Ethics Professional Conduct: American Dental Association
Ethics Professional Conduct: American Dental Association
Ethics Professional Conduct: American Dental Association
principles of
Ethics
a n d
co d e o f
Professional
Conduct
With official advisory opinions revised to April 2012.
CONTENTS
I. INTRODUCTION.. . . . . . ................................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
V. INDEX.. . . . . . . . . . . . . . . . . . . . ................................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
I. INTRODUCTION
The dental profession holds a special position of trust within society. As a conse-
quence, society affords the profession certain privileges that are not available to
members of the public-at-large. In return, the profession makes a commitment to
society that its members will adhere to high ethical standards of conduct. These
standards are embodied in the ADA Principles of Ethics and Code of Professional
Conduct (ADA Code). The ADA Code is, in effect, a written expression of the obliga-
tions arising from the implied contract between the dental profession and society.
Members of the ADA voluntarily agree to abide by the ADA Code as a condition
of membership in the Association. They recognize that continued public trust in the
dental profession is based on the commitment of individual dentists to high ethical
standards of conduct.
The ADA Code has three main components: The Principles of Ethics, the Code
of Professional Conduct and the Advisory Opinions.
The Principles of Ethics are the aspirational goals of the profession. They provide
guidance and offer justification for the Code of Professional Conduct and the Advisory
Opinions. There are five fundamental principles that form the foundation of the ADA
Code: patient autonomy, nonmaleficence, beneficence, justice and veracity. Principles
can overlap each other as well as compete with each other for priority. More than one
principle can justify a given element of the Code of Professional Conduct. Principles
may at times need to be balanced against each other, but, otherwise, they are the
profession’s firm guideposts.
The Code of Professional Conduct is an expression of specific types of conduct
that are either required or prohibited. The Code of Professional Conduct is a product
of the ADA’s legislative system. All elements of the Code of Professional Conduct
result from resolutions that are adopted by the ADA’s House of Delegates. The Code
of Professional Conduct is binding on members of the ADA, and violations may result
in disciplinary action.
The Advisory Opinions are interpretations that apply the Code of Professional
Conduct to specific fact situations. They are adopted by the ADA’s Council on Ethics,
Bylaws and Judicial Affairs to provide guidance to the membership on how the Council
might interpret the Code of Professional Conduct in a disciplinary proceeding.
The ADA Code is an evolving document and by its very nature cannot be a
complete articulation of all ethical obligations. The ADA Code is the result of an on-
going dialogue between the dental profession and society, and as such, is subject to
continuous review.
Although ethics and the law are closely related, they are not the same. Ethical
obligations may–and often do–exceed legal duties. In resolving any ethical problem
not explicitly covered by the ADA Code, dentists should consider the ethical principles,
the patient’s needs and interests, and any applicable laws.
II. PREAMBLE
The American Dental Association calls upon dentists to follow high ethical standards
which have the benefit of the patient as their primary goal. In recognition of this
goal, the education and training of a dentist has resulted in society affording to the
profession the privilege and obligation of self-government. To fulfill this privilege,
these high ethical standards should be adopted and practiced throughout the dental
school educational process and subsequent professional career.
3
The Association believes that dentists should possess not only knowledge, skill
and technical competence but also those traits of character that foster adherence to
ethical principles. Qualities of honesty, compassion, kindness, integrity, fairness and
charity are part of the ethical education of a dentist and practice of dentistry and
help to define the true professional. As such, each dentist should share in providing
advocacy to and care of the underserved. It is urged that the dentist meet this goal,
subject to individual circumstances.
The ethical dentist strives to do that which is right and good. The ADA Code is an
instrument to help the dentist in this quest.
ADVISORY OPINION
2.B.1. SECOND OPINIONS.
A dentist who has a patient referred by a third party1 for a “second opinion”
regarding a diagnosis or treatment plan recommended by the patient’s treating
dentist should render the requested second opinion in accordance with this Code
of Ethics. In the interest of the patient being afforded quality care, the dentist
rendering the second opinion should not have a vested interest in the ensuing
recommendation.
5
2.C. USE OF AUXILIARY PERSONNEL.
Dentists shall be obliged to protect the health of their patients by only assigning to
qualified auxiliaries those duties which can be legally delegated. Dentists shall be
further obliged to prescribe and supervise the patient care provided by all auxiliary
personnel working under their direction.
ADVISORY OPINION
2.D.1. ABILITY TO PRACTICE.
