling intransigents. “Killing insurgents,while necessary, especially with respectto extremists, by itself cannot defeat an insurgency.” That manual is aboutcreating conditions that allow legitimategovernments to regain their equilibria.“Counterinsurgency is military, paramili-tary, political, economic, psychological,and civic actions taken by the governmentto defeat insurgency.” The military missionis subservient to the political one, andmilitary personal are answerable to civilians. The commander-in-chief of allAmerican forces is a civilian, and warscan only be declared by Congress.

The goal of counterinsurgency is to allow a government to stand on itsown feet, but only if it honors values ofself-determination for citizens. This isthe American ideal of democracy. In theCounterinsurgency Field Manual, thisis itemized as meaning people must befree to decide about their own destiny asexpressed in six standards: (a), perceptionof government legitimacy, (b) security forcitizens, (c) free and frequent elections,(d) popular participation in government,(e) stability of institutions, and (f) a “culturally acceptable” level of corrup-tion (as in the United States).

Two points bear emphasis: coun-terinsurgency uses a coordinated arrayof interventions to create conditions

where countries that are destabilizedcan regain equilibrium and this militaryeffort is under civilian control. Theseecho the principles of Hippocratic healthand important work being too importantto leave to those who do it. The term“hero” somehow does not fit well onthose who pick fights so they candemonstrate their prowess.

It might be feared that this is thenew “soft” military. Clausewitz, the 18thcentury German strategist who set thetone for war up to our day, said, “Thepolitical object, as the original motive of the war, would be the standard fordetermining both the aim of the militaryforce and also the amount of effort to be made.” Going back much farther, the4th century BC Chinese manual for warattributed to Sun Tzu, The Art of War,contains the timeless wisdom of choosingterrain, employing spies, engaging indeception, judging the character ofopposing generals, and always leaving ameans of flight available to the enemy so they may flee rather than fight out ofdesperation. This 2,400-year-old manualadvises, “Thus a victorious army wins its victories before seeking battle; anarmy destined to defeat fights in hope of winning.” In other words, winningarmies prepare all the circumstances for the new equilibrium before engagingin battle. And one more point insisted on by Sun Tzu: politicians, and nevergenerals, decide on war.

3

Journal of the American College of Dentists

Editorial

One metaphor for dentistry is thatdentists save patients by deciding whichinterventions they want to use to wipeout the effects of disease. Another is that patients or groups of citizens enlistthe help of professionals to help themreach the level of health they prefer. The timeless wisdom of military conflictand the venerable Hippocratic traditionencourage the second metaphor.

Michael Meru, DDS

NoteThis editorial won the 2009 AmericanCollege of Dentists and AmericanAssociation of Dental Editors Prize forJournalism. It appeared in the Spring 2008issue of Mouth, the publication of theAmerican Student Dental Association, and is reprinted by permission.

On an unusually tropical day in San Francisco, former dentist and oral surgeon Tony

Protopappas appeared before the U.S.Supreme Court, March 24, 2004, with awrit of habeas corpus petitioning hisrelease from prison. Twenty years earlier,in 1984, Protopappas was charged withsecond-degree murder and sentenced to three concurrent terms of 15 years to life for the deaths of three womenthat occurred while they were undergeneral anesthesia.

Protopappas’ career began shortlyafter he graduated from dental schooland completed his oral surgery residency.He opened his Costa Mesa CaliforniaDental Clinic in 1974 and by 1982 thepractice was flourishing. Protopappasemployed five other dentists, as well as many office staff. He was the onlypractitioner in the office with a licenseto administer general anesthesia and wasresponsible for standardizing the dosesgiven the patients that were prepared by the office assistants (People v.Protopappas, 1988).

On September 28, 1982, a feeble KimAndreassen presented at the Costa MesaClinic for a root canal, three fillings, anda crown. Andreassen’s medical historyconsisted of lupus, total kidney failure(requiring thrice-weekly dialysis), highblood pressure, anemia, a heart murmur,and a chronic seizure disorder. Herphysician informed Protopappas that

she was not to be placed under generalanesthesia. Despite the dentist havingbeen warned by the physician, Andreassenwas placed on an IV general sedationsetup. During the procedure, signs of respiratory distress were noted by theassistant, yet Protopappas’ reply was,“Maybe that’s normal for her becauseshe is so ill.” Ten to 15 minutes later therespiratory distress worsened, her pulsebecame weak, and her face turned blue.Shortly thereafter the paramedics werecalled and brought Andreassen to thehospital. Upon arrival, Andreassen waspronounced clinically dead.

After the tragic events of September28, Protopappas continued to practice asusual until the week of February 6, 1983.On Tuesday, February 8, Protopappassaw 13-year-old Patricia Craven for theremoval of her third-molars, as well asfor eight fillings and a crown. Cravenwas active and healthy, aside from herswollen tonsils. During the procedure,which was done under general anesthe-sia, Craven was given massive amountsof drugs, which caused her to go into acoma later that day. On Friday, February11, while Craven was still in a coma,another patient, 31-year-old CathrynJones, sought dental care under generalsedation at Protopappas’ clinic. She wasalso given massive amounts of drugs,

4


Following Your Moral Compass: Ethics in Dental School

Dental Editors Prize for Journalism

Dr. Meru is a resident in the orthodontic program at the University of SouthernCalifornia and Immediate Past President of ASDA;[email protected].

which caused her to go into a coma aswell. Both Craven and Jones died dayslater and were found to have sufferedmassive drug overdoses.

After the third victim was pronounceddead, Tony Protopappas was brought totrial. One expert witness, an oral surgeon,testifying in regard to Andreassen’s death,reported that the combination of drugsadministered did not make any sense. He stated, “It is not a regimen to sedate apatient. It is illogical. It is—I don’t knowanybody who does this kind of thing forsedation or anesthesia. It is really anillogical approach to treating people”(People v. Protopappas, 1988).

From the People v. Protopappas casenotes: “Dr. Frank McCarthy, chair of the anesthesiology department at theUniversity of Southern California’s dental school, testified that Andreassen’sirregular breathing was symptomatic of severe toxicity and should have beeninterpreted as urgent and life threaten-ing. He concluded Protopappas did notrecognize or respond to Andreassen’sCheynes-Stokes breathing” (People v.Protopappas, 1988).

In his own defense, and throughoutthe trial, Protopappas maintained that hefelt he was treating the patients correctly,to the best of his ability, and with nointent of harming anyone.

One aspect of his life that did not surface in his trial notes is the allegationshe faced while in dental school. Asdescribed in an ethics class taught at theUniversity of Southern California Schoolof Dentistry, many people, including faculty and other students, knew very

well that Protopappas had problemswith academic dishonesty and that hecheated numerous times. He put gettingahead in life, in the easiest manner possible, in front of the learning processthat dental schools grant to each studentin order to ensure proper breadth anddepth of education.

There may or may not be a correla-tion between Protopappas’s cheating indental school and his eventual killing ofthree women. But as one study of med-ical students found, academic dishonestyduring medical school does predispose aperson to cheating in patient care laterin life (Westerman et al, 1996). As dentalstudents and future practitioners we arecommitted to being lifelong learners.Not only is that important for each of usto be successful, but it also ensures thatthose that we care for will also be pro-tected. The arduous nature of continuedstudy and practice should never take aback seat to finding the easy way out.

Protopappas’ petition for writ ofhabeas corpus was denied on March 24,2004, and he is currently serving histerm in Folsom State Prison.

Academic dishonesty is a pandemicthat has existed in our nation for decadesand has continually worsened. A studyof college students at the University ofGeorgia (Andrews et al, 2007) found that from 1969 to 1989, the percentageof students who admitted to cheatinghad doubled from 34% to 68%.

5



In dentistry, ethics is

crucial, owing to the fact

that patients seeking care

place their well-being in

the dentist’s hands.

The profession of dentistry is ranked by consumers as one of the tenmost trusted and ethical professions inAmerica. So one might be inclined tobelieve that issues of academic dishonestyand cheating would be much less severe.In the August 2007 edition of the Journalof Dental Education, Andrews and others reported a study in which 1,153dental students were surveyed in regardsto academic integrity. The survey foundthat nearly 75% of the respondentsadmitted to some level of cheating. Andduring the past several years, the dentaleducation community has been shakenwith cheating scandals at dental schoolsaround the nation.

According to the Oxford AmericanDictionary, “School of ethics in Westernphilosophy can be divided, very roughly,into three sorts. The first, drawing on thework of Aristotle, holds that the virtues(such as justice, charity, and generosity)are dispositions to act in ways that benefit both the person possessing themand that person’s society. The second,defended particularly by Kant, makes the concept of duty central to morality:humans are bound, from a knowledge oftheir duty as rational beings, to obey thecategorical imperative to respect otherrational beings. Thirdly, utilitarianismasserts that the guiding principle of conduct should be the greatest happinessor benefit of the greatest number.” TheOxford American Dictionary goes onto define ethics as “moral principles thatgovern a person’s or group’s behavior.”

Nash, in the May 2007 issue of theEuropean Journal of Dental Education,stated “ethics is about the basic moral

standards inherent in the structure ofsocial living, incumbent on all humanbeings regardless of the presence orabsence of any religious convictions.”

In dentistry, ethics is crucial, owingto the fact that patients seeking careplace their well-being in the dentist’shands. In the American DentalAssociation’s Principles of Ethics andCode of Professional Conduct, it states,“The dental profession holds a specialposition of trust within society. As a con-sequence, society affords the professioncertain privileges that are not availableto members of the public-at-large. Inreturn, the profession makes a commit-ment to society that its members willadhere to high ethical standards of con-duct.” Nash added that “The goal of therelationship in which one assumes therole of health professional and the otherthat of the patient is the benefiting ofthe patient.”

The ADA’s Principles of Ethics andCode of Professional Conduct sets forthfive major ethical principles that dentistsmust adhere to. They are: autonomy(self-governance), nonmalfeasance (dono harm), beneficence (do good), justice(fairness), and veracity (truthfulness).The document states that “members ofthe ADA voluntarily agree to abide by theADA Code as a condition of membershipin the Association. They recognize thatcontinued public trust in the dental profession is based on the commitmentof individual dentists to high ethicalstandards of conduct.”

In 2002, the American Student DentalAssociation (ASDA) adopted its own codeof ethics (http://asdanet.org/_aboutpage.aspx?id=1556) which states, “TheAmerican Student Dental Associationrecognizes the importance of high ethical standards in the dental schoolsetting. Therefore, the Associationbelieves students should conduct them-selves in a manner reflecting integrityand fairness in both the didactic and

clinical learning environments. Ethicaland professional behavior by dental students is characterized by honesty, fair-ness, and integrity in all circumstances;respect for the rights, differences, andproperty of others; concern for the welfare of patients, competence in thedelivery of care, and preservation of confidentiality in all situations wherethis is warranted.”

All ASDA members are also membersof the ADA, and we commit to abide bythe ethical principles within these twocodes. Not only do we commit to observethese two codes, but also it is likely that we have codes of ethics and ethicscurricula specific to our dental schools.

Despite the codes of ethics that weagree to live by and the principles taughtto us by experts in the field of dentalethics, the harrowing statistic still stands—that nearly 75% of dental studentsadmit to some form of cheating.

So in what nature do dental studentscheat, and why? Instances that havebeen reported include cheating on exams,paying for patients, stealing lab equip-ment, charging out fake procedures topatients to earn points, stealing facultyusernames and passwords to increaseproduction, stealing exams, using oldexams, paying for outside lab work to be graded as one’s own, compilingillegal national board exam questions,among many others. With advances intechnology and the use of items such as cell phones, PDAs, cameras, hackingsoftware, online file sharing sources,etc., cheating has never been so accessi-ble to the masses.

For example, Andrews and others(2007) reported an instance where “tenstudents each using camera cell phones,[took] one picture of one page of anexam at varying times in an exam, then[collaborated and put] them into a Word

6



document to distribute to the next year’sclass,” thus using technology to not onlycheat themselves, but to tempt futureclasses into cheating as well.

In a survey of dental school deansconducted by Beemsterboer and others(2000), 83% of schools reported inci-dences of copying using didactic exams,52% had occurrences of students writing untrue treatment records inpatients’ charts, and 50% reported thatstudents had signed faculty names in a patient’s chart.

Now we know how they cheat, butwhy? In the article written by Andrewsand others (2007), many reasons as towhy dental students cheat were revealed.Some of the prominent motivationswere: “Everyone does it”—students feltthat in order to be on a level playingfield with the rest of their classmates,they had to cheat also; stress, pressure,and workload; belief that their adminis-tration does not enforce school policieson cheating; and they did not agree with the school’s definition of cheating.

Academic dishonesty is contagious,both to yourself and to those around you. The basis of academic dishonesty beingcontagious to oneself is that continuedcheating breeds two outcomes. First, itcauses the person cheating to becomedesensitized to the inherently wrongnature of the act, making it easier to justify that same behavior in the future.Second, it fosters an attitude of compla-cency rather than hard work, becausethe cheater gets all of the glory withoutany of the stresses that come along theroad to success.

The rationale for academic dishon-esty being contagious to those aroundyou is twofold as well. First and foremostis the reason stated by Andrews and others (2007) that when some studentscheat, giving themselves an unfairadvantage, the remainder of the studentsfeel they must cheat in order to maintain

equity. Second, the supposed ease thosewho cut corners have in getting highgrades and into residency programscauses others who may not havebehaved that way to follow suit.

Issues of cheating are not the onlyethical problems facing dental educationtoday. One major ethical issue facing ourprofession is the use of live patients inthe current format of clinical licensureexams. Dr. Brooke Loftis, ASDA’s imme-diate past president, stated, “ASDAcontinues to fully support the elimina-tion of live patients in its current formatfor the use of initial clinical licensure.How can we continue to allow an examination process that encouragesmarginally unethical behavior from stu-dents? We must protect our patients andprovide them with the best care possible.After four years, the clinical licensureexam procedures I recently completedare the last clinical procedures I will perform within my dental school. I willnever forget the students who weredelaying treatment of patients, over-radiating their patients, over-treatinglesions, and paying outside services forthe supply of patients to use during theexam. How can this be ethical?”

So wherein lies the problem? Theblame cannot be assigned to one groupor individual. It is a shared burden—one that students, faculty, administrators,and the profession have to recognize,speak out against, band together and conquer.

Current dental ethics literatureagrees that change must be made. Thequestion is not if, but how to change.Below is a series of suggestions found inthe literature (Andrews et al, 2007; Nash,2007; Maitland, 2006) and compiled bythe author:

7



Doing the right thing may

have an immediate negative

effect publicity-wise; but

not punishing unethical

behavior fosters continued

unethical actions that will

pollute and ultimately

undermine an institution

and our profession.

Lead by Example: “Faculty must not look the other way, nor take the easyway out, but be firm monitors of theideals that our code of ethics explains asour special privilege,” stated Dr. Maitlandin his article “Disturbing trends in dentaleducation” in the June 2006 issue of theJournal of Esthetic and RestorativeDentistry.

In the article by Andrews and others(2007), one student was quoted as saying,“There is a huge double standard imple-mented by the faculty of my school. Theyoften get upset at us for using old tests tofocus our studying; however, they ask usto memorize questions on NationalBoards to help the classes below us.”

Enforce School Policy: “We mustinsist on accountability and responsibility.Discipline, when indicated, should befair, swift, and strong, without the imageof weakness and forgiveness,” Maitland(2006) stated. “We not only have toreconnect with honor, we have to send a clear message.”

In the article by Andrews and others(2007), another student was quoted assaying administrations must “actuallyfollow the enforcements that are listed inthe handbook for students caught cheat-ing. Come down hard on cheaters; we hadten accounts against the same student inwriting and signed…nothing happened.”

We must not back down at the threatof lawsuits or bad press. Doing the rightthing may have an immediate negativeeffect publicity-wise; but not punishingunethical behavior fosters continuedunethical actions that will pollute andultimately undermine an institution andour profession.

Dr. Loftis stated, “When students seeother students behaving unethically andno punishment is applied, it becomesharder and harder for students who

struggle in ethical situations to maintainan ethically sound mentality.”

Write New Exams: This applies notonly to professors and individual schools,but to the ADA as well. When an examsuch as the NBDE I is offered nationwideand can be taken on almost any givenday, with a limited variety of tests thatare not routinely changed, it is inevitablethat students will begin to cheat andwrite down remembered questions. Itonly takes one person to start the domi-no effect. If the tests cannot be changedon a regular basis, it may be beneficial togo back to offering the test twice peryear in order to avoid such behavior.

In regard to tests in individual insti-tutions, the suggestion would be to writenew exams for each class in order tominimize cheating.

