Position Statement

Integrity in Prosthodontic Care 

Position Statement of the American College of Prosthodontists
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Integrity is defined as “a personal choice, an uncompromising and predictably consistent commitment to honor moral, ethical, spiritual, and artistic values and principles”. 1 When discussing “integrity” within a clinical field, our patients must be the first consideration, as our purpose is to serve them. In prosthodontics, patient concerns can be as varied as the patients themselves, including but not limited to improvements in symptoms, pain, function, esthetics, and cost. Due to the complexity of prosthodontic care, patients may not completely understand the subtleties of their clinical diagnoses, treatment options, or the quality of the prosthodontic care that they receive -- all of which have an impact on the long-term clinical outcomes of the care. Thus, patients rely on the quality and quantity of the information provided by their prosthodontist. 

It is the duty of the prosthodontist to deliver care with the utmost integrity, while adhering closely to the American College of Prosthodontists’ Parameters of Care for the Specialty of Prosthodontics,² even in the midst of distracting forces related to reimbursement, efficiency, productivity, and profit. These distracting forces can tempt clinicians to rationalize what is best for the patient (e.g., creative diagnosis, unnecessary care, and lack of treatment alternatives) toward their own benefit. Prosthodontists not familiar with the most current evidence are at risk for such rationalization. To provide care with integrity, the prosthodontist is guided by strong ethics,^3-5 is committed to patient-centered care,⁶ and uses evidence-based principles⁷ to guide decision-making.

Prosthodontists must rely on professional ethical standards^3-5 when providing care for their patients, by adhering to the American Dental Association’s Code of Ethics,² which has been in existence since 1866. This Code of Ethics marks the moral boundaries within which professional dental care may be ethically provided. Five fundamental principles form the foundation of this Code of Ethics, as detailed below:

• Patient’s autonomy (self-governance): The dentist has the duty to respect the patient’s right to self-determination and confidentiality.
• Non-maleficence (do no harm): The dentist has a duty to refrain from harming the patient.
• Beneficence (do good): The dentist has a duty to promote the patient’s welfare.
• Justice (fairness): The dentist has a duty to treat people fairly.
• Veracity (truthfulness): The dentist has a duty to communicate truthfully.

When an ethical dilemma arises while providing care, such as complex treatment beyond a professional's training, prosthodontists are strongly encouraged to use the “ACD Test for Ethical Decisions,” proposed by the American College of Dentists⁵ to help negotiate ethical decisions. 

In the test, providers are to consider the following questions: 

ACD Test for Ethical Decisions⁴

Assess

• Is it true?
• Is it accurate?
• Is it fair?
• Is it quality?
• Is it legal?

Communicate

• Have you listened?
• Have you informed the patient?
• Have you explained outcomes?
• Have you presented alternatives?

Decide

• Is now the best time?
• Is it within your ability?
• Is it in the best interest of the patient?
• Is it what you would want for yourself?

To support this intended level of integrity, prosthodontists are highly encouraged to adopt the Institute of Medicine’s recommendations on patient-centered care,³ as these recommendations provide a framework for a positive clinical practice environment that promotes not only transparency, but also knowledge transfer to patients and their families. Patient-centered care involves patients and families in decisions regarding health and health care, tailored to fit their preferences. Prosthodontists must ensure their patients and family members are fully engaged and participate in the care decision, which includes information transfer regarding diagnosis, treatment options, and relevant long-term outcomes. Seeking second opinions should also be encouraged. This informed consent process must be documented.

Finally, the prosthodontists uses evidenced-based practice for the integrity of clinical-based decision making. Evidence-based practice is “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient.”⁷ Our profession has evolved through evidence-based practice, long before “evidence-based practice” was given a name. Staying abreast of current clinical science and integrating clinical expertise with that science are essential to providing quality care for patients. Because science and research continue to change over time, the prosthodontist who practices with integrity must be committed to life-long learning and synthesis of information. 

It is the position of the American College of Prosthodontists that prosthodontists provide clinical diagnosis, treatment planning, and prosthodontic care with the utmost integrity by relying on strong ethics, a commitment to patient-centered care, and the use of evidence-based practice.   

References

1. Killinger B: Integrity: Doing the right thing for the right reason. McGill-Queen’s Press – MQUP, 2010, 221 pages. ISBN 9780773582804.

2. American College of Prosthodontists: Parameters of Care for the Specialty of Prosthodontics. J Prosthodont 2005;14:1-103

3. ADA, Council on Ethics Bylaws and Judicial Affairs: Principles of Ethics and Codes of Professional Conduct. Chicago, IL, American Dental Association, 2018. (URL: https://www.ada.org/en/about-the-ada/principles-of-ethics-code-of-professional-conduct)

4. American College of Dentists: Ethics Handbook for Dentists. Gaithersburg, MD, American College of Dentists Foundation, 2016. (URL: https://www.acd.org/ethics/publications/ethics-handbook/)

5. Brands W, Naidoo S, Porter S, Sereny M, van Dijk W, Welie J: Dental Ethics Manual 2, FDI World Dental Federation, 2018, 127 pages. (URL: https://www.fdiworlddental.org/resources/manuals/dental-ethics-manual-2)

6. Scambler S, Degado M, Asimakopoulou K: Defining patient-centered care in dentistry? A systematic review of the dental literature. Br Dent J 2016; 221:477-484.

7. Needleman I, Worthington H: Evidence based dentistry for effective practice. London and New York: Martin Dunitz. ISBN 1-84184-199-4