A dentist who contracts any disease or becomes impaired in any way that might
endanger patients or dental staff shall, with consultation and advice from a
qualified physician or other authority, limit the activities of practice to those areas
that do not endanger patients or dental staff. A dentist who has been advised
to limit the activities of his or her practice should monitor the aforementioned
disease or impairment and make additional limitations to the activities of the
dentist’s practice, as indicated.
6
Section 3 PRINCIPLE: BENEFICENCE (“do good”). The dentist has a duty to promote
the patient’s welfare.
This principle expresses the concept that professionals have a duty to act for the
benefit of others. Under this principle, the dentist’s primary obligation is service to
the patient and the public-at-large. The most important aspect of this obligation
is the competent and timely delivery of dental care within the bounds of clinical
circumstances presented by the patient, with due consideration being given to the
needs, desires and values of the patient. The same ethical considerations apply
whether the dentist engages in fee-for-service, managed care or some other practice
arrangement. Dentists may choose to enter into contracts governing the provision of
care to a group of patients; however, contract obligations do not excuse dentists from
their ethical duty to put the patient’s welfare first.
ADVISORY OPINION
3.E.1. REPORTING ABUSE AND NEGLECT.
The public and the profession are best served by dentists who are familiar
with identifying the signs of abuse and neglect and knowledgeable about the
appropriate intervention resources for all populations.
A dentist’s ethical obligation to identify and report the signs of abuse and
neglect is, at a minimum, to be consistent with a dentist’s legal obligation in
the jurisdiction where the dentist practices. Dentists, therefore, are ethically
obliged to identify and report suspected cases of abuse and neglect to the same
extent as they are legally obliged to do so in the jurisdiction where they practice.
Dentists have a concurrent ethical obligation to respect an adult patient’s right to
7
self-determination and confidentiality and to promote the welfare of all patients.
Care should be exercised to respect the wishes of an adult patient who asks that
a suspected case of abuse and/or neglect not be reported, where such a report is
not mandated by law. With the patient’s permission, other possible solutions may
be sought.
Dentists should be aware that jurisdictional laws vary in their definitions
of abuse and neglect, in their reporting requirements and the extent to which
immunity is granted to good faith reporters. The variances may raise potential legal
and other risks that should be considered, while keeping in mind the duty to put
the welfare of the patient first. Therefore a dentist’s ethical obligation to identify
and report suspected cases of abuse and neglect can vary from one jurisdiction to
another.
Dentists are ethically obligated to keep current their knowledge of both identi-
fying abuse and neglect and reporting it in the jurisdiction(s) where they practice.
ADVISORY OPINION
3.F.1. Disruptive Behavior in the Workplace.
Dentists are the leaders of the oral healthcare team. As such, their behavior in
the workplace is instrumental in establishing and maintaining a practice environ-
ment that supports the mutual respect, good communication, and high levels of
collaboration among team members required to optimize the quality of patient
care provided. Dentists who engage in disruptive behavior in the workplace risk
undermining professional relationships among team members, decreasing the
quality of patient care provided, and undermining the public’s trust and confidence
in the profession.
Section 4 PRINCIPLE: JUSTICE (“fairness”). The dentist has a duty to treat people fairly.
This principle expresses the concept that professionals have a duty to be fair in their
dealings with patients, colleagues and society. Under this principle, the dentist’s
primary obligations include dealing with people justly and delivering dental care
without prejudice. In its broadest sense, this principle expresses the concept that the
dental profession should actively seek allies throughout society on specific activities
that will help improve access to care for all.
ADVISORY OPINION
4.A.1. PATIENTS WITH BLOODBORNE PATHOGENS.
A dentist has the general obligation to provide care to those in need. A decision not
to provide treatment to an individual because the individual is infected with Human
8
Immunodeficiency Virus, Hepatitis B Virus, Hepatitis C Virus or another bloodborne
pathogen, based solely on that fact, is unethical. Decisions with regard to the type
of dental treatment provided or referrals made or suggested should be made on
the same basis as they are made with other patients. As is the case with all patients,
the individual dentist should determine if he or she has the need of another’s skills,
knowledge, equipment or experience. The dentist should also determine, after
consultation with the patient’s physician, if appropriate, if the patient’s health
status would be significantly compromised by the provision of dental treatment.
ADVISORY OPINION
4.C.1. MEANING OF “JUSTIFIABLE.”
Patients are dependent on the expertise of dentists to know their oral health
status. Therefore, when informing a patient of the status of his or her oral health,
the dentist should exercise care that the comments made are truthful, informed
and justifiable. This should, if possible, involve consultation with the previous
treating dentist(s), in accordance with applicable law, to determine under what
circumstances and conditions the treatment was performed. A difference of
opinion as to preferred treatment should not be communicated to the patient in a
manner which would unjustly imply mistreatment. There will necessarily be cases
where it will be difficult to determine whether the comments made are justifiable.