Move to Methods of Testing thatAre Difficult to Cheat with: Ideally, students would self-govern and therewould be no worry of academic dishon-esty. Since that is not the case, we mustmove to methods of testing that make itdifficult to cheat. Andrews and others(2007) reported that students felt that“there should be increased surveillancewithin the testing area to help discouragecheating. Suggestions include changingseating arrangements, videotaping, orhaving specific rooms designated fortesting.” It was noted that the number ofproctors should increase as well.

Institutions must also stay currentwith technology and literature regardingacademic dishonestly so that they arebetter equipped to combat new strains of cheating.

Continually Teach ProfessionalEthics in Dentistry: Nash (2007) stated, “The justification for teachingprocessional ethics in dentistry is to facilitate the personal and professionaldevelopment of aspiring dentists intosocially and professionally responsiblehuman beings.”

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Institutions must also staycurrent with technologyand literature regardingacademic dishonestly so that they are betterequipped to combat newstrains of cheating.

Increase Research into theSpecifics of Dental Ethics: There arevery few studies with scientific backing inthe arena of dental ethics and academicintegrity. In order for the profession ofdentistry and dental education to betterunderstand this pandemic and to verifyand pinpoint where the problems lie, we must have correct and specific data.These data will enable the profession toaccurately propose and execute solutions.

Notwithstanding the fact that the situation of dental ethics hitherto por-trayed may appear disheartening, thereis reason to be hopeful. Organizationsaround the nation are coming togetherand collaborating in order to find solu-tions, including organizations such asASDA, the ADA, the American College ofDentists, the American Society for DentalEthics, the American Dental EducationAssociation, the Student Professionalismand Ethics Clubs, numerous state dentalsocieties, individual schools, amongmany others. As stated earlier, we havean obligation to our patients, to ourselves,and to our profession to be ethical in allsenses of the word.

In looking back at the Protopappasmurder case, the trial notes conclude,“The most troubling aspect of this case isthat Protopappas has been convicted ofmurder for acts committed as a practicing,licensed dentist under circumstanceswhere there can be no doubt he did nottruly intend to kill anyone. Certainlyevery reasonable dentist or physicianexamining this opinion would agreeProtopappas was grossly negligent ineach of these three homicides, but whereis the evidence of the malice necessaryto justify a murder conviction? For thebenefit of the concerned dental andmedical professional, the answer to thatquestion is simple: this case is highly

unusual and, hopefully, unlikely to recur;for it is the health care equivalent ofshooting into a crowd or setting a lethalmantrap in a dark alley” (People v.Protopappas, 1988). Protopappas didn’twant or mean to commit the crimes that perchance may have been avoidedhad he not taken shortcuts in his profes-sional career.

May each of us follow the ASDA Code of Ethics that states that we willconduct ourselves in a manner reflectingintegrity and fairness and that we willmaintain high standards of moral andethical behavior. If each one of us followsour code and bands together to speakout against academic dishonesty, ourprofession will remain one of the mosttrusted professions in America. ■

ReferencesAndrews, K., Smith, L., Henzi, D., & Demps,E. (2007). Faculty and student perceptionsof academic integrity at U.S. and Canadiandental school. Journal of Dental Education,71 (8), 1027-1039.Beemsterboer, P., Odom J., Pate, T., &Haden K. (2000). Issues of academicintegrity in U.S. dental schools. Journal ofDental Education, 64 (12), 833-838. Maitland, R. (2006). Disturbing trends indental education. Journal of Esthetic andRestorative Dentistry, 18 (6), 307-309.Nash, D. A. (2007). Commentary on ethicsin the profession of dentistry and dentaleducation. European Journal of DentalEducation, 11, 64-74.People v. Protopappas (1988). 201Cal.App.3d 152 [256 Cal.Rptr.915]. Court ofAppeals of California, Fourth AppellateDistrict, Division Three.Westerman, G., Grandy, T., Lupo, J., &Tamisiea, P. (1996). Attitudes toward cheat-ing in dental school. Journal of DentalEducation, 60 (3), 285-289.

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Organizations around

the nation are coming

together and collaborating

in order to find solutions.

Larry Emmott, DDS

AbstractA leading consultant on dental practicetechnology explains the advantages, especially issues of cost in handling paperin the office. A practical approach toreplacement of paper as it is used, ratherthan a comprehensive conversion, is suggested. Common mistakes include converting only part of the office or storing electronic information in differentand non-integrated systems.

Is it really possible to go paperless? The best answer to this question isyes…but. It depends on what you

mean by “paperless.” The goal is not toeliminate all paper. There are manyeffective uses and needs for paper.However what is possible and highlydesirable is to create a paperless dentalrecord or better yet an Electronic DentalRecord or EDR.

Many offices have already success-fully adapted an EDR. So as Omar Reedfamously said; “If someone has done it, it is probably possible.” An EDR meansthat there is no paper folder with patientinformation. All the charting, diagnostics,correspondence, prescriptions, referrals,financial records, scheduling, and so onis recorded and saved on a computer.There is no paper record.

It has become fashionable on theInternet to refer to traditional magazinesand newspapers as “dead tree” media.This of course refers to the many thou-sands of trees that are cut down everyday and used to make paper. If you areusing traditional paper charts, then youare using “dead tree” charts. There is abetter way.

An EDR is:• Faster: You don’t need to go get the

chart and re-file it; you don’t need tospend time writing the same thingover and over again.

• Better Organized: Everything isn’tstuffed in a folder but is organized in the electronic chart by default.

That means users can instantly findanything with an electronic search.The chart will never be lost some-where in an office stack.

• Less Expensive: Paper charts andfile cabinets for 2,500 patients willcost at least $25,000 and take up achunk of office space. A good dataserver for the dental office will costabout $3,500, accommodate a lotmore than 2,500 patients and takeup about a foot of space.

In order to demonstrate the advan-tages of an EDR let’s make an imaginaryvisit to the traditional dental office of Dr. Paperman.

As a new patient the first thing thathappens is that you are handed a brownMasonite clipboard with one cornerchipped off. On the clipboard are severalforms. The top form is crooked on thepage and has been copied so many timesit is speckled. A plastic pen is tied ontothe clipboard with dental floss. You now tediously fill in the spaces. Name,address, phone number, employer,spouse….. Then you get to the importantpart, the insurance information.However, you do not understand any ofthat. Then there are all those healthquestions. Check off the box and write inthe details. Are you pregnant? (Well, if I

10


Electronic Dental Records in Dentistry


Dr. Emmott is a consultant on dental practice technologybased in Phoenix, Arizona;www.drlarryemmott.com

am, my wife will certainly be surprised.)How do you spell infarction? It does notreally matter; no one can read your writing anyway. And then sign it.

You then hand the papers back tothe front desk. You now get to sit andwait while she then re-enters all thisinformation into the computer. Where isyour insurance card? If you brought thecard to Judy, the front desk person, shewill copy it to another piece of paper.Wait! Don’t sit down yet. Take all thesepapers (lawyers say we need them toprotect us from lawyers) and read thensign them. More overcopied, speckledpages. There are a couple of consentforms. A HIPPA privacy form, a financialresponsibility form, an insurance releaseand so on.

Sit and wait while a label is typedand stuck on a file folder. Several otherforms are put in there as well, includinga tooth chart and pages for future notes.At last, you are allowed to enter the backpart of the office. You have not yet seteyes on Dr. Paperman and already youhave a chart that contains ten to twelvepages of paper.

The FutureEventually we will be able to carryaround all our important medical historysecurely encoded on a microchip, possiblyin a smart card. When you visit a newmedical office you will not be faced withstacks of redundant forms you couldsimply swipe your card and all your datawill transfer immediately to the officecomputer and become part of your electronic record

Getting a chart started at Dr.Paperman’s certainly entailed a lot oftime, paper, and redundancy, but that’snot all. The hard costs to create andmaintain paper charts can be significant,but we often do not see them becausethey are hidden in the process of doingbusiness. Paper charts don’t just appearin the office for free. The paper folder,the forms, and all the other papers costabout $3.00 each. If you have 2,500charts, they cost you at least $7,500 tocreate; and every time a new patientwalks in, it’s another three bucks; cha-ching.

Other chart contents, like x-rays andphotographs, can be even more costly. A set of bitewings with film, processing,and mounts can be several dollars. Aphoto printed from the intraoral camerais $1.50 or more. It is reasonable to addat least another $4.00 to the cost of eachchart and for all these contents, addinganother $10,000 to the overall office cost.

Storing the records isn’t free either. A typical office with 2,500 charts willneed three or four full-size lateral files tohold them all. Depending on how nicethe files are, they will cost about $4,000and could be a lot more. They will takeup office space. A 10' x 5' file room willcost $7,500 to build. That is 50 squarefeet at $150 per foot. Not to mention all the “inactive” charts stashed awaysomewhere else.

So far, our inexpensive paper files are costing us $29,000, but that is not thetotal cost. There is the human effort to

11



make the chart, type the label, arrangethe contents, file new bits when theyarrive in the mail, write the notes, pullthe charts every day, and then re-filethem. And of course there is the daily ritual of the lost chart, which no one can find—only to have it turn up dayslater either misfiled or hiding in a stackon the dentist’s desk.

So we can see that the paper chart-ing system at Dr. Paperman’s office costsa great deal and takes a lot of staff timeto create and even more time and effortto maintain in an organized manner.

Once the system to create all the digital information is in place, you simply stop making paper. Everythingnew is electronic; everything from thepast is paper.

Going paperless is a

process, not an event.

One of the common mistakes dentistsmake with electronic charting is thatthey only go part way. Sometimes wemiss the obvious, it is the old “can’t seethe forest for the trees” (dead or alive)thing. In this case, the trees are the individual processes that can be used tocreate digital information. The forest isthe paperless record. If all you see aretrees, then you might use an electronicchart for treatment planning but makeprogress notes on paper. You mightinstall a digital radiograph system andnot link it to other records. You mighthave a computer up front for financesand scheduling but not have computersin the back for charting.

The tendency is to concentrate onindividual processes or technologieswithout integrating the process into thewhole. For example, the office may use apaper chart in the treatment room dur-ing diagnosis to mark future treatment.Then they take the paper chart to thecomputer and enter everything again.

They will use the computer to create anestimate, insurance forms, and schedule.Then they will go back to the paperchart to enter procedure notes, back tothe computer to take a payment, back to paper for a prescription, back to thecomputer for the next appointment,then back to paper to check the x-rays.What the office ends up with is a mess.Everything is done at least twice; thepaper chart is still needed and no one isever sure if something is on paper or inthe computer. As a result, the computerchart doesn’t save time and money, itmakes things worse.

Another mistake is to gather digitalinformation, such as photographs, butstore it in separate software that is notpart of the patient’s digital record. To be most effective the digital informationmust be all part of the same record, eitherusing a fully integrated system or linkingeach system using computer bridges.

Going paperless is a process not anevent. Many dentists believe that in order to go paperless they must scan and convert all their old records. This isa huge, time-consuming, and expensivetask with a very limited benefit. Do not

do it. At most you may wish to scan themost recent records of patients who are currently under treatment.

At first you will need the papercharts on all your patients as you will bereferring to the previous paper entries.(Note: you won’t be making any newpaper entries just reading the old ones!)As time goes on you will need to referless and less to the old, paper records.After a year, all the current x-rays will bedigital and all the patients recent entriesand treatment plans should be digital. It is now possible to stop pulling charts.The only time you will need to refer tothe old charts is for entries or x-raysmore than a year old. Eventually you will rarely, if ever, need to pull a chart.

Often the dental office has every-thing in place to go paperless, but they still make paper just because that is the way they have always done it.Overcoming the inertia of change is frequently the most difficult task ofgoing paperless. The future is comingand it will be amazing! ■

12



Process The Paper Way The Digital Way

Enter it We use paper and pen to write on a chart, fill out a prescription, make notes, or draw on the dental chart.

We use a mouse and a keyboard to enter the same information.

Capture it We use film exposed to light in a camera or x-rays, which are then processed to create photographs or radiographs.

We use a sensor which is exposed toeither light in a camera or to x-rays, which then creates an image on the computer monitor.

Scan it We take a piece of paper with important information, make a copy, and put the paper copy in the chart folder.

We take a piece of paper with important information and make a digital electronic copy, which becomespart of the digital record.

Import it We add information we have receivedfrom someone else, such as an insurance EOB, to the chart folder.

We never see a paper EOB. We justimport this information in a digital formatdirectly to the patient’s digital record.

How to Do ItThere are four ways to turn allthe “stuff” we have crammedinto our paper folders into digital information that can be stored as part of an EDR.They are listed in this table.

Stephen I. Hudis, DDS

AbstractThe gradual conversion of a prosthetic specialty office to digital format isdescribed. Electronic format and equipmentdoes not create effective office systems; it reflects the existing systems and makesimprovement possible. An incrementalapproach is favored because it is possibleto ensure the success and integration of each step and because it does not overwhelm the dentist’s and staff’s under-standing of the practice. In addition toefficiency, office technology has greatpotential for improving communication,both with patients and with other practitioners. The electronic practice is anopportunity for continuous improvement.

One of the many truths I havelearned over the last 15 years is“Digital technology is wonderful

when it works, and when it doesn’t…” For me, converting to digital records

has been an evolutionary process overmore than a dozen years. One of the firstlessons I learned as a Pride client wasthat computers don’t create systems; theymerely replace existing paper systems. Ifyou do not have appropriate systems inplace, i.e. hygiene recall, billing, schedul-ing, etc., do not expect the computer tocreate them. Once you have good practicemanagement systems and protocols inplace, then it becomes relatively easy todigitize them.

Having good paper systems in placealso sets a standard against which tomeasure success. If your paper systemsare working, and you have a set of criteriafor evaluating them, then it is easy tomeasure your success in converting to a digital replacement. Office practice systems are the road map that we use toget to our final destination. Withoutknowledge of what our final destinationis, then the road map is useless. It is critical with any system that we havegoals and criteria against which to assesswhether we are achieving those goals.

Having said that, and presuming that all the relevant systems are in place,the next step is to gradually replace yourpaper systems. And I use the term “grad-ually” advisedly. I have a very proactive,self-motivated, and computer-savvy staff.One of the many lessons that my teamand I have learned over the years is to

always take small steps. We pick a specifictask or system to start with. Next weanalyze the components of that system,and look at the technology that we willbe using to replace the paper system. Wetalk about who will take the lead in theconversion, set a timetable, and establishthe criteria for goal assessment. Eachmember of the team focuses on his orher particular aspect of the conversion.Once we are satisfied that the conversionwas successful and that we have success-fully replaced the paper system inquestion, we move on to the next task.

It is critical to get a comprehensiveview of the entire project. As with any complex treatment plan, it is crucial tohave a vision of what the final result will look like. The same rule applies tooffice systems and protocols. You have tohave a clear assessment of your startingpoint, and a clear vision of what thefinal product will look like. A list shouldbe made of all of the systems in the office.They would include financial and billing,scheduling, charting and treatmentplanning, radiography and photography,progress notes, correspondence, and,finally, consent forms, medical/dental

13


Converting to Electronic Dental Records


Dr. Hudis is a diplomate of the American Board ofProsthodontics who practicesin Princeton, New Jersey;[email protected].

questioners and HIPPA release forms. As you can see, this is quite a long list.There is an immense amount of infor-mation here. Attempting to change allthis at once is practice suicide. It guaran-tees that the team will throw their handsup in the air, agree as a group that itwon’t work, and request a return topaper. I have been fortunate, in that ascomputer technology and capability haveimproved, I have added new componentsto my practice. In hindsight, the timesthat we struggled were when we tried toaccomplish too much at once. In thisprocess, as in life, success usually breedssuccess. While failure can sometimesprovide the best learning crucible, toomuch failure can doom any project. Asthe team succeeds, it is important toevaluate that success and what createdit. Those skill sets can then be used asthe team moves onto the next task.

While I have found that digital technology has greatly improved officeefficiency and accountability, it is also anamazing communication tool. We havedual monitors in all of the treatmentrooms. When a clinical staff member istaking radiographs, they are visible tothe patient on the second monitor. I havean intra-oral camera, as well as a full-sized digital SLR camera. My hygienistsare particularly fond of the intra-oralcamera. Quite often when I enter theroom for a hygiene check I am informedthat the hygienist and patient havealready discussed a particular tooth, aswell as the proposed treatment. Manytimes I merely offer confirmation andsupport for my hygienist, and answer

any additional questions the patient mayhave. Having the patient see what wesee, both the radiograph and clinical picture, is a wonderful communicationtool. I do not take insurance in my office.When we print a walkout statement forthe patient we additionally print a copyof the x-ray and intra-oral photo. This isdone from a small photo printer right atthe front desk. This serves two purposes.The combination of x-ray and photo has dramatically reduced the number ofrejection appeals, and the patient has an additional opportunity to view theproposed tooth. We have lately startedtaking photos after the preexistingrestoration has been removed and thecaries excavated. My feeling is you cannever document too much, and theintra-oral camera makes it easy.

Patients like to see high tech. It makesthem feel that their dentist is current. A number of years ago we created a Website. At the time, the reason was so thatwe could have patients do their medical,dental, and HIPPA forms online. Thathas been a great success. In the privacyof their homes we have found that theforms are filled out more completely.The forms are then reviewed with thedentist and signed in the treatmentroom. Additional benefits of the Web site have been information and commu-nication. The Web site offers potentialpatients information about the practice.They can learn about the dentist and the team. They can also learn about

14



The times that we

struggled were when

we tried to accomplish

too much at once.

office policies. The Web site can also beused to provide informational links thepatient can pursue. As Sy Syms says, “An educated customer is our best shop-per.” The corollary certainly holds. Aneducated, informed patient is the patientwho makes the wisest choices wherehealth is concerned. There is no suchthing as a stupid question.

I stated before that digital imagerywas a great communication tool forpatients. Another amazing aspect of digital technology is communicationwith other dentists. It can be a patientthat was referred to me by a generalpractitioner or a patient that I referred to another specialist. Many times I willhave a patient in the chair and simply e-mail an image to the other dentist. We can have a conversation while thepatient is in my chair. That I find simplyamazing, and patients love the conven-ience and time savings.

The most recent step for us in theprocess of digital conversion has beenprogress notes. Many years ago I wasbanned from writing up charts, as manytimes even I could not read my ownhandwriting. Now, most of the progressnotes are preset as templates. I simplymodify the template, or dictate any additional notes while the patient is stillin the chair. I review the note and sign it before the patient is dismissed. Thenotes are clear, concise, and legible, andbecause they are locked when they aresigned, they are a legal record. This alsoeliminates reviewing charts at the end ofthe day. Significant time savings for me.

15



That leaves only one issue to discuss:hardware. I think dual monitors in thetreatment rooms are essential. I alsohave a consult room with a 20-inchmonitor. Allowing the patient to seewhat we see is the best communicationtool. When patients see what we see,they ask better questions and have amuch better concept of what is beingdone for them.

The more you do with computers,the more essential back-up becomes. Adear friend of mine recently had an accident with his laptop and had neverdone a backup. He explained to me thatthere were two types of individuals.Those that have always backed up theirdata and those that back up NOW! I recommend highly against the latter. Ihave three mirrored drives in my serverand do an external hard drive backupevery night. Additionally I do a live copyto my laptop every night. This providesme with an additional backup, and if my entire system should go down, it is afully functioning terminal separate frommy network. Finally, if I travel to anotheroffice, I can take my entire databasewith me.

I personally find computer technologyto be a wonderful tool in my day-to-daypractice. It has been and continues to bea time- and finance-intensive work-in-progress. The more careful and organizedwe are at setting up the systems andentering the information, the better andmore accurate the information comingout will be. ■

While I have found that

digital technology has

greatly improved office

efficiency and accountability,

it is also an amazing

communication tool.

Richard Fredekind, DMD, MA

AbstractThe three-year-plus transition from a partial to a full electronic set of clinics in a dental school is described. Theprocesses of requirement determination,vendor selection, and implementation are described, as well as challenges andbenefits. A number of recommendationsare offered, including the wisdom ofinvolving, early in the process, all who areaffected by the conversion, recognition that different users interact with the clinicdifferently and therefore have differentrequirements and expectations, and thatsome individuals adapt easily to changeand others find it more challenging. It iseasy to underestimate the resources oftime, money, and energy necessary for a conversion to an electronic health record,especially in a multi-clinic organization; but such changes are inevitable.

The University of the Pacific, ArthurA. Dugoni School of Dentistry(Pacific Dugoni) is a private dental

school located in San Francisco, California.It has a 36-month undergraduate cur-riculum and matriculates approximately140 undergraduate students and 22International Dental Studies studentseach year in July. Pacific Dugoni also hasthree postgraduate programs and a dental hygiene program. There are 14clinics in the Pacific Dugoni system, allbut three of which are located on theSan Francisco campus. Approximately100 staff members and 200 faculty members support clinic operations.Pacific Dugoni treats about 12,000patients each year in our clinics.

Pacific Dugoni took a half-steptoward an electronic health record (EHR)in the mid-1990s when we convertedfrom a nearly 100% paper chart to achart that was about 50% paper and50% electronic. The conversion includedhard-tissue charting, periodontal chart-ing, procedure tracking, and variousbusiness-related activities. Remaining on paper were informed consent, intakedocuments, routing forms, and the treatment record. Radiographs were allanalog and located in a pocket in thepaper chart. One of the biggest issueswith the legacy system was the fact that it was not a mature system for usein a dental school. The system requiredongoing upgrades in order to make itfunctional in our programs. Report

development was a huge task thatInformation Technology (IT) worked onextensively. Certain reports that werecreated were outstanding for the detailedinformation that was available to facultyand staff members. Nonetheless, theinformation in many other reports wasnot trusted by faculty who used them.These issues created challenges in atleast three important clinic activities:patient care, student education, and clinical research.

An immature, half-digital patientrecord created numerous problems forstudents, staff, and faculty members during patient care. Charts were oftenmisplaced, signatures and entries weresometimes illegible, and there was a lotof going back and forth between thepaper chart and the EHR. Frequently,two people needed the same chart simul-taneously. Certain patients had differentpaper charts because they were treatedin more than one clinic. For awhile,hard tissue charting was completed inboth systems. Students all had their ownlaptop computers that they had to bringwith them to every appointment. All laptops had to be plugged in to the network at a dataport in each operatory.Generally, there were two different systems to manage and each had theirown set of challenges.

16


Electronic Health Record Conversion in a Private Dental School


Dr. Fredekind is AssociateDean for Clinical Services at the University of the Pacific, Arthur A. DugoniSchool of Dentistry; [email protected].

Student education relating to infor-mation management was archaic andconfusing. We were teaching studentsthat it was okay to manage informationby using two different systems when in fact it was the least acceptable option. A better option would have been eitherfully paper or fully electronic. Many students had worked in dental officesprior to matriculating and had experi-ence with mature EHR systems. Theywere frustrated and confused by theinformation system at Pacific Dugoni, so this was a significant challenge to our educational program.

Clinical research was very difficult.Projects involving patient health infor-mation were tedious to complete usingpaper charts. It required looking throughevery chart by hand and extractinginformation chart by chart. This made itchallenging to complete collaborativeresearch at multiple sites and probablyprevented those types of research projectsfrom getting completed.

Product SelectionIn 2006, the dean charged clinic admin-istration to create a fully electronichealth record. Thus began a three-yearprocess of product identification, evalua-tion, and selection. A working group wasformed to steer us through this processand it included clinical faculty and ITstaff members.

We first identified all the productsthat could possibly meet our needs. Itquickly became evident that most ofthem were deficient, primarily becausethey had no mature grading/evaluation

component required to provide studentswith feedback. Two products emerged aspossibilities: Salud 210 and axiUm. Saludis a product popular in European dentalschools, and axiUm is found in manyUnited States dental schools. Vendor representatives from each company spenta few days at Pacific Dugoni presentingthe highlights of their products. Approxi-mately 60 faculty and staff membersattended these sessions and providedfeedback. Other dental schools that usethese products were contacted to obtaintheir detailed impressions about theproducts. Representatives from PacificDugoni visited other dental schools aswell to see the systems firsthand. In theend, axiUm was the preferred productand the contract was signed in fall 2008.

The process of product evaluationwas an important part of creating buy-inamong faculty and staff members. Theirdirect and active involvement in evalua-tion of both products enabled them toget an up-close view of each early on.Their feedback enabled clinic adminis-tration not only to understand userneeds but also to get an idea of howusers perceived the project in general.They began to realize how deficient our current system was and how different,and better, another system would be.This created very positive feelingsamong staff and faculty users about theproject in general and momentum formoving the project forward efficiently.

17



The process of product

evaluation was an important

part of creating buy-in among

faculty and staff members.

This began to create very

positive feelings among staff

and faculty users about the

project in general and

momentum for moving the

project forward efficiently.

ImplementationA five-person committee called the CoreTeam (a mix of IT and clinic faculty) wascreated to provide primary leadership ofthe implementation phase of the project.A full-time project coordinator was hiredfrom the software industry to superviseall the phases leading up to implementa-tion and was incorporated into the CoreTeam. Oversight was provided by theSteering Committee, which included thedean of the dental school and variousadministrators. The project had a well-defined budget that could not be increased.As shown in the first sidebar, nine different teams managed the variousactivities of the implementation process,each with an assigned Team Leader.Team membership differed dependingon the tasks assigned to that team.

The 12 months before implementa-tion (July 2008 to July 2009) involved anumber of phases which needed to becarefully managed and for which theproject coordinator was hired. Theyincluded identification of existing pro-cesses, and modification if necessary;identification of software system require-ments; a detailed statement of work that was signed off by appropriateemployees; a description of softwaredesign; configuration/development;

testing in small clinics; and training of allstakeholders. Each phase was assigned atimeline for completion and the CoreTeam was responsible for content andtimeliness. During the identification ofprocesses, it was discovered that each of the 14 clinics had different businessrules, which explains some of the confusion among students who rotatedthrough those clinics. Training was achallenge due to the differences amongusers in tasks they needed to perform inthe system, their experience level withtechnology, and their motivation tolearn. Each group (students, staff, andfaculty) had to be trained differentlybased on those issues.

Implementation of axiUm was scheduled for 13 of the 14 Pacific Dugoniclinics. The Orthodontic program had an existing discipline-specific informa-tion system that functioned adequately. Of the 13 other clinics, ten clinics implemented axiUm in July 2009, one in October 2009, and two more inFebruary 2010. The day before imple-mentation began at each clinic, all datafrom the legacy information system was converted to the new informationsystem. At no time did any clinic runparallel information systems.

ChallengesThere were a number of challenges inthe implementation of axiUm, including: • Resources required (time, effort,

and money)• Behavior changes for all users• Communication• Change management: habit,

tradition, and uncertainty

This was a costly endeavor in termsof time spent, effort expended, andmoney required. It took three years ofsustained preparation before we couldimplement the system. It will probablytake another three years to work out the kinks. All employees had to find

18



ImplementationImplementation teams for Pacific Dugoni’s conversion to an electronic dental record system for its clinics.

Team LeaderTeam Activity Position Team Membership

Training Staff Staff, faculty, students

Student feedback/evaluations Faculty Faculty, students

Hardware/ergonomics Faculty Staff, faculty

Dispensing Faculty Staff

Charting Faculty Staff, faculty

Finance Staff Staff

Inventory Staff Staff

Technology Staff Staff

Patient Services Staff Staff, faculty

time in their already busy days to workon this project. The number of work-force hours expended is measured in thetens of thousands and the project costmillions of dollars just to implement.Additional costs in support and upkeepwill continue indefinitely.

Perhaps the most difficult compo-nent of this project was the behaviorchanges required of all users. We spenthours of time talking with other dentalschools that implemented axiUm andthey all said this would be a large hurdle.They were right. They said the facultywould be the most challenging popula-tion to manage. They were right. It wasrelatively easy (but time consuming) toselect the product, install the hardware,and look at training manuals. It was dif-ficult to get people to change how theyfunction in the everyday tasks attachedto information management. Tasks thatwere especially difficult were financialmanagement of cases, laboratory com-munications, student evaluation andfeedback, and report writing. All of thosecontinue to be resource intensive morethan six months after implementation.

Communication was a challengebecause it required different informa-tion, packaged in different ways, fordifferent stakeholders. Students wereprovided with unique sets of informationbased on their learning and patient careneeds. Staff members were providedinformation based on the specific tasksthey performed in support of clinic oper-ations. Faculty members were providedinformation based on educational andcurriculum needs and patient care.Communication techniques used in thisproject included e-mail, small groupmeetings, large group lectures, telecon-ferencing and videoconferencing,informal hallway “meetings,” hands-ontraining, and training manuals in electronic and paper formats. Regularweekly e-mail updates were sent to stu-dents, intended to answer questions thatcame up during the week. Thousands of

workforce hours were spent in meetingsand communication, and yet we probablydid not communicate enough.

Change is hard and this projectrequired lots of change that directlyimpacted 450 students, 100 staff mem-bers, and 200 faculty members at PacificDugoni. Indirectly, it affected 12,000patients as well. As this project began,people had well established individualhabits, the institution and clinic operationshad many well established traditions,and the requirement to change thosehabits and traditions created uncertainty.That, in turn, impacted people in different ways. Some thrived in thoseconditions and some did not. It wasimportant to figure out who adaptedquickly and who struggled with theuncertainty. Thrivers were allowed tomove forward with support as theydeemed necessary. Strugglers wereactively supported as much as possible.

BenefitsThe benefits of eliminating paper fromour clinic operations were expected torevolve around four general improvements:• Improved patient care• Improved student education• Improved faculty research• Improved staff support

We anticipated that these generalbenefits would be realized through specific improvements, some of whichare listed in the accompanying sidebar.Certain improvements have already beencompleted six months after the cutoverand some are still in progress.

For the anticipated improvementsthat are yet to be fully realized, there is arange of progress. Accountability andcontrols are inherent in the informationsystem setup. User adaptation in exercis-ing these controls remains to becompleted. Records audits have justbegun after extensive reworking of the

19



Progress Toward Project GoalsStatus six months after conversion to an electronic dental record in a dental school context.

Improvement Details Status

No misplaced charts Completed

Charts available to two Completeddifferent people at the same time

No waiting lines at the Completed chartroom window

Readable entries and Completedsignatures

Better accountability In Progressand controls

Easier and more convenient In Progressrecords audits

Improved capacity for In Progresscollaborative research using tools like diagnostic codes

Timely and more In Progresscomprehensive student feedback

More trusted information In Progress

A mature information Completedsystem that required less IT staff resources to modify

Process standardization In Progressacross clinics

All digital clinic information In Progressinstead of a combinationof digital and paper

Common clinic processes In Progress

• Communicate effectively and oftenwith everyone involved in the project,including your family; (they will besucked into its wake, so make surethey see it coming).

• Have clear goals for the project andkeep them in front of you; doing thiswill help you make correct decisionsthat improve important issues.

• Adapt quickly and with conviction.• Navigate uncertainty with under-

standing and clear direction, andlearn how to function with uncer-tainty for an extended period of time.

• Get buy-in early and confirm it often.• Expect slowdowns, problems, and

disappointments. Manage themimmediately and carefully.

• Spend the money necessary to getthe best product for your needs, andspend the time necessary to prepareadequately for implementation.

• Name one leader who will guide the project with support from appropriate sources.

• Obtain help from an experiencedsource and make sure that helpspends time in your practice bothbefore and after implementation.Help can also come from other institutions or practices that use the same product.

• Work together.

ConclusionPaperless information systems are here to stay and will increase in number over time. If you have one already, beprepared to upgrade it periodically. If you do not have one, be prepared tojump in someday soon. Most dentalschool graduates will enter practiceswith a significant amount of technologyexperience from both formal and infor-mal sources. A technology-savvy practicewill attract the best of these graduates.■

20



audit instrument. Research projects arebeing developed within Pacific Dugoniand are anticipated to expand to collabo-rative efforts with other schools. Use of the student feedback instrument isactively progressing in certain clinicaldepartments while others have beenstalled. Trust among users will just taketime as they use the system. Continuedcommunication among faculty usersand IT will ensure report validity andhasten development of trust. Standard-ization of processes requires changes inbehavior among users. Some haveadapted faster than others. A very smallamount of information is still managedon paper, for example patient intake documents (which are completed onpaper, and then scanned into the system) and laboratory prescriptions (which arecompleted on paper and tracked throughaxiUm). Both require additional workbefore we can eliminate their papercomponent. Lab prescriptions have anadditional constraint: the labs are not yet electronic. The creation of commonprocesses across all clinics at PacificDugoni continues to challenge us. Wehave discovered that certain clinicsrequire slightly different processesbecause of the nature of the providers or the patients who receive care there.However, the goal remains that for most activities, the clinics will functionsimilarly, and for that to happen, peoplewill need to change some behavior. Aswith other activities requiring behaviorchange, certain individuals have alreadymade necessary modifications while others have not.

RecommendationsWhile our institution is different fromother organizations, clinics, and privatepractices, there are certain recommenda-tions that are generalizable in consideringconversion to an EHR. The list belowsummarizes the recommendations.