Therefore, this section is phrased to address the discretion of dentists and advises
against unknowing or unjustifiable disparaging statements against another dentist.
However, it should be noted that, where comments are made which are not
supportable and therefore unjustified, such comments can be the basis for the
institution of a disciplinary proceeding against the dentist making such statements.
ADVISORY OPINION
4.D.1. CONTINGENT FEES.
It is unethical for a dentist to agree to a fee contingent upon the favorable
outcome of the litigation in exchange for testifying as a dental expert.
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4.E. REBATES AND SPLIT FEES.
Dentists shall not accept or tender “rebates” or “split fees.”
ADVISORY OPINION
4.E.1. SPLIT FEES IN ADVERTISING AND MARKETING SERVICES.
The prohibition against a dentist’s accepting or tendering rebates or split fees
applies to business dealings between dentists and any third party, not just other
dentists. Thus, a dentist who pays for advertising or marketing services by
sharing a specified portion of the professional fees collected from prospective or
actual patients with the vendor providing the advertising or marketing services
is engaged in fee splitting. The prohibition against fee splitting is also applicable
to the marketing of dental treatments or procedures via “social coupons” if
the business arrangement between the dentist and the concern providing the
marketing services for that treatment or those procedures allows the issuing
company to collect the fee from the prospective patient, retain a defined
percentage or portion of the revenue collected as payment for the coupon
marketing service provided to the dentist and remit to the dentist the remainder
of the amount collected.
Dentists should also be aware that the laws or regulations in their jurisdictions
may contain provisions that impact the division of revenue collected from
prospective patients between a dentist and a third party to pay for advertising
or marketing services.
ADVISORY OPINIONS
5.A.1. DENTAL AMALGAM AND OTHER RESTORATIVE MATERIALS.
Based on current scientific data, the ADA has determined that the removal of
amalgam restorations from the non-allergic patient for the alleged purpose of
removing toxic substances from the body, when such treatment is performed
solely at the recommendation of the dentist, is improper and unethical. The
same principle of veracity applies to the dentist’s recommendation concerning
the removal of any dental restorative material.
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recommended or performed by the dentist has the capacity to diagnose, cure or
alleviate diseases, infections or other conditions, when such representations are
not based upon accepted scientific knowledge or research, is acting unethically.
ADVISORY OPINIONS
5.B.1. WAIVER OF COPAYMENT.
A dentist who accepts a third party1 payment under a copayment plan as payment
in full without disclosing to the third party1 that the patient’s payment portion will
not be collected, is engaged in overbilling. The essence of this ethical impropriety
is deception and misrepresentation; an overbilling dentist makes it appear to the
third party1 that the charge to the patient for services rendered is higher than it
actually is.
5.B.2. OVERBILLING.
It is unethical for a dentist to increase a fee to a patient solely because the patient
is covered under a dental benefits plan.
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5.C. DISCLOSURE OF CONFLICT OF INTEREST.
A dentist who presents educational or scientific information in an article, seminar or
other program shall disclose to the readers or participants any monetary or other
special interest the dentist may have with a company whose products are promoted
or endorsed in the presentation. Disclosure shall be made in any promotional material
and in the presentation itself.
ADVISORY OPINIONS
5.D.1. REPORTING ADVERSE REACTIONS.
A dentist who suspects the occurrence of an adverse reaction to a drug or dental
device has an obligation to communicate that information to the broader medical
and dental community, including, in the case of a serious adverse event, the Food
and Drug Administration (FDA).
5.F. ADVERTISING.
Although any dentist may advertise, no dentist shall advertise or solicit patients in
any form of communication in a manner that is false or misleading in any material
respect.3
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ADVISORY OPINIONS
5.F.1. PUBLISHED COMMUNICATIONS.
If a dental health article, message or newsletter is published in print or electronic
media under a dentist’s byline to the public without making truthful disclosure of
the source and authorship or is designed to give rise to questionable expectations
for the purpose of inducing the public to utilize the services of the sponsoring
dentist, the dentist is engaged in making a false or misleading representation to
the public in a material respect.3
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curriculum vitae. In all instances, state law should be consulted. In any review by the
council of the use of designations in advertising to the public, the council will apply
the standard of whether the use of such is false or misleading in a material respect.3
5.F.4. REFERRAL SERVICES.