Perhaps the most difficult component of this project was thebehavior changes required of all users.

Bruce Peltier, PhD, MBA; Lola Giusti,DDS; Terry Hoover, DDS; JenniferFountain; Jared Persinger, DDS; andScott Sutter

AbstractPatients sometimes appear for dentalappointments after consuming alcohol ormarijuana. There is presently no consensusstandard of care in this area, and dentistsvary in their responses to such patients.This paper includes interviews with practitioners and a review of the relevantbiochemical and physiological science. The ethics of various ways to handle thischallenging situation are examined, andevidence-based recommendations for dental practice are offered. While there is reason for caution, the authors concludethat a blanket “do not treat” policy isunwarranted. Informed consent and transportation safety issues pose signifi-cant moral challenges when a dentalpatient is “high.”

The Dental Patient Who Is “High”

Ethical and Scientific Recommendations for the Standard of Care

Issues in DentalEthicsAmerican Society for Dental Ethics

Associate EditorsJames T. Rule, DDS, MSDavid T. Ozar, PhD

Editorial BoardMuriel J. Bebeau, PhDPhyllis L. Beemsterboer, RDH, EdDLarry Jenson, DDSAnne Koerber, DDS, PhDDonald E. Patthoff, Jr., DDSBruce N. Peltier, PhD, MBAJos V. M. Welie, MMedS, JD, PhDGary H. Westerman, DDS, MSGerald R. Winslow, PhDPamela Zarkowski, RDH, JD

Correspondence relating to the Issues in Dental Ethics section of theJournal of the American College ofDentists should be addressed to: James Rule8842 High Banks DriveEaston, MD [email protected]

You are about to begin treatmentof a 28-year-old patient when he volunteers the following: “Doc,

I want to be completely honest with you.I don’t know if this really matters, butdental appointments make me verynervous, so I smoked a little weed justbefore I came in. It calms me down.”

The goal of this paper is to begin aconversation that will ultimately shapeand clarify the standard of care in dentalpractice with respect to patients whoappear for appointments after consum-ing alcohol or marijuana. While eventslike the above are not common in den-tistry, they are probably more commonthan most dentists think, and there is little or no consensus about how theyshould be handled.

This examination began with the following assumptions, observations,and hypotheses:

Most, if not all dentists will be con-fronted by patients who present forappointments after drinking alcoholor smoking marijuana. Most peopleexperience mild to moderate fear of dentistry and some patients useone or both of these drugs to self-medicate against anxiety. Somepeople smoke marijuana or drinkalcohol on a daily basis anyway.

Dentists vary significantly in theirresponses to patients who have con-sumed small to moderate amounts of

21


Issues in Dental Ethics

Drs. Peltier, Giusti, and Terry Hoover are faculty members, Dr. Persinger is a graduatestudent, and Jennifer Fountain and ScottSutter are predoctoral students at the Universityof the Pacific, Arthur A. Dugoni School ofDentistry, San Francisco; [email protected] authors wish to thank the staff of theHealth Sciences Library, California PacificMedical Center in San Francisco.

alcohol or marijuana just prior to a treatment appointment. Dentists do nottypically have a rational or scientificbasis for their practice policies in thisarea and typically cannot articulate asound reason for their decisions. Dentalschool curricula do not address theseissues in a direct or systematic way, andmost dentists have not investigated therelevant biochemistry or physiologyinvolved with treatment of people whohave marijuana or alcohol in their system.

This paper will use the term “high”to describe a patient who smoked asmall amount of marijuana or consumeda small amount of alcohol prior to his orher dental appointment (or used both).The term “smoke” or “smoking” refers tomarijuana rather than tobacco.

The SituationThe use and prevalence of alcohol in the United States is well-known andwell-documented. Data from the Centersfor Disease Control and Prevention indi-cate that 61% of adults drank alcohol in2006 and 20% have had five or moredrinks during the same day on at leastone occasion (National Center for HealthStatistics, 2008). Survey data typicallyassert that about 5% of the general population abuses alcohol.

Accurate prevalence data for mari-juana consumption is more difficult toascertain, but it is generally thought that at least 4% of the American publicsmokes it. California has an estimated100,000 users of medi cal marijuana(Okie, 2005), and San Francisco has

more medical cannabis dispensariesthan McDonald’s res taurants (Jouvenal,2005). Marijuana use is not limited toyouthful smokers or any single demo-graphic group. The U.S. Department ofHealth and Human Services recentlyreported that Baby Boomers still gethigh. “Those aged 50 to 59 reporting useof illicit drugs within the past year hasnearly doubled from 5.1% in 2002 to9.4% percent in 2007.” Marijuana is thelargest cash crop in several Americanstates, including California, and the governor of that state recently called fora formal debate about legalization andtaxation of marijuana for recreationaluse (Buchanan, 2009). Marijuana ishere to stay, and trends imply thatincreased marijuana use in the UnitedStates is likely.

These numbers indicate that a met-ropolitan area such as Denver or Atlantamight conservatively include 30,000 people who abuse alcohol or use mari-juana regularly. There are likely to bemore than half a million such people inthe Los Angeles area. Nearly all of thesepeople have teeth. That said, there issimply no way to know how many peo-ple show up for dental appointmentsafter consuming alcohol or marijuana.Many who do so are reluctant to informtheir dentist out of embarrassment, fearof legal ramifications, or a fear that theymight not be treated if they disclosed.Some patients might not think the infor-mation is important, while others maycorrectly discern that their dentist oughtto know. Dentists often feel that they can tell when a patient has consumedmarijuana or alcohol, but this is mostassuredly not always the case.

The issue of legally sanctioned medical marijuana poses an additionalchallenge. In some places, marijuanacan lawfully be obtained and used with a doctor’s recommendation. Some cancer patients use marijuana on a dailybasis as an anti-emetic, and they certainlyneed regular dental care. One can easily

imagine a situation where a patientlegally smokes medical marijuana, fallsdown, avulses a front tooth, and appearsat a dentist’s office for help.

Little formal help or advice is availableto dental practitioners. The respectiveethics codes of the American DentalAssociation and component groups suchas the California Dental Association(2005) make no mention of the issuesdescribed in this paper. One essay by aphysician and a dentist in the Journal of the American Dental Associationeven made the following assertion severalyears ago (McCarthy & Hayden, 1978):“Alcohol is an effective mild sedative fordental therapy when used in suggesteddosage, and its use is encouraged.”

It is unlikely that state dental practiceacts address this issue. Dental school curricula typically do not cover thesechallenges in any formal or structuredway. Dental students report that facultymembers give varying and sometimesstrident and conflicting counsel. In short,there is currently no consistent or coher-ent standard of care regarding treatingpatients who present for treatment andare high on alcohol or marijuana.

This analysis consists of four parts.The first section is a small, informalqualitative inquiry of dentists that servesto establish baseline information abouttypical practitioner thinking and behavior.In the second part, the available scienceis examined. A third section explorespractical and ethical issues, and the finalsection offers recommendations for astandard of care in this area.

A Survey: What Dentists Say About Patients Who Are highMethods: After IRB approval, 24 dentalpractitioners were interviewed anony-mously in the autumn of 2008 using theprotocol posted at the end of this paper.A small convenience sample was used,

22



and the interviewees included ten dentists in private practice, five dentalschool faculty members, and three students. Two of the faculty membersare oral surgeons, and one other is a recognized expert in dental anesthesia.Interviewees practiced or taught inNorthern California or Northern Arizona.Students were from the University of thePacific. Some dentists had been practicingfor more than 30 years, while othersfewer than ten. They were asked a seriesof questions (face to face or telephon-ically) related to patients who presentfor treatment after smoking marijuanaor drinking alcohol.

Results: Virtually all intervieweesagreed that they would not treat anuncooperative or belligerent patient. Ifmarijuana or alcohol consumption resultedin a patient’s inability to participate competently in the dental appointmentfrom a behavioral or psychosocial pointof view, all would decline to treat thepatient. Some of the interviewees wouldoffer to reappoint patients.

Most of the interviewees expressedconcern about transportation problems.How would this person get home? Wouldthey drive and would they be safe?Would the dentist incur liability?

Some wondered about informed consent. Would a patient who consumeda small amount of an intoxicant be capable of granting real consent? Wouldthey understand the information providedby the dentist? Would their consent beauthentic and complete? Most concededthat it would be impossible to make anaccurate assessment of these questions,and no one had a clear answer abouthow to resolve this challenge.

Beyond those issues there was littleconsensus. Several dentists said that they simply would not attempt to treatsomeone who consumed alcohol or marijuana prior to an appointment. Oneyounger dentist asserted that, “It is myethical responsibility not to treat anyone

that I suspect is under the influence ofdrugs.” That dentist also said, “I woulddismiss the patient by saying that ethi-cally I am not able to treat patientsunder the influence of alcohol.” Anotheryoung dentist responded to the questionabout a patient who has smoked mari-juana by simply stating, “Treat thepatient.” One experienced oral surgeonstated that, “If I have a patient with prior informed consent and a simple,straightforward procedure involvinglocal anesthesia only, and I find outabout recent intake of alcohol or use of marijuana and the patient is fullycompliant, I have no concerns over completing the treatment.”

Others would treat a cooperativepatient who had used marijuana “legally”(with a medical recommendation), butwould not treat a patient who was usingmarijuana illegally. Several thought itwould be a good idea to verify the physi-cian’s recommendation and documentthis action. Some said that they wouldnot treat a patient if the procedurewould require an injection, and nearlyall were extremely wary of the use of IVsedation under these circumstances.

A number of the dentists reportedthat they would decline to treat patientswho were high and would explain theirdecision to the patient, yet none of theinterviewees were clear about the bio-chemistry involved in treating patientswho were drinking or high. While oneoral surgeon was concerned about bloodpressure and heart rate, none of theinterviewees offered a clear, logical, orscientific rationale for their treatmentdecision. They seemed to possess avague sense that treatment of such apatient might be contraindicated, butthey could not describe the biochemistrythat might justify such a decision. Most

23



It appears that a

blanket non-treatment

policy is not supported

by available science

or ethical analysis.

wondered about the interaction betweenmarijuana, alcohol, and anesthetics, andseveral speculated that it is more difficult to achieve adequateanesthesia when someone has used“drugs.” Some felt that alcohol or marijuana might “give false readings forblood pressure and pulse.” One reportedthat he did not know much about thebiochemistry and said, “I don’t have a lot of experience with marijuana and all I know is it makes the calculus a different color.” One dentist observedthat “usually people who are drunk areunruly and combative.”

Several of the dentists took a defen-sive stance and were wary of personal or professional “trouble.” If somethingwent wrong, the patient could claim thathe or she did not understand or giveconsent. “Do you want to mess with thissort of problem?” one wondered.Another noted that, “if anything goeswrong…they can come back to you andsay they didn’t know what was goingon…. So you would be screwed.” Onesaid that “Dentistry is hard enough; youdon’t want to deal with another element.”Others were concerned for their ownsafety and any associated risks to thedoctor and staff. One said that he would“throw him out of the office. I can’t putmy staff or other patients in harm’s wayor be treated disrespectfully.” One saidthat if a patient (who seemed high)denied use of marijuana, “then I wouldhave him sign something saying he hasn’t used anything and treat him.”One would decline to treat a person who had gotten high and after a secondsuch incident would discharge thepatient and carefully document the discharge. One said, “You just give themthe office policy. Just say that to becomea patient of this office, you have to besober, and that if we even suspect thatyou are not sober, we will not work on you because we need a safe workenvironment.” Another said, “You don’t

have to work on people that you don’twant to. Refer to a specialist or anotherdentist.” (Is there a specialty for dentistswho treat patients who are “high?”) One said, “It is my choice, and alwaysmy choice if I treat a patient. It is not thepatient’s choice.” Several used the phrase“kick them out of the office.”

Dental students reported that theydid not know the biochemistry involved,but felt able to rely on faculty wisdom toback them up in clinic. They expressedthe same kinds of concerns as youngerpracticing dentists did, and one offered“I don’t want him leaving my office andhitting a skateboarder.”

Several older dentists divulged vagueanecdotes about dentists who had acourtesy bar in the reception area, dentists who allowed patients to smokemarijuana in the dental office or bath-room, and practitioners who hadrecommended a shot of brandy (for thepatient) before a difficult procedure.

The ScienceAn extensive review of the scientific literature was conducted with a focus onthe following questions:

1. What is the short-term impact ofsmall amounts of alcohol on thebody, and what are the implicationsfor dental practice?

2. What is the short-term impact ofsmall amounts of marijuana on thebody, and what are the implicationsfor dental practice?

3. How do these two drugs affect theprocess of dental anesthesia? Arethere important drug interactionsthat dentists should consider?

4. What physiological or practical dangers does ingestion of alcohol ormarijuana pose to patients in thedental chair?

24



Dental school curricula do not address theseissues in a direct or systematic way, and most dentists have notinvestigated the relevantbiochemistry or physiologyinvolved with treatment of people who have marijuana or alcohol intheir system.

While this review focused on short-term effects of small amounts of thesetwo drugs, most reports in the chemistryand physiology literature quickly shiftfocus to the dangers of long-term, heavyuse or abuse of these drugs. There is precious little in the literature about thescience of situational use of drugs andalcohol in dentistry and medicine.

Alcohol and Dental Care

Alcohol is a central nervous systemdepressant that affects all organ systems.The long-term impact of heavy, chronicuse is well-established and includes prolonged bleeding time and excessivebleeding, hypertension, poor woundhealing, higher infection risk, greaterlikelihood of developing periodontitisand subsequent tooth loss, reduction insalivary flow and buffering capacity,greater risk of oral cancers, worseningof age-related diseases, poor nutritionwith glossitis, angular cheilosis, and gingivitis, nutritional deficits, cardiovas-cular disease, liver cirrhosis, pancreatitis,cognitive losses along with inappropriatesocial behavior, problems in judgment,and traumatic injuries resulting fromfalls or fights. A compromised liver cannot metabolize drugs adequately,resulting in elevated concentrations ofmedicines such as acetaminophen, erythrocin, tetracycline, ketoconazole,phenobarbital, secobarbital, diazepam,lorazepam, chloral hydrate, and opioids.These and other long-term implicationsare well-described in Friedlander,Marder, Pisegna, & Yagiela (2003).

The problems associated with con-sumption of a small amount of alcoholare somewhat more complex. Whilemuch is unclear about low to moderatedoses of alcohol, the following effects aregenerally accepted in scientific literature:• Alcohol’s action as a positive

allosteric modulator of GABA(Gamma-Aminobutyric Acid) causesrelaxation, relief from anxiety, seda-tion, ataxia, disinhibition, and an

increase in appetite (Mehta & Ticku,1988; Wallner, Hanchar, & Olsen,2006)

• The release of endogenous opioidpeptides (endorphins andenkephalins) results in feelings ofpleasure (Friedlander et al., 2003;Froelich, Badia-Elder, Zink,McCullough & Portoghese, 1998)

• Drying of the mouth (which mightactually be helpful in some dentaltreatments)

• Synergistic or additive effects withCNS depressant medication

• Impairment of coordination• Cognitive difficulties, including

diminished ability to focus attentionand diminished executive function,planning and problem-solving capacity

• Lowered social inhibition, alteredjudgment

• Harmful impact on cardiovasculardisease and possible adverse interac-tions with the medications used totreat these problems

• Mild sedation, resulting from a small to moderate amount of pre-appointment consumption of alcoholthat may actually benefit a patient(McCarthy & Hayden, 1978, p. 285)

• A variety of clinical effects followingtwo glasses of red wine, includingincreases in sympathetic nerve activi-ty, heart rate, pumped blood volume,and blunted ability of the brachialartery to expand in response toblood flow (Spaak et al, 2008)

• Problematic interactions with the following medications used in dentistry (Friedlander, et al, 2003):1. Cephalosporins and metronida-

zole: possible accumulation ofacetaldehyde with headache, palpitation, and nausea

2. Erythromycin: decreased absorp-tion and diminished effectiveness

3. Tetracycline: increased absorptionand plasma concentration inhealthy subjects

4. Penicillins: possible decreasedefficacy

5. Ketonconazole (anti-fungal): possible accumulation ofacetaldehyde with headache, palpitation, and nausea

6. Barbiturates and benzodiazepines:enhanced (and potentially dan-gerous) CNS depressant effect

7. Chloral hydrate: significantincrease in CNS depressant effect

8. Opioids: marked increase in sedative side effects

Alcohol affects people quite variably.Some people are nearly incapacitated bytwo drinks, while others seem unaffectedby several. Many chronic drinkers canfunction rather well after consumingone or two drinks, and observers areoften unaware that such a person hasbeen drinking at all. Some peoplebecome combative when drinking, whileothers get happy and sedated. Somebecome more talkative and others morequiet. Alcohol puts some people to sleepand agitates others. The effects of drink-ing can also vary from day to day in thesame person, resulting in little impair-ment on one day and significantly moreimpairment on another. Low doses ofethanol are likely to have a greaterimpact on the aged.

Self-report of drinking behavior isalso problematic. People often do notaccurately assess or report their drink-ing, either for lack of memory or socialembarrassment. The very definition of a

25



“drink” is variable from person to person,even though there is substantial agree-ment in scientific and law-enforcementcircles that one drink is defined as .5–.6ounces of ethanol or 1.5 ounces of 80proof (40%) liquor or 5 ounces of wine(11-14%) or 12 ounces of 5% beer. While scientists agree on a definition of a “drink,” one never knows what consumers really mean when theyreport that they had “a drink or two.”

Marijuana and Dental Care

Like most drugs, marijuana poses acuteand chronic risks to the oral health andoverall physical health of the consumer.While long-term effects of heavy chronicuse have been studied (National Institutesof Health, 2009), there is little of substanceto be found in the scientific literatureabout safe dental treatment of a patientwho is high.

Research in this area is extremelychallenging. First, it would be difficult, ifethical, to conduct experimental studiesthat would generate information ofdefinitive value. Subjects cannot berequired to smoke marijuana in order tosee if dental anesthesia or proceduresare harmful. We are therefore resignedto animal studies and the use of lesspowerful correlation methods and anec-dotal self-report. Second, it is difficult toquantify marijuana dosage, since densityand type of cannabin is so variable inthe weed smoked by consumers. Mostlaboratory research uses pure THC(tetrahydrocannabinol) which is quitelikely to contain chemicals differentfrom those found in typical marijuanajoints, resulting in differing effects andoutcomes, along with challenges toexternal validity (Jones, 2002; Amar,2006; Bornheim & Grillo, 1998). Finally,since marijuana use is typically illegal

and considered by many to be antisocial,consumers are understandably reticentto be open or honest about its use.

A review of the literature reveals that marijuana has been shown to havethe following general effects on its users (Gregg et al, 1976; Nguyen, 2004;Horowitz & Nersasian, 1978; Hernandez,Birnbach, & Van Zundert, 2005; Cho,Hirsch & Johnstone, 2005; Beaconsfield,1974; Jones, 2002). In that much isunknown about how marijuana affectsthe human body; the following list ofeffects is not complete or definitive:• Short-term memory impairment• Sympathomimetic activity concomi-

tant with parasympatholytic activity(both act to increase heart rate withincreased output at low to moderatedosages)

• High doses can have the oppositeeffect, inhibiting sympathetic but notparasympathetic activity, resulting inpossible hypotension and bradycardia

• Acute anxiety/panic attack• Analgesic effects• Drying of the mouth (which might

actually be helpful in some dentaltreatments)

• Widespread vasodilation (as much as 50%) and subsequent increase inheart rate to maintain blood pressure(reflex tachycardia) of 20% to 100%starting in the first 10 minutes aftersmoking and lasting several hours

• Increased oxygen consumption—upto 30% (Nguyen, 2004)

• Possible inhibition or metabolic alteration of many other drugs(Bornheim & Grillo, 1998)

• Patients have delayed reporting ofangina due to the analgesic effect ofmarijuana (Cho, Hirsch, &Johnstone, 2005)

• Euphoria and dysphoria• Mild sedation and relief of mild anxiety

(potentially helpful in dental care)• Mood-intensification (marijuana is

not a pure CNS excitant, euphoriant,or depressant)

• Paranoid or manic states, confusion,disorientation, even hallucinationswith some users

• Impaired thinking and judgment• Athymhormia (loss of motivation or

initiative)

Precious little research has focusedspecifically on marijuana and the dentalexperience, and most of that was donein the 1970s. The literature consists ofscattered case reports and informedanecdotes describing potential pitfalls.Here is an overview of what researchand case reports have to say aboutpotential problems when a dentalpatient has smoked marijuana.

The most widely reported concern is dose-related tachycardia (Gregg et al,1976).

Transient hypotension has beenreported (Gregg et al, 1976). Evidencerelated to induction of arrhythmia isconflicting. Some studies imply the possibility, while others were unable tofind such evidence (Gregg et al, 1976;Nguyen, 2004; Jones, 2002). A possiblerisk of ischemic problems secondary to vasodilation and elevated heart ratehas been reported (Nguyen, 2004; Cho,Hirsch, & Johnstone, 2005).

The most important effect of CBD(cannabidiol) is that it interferes withdrug metabolism by inactivating thehepatic cytochrome P450, responsiblefor metabolizing more than 60% of clinically prescribed drugs, includinglidocaine, macrolide antibiotics, antide-pressants, antihistamines, benzodia-zepines, and others (Bill, Clayman,Morgan, & Gampper, 2004; Bornheim &Grillo, 1998). The clinical significance isthat the concentration of drugs in thesystem can rise to hepatotoxic levels ifP450 is inactivated. Interactions withdrugs that dentists prescribe might includeanticholinergic/parasympatholyticagents (e.g., atropine) used to control

26



salivation. This process can exacerbatetachycardia and hypertension (anti-cholinergics already increase heart rate),while opioids may produce mutualpotentiation of effects (Seamon, Fass,Maniscalco-Feichtl, & Abu-Shraie, 2007).

Marijuana has properties that canpotentiate immunosuppression from systemic corticosteroids which couldslow healing or risk infection (Seamonet al, 2007).

Darling & Arendorf (1992) observedthat “oral surgical procedures on subjectsintoxicated with cannabis may result inacute anxiety, dysphoria, and psychotic-like paranoiac thoughts—all intensifiedby the stress of surgery.” The effectsinclude upper-airway irritability, chroniccough, bronchitis, emphysema, broncho-spasm (Hernandez, Birnbach, & VanZundert, 2005).

The actual interaction between THC and dental anesthetics is not wellunderstood. Studies reveal a complexinteraction between the physical andpsychosocial stress of procedures, epinephrine, and THC. An analysis ofresearch on the impact of THC and epinephrine on dental patients is franklyinconclusive. It is difficult to attributethe tachycardia documented in studiesby Horowitz and Nersasian (1978) andGregg and others (1976) to either a stress response or a strict drug-druginteraction. Nguyen summed up the situation in her 2004 paper, concludingthat “the interaction between anesthesiaand the use of cannabis is still poorly documented.” (p. 5).

Several studies revealed that mari-juana is not an ideal dental medicationby itself, either for pain relief or anxiety.In one oral surgery study, ten subjectsgiven diazepam, THC, or placebo ratedhigh-dose marijuana as the worst pre-medication, associating it with the mostpain. Those receiving marijuana alsohad higher anxiety inventory scores(Gregg et al, 1976).

Treatment Considerations Basedupon Available Science

When a patient reports that he or shehas “had a drink,” one can never be certain about what this statement reallymeans. For some people, one drink canmean a large tumbler of vodka. It is alsoimpossible to determine reliably fromreports of today’s use of alcohol whatthe history of long-term use might be.Most serious drinkers minimize theirreports. A dentist inclined to treat such aperson should make explicit inquiriesabout the amount consumed and historyof consumption (and any other drugstaken at the time), should explain relevant dangers, and should offer toreappoint that patient. This interactionis best conducted in a way that does notunnecessarily embarrass patients andmight include assurances of confiden-tiality, as appropriate.

Complex procedures that involvesedation should probably be postponed,as the possibility of a dangerous drug-drug interaction is real. There are knownsynergistic effects when alcohol and central nervous system depressants com-bine. Dentists should review medications (listed earlier in this paper) known tointeract with ethanol, discuss possibleinteractions with patients, and prescribeappropriately. Patient cardiac historyshould be given special considerationwith a drinking patient, as alcohol can have an adverse impact on cardiacfunctioning and can result in adverseinteractions with cardiac medication.

As with alcohol, it is virtually impos-sible for a dentist to discern how muchTHC is present in a patient’s body.Patients do not even know the answer to this question, as the ingredients inmarijuana joints vary wildly. Since THC

27



There is currently no

consistent or coherent

standard of care regarding

treating patients who

present for treatment

and are “high” on

alcohol or marijuana.

metabolites remain in the system forextended periods of time, a dentist neverreally knows if he or she is treating apatient with some THC on board. Thereis a recommendation in the literature(Horowitz & Nersasian, 1978) thatpatients abstain from marijuana for oneweek prior to a dental appointment, butthe science supporting such a recom-mendation is insubstantial.

Patient cardiac history should receivespecial consideration with a patient who uses marijuana given the risk ofischemia, myocardial infarction, or TIAin susceptible patients.

When treating someone who usesmarijuana, consider avoiding epinephrine-containing local anesthetics or use as little epinephrine as possible to achieveadequate anesthesia if immediate treat-ment is essential and effective localanesthesia of sufficient duration cannotbe achieved otherwise. Since local anes-thesia with epinephrine works longerand better, a patient may experiencemore discomfort when using local anesthesia without epinephrine andthereby induce a significantly greaterendogenous production of just that: epinephrine. Planned pharmacosedativeappointments should be rescheduled dueto risk of synergistic effects of marijuanaand sedatives leading to excessive CNSdepression. Before injecting local anes-thesia, aspirate well to minimize directvascular injections and the possibility of excessive tachycardia. If possible,avoid IV sedation and especially generalanesthesia for at least three days followingmarijuana consumption, due to airwayand postoperative heart rate concerns.Airway obstruction and oxygenationissues lead to a preference of local anesthesia over general anesthesia.

Never prescribe atropine or otherparasympatholytics to a patient who hasrecently used marijuana. Warn patientsagainst risk of combining opiates or ben-zodiazepines with marijuana, especiallyif they are to drive an automobile.Consider reappointment if patient’sheart rate is elevated or if the patientseems groggy or heavily “stoned.”Dentists need to make an independentdecision about whether to treat someonewho shows behavioral signs of intoxica-tion or incapacity to effectively participatein care. It is recommended not to treat apatient who prefers to take a break toconsume more marijuana (during theappointment). This patient must becounseled about excessive use, depend-ence, and available addiction treatment.

Ethical IssuesThe scenario of greatest interest in thispaper is the one where such a patient is mildly high and completely coopera-tive. Issues will be examined using aprinciple-based approach, a utilitarianmodel which weighs competing interests,and Ozar and Sokol’s (1994) “central values” method.

The Principle Based Approach

In this view, bioethical normative principles are accessed as a guide toright behavior.

Nonmaleficence: The AmericanDental Association’s Principles of Ethicsand Code of Professional Conductstates that, “This principle expresses theconcept that professionals have a duty toprotect the patient from harm.” It seemsclear that if treatment of someone who ishigh poses any physical or psychologicaldanger to that patient, it would be wrongto treat. Such harm might also derivefrom a patient’s inability to recall postoperative instructions, althoughpractitioners could follow up in suchcases. Harm could also come from post-treatment transportation danger shoulda patient attempt to drive a car.28



They seemed to possess a vague sense that treatment of such a patientmight be contraindicated,but they could notdescribe the biochemistrythat might justify such a decision.

Beneficence: Dentists strive to dopositive good for patients. This matterbecomes complicated when a dentistcould do good by treating a patient whoneeds treatment, but also does not wishto harm that patient. A clear moraldilemma occurs (when two principlesconflict) when a high patient falls,knocks out a tooth, and then rushes tothe dentist for help. A similar, more likely scenario is the case of the chronic,daily user of alcohol or marijuana whoneeds serious dental care. Must such apatient resolve his or her addictionbefore receiving dental care? Shouldaddicts be excluded from dental treatmententirely? It must be noted that it is unrealistic to ask many addicts to refrainfrom substance use for even short periodsof time, and that people diagnosed withalcoholism (“alcohol dependence”) oftenmeet criteria for impairment under theAmericans with Disabilities Act. Thisdoes not imply, however, that dentistsmust always treat patients who haveconsumed alcohol or marijuana justprior to treatment. Beneficent action inthis case may involve a referral to anaddiction resource.

Justice: This is the “fairness” princi-ple, and it advocates that people betreated equally; that each receives his orher “fair share.” On a practical level thisprinciple requires equitable distributionof treatment resources. Some parties arenot arbitrarily favored over others, andthe criteria for any uneven resource allo-cation must be transparent, reasonable,and relevant. In the current analysis itseems unfair to decline to provide treat-ment to people on the basis of personalhabits (if those personal habits do notconflict with treatments for clinical reasons). It also seems wrong to refusetreatment to a patient because they suffer from an addiction.

Veracity: This principle insists ontruth-telling. Obviously, the optimalpatient-dentist relationship is character-ized by honesty. However, if it isunrealistic to insist that addicts refrainfrom use, and dentists make it clear (assome did in their interviews) that theywill categorically refuse to treat someonewho is “high,” then lying certainlyseems like an attractive option to anaddict with a toothache (or periodontaldisease or other serious dental problems).On the other hand, are dentists beingcompletely truthful when they tellpatients that they refuse to treat thembecause of concerns for that patient’swelfare if the dentist does not actuallyknow the related biochemistry and thereality of physiological danger? It seemsmore honest to tell patients that the biochemistry is unclear, that the dentistis uncomfortable with the ambiguityand chooses to err on the side of safety.This insight may establish a foundationfor effective communication and openthe door to a conversation that aims tosolve the problem in a practical way.

Autonomy: Both parties—dentistsand patients—possess autonomy, theright and duty to self-govern. Patientscan certainly choose to show up high for a dental appointment, but they have no right to be treated under thosecircumstances. Such a right would implythat dentists have a duty to treat them.Obviously dentists may also choose toexercise professional autonomy anddecline to treat. In fact, if dentists havegood reason to believe that it would bedangerous or wrong to treat a highpatient, they have a duty to decline.

The principle of autonomy forms thebasis for informed consent, as patientscan only consent when they are makingan informed decision. A patient must beable to participate in treatment decisions—not just at the beginning of treatment—but on an ongoing basis. As there is noway to assess the level of comprehension

of a high patient, it is reasonable if notimperative to question the ability of sucha patient to comprehend, remember, andparticipate adequately.

The Utilitarian or Values Maximizing Approach

This method compares the interests ofvarious relevant parties, along withpotential harm and benefits to those parties. The parties include patients,dentists, dental team members, and anyone else who might benefit or beharmed. In this analysis, the term “interest” is used synonymously with the concept of a “stake” or share in theoutcome. Interests, in this usage, arealways self-interests.

Patient interests: Patients have the following interests related to thequestions at hand: • Getting adequate dental care, espe-

cially in emergency situations• Experiencing comfortable dental

appointments and treatments• Receiving treatment that is safe; not

being subjected to harm or danger• Maintaining dignity and self-esteem• Being informed of risks and benefits

so they can take responsibility fortheir oral health

Dentist interests: Dentists have thefollowing interests:• Maintaining a viable private practice

and going concern• Maintaining their dental license

avoiding lawsuits• Feeling comfortable in their practice

decisions and treatments

Staff interests: Members of the dental team have the following interests:• Working in a safe and interpersonally

comfortable environment (whichmay include training for difficultpatient interactions)

29



If, in fact, there is little physiologicaldanger, then the patient’s interest inexperiencing adequate dental care in a comfortable way seems to clearlyoutweigh the dentist’s concerns aboutdanger to the practice, avoiding lawsuits,and comfort in his or her decisions.

If a dentist is uncomfortable treatinga patient only because that person isunlawfully consuming a substance thatis illegal, would not that also mean thatsuch a dentist should refuse to treat taxcheaters or patients who cheat on theirspouses? Should dentists refuse to treatall people who do illegal things? If dentists are uncomfortable treatingaddicts per se, shouldn’t they also beuncomfortable providing dental treatmentto tobacco addicts or even to compulsivegamblers? If dentists are unwilling totreat addicts, how will addicts get dentalcare? Are they to be excluded from dental care?

The Central Values Method

This third model of decision-makinginvolves a hierarchy described in Ozarand Sokol’s 1994 book Dental Ethics atChairside. Ozar and Sokol assert thatevery profession has a small number ofessential, defining values. These valuesare ranked in a hierarchy and must behonored in the order they are ranked. Alower-ranked value cannot take prece-dence over a higher one. The centralvalues of dentistry, according to Ozarand Sokol, ranked from most importantto least, are:1. The patient’s life and general health2. The patient’s oral health3. The patient’s autonomy4. The dentist’s preferred patterns of

practice5. Esthetic values6. Efficiency in use of resources

This hierarchy highlights the importance of accurate scientific infor-mation about danger. If consumingsmall amounts of alcohol or marijuanaendanger a dental patient, that patientshould not be treated, or the situationmust be managed in a way that is notunsafe. A patient’s life and generalhealth trump all other values.