There are two basic types of referral services for dental care: not-for-profit and
the commercial. The not-for-profit is commonly organized by dental societies or
community services. It is open to all qualified practitioners in the area served. A fee
is sometimes charged the practitioner to be listed with the service. A fee for such
referral services is for the purpose of covering the expenses of the service and
has no relation to the number of patients referred. In contrast, some commercial
referral services restrict access to the referral service to a limited number of
dentists in a particular geographic area. Prospective patients calling the service may
be referred to a single subscribing dentist in the geographic area and the respective
dentist billed for each patient referred. Commercial referral services often advertise
to the public stressing that there is no charge for use of the service and the patient
may not be informed of the referral fee paid by the dentist. There is a connotation
to such advertisements that the referral that is being made is in the nature of a
public service. A dentist is allowed to pay for any advertising permitted by the
Code, but is generally not permitted to make payments to another person or entity
for the referral of a patient for professional services. While the particular facts and
circumstances relating to an individual commercial referral service will vary, the
council believes that the aspects outlined above for commercial referral services
violate the Code in that it constitutes advertising which is false or misleading in a
material respect and violates the prohibitions in the Code against fee splitting.3
ADVISORY OPINION
5.G.1. DENTIST LEAVING PRACTICE.
Dentists leaving a practice who authorize continued use of their names should
receive competent advice on the legal implications of this action. With permission
of a departing dentist, his or her name may be used for more than one year, if, after
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the one year grace period has expired, prominent notice is provided to the public
through such mediums as a sign at the office and a short statement on stationery
and business cards that the departing dentist has retired from the practice.
GENERAL STANDARDS.
The following are included within the standards of the American Dental Association
for determining the education, experience and other appropriate requirements for
announcing specialization and limitation of practice:
1. The special area(s) of dental practice and an appropriate certifying board must be
approved by the American Dental Association.
2. Dentists who announce as specialists must have successfully completed an
educational program accredited by the Commission on Dental Accreditation, two or
more years in length, as specified by the Council on Dental Education and Licensure,
or be diplomates of an American Dental Association recognized certifying board.
The scope of the individual specialist’s practice shall be governed by the educational
standards for the specialty in which the specialist is announcing.
3. The practice carried on by dentists who announce as specialists shall be limited
exclusively to the special area(s) of dental practice announced by the dentist.
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ADVISORY OPINIONS
5.H.1. DUAL DEGREED DENTISTS.
Nothing in Section 5.H shall be interpreted to prohibit a dual degreed dentist who
practices medicine or osteopathy under a valid state license from announcing to
the public as a dental specialist provided the dentist meets the educational, expe-
rience and other standards set forth in the Code for specialty announcement and
further providing that the announcement is truthful and not materially misleading.
5.H.2. SPECIALIST ANNOUNCEMENT OF CREDENTIALS IN NON-SPECIALTY
INTEREST AREAS.
A dentist who is qualified to announce specialization under this section may not
announce to the public that he or she is certified or a diplomate or otherwise
similarly credentialed in an area of dentistry not recognized as a specialty area
by the American Dental Association unless:
1. The organization granting the credential grants certification or diplomate
status based on the following: a) the dentist’s successful completion of a formal,
full-time advanced education program (graduate or postgraduate level) of at least
12 months’ duration; and b) the dentist’s training and experience; and c) successful
completion of an oral and written examination based on psychometric principles;
and
2. The announcement includes the following language: [Name of announced area
of dental practice] is not recognized as a specialty area by the American Dental
Association.
Nothing in this advisory opinion affects the right of a properly qualified dentist
to announce specialization in an ADA-recognized specialty area(s) as provided
for under Section 5.H of this Code or the responsibility of such dentist to limit
his or her practice exclusively to the special area(s) of dental practice announced.
Specialists shall not announce their credentials in a manner that implies specializa-
tion in a non-specialty interest area.
5.I. GENERAL PRACTITIONER ANNOUNCEMENT OF SERVICES.
General dentists who wish to announce the services available in their practices are
permitted to announce the availability of those services so long as they avoid any
communications that express or imply specialization. General dentists shall also state
that the services are being provided by general dentists. No dentist shall announce
available services in any way that would be false or misleading in any material respect.3
ADVISORY OPINIONS
5.I.1. GENERAL PRACTITIONER ANNOUNCEMENT OF CREDENTIALS
IN INTEREST AREAS IN GENERAL DENTISTRY.