If, on the other hand, marijuana oralcohol does not endanger a patient, thenext value on the hierarchy must behonored, and that is the patient’s oralhealth. This model insists that a patient’soral health takes priority over a dentist’spreferred pattern of practice. This meansthat, absent physiological danger, dentisthave an obligation to treat patients ofrecord who are “high,” assuming thatthey are cooperative and able to partici-pate. Indeed, this model even impliesthat a patient’s choice to get high priorto a dental appointment (assumingphysical safety and ability to adequatelyparticipate) also trumps a dentist’s prac-tice preferences. These ideas obviouslyconflict with the widely held belief ofdentists that they have a more or lessabsolute right to treat whomever theyplease and to decline to treat patientswhenever they choose to do so. In fact,the ADA’s Principles of Ethics and Code of Professional Conduct asserts in section 4.A. (“Patient Selection”) that dentists “may exercise reasonablediscretion in selecting patients for theirpractices.” Once a person becomes a“patient of record” in a practice, how-ever, that practice has certain treatmentobligations.

Given that the highest ranking valueis the patient’s life and general health, itseems that dentists have an obligation to assess for addiction and to attempt toinfluence or refer patients (for addictiontreatment) who simply cannot show upfor a dental appointment without gettinghigh. It would be unethical to sidestepthis issue completely.

If patient autonomy is to be honored,patients must be capable of making rea-soned, informed decisions about theirtreatment. This is problematic for thepatient who is high because informedconsent is an ongoing process and not a one-time event at the beginning of treatment or even the beginning of thetreatment appointment. Changes thatoccur during treatment sometimesrequire new decisions.

In addition, Ozar and Sokol’s hier-archy, as well as the ADA Code (dentistsare “obliged to make reasonable arrange-ments for emergency care”) clearly implythat dentists cannot simply “dismiss” apatient of record who presents with adental emergency but is high. With suchpatients the question of what constitutes“reasonable arrangements” becomessomewhat complex and important.

Recommendations for a Standardof Care with CommentaryIt appears that a blanket non-treatmentpolicy is not supported by available science or ethical analysis. Patientsshould be considered on a case-by-casebasis, with special attention to medicalor dental conditions that could put ahigh patient at special risk, along with informed consent challenges andtransportation issues.

In addition to this general conclu-sion we propose the followingrecommendations for development of astandard of care.1. Dentist’s Point of View:

Practitioners should examine theirattitudes toward alcohol and mari-juana use (and addiction in general)and decide whether negative moralattitudes have an appropriate role intreatment decisions. It must be notedthat Ozar and Sokol’s Central ValuesHierarchy places a patient’s general

30



and oral health (as well as patientautonomy) above the dentist’s preferred practice patterns. On thisbasis, it is unethical to assert thataddicts and those who show up for an appointment high should categorically be denied dental care.

2. Professional Autonomy: Despite the assertion above, there is no legalor ethical requirement that dentists provide treatment to a patient whopresents with marijuana or alcoholin their physical system. Similarly,there is little reason to attempt totreat someone who is uncooperativeor surly. However, our review of thebiochemical and physiology litera-ture allows a case to be made thatdentists should consider treatingsomeone who consumed alcohol ormarijuana prior to a dental appoint-ment. This assumes that such apatient is completely cooperative andable to participate in care. There are,nonetheless, significant challenges to this assertion.

3. Informed Consent: This may be themost challenging ethical aspect ofall. Persons whose cognitive capacityis impaired cannot give real consent,as they are unlikely to fully under-stand the situation and may not becapable of prudent judgment.Dentists are not trained in assess-ment of cognitive capacity, nor arethey expected to be expert in thisarea. How are they to determinewhether a patient is capable ofunderstanding and consenting? Thisproblem could be ameliorated tosome extent by discussions at a timewhen the patient is not impaired,combined with written or videoinformation that a patient couldstudy at home. The more significantchallenge, however, derives from thefact that informed consent is not aone-time event that only occurs prior to the onset of treatment. The

informing and consenting process iscontinuous throughout treatment, as new decisions are often madealong the way. One might note that a patient who is sedated cannoteffectively participate in this processno matter what drug was used toproduce sedation. In any case, anticipation of treatment changes or options is important at the onsetof care (e.g., when treating extensiveor deep carious lesions).

The matter of capacity to understandpostoperative instructions is alsochallenging, although this can beameliorated to some extent withclear written instructions and a sub-sequent telephone call. Oral surgeonsoften send groggy patients homeafter IV sedation, typically accompa-nied by a competent companion.

4. Transportation: Dental practitionersmust decide whether to participatein a patient’s decision to drive homefrom an appointment. Again, thisdecision depends upon the dentalstaff’s ability to make a sophisticateddecision about cognitive and psy-chomotor competence. But there is alot at stake in this decision, and it isa decision that must be made even if a dentist decides not to treat apatient they believe to be impaired. It seems immoral to send a patienthome in their automobile aftertelling them that they will not betreated because they have smokedmarijuana or drunk alcohol. Anotherchallenging situation arises when apatient refuses assistance and insistson driving a car after being told they could not be treated. Do you call the police?

31



Practitioners should

examine their attitudes

toward alcohol and

marijuana use (and

addiction in general) and

decide whether negative

moral attitudes have

an appropriate role in

treatment decisions.

5. Assessment of the Patient: Patientsshould be queried about the quantityand time of consumption prior to an appointment. This discussion will be easier when the practitionerviews alcohol and marijuana from amedical-dental point of view ratherthan as a moral shortcoming, and itis essential that practitioners educatepatients about the confidentialnature of the doctor-patient relation-ship. Practitioners should alwaysconsider the possibility that patientsunderreport the amount of alcoholor drugs consumed. Patients aremuch more likely to be honest andforthcoming about their use of marijuana if they possess an accurateperception of how the informationwill be used by their dentist. (Somepatients will be concerned that theirdentist might call law enforcementshould they disclose illegal marijuanause.) Such a discussion can helppractitioners make the determinationbetween small or moderate use versus high levels of consumption.Dentists should also query thepatient about the possibility of othermedications taken prior to theappointment. The most significantrisk of the high patient has to dowith the combined effect of alcoholand CNS depressants along with thecomplex effects of alcohol on theliver’s ability to metabolize medica-tions. Other medications combinedwith ethanol (prescribed or not—especially CNS depressants) haveadditive or synergetic effects. Theseadditive effects can be unpredictable.

Dentists must also obtain and maintain an accurate health history for all patients. Cardiac andblood pressure issues are of specialimportance in dealing with thedrinking or smoking patient.Obviously, a patient’s report of

32



Appendix: Interview Protocol

A. Hand your subjects the list of clinical scenarios (below) and ask them toread them.

B. Here are some suggested questions and triggers for discussion:

1. Pick one of the scenarios on the list and tell me how you would handle it in clinical practice.

2. What were you taught about such situations in dental school or afterwards?

3. Do you think that there are medical-physiological aspects that must be considered?

4. Do you think that your colleagues would treat such situations in the same way that you would?

5. What do you think is the standard of care in such situations?

6. Under what circumstances would you turn a patient away or refuse to treat them (relative to the scenarios on the sheet)?

7. Do you know if there are laws that must be considered in these scenarios?

C. Clinical Scenarios

1. Have you ever treated a patient who showed up for the dental appointment after having consumed alcohol or smoked marijuana or taken any other drug, prescribed or not? If so, what did you do?

2. What were you taught in dental school about this problem or issue?

3. What do you think is the standard of care in this situation?

4. Can you think of any biological or pharmacological issues that need to be considered?

5. Can you imagine any behavioral issues that might be involved?

6. What would you do if a patient showed up for an appointment nextweek and they smelled of alcohol or marijuana or told you that they had used those drugs before they showed up at your office? Do you have a policy or protocol?

alcohol or marijuana consumptionshould be noted in the clinicalrecord, and it seems fair to alertpatients of that documentation.

Dentists and other dental practitioners are not the only partieswith ethical duties. It should also benoted that the role of dental patientinvolves certain well-acceptedresponsibilities. Most practitionersand patients would agree that patientshave a duty to show up for appoint-ments ready, willing, and able tocompetently and safely participate,although this duty is certainly miti-gated from time to time by medicalemergency or cognitive incapacity.

6. Clear Policy: Practitioners, clinics,and dental schools should considerwritten policies that urge patients to disclose the use of prescriptionand recreational drugs (explicitlymentioning alcohol and marijuanaalong with accurate assurances ofconfidentiality). The policy should bediscussed with all patients early inthe treatment relationship. Writtenstatements should be crafted carefullyso that they do not discourage addicted patients from seeking dentalcare, especially since addictive druguse often damages gums and dentition.

7. Monitoring Vital Signs: As a generalpractice, dentists should monitorblood pressure and pulse rate regu-larly. Do this more frequently withknown users of marijuana, alcohol,or other drugs.

8. Older Patients: Special attentionmust be paid to older patients sincesmaller amounts of alcohol can havea more deleterious effect. Aged peopleoften take numerous prescriptionmedications, and it is difficult toknow how alcohol and other drugswill interact, especially in relation toage-related conditions such as cardio-

vascular disease, strokes, and themedications used to treat them. Notealso that older patients sometimessmoke marijuana.

9. Enhanced Dental Education: Thebiochemistry, physiology, and ethicsrelated to treatment of patients whouse alcohol or marijuana should be taught explicitly in the dentalschool curriculum. Clear, scientificexplanations should be provided.Where science is inadequate, studentsshould be told as much. Dental students should not simply be told“do not treat these patients.”

10. Development of Protocols:Ongoing professional discussion ofthese topics is required in order todevelop clearer treatment protocolsfor dentistry. A coherent, science-based consensus standard of care inthis area is much needed.

11. Knowing What to Say: And finally,how should one respond to that high patient? Here are two possibleresponses to the patient’s commentat the beginning of this report:

A. If the dentist decides not to treatthis high patient:“Thank you, Mr. Patient, for lettingme know. You’re right, that isimportant information. While thescience isn’t conclusive about thematter, I don’t believe it’s a goodidea to treat someone who ishigh. Let’s see if we can worktogether to schedule appointmentswhen you do not have marijuanaor alcohol in your system. If youwill be unable to come to dentalappointments without smokingmarijuana I will not be able toprovide your dental care. I wantto make sure that your treatmentis as safe as absolutely possible.What do you think?”

B. If the dentist decides to treat this patient:“Thank you, Mr. Patient, for lettingme know. You’re right, that isimportant information. If it issimply not possible for you toshow up for appointments without smoking marijuana, Iwill try to work with you. Pleasekeep me informed about yourintake. I will closely monitorsome important medical signs toensure that your dental care is assafe as absolutely possible. Withthat said, it would be best if youuse as little as possible when youhave a dental appointment, and Iam going to insist that you have acompanion here to help you gethome safely. We also have to makecertain that you are absolutelyclear about the treatments, theoptions, the risks, the alternativesand any possible changes weanticipate.” ■

ReferencesAmar, B. (2006). Cannabinoids in medicine:A review of their therapeutic potential.Journal of Ethnopharmacology, 105, 1-25.Beaconsfield, P. (1974). Some cardiovascu-lar effects of cannabis. American HeartJournal, 87 (2), 143-146.Bill, T. J., Clayman, M. A., Morgan, R. F., &Gampper, T. J. (2004). Lidocaine metabo-lism: Pathophysiology, drug interactions,and surgical implications. AestheticSurgery Journal, 24, 307-311.Bornheim, L. M., & Grillo, M. P. (1998).Characterization of cytochrome p450 3Ainactivation by cannabidiol: Possibleinvolvement of cannabidiol-hydroxyquinoneas a p450 inactivator. Chemical Researchin Toxicology, 11, 1209-1216.

(References continued on next page.)

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Buchanan, W. (2009). Effort to ease potlaws gets a boost; Governor would welcome debate on legalization. San Francisco Chronicle, May 6, 2009, A1.California Dental Association (2005). CDACode of Ethics. Sacramento, CA.Cho, C. M., Hirsch, R., & Johnstone, S.(2005). General and oral health implica-tions of cannabis use. Australian DentalJournal, 50 (2), 70-74.Darling, M. R. & Arendorf, T. M. (1992).Review of the effects of cannabis smokingon oral health. International DentalJournal, 42, 19-22.Friedlander, A. H., Marder, S. R., Pisegna,J. R., & Yagiela, J. A. (2003). Alcohol abuseand dependence: Psychopathology, medicalmanagement and dental implications.Journal of the American DentalAssociation, 134, 731-741.Froelich, J. C., Badia-Elder, N. E., Zink, R.W., McCullough, D. E., & Portoghese, P. S.(1998). Contribution of the opioid system toalcohol aversion and alcohol drinkingbehavior. Pharmacology, 287, 284-292.Gregg, J. M., Campbell, R. L., Levin, K. J,Ghia, J., & Elliot, R. A. (1976). Cardiovasculareffects of cannabinol during oral surgery.Anesthesia & Analgesia, 55 (2), 203-213.Hernandez, M., Birnbach, D. J., & VanZundert, A. A. J. (2005). Anesthetic man-agement of the illicit-substance-usingpatient. Current Opinion in Anaesthesiology,18 (3), 315-324.Horowitz, L. G. & Nersasian, R. R. (1978). A review of marijuana in relation to stress-response mechanisms in the dentalpatient. Journal of the American DentalAssociation, 96 (6), 983-986.Jones, R. T. (2002). Cardiovascular systemeffects of marijuana. Journal of ClinicalPharmacology, 42, 58S-63S.Jouvenal, J. (2005). Fast-food giants outnumbered by pot clubs. San FranciscoExaminer, July 18. McCarthy, F. M. & Hayden, J. (1978). Ethylalcohol by the oral route as a sedative indentistry. Journal of the American DentalAssociation, 96, 282-287.

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Mehta, A. K. & Ticku, M. K. (1988). Ethanolpotentiation of GABAergic transmission incultured spinal cord neurons involvesgamma-aminobutyric acid A-gated chloridechannels. Journal of Pharmacology andExperimental Therapeutics, 246, 558-564.National Center for Health Statistics(2009). Health, United States, 2008. TheCenter, Washington, DC.National Institutes of Health (2009). NIDAInfofacts: Marijuana. Hyattsville, MD.Nguyen, H. T. A. (2004). Cannabis (marijua-na) and anesthesia. AnesthesiologyRounds, 3 (9), 1-6. Okie, S. (2005). Medical marijuana and theSu preme Court. New England Journal ofMedicine, 353, 648-651.Ozar, D., & Sokol, D. (1994). Dental ethicsat chairside: Professional principles andpractical applications. St. Louis: Mosby.Seamon, M. J., Fass, J. A., Maniscalco-Feichtl, M., & Abu-Shraie, N. A. (2007).Medical marijuana and the developing roleof the pharmacist. American Journal ofHealth-System Pharmacy, 64, 1037-1044.Spaak, J., Merlocco, A. C., Soleas, G. J.,Tomlinson, G., Morris, B. L., Notarius, C. F.,Chan, C. T., & Floras, J. S. (2008). Dose-related effects of red wine and alcohol onhemodynamics, sympathetic nerve activity,and arterial diameter. American Journal of Physiology: Heart and CirculatoryPhysiology, 294, 605-612.Wallner, M., Hanchar H. J. & Olsen R. W.(2006). Low dose acute alcohol effects onGABAA receptor subtypes. Pharmacology &Therapeutics, 112 (2), 513-528.

Persons whose cognitivecapacity is impaired cannot give real consent,as they are unlikely to fully understand the situation and may not be capable of prudentjudgment.

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

AbstractA defining characteristic of humans is ourcapacity to create a better world throughmutual action. Traditional ethics attemptsto define and impose the one or severalthings we should all want. The alternativeargued here is that we can retain our individual definitions of what matters andstill work together for mutual improvement.Agreeing on common ethical principles isnot a precondition for an effective morallife. This approach to morality is based ongame theory, which holds that in purposelysocial interactions: (a) there are basicunderstandings, (b) individuals pursue theirown interests, (c) we can judge others’interests, and (d) the distribution of benefitsand burdens depends on the joint action ofindividuals, not on the action of individualsin isolation. In this view, immoralitybecomes a matter of cheating in the gameof life. The three primary forms of cheatingare deception (misleading others into thinking they are playing a game otherthan the one that is to their advantage toplay), coercion (blocking courses of actionothers would normally be entitled to), andreneging (playing the game and then dodging the payoff if one does not like theoutcome). These three evils are illustratedby Shakespeare’s plays Othello, Richard III,and Antony and Cleopatra.

We can learn a lot about ethicsby watching the play of children ages four to eight.

It is not because that is the age whensome are getting good ethics from theirparents and others are not; most childrenthat age are really clumsy in their rela-tions with others and many or perhapsmost have strong tendencies towardbeing brutish. What we can learn comesfrom the fact that they struggle so muchand have yet to learn the arts of conceal-ment. They tip their hands about howthey think people should get along.

Imagine a four-year-old buildingwith blocks or zooming a toy airplanearound the kindergarten room. Oftenthese acts are accompanied by soundeffects; they appear to have a structure.The blocks and the plastic object (even if it is only the small plastic rake from abeach set that stands in for an airplane)are elements in an imagined world thatgives them some sort of meaning. Onechild is building the tallest structure inthe world or a wall to keep out creaturesof an indescribable nature; the other issetting a speed record, showing off won-derful aerobatics, or even experiencingsome form of kinesthetic thrill.

Despite their verbalizations, theirplaying in the same space, and eventheir acknowledgment of the others’presence, they are playing together onlyin a contrived sense. Psychologists callthis parallel play. There is no thought of reenacting the World Trade Center disaster, because the block builder andthe plane zoomer are in different worlds.

As children grow, they acquire theability to include images of others in thecontextual world that surrounds theirplay behavior. In Bob Dylan’s lyrics, “I’lllet you in my dreams if you let me inyours.” Semicooperative games emergelater, such as “cops and robbers” and tea parties or pretend family episodes. Theseare still largely private activities (hidingfrom others and arranging one’s things),but the presence of others and theirinfluence on the meaning of the game isacknowledged to some extent. Personally,I never could understand how we resolvedthose disputes in cops and robberswhere I claimed to have shot my buddy,but he said I missed. I think a major reason we were able to carry on wasthat he relished the opportunity to playout dying in a spectacular fashion. Littlegirls seem to find some way to continuewhen there is disagreement overwhether the baby (doll) is hurt or sad orsomething else. The balance betweenprivate but interlocking worlds that provide the context for public actions isan essential skill and the foundation forour norm of “plays well with others.”This is the foundation for morality.

As we mature, we continue develop-ing interpretative frameworks for ourbehavior that allow both our own andimportant others to participate in ourworlds. Eventually we accumulate a fullrepertoire of these frameworks, slightly

35


Evil Games

Leadership

different ones for different circumstances,that permit us to function effectively inmany context were other folks are alsoworking within the parameters of theirframeworks. A good marriage or a goodpatient-dentist relationship means thatwe can count on the other to behave in a fashion that will not challenge ordamage our own way of proceeding andvice versa. Friendship is a special casewhere we believe our friend will sustainthe interlocking frameworks in situationsthat have not been tested yet or will even go out of their way to preserve therelationship when our behavior appearsa bit dodgy. But we never escape parallelplay. Consider all the individuals whobelieve they have gifted hands, would be strong candidates for elected office,think they have a great sense of humorbecause they pass on others’ jokes totheir e-mail list of friends, or fantasizethat there will be more than a few readersof long papers on dental ethics.

These functionally interlockingframeworks are not exactly the same asnorms, as in the sense that the ADAPrinciples of Ethics is based on norma-tive principles. Norms, and even more so rights, are abstract, universal, andreciprocal expectations for behavior. It is a normative principle that everyonewill exhibit veracity or truth telling at all times—whatever that means andwhatever is entailed if it should not occur.By contrast, a mutually sustainable inter-locking moral framework is a foundationthat permits joint behavior that honorsthe dignity of each party. That is themoral foundation for social life.

The view that morality is based oninterlocking frameworks rather thanexternal, universal principles does notlead to categorizing behavior as “accept-able” or “unacceptable,” as in the case in

much of law. Hitting another person inthe face as hard as possible is not wrongif one is a boxer. Taking another’smoney is not wrong if one is operating a gambling establishment. Causing orofacial pain is only wrong under certain circumstances. It is the behaviorin mutually overlapping contexts thatmatters. In England, operating on apatient is legally a battery, absent informedconsent. Otherwise is may be acceptableif one is licensed to do so and the actionconforms to the standard of care.

The frames that provide the contextand foundation for social moral behaviorneed not be identical across individuals.A dentist may think he or she completeda spectacular restoration while colleaguesand patients judge it to be merely accept-able. Even this difference is moral to the extent that none of the parties wouldchoose to do anything else given fullknowledge of the situation. A dentistwho charges 10% above “fair marketvalue” for a restoration that the patientwould be willing to pay 20% above parto receive, is moral, provided that thepatient and others have not been trickedinto believing that this is a low price,that it is the only alternative the patienthas, or that the work is anything lessthan what it is said to be. It is the overlap,not the identity, if frameworks such thata common behavior is acceptable to bothparties that makes it moral. Universalnormative principles would be an accept-able alternative foundation for moralsprovided that there are no disagreementsover which principles matter, which takeprecedence in cases of conflict, and howthey apply in particular situations.

Moral GamesThe ideas presented above are back-ground to the view that moral behaviorcan be understood in terms of game theory. It is certain that children are recognized as responsible citizens to the extent that they learn how to playgames well, including the master game

of pursuing their own interests whilesimultaneously allowing others to do thesame. The Western Liberal tradition, asembodied in the Declaration of theRights of Man, makes the highest idealto maximize each individual’s welfareconsistent with a comparable opportunityfor all others to do the same. The largequestion in ethical philosophy has beenhow to bring this about. This essay proposes that we look to game theoryfor one answer.

Characteristics of Games

Set aside notions that games are intrinsi-cally trivial, only involve head-to-headcompetition between individuals fightingover the same prize, or the deviousnessof “gaming” the system. Game theory isa well-developed discipline that crossedthe fields of decision science, economics,and ethics. Four features define a game:

Understandings: Some behaviorsare appropriate and others are not.Agreement on process need not be thesame for all players. For example, insur-ance companies are exempt from certainanti-trust regulations that hospitals anddentists must follow. In certain cases,those who “break the rules” are penalized.If they accept the penalties they have notbroken the rules, they have just made acalculated move. Civil disobedience andrequesting a late filing for income taxesare examples. When understandings arereally broken with an intent to avoiddetection or sanction, it amounts to aredefinition of the game.

Payoffs: Outcomes are associatedwith payoffs, one set for each player.Both the associate and the senior dentistcan expect to benefit from a practiceagreement if the relationship is success-ful and one or both can expect to sufferif the practice does not thrive. So-called“zero-sum games,” where the availablebenefits are fixed and one person cannot

36


Leadership

win unless the other looses, are con-trived and not that common. Certainlyboth patient and dentist expect to benefitfrom each appointment. The progress of mankind over the centuries is cleartestimony that, in the aggregate, we havebeen playing games where the typicalperson can expect to move up.

Predictable Goals: It is a necessarycondition of games that all players are“in to win.” Normally, this can be takento mean that each person seeks to maxi-mize his or her own interests. There iscurrently debate in scientific circles overhow to handle altruism—a consistentpattern of behavior that seeks to advancethe interests of others with no clearapparent advantage to the altruist. Allthat is necessary for game theory is anunderstanding that players seek to maximize a recognizable goal in someconsistent fashion and that the bestinterests of others can be predicted tosome extent. For example, MotherTheresa could be counted on to fight forthe interests of the poor in Calcutta. Thereason for the requirement that goals be predictable is that cooperative andcompetitive behavior presupposes someability to understand how others areplaying. This is what children learn as theymove from parallel play to responsibleadult behavior. It is also why one cannothave a conversation with a madman.

Joint Outcomes: The lynchpin ofgame theory is that outcomes cannot becontrolled by either player alone. It is thejoint action of all concerned that deter-mines how the payoff will be distributed.Dentists may wish for the optimal oralhealth outcomes for patients who lackresources or personal values to engagein care, but they cannot necessarilymake it happen. Patients may wantexcellent oral health but not be able tofind a dentist near enough or honestenough to provide that kind of treatment,but they cannot necessarily make it happen. It is only when the joint actions

of parties coincide such that neitherparty would be better off doing anythingelse that we get the results we want.(This criterion of joint best outcomessuch that neither party would be betteroff doing anything else is called “equilib-rium”—an important technical term ingame theory) For this approach to moralbehavior, no individual can be ethical inisolation. Regardless of a high code thatis carefully followed, pious recluses haveeither created an imaginary world wherethey win by their private rules or theyare just lucky to have surrounded them-selves with like-minded individuals whoprobably carp about the others who“don’t get it” or may even have coercedothers into taking their word for howthings are.

In What Sense Are Games Ethical?

The game structure provides a usefulway of looking at various approachesthat have been taken toward ethics.

The most common approach by farto building ethical theory is built on suggesting to others that one or anotherset of payoff values should be preferredby everyone. The ADA Principles ofEthics is based on this notion. Otherthings being equal, it is better that peoplehelp others, avoid harming them, tellthe truth, distribute benefits and burdensfairly in society, and allow others tomake up their own minds about things.Here is the rub: this set is proposed asbeing the set of values that all shouldadhere to. That makes the principle ofautonomy (everybody gets to make uptheir own mind) sound a bit hollow.Even such an obvious candidate for aworthy outcome as great oral healthmay not place high among all Americans.Most have nothing against it, but preferfood on the table or flat-screen TVs. It

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Leadership

The balance between

private but interlocking

worlds that provide

the context for public

actions is an essential

skill and the foundation

for our norm of “plays

well with others.”

This is the foundation

for morality.

may be sound to operate as thoughrational individuals act based on whatthey believe to be a consistent set of values, but it is not as obvious that thevalues are or even should be the samefor everybody, or if so who gets to decideon what they should be. Perhaps the factthat we are still struggling with our mas-ter list of universal values (best payoffs)after 2500 years of debate is an indica-tion that this is not the best strategy.

Another approach to ethics has beento emphasize rules and rights. “Firstensure that everyone has a basic level ofhealth care and then distribute the restby some algorithm” and “it is illegal toaccept insurance payment as payment infull and waive copays” are examples. Sois the Golden Rule: “Treat everyone as ifhe or she has the same values I do.”These are cases where the rules of thegame have been set by third parties. It isnot unethical to ignore such rules; it is,however, immoral to ignore them whileclaiming to honor them and to expectthe benefits that would be given to thosewho follow the rules.

The branch of ethical theory knownas contractarianism leans heavily on the part of game theory concerned withself-interests. Thinkers such as ThomasHobbes, Adam Smith, and the modernday David Geuthier, and to some extentJohn Rawls, make a strong case thatindividuals are better off in the long runworking together than individually. Weare thought as a society to acknowledgesome form of “social contract” where wecan assume that it is in everybody’s ownbest interests to agree on certain minimalrules. As attractive as this idea is, it isembarrassed by the persistence amongus of free-riders, con artists, and quacksand charlatans. A variation on this

approach from self-interests is evolution-ary ethics. E. O. Wilson and BrianSkyrms are examples of philosopherswho argue that it is hardwired into individuals as survival instincts that weprefer to cooperate, especially with thosein our family or with our friends.

For me, the key to moral behavior isnot in arguing about the rules and theprizes, but in the play of the game. Some people agree to the operationalunderstandings, and even self- andother-interested joint play, but theycheat. They pretend to be playing onegame while in reality they are playinganother. They block other’s options inways that violate the spirit of the game.Some people even play by the rules andthen fail to abide by the consequences oftheir losing. Failure of morality, on myview, is not a matter of having differentvalues or different ethical theories, nor isit a matter of declining to play the gamethat others find enjoyable. Immoralitycomes down to playing, but playing dirty.

The remainder of this essay is devotedto a discussion of the three principal flavors of immorality understood ascheating on the game of life. Each willbe illustrated through a discussion ofone of Shakespeare’s plays.

DeceptionIn a perfectly transparent game, theunderstandings and payoffs are fullyunderstood and each player has a reason-able way of anticipating what is in thebest interests of the other. In deception, aplayer attempts to gain an unfair advan-tage by distorting the way the game isunderstood. If, for example, a dentist failsto mention that posterior compositeshave a shorter expected serviceabilitythan amalgam restorations in the samearea, the patient will likely make thewrong choice, even when following aperfectly logical decision process. By

“wrong choice,” I mean that they wouldconclude that their interests were bestserved by a different action if they hadavailable all the information they couldreasonably have expected. A patient mayattempt to deceive a dentist about his orher need for pain medication or intent tofollow through on treatment or paymentfor care. Distorting others’ understandingof the game of life for personal advantageis immoral; it is deception.

A classic example of game theoryoccurs near the beginning ofShakespeare’s Othello where theVenetian war council is debating how toemploy their great general Othelloagainst the Turks. It is known that theTurks have assembled a large fleet, but itis not known for certain whether theattack will be made against Rhodes oragainst Cyprus. Most of the field intelli-gence coming in suggests Rhodes as thetarget. The Venetians decide to sendtheir fleet to Cyprus. There are fourpotential outcomes: (a) The Turks attackCyprus and Venice defends it—a probableand important victory for Venice; (b) theTurks attack Cyprus and Venice defendsRhodes—a major strategic blunder; (c)the Turks attack Rhodes and Venicedefends it—just a check on the Turks;and (d) the Turks attack Rhodes and theVenetians defend Cyprus—a clean butsmall win for the Turks. Overall, the beststrategy for both armies is to attackCyprus [see the recommended readingon game theory to understand why thatwould be the case]. But the Turks attemptto disguise their intentions by pretendingan attack on Rhodes, just as the Allies didin World War II by signaling an invasionat Calais rather than Normandy.

The Venetians solve the problem bylooking at the four outcomes and asking“What is the most stable outcome basedon both party’s real interests, ratherthan their professed actions?” This is not the best outcome for either party:instead it is the best joint outcome forthe parties, the best one could hope for38


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assuming that the other is seeking tomaximize their interests. Both fleets meetoff Cyprus in a great battle, a victory forVenice, that is alluded to between Acts Iand II of Shakespeare’s Othello.

The plot of the play is introduced inthe first speech of the play where Iago,Othello’s aide-de-camp, is fuming overbeing passed over for promotion and vows revenge against his general. This isachieved by Iago deceiving Othello intobelieving that his wife Desdemona isunfaithful. In the progress of the play,Iago ruins the personal fortune of afriend and the reputation of the manOthello promoted instead, and he promptsOthello to kill his wife and commit sui-cide. Throughout all of these maneuvers,he acts indirectly through rumor, falseevidence, and promotion of suspicion.The word “honest” appears 54 times in theplay. Twenty times Iago is described ashonest by others, nine times he describeshimself as honest to others, and ninetimes he privately mocks honesty, as inthe line “Honesty’s a fool.” In a word, Iagooffers to play one game in public whileactually playing another to his ownadvantage. He is deception personified.

Iago eggs a friend and former suitorof Desdemona to engage Cassio (Othello’snew lieutenant) in a drunken fight inwhich Cassio accidentally wounds aninnocent bystander. Othello places Cassioon probation. Iago convinces Cassio toplead his case through Desdemona, thusraising suspicions in Othello’s mind overDesdemona’s affections. These suspicionsare fanned by disguised professions ofCassio’s innocence from Iago, who reluctantly reports rumors that cannotbe verified (“Cassio was overhead mentioning Desdemona in his sleep”)and exaggerated pictures of the shamethat would come to Othello if Desdemonawere not honest (a play here on thephrase “an honest woman”). Iago tricks

Cassio into boasting about his affairswith his mistress, Bianca, which Othellois led to believe are references Desdemona.Iago also succeeds in getting a hand-kerchief that Othello has given toDesdemona and placing it in Cassio’sroom, knowing that its eventual emer-gence will be misunderstood. In eachcase, Iago succeeds in substituting acounterfeit game structure that provesdisastrous for those who act on it.

Following are nine examples ofdeception in Shakespeare’s Othello:• Desdemona deceives her father by

eloping with Othello.• Iago enlists Roderigo’s help by

promising to win Desdemona’s affections for him using moneyRoderigo gives Iago.

• Othello is accused of using witchcraftto win Desdemona.

• The Turks feint toward Rhodes whenthe real target is Cyprus.

• Iago sets up Cassio for a drunkenfight, estranging Othello fromCassio.

• Iago sets up Cassio to plead his casethrough Desdemona, thus making it appear that there is a deeper relationship between them.

• Iago uses suspicion of possibility andconsequences of infidelity, thenunconfirmable rumors, then possi-bility of future “proofs” to makeOthello jealous.

• Iago arranges a misleading interviewand discovery of handkerchief as“proofs.”

• Iago persuades Roderigo to ambushCassio.

Cheating is a sometimes misunder-stood example of deception. The act ofbreaking into a faculty member’s officeto copy the answer key is an invasion of

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A good marriage or

a good patient-dentist

relationship means

that we can count on

the other to behave

in a fashion that will

not challenge or

damage our own way

of proceeding and

vice versa.

privacy, and getting a friend to takeNational Boards to report content cover-age and some answers is an abuse offriendship. The cheating comes fromattempting to deceive others (faculty orboards) about the meaning of the testscores. So is upcoding, incompleteinformed consent, failure of full disclo-sure in contract negotiations, and tellingpart of the story on access and otherpublic health issues.

Coercion In a fair game, parties are free to chooseamong a set of alternative courses ofaction sanctioned by society at large.There should be no constraints on usthat do not apply to others in similar situations. We should be autonomousindividuals. Coercion is the unjustmanipulation for personal benefit of theactions open to others. Papoose boardingis often regarded as coercion. So are sexual harassment, withholding services,and threatening nuisance lawsuits.

Use of force is not necessarily coerciveif it is understood to be part of theencounter between parties sanctioned by society in such circumstances.Aristophanes’ play Lysistrata is a case inpoint. The women of Athens sought tolimit war by withholding sexual favors.It was the women who engaged in coercive behavior essentially by doingnothing, and the play is properly under-stood as criticizing, not praising, thewomen. In football, physical force isexpected as a means of advancing one’sends. But there are rules about whichkinds of force are coercive and which are allowable.

Shakespeare’s Richard III is a study incoercion. Based on the historical figure,Richard, Duke of Gloucester, the lastking in the Plantagenet line founded byWilliam the Conqueror, Richard usurped

the English crown for the years 1483–1485. Shakespeare’s version of history issubstantially without foundation, but theBard credits Richard with seven murders,including the deaths of his adolescentnephews, and the seduction by force ofseveral women. Richard’s problem wasthat he wanted to be king, but wasfourth in the line of succession behindhis two older brothers and the sons ofhis oldest brother. The oldest brother,Edward IV dies of natural causes, althoughin somewhat confused circumstances. In Shakespeare’s view, Richard had facilitated this death and the secondbrother’s drowning in a wine vat in theTower of London, and later he detainedthe nephews in the Tower and orderedthem killed. He had several members ofa rival house arrested and then killed,and even had one of his own factionarrested and executed when he got coldfeet. The women were cowed into sub-mission by physical threats or promisesof sharing power. And in all cases thewomen were the mothers or formerwives of men Richard had dispatched.

The deaths in battles caused byRichard and his brothers were not coercion, but the fortunes of war. Themurders were coercion. Consider thecase of Richard’s brother—the onedrowned in the wine vat—who wasordered to the Tower by the oldest brother and later pardoned. Richard was entrusted with the written pardon,but converted it into a warrant for anexecution. Clearly the options normallyopen to the second brother were alteredto Richard’s advantage. There is no coercion involved in arresting, trying, and(if found guilty) executing individuals.The coercion came in the form of omit-ting the trial. This is a fundamental rightin Western society today; it was an evenmore fiercely defended privilege amongthe medieval nobility. Killing was not theproblem; killing without an opportunityto defend oneself was. It removed anoption—trial by a jury of one’s peers—

that one was entitled to by birth. A similar violation of normal freedom bycoercively cutting off freedom involvedhis ordering violation of sanctuary inchurches in arresting one of the nephews.

Following are 12 examples of coercionin Shakespeare’s Richard III:• Inflames hatred between Edward IV,

his brother the Duke of Clarence, andWoodville faction and prevents theirattempts at reconciliation blockingnormal relations among them.

• Prevents pardon from Edward IV ofhis brother from reaching jailors intime to prevent his execution.

• Arrests and then executes Rivers,Grey, Vaughan, and others withoutwarrant or trial.

• Authorizes violation of sanctuarylaws.

• Confines young princes to the Tower, thus depriving them of natural support.

• Frames and executes Hastings with-out warrant or trial and falselyrepresents a confession to the Mayorwhen the dead Hastings can saynothing in his own defense.

• Spreads rumors of bastardy of youngprinces when credible witnesses aredead or silenced and there is no timeto verify the claims.

• Denies access of parents and grand-parents to their children in the Tower.

• Orders secret execution of youngprinces.

• Gets rid of inconvenient wife, LadyAnne, in order to marry another.

• Causes Queen Margaret’s curses to bedrowned out by drums and trumpets.

• Holds friend’s son hostage.

Coercion exists in dentistry, princi-pally through denying patients access tooptions that would normally be availableto them for promoting their health. Acommon example involves presentingtreatment plans that cover only those

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options the dentist prefers. All overtreat-ment is coercive. It generally takes theform of creating the impression of athreat of ill health that can apparentlyonly be mitigated by a single course ofaction. Coercion would exist in insurancecontracts if there were an attempt toenforce conditions that had not beenagreed to or were not available to others.(Being legally forced to fulfill the termsof a bad contract is not coercive.)

RenegingThe third major way to cheat on therules of the game of life is by not follow-ing through on promises made aboutoutcomes. It has sometimes been saidthat in a liberal Western society, each ofus is free to do whatever we choose, aslong as we are willing to accept the con-sequences. What is not okay is to agreeto play a game and then change one’smind when the results turn out to beunfavorable. A free dental exam thatturns out to cost something is reneging.Running for election to an office inorganized dentistry and is an example of reneging, as is bad debt.

The difference between deceptionand reneging is when the decision tocheat is made. In deception, the mutualgame is distorted from the very begin-ning, or at least prior to commitments toaction. Reneging occurs after the out-comes of the joint action are known orare apparent. When agreeing to a treat-ment plan, the patient may have everyintention of following through withappointments and other behavior andon payments. But the picture looks different after the first steps are taken.And in fact, the world has changed andit may not be so obvious that follow-through is so advantageous. No dentalstudent ever came to school three daysin a row wearing the same clothes andexuding the same respect that was evident in the admissions interview. And few individuals treat their spousesnow the way they did while courting.

Order in civil society depends on ourbeing able to count on the world notchanging moment to moment to satisfyour temporary advantage. It is doubtfulthat we owe anything to a fool or a madman, despite our having given our word.But we do owe it to ourselves and tothose we care about not to engage withthose who can be expected to renege.Alcoholism or any other addiction is acase of self-reneging.

The study case for reneging inShakespeare’s work is Antony andCleopatra. The story is well-known andthe play follows history rather faithfully.The setting for the play builds on earlierevents. Julius Caesar was assassinated, inpart, because of a fear of concentratingtoo much power in a single individual.Following his death and a short civil war,the empire was ruled by a triumviratebased on dividing the empire into threeadministrative sections with an agree-ment to share the spoils. The triumvirateincluded Mark Antony, Lepidus, andOctavius (also known to us as Octavianor Caesar Augustus). A holdover fromthe former power group, Sextus Pompey,was a powerful military pretender topower. Mark Antony was married toFlavia, who, by successive marriages,became a great power broker. But Antony,who was responsible for the eastern partof the empire, took up with Cleopatra—atleast long enough for them to have twochildren together. It is at this point thatthe play commences. On Flavia’s death,Antony returned to Rome to present aunited front to the outsider Pompey andthere married Octavius’ sister, Octavia,as a political bargain. Antony abandonedOctavia and Octavius unilaterally didaway with Pompey and then Lepidus.This sets the stage for a showdownbetween Antony and Cleopatra on one

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Universal normative

principles would be an

acceptable alternative

foundation for morals

provided that there are

no disagreements over

which principles matter,

which take precedence

in cases of conflict,

and how they apply in

particular situations.

hand and Octavius on the other. In thefirst major battle at Actium on the eastcoast of Greece, Antony unwisely choseto fight at sea because Cleopatra hadprovided many war galleys. In the heatof battle, the Egyptians fled. Antonymade a later stand near Alexandria, butwas again abandoned by the Egyptiansand other partners. Antony killed him-self when he learned that Cleopatra hadcommitted suicide. But she had onlyspread this rumor and was negotiatingwith Octavius. In the end she did inflicta deadly snake bite on herself when shecame to believe that Octavius would nothonor his negotiated power sharing deal.

The most outrageous example ofreneging in the play is the Egyptian fleetfailing to engage the forces of Octavius atboth Actium and Alexandria as promised.Antony’s marriage to Octavia is also representative example of reneging. Heaccepts the benefits of this game (politicalstability with a handsome opportunityfor spoils in the east) but fails to honorhis end of the bargain. Antony freed aslave, Eros, in his youth and made himpromise to kill him if necessary to pre-serve Antony’s honor. The freed slavewent back on his word, killing himselfinstead. Cleopatra’s death is yet anotherexample. She negotiated a treaty withOctavius but denied him the opportunityto celebrate his victory.

Following are 12 examples of renegingin Shakespeare’s Antony and Cleopatra:• Antony is accused by his generals of

forsaking his responsibilities in warand statesmanship for pleasureswith Cleopatra.

• Antony resolves to leave Cleopatraand return to Rome.

• Octavius accuses Antony of renegingon his promise to provide arms intimes of war.

• Antony marries Octavia for politicalreasons but abandons her, retuningto Cleopatra.

• Treaty of Misenum between Pompeyand the triumvirate broken unilater-ally by Octavius.

• Octavius deposes Lepidus.• Cleopatra’s fleet flees in battle of

Actium.• Cleopatra negotiates with Octavius,

and although he appears to accepther terms, she kills herself instead.

• Some of Antony’s army defects afterActium, more kings defect before thebattle of Alexandria. The Egyptianfleet defects for a second time atAlexandria.

• Enobarbus, one of Antony’s best generals, defects.

• Cleopatra counterfeits her death.• Eros kills himself rather than Antony,

as he was duty-bound to do.

There is a subtheme in Antony andCleopatra that corresponds to a branchof the academic discipline of moral philosophy as games. This is the topic of coalitions and the human tendency toshift our allegiances to those combina-tions we feel will best serve our interests.

The theory of coalitions is very simple:individuals choose among individualgames and team games played with various partners with a view towardjoining the game that offers the greatestadvantage. Attractive coalitions maycease to look so good based on changesin our own situation, modifications inour partners’ positions, and especiallythrough alternations in the coalitions we are facing. Recall that a key tenant ofgame theory is that we alone cannotdetermine what is morally appropriate.Prior to the battle of Actium, whenAntony announced that he would fightat sea to take advantage of the apparentstrength of his Egyptian partner, some of

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Leadership

Failure of morality, in my view, is not a matter of having different valuesor different ethical theories, nor is it a matterof declining to play thegame that others findenjoyable. Immoralitycomes down to playing,but playing dirty.

the generals in Antony’s army desertedto Octavius because they calculated theirbenefits as being most promising if theyadded their land armies to Octavius thanif they added their armies (of minimalvalue in a sea battle) to Antony.Cleopatra was a master at shifting herallegiances to the winning coalition.Enobarbus was one of Antony’s generalswho shifted coalition partners, but hediscovered he had made a mistake indoing so and then committed suicide.

Health care in America is an especiallyrich field for studying the effects of shift-ing coalitions. There is a compellingreason for this situation. The amount ofhealth care needed in America exceedsthe resources available to address it—by avery large extent. The only wise strategyis to form coalitions in an effort to con-trol access to the most lucrative patients.Winning coalitions spend money to prevent rule changes. And because theimbalance between need and resourcesis so great and because there are somany players, very small changes in therules provoke coalition changes.

Dental practitioners must choose theform of their practice, especially the levelof care and extent of insurance participa-tion. The dogmatic approach to ethicstends to pit one group of practitionersagainst others who attack each other’sprinciples. Practitioners join or shiftcoalitions because they believe they canimprove their interests. They sometimesswitch sides when their practice circum-stances change, for example when theyhave paid back the large debts they haveencumbered in purchasing a practice.Access to care can also be viewed as acoalition issue and the current thinkingis that the profession’s interests are best served by not entering into anycoalitions at all unless other groups form that could destabilize the game.

ConclusionIf we lived solitary lives, there would be little concern for ethics—certainly nopossibility of discussing them. It isinescapable that as social beings whomake choices based on potentially over-lapping visions of life we (a) roughlylearn and follow agreements, (b) cherishour values of what is worthwhile, (c)make generally useful assessments ofwhat others value, and (d) earn theblessings and burdens of life collectively—based in large part on mutual behavior.In a word, we play the game of life. Thisview does not require that we convinceothers what is right or wrong before wecan play. But it does require many yearsto learn to play well with others. Becausesocial relationships are complex, we playmany such games simultaneously, andin most contexts we are satisfied withworkable approximations of playing thesame game.

All of us cheat a little, but each of usbelieves we are basically ethical. There is no inconsistency here. This is like saying that Dr. Perspicacious is a masterorthodontic diagnostician; but we expectthat Dr. Perspicacious does other thingsduring the day, such as eating, chattingwith the office staff, dancing the Macarena,and occasionally muffing a diagnosis.

The point of this essay has been tomake a case for evil games. It is possibleto characterize specific kinds of mutualgoal-directed social behavior that shouldbe avoided because this damages individ-uals and damages the groups in whichsuch immoral behavior occurs. An evilgame is not the same thing as one anindividual is apt to lose. All of us havebeen dealt losing hands in variousaspects of our lives. The evil comes fromnot playing the game fairly. Deception isa form of cheating at games by creatingor allowing others to form unrealisticviews of what is at stake in the game; forsomeone else’s advantage, victims ofdeception are seduced into playing

games that differ from the ones theybelieve they are playing. Coercion is evilbecause it manipulates, for someone’sunfair advantage, the structure of agame by denying others actions theywould normally be entitled to. Renegingis evil because it perverts the payoffs,again from someone’s advantage, afterthe game has been played.

What do these forms of cheatinghave in common that makes them soevil? In all cases they diminish the dignity, autonomy, and distinctly humancharacteristic of others. As far as scienceknows, humans are the only life formcapable of mutual, future-oriented volition. The great ethical philosopherImmanuel Kant overlooked a fundamen-tal point when he argued that humanbeings should true their moral compassesto universal reason. Mankind is nothomo rationalis. The Great Scots AdamSmith and David Hume were closer tothe mark by offering a morality for homosapiens. We are the unique sapientspecies, meaning that we are intercon-nectedly volitional, that we are capableof making and executing common plans,and that we are sensitive to what otherswant. Only humans are capable of playing the game of life. The definitionof immorality is to cheat at it so as to cheapen not only the game but alsothose who play it. ■

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Recommended Reading

Although there are many introductorybooks on game theory, most peoplefind the material technical in nature.There are summaries of two textsavailable. There are also summariesof the three plays by Shakespeare discussed in the essay. Each is aboutfour pages long and conveys both thetone and content of the original sourcethrough extensive quotations. Thesesummaries are designed for busyreaders who want the essence of thesereferences in 20 minutes rather thanfive hours. Summaries are availablefrom the ACD Executive Offices inGaithersburg. A donation to the ACDFoundation of $15 is suggested for the set of summaries on behavioraleconomics; a donation of $50 willbring you summaries for all the 2010leadership topics.

Heap, Shaun P. Hargreaves andVaroufakis, Yanis (1995).Game Theory: A CriticalIntroduction* London: Routledge. ISBN 0-415-09403-8,285 pages, cost unknown.

Difficult but effective introduction togame theory, beginning with normalform games (two players selecting alter-native, one-off actions independent ofeach other), the concepts of equilibrium(neither player has an incentive to chooseotherwise) and common knowledge ofrationality (ability to predict what othersconsider to be in their best interests) arediscussed. Dynamic games (extensiveform games) are discussed next, beinggames where players alternate movesand gain knowledge from other’s previousmoves. The Nash bargaining solution ispresented as the most fair way of dividingshared benefits and burdens. ThePrisoner’s Dilemma and other famousgames, including evolutionary ethics,are also presented.

Gauthier, David (1986).Morals by Agreement* Oxford, England: Oxford University Press.ISBN 0-19-824992-6; 367 pages; about$20.

Moral action is analyzed in game-theoryterms. It is assumed that perfectly rationaland fully knowledgeable individuals recognize that cooperation offers eachperson better prospects than does thestate of nature, where it is “every man forhimself.” An economic model is first con-sidered in which each participant selectsthe strategy that ensures a maximal

return based on the assumption that others will attempt to minimize what isavailable. This can be improved upon byagreeing in advance to some principlefor fairly sharing the common surplus in society. Gauthier’s libertarian viewsshow through at times.

Shakespeare, William

Summaries include historical contextand characters, plot, description ofaction by scene, and list of examples oftheme for each play.

• Othello: Deception• Richard III: Coercion• Antony and Cleopatra: Reneging

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