A general dentist may not announce to the public that he or she is certified or a
diplomate or otherwise similarly credentialed in an area of dentistry not recognized
as a specialty area by the American Dental Association unless:
1. The organization granting the credential grants certification or diplomate
status based on the following: a) the dentist’s successful completion of a formal,
full-time advanced education program (graduate or postgraduate level) of at least
12 months duration; and b) the dentist’s training and experience; and c) successful
completion of an oral and written examination based on psychometric principles;
2. The dentist discloses that he or she is a general dentist; and
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3. The announcement includes the following language: [Name of announced area
of dental practice] is not recognized as a specialty area by the American Dental
Association.
5.I.2. credentials in general dentistry.
General dentists may announce fellowships or other credentials earned in the
area of general dentistry so long as they avoid any communications that express
or imply specialization and the announcement includes the disclaimer that the
dentist is a general dentist. The use of abbreviations to designate credentials shall
be avoided when such use would lead the reasonable person to believe that the
designation represents an academic degree, when such is not the case.
NOTES:
1. A third party is any party to a dental prepayment contract that may collect premiums, assume financial
risks, pay claims, and/or provide administrative services.
2. A full fee is the fee for a service that is set by the dentist, which reflects the costs of providing the
procedure and the value of the dentist’s professional judgment.
3. Advertising, solicitation of patients or business or other promotional activities by dentists or dental
care delivery organizations shall not be considered unethical or improper, except for those promotional
activities which are false or misleading in any material respect. Notwithstanding any ADA Principles of
Ethics and Code of Professional Conduct or other standards of dentist conduct which may be differently
worded, this shall be the sole standard for determining the ethical propriety of such promotional activities.
Any provision of an ADA constituent or component society’s code of ethics or other standard of dentist
conduct relating to dentists’ or dental care delivery organizations’ advertising, solicitation, or other
promotional activities which is worded differently from the above standard shall be deemed to be in
conflict with the ADA Principles
of Ethics and Code of Professional Conduct.
4. Completion of three years of advanced training in oral and maxillofacial surgery or two years
of advanced training in one of the other recognized dental specialties prior to 1967.
A
Abandonment, 6
Ability to practice (2.D.1.), 6
Abuse and neglect, 7
Abuse and neglect (reporting) (3.E.1.), 7
Adverse reactions (reporting) (5.D.1.), 12
Advertising, 12
Credentials
general dentistry (5.I.2.), 17
interest areas, general dentistry (5.I.1.), 16
non-specialty interest areas, specialist (5.H.2.), 16
nonhealth (5.F.3.), 13
unearned (5.F.3.), 13
honorary (5.F.3.), 13
membership and other affiliations (5.F.3.), 13
specialty, 15
Dual degrees (5.H.1.), 16
False and misleading (examples) (5.F.2.), 13
General dentists, 17
HIV test results (5.F.5), 14
Honorary degrees (5.F.3.), 13
Infectious disease test results (5.F.5.), 14
Name of practice, 14
Non-specialty interest areas (5.H.2. and 5.I.1.), 16
Published communications (5.F.1.), 13
Referral services (5.F.4.), 14
Services, 16
Specialties, 15
Unearned, nonhealth degrees (5.F.3.), 13
Advisory opinions (definition), 3
Amalgam and other restorative materials (5.A.1.), 10
Announcement of specialization and limitation of practice, 15
Autonomy (patient), 4
Auxiliary personnel, 6
B
Beneficence, 7
Billing, 11
Bloodborne pathogens, exposure incident, 6
Bloodborne pathogens, patients with (4.A.1.), 9
C
Code of professional conduct (definition), 3
Community service, 7
Confidentiality of patient records (1.B.2.), 4
Conflict of interest, disclosure, 12
Consultation and referral, 5
18
Copayment, waiver of (5.B.1.), 11
Copyrights and patents, 7
Credentials (see advertising)
D
Degrees (advertising) (5.F.3. and 5.H.1.), 13, 16
Dental amalgam and other restorative materials (5.A.1.), 10
Dental procedures, fees (5.B.5.), 11
Dentist leaving practice (5.G.1.), 14
Devices and therapeutic methods, 12
Disclosure, conflict of interest, 12
Disruptive behavior (3.F.1.), 8
Dual degreed dentists (5.H.1.), 16
E
Education, 5
Emergency service, 9
Expert testimony, 9
F
False and misleading advertising, examples (5.F.2.), 13
Fees
contingent (4.D.1.), 9
differential (5.B.3.), 11
rebates, 10, 14
representation, 11
split, 10, 14
Furnishing copies of records (1.B.1.), 4
G
General practitioner announcement of credentials (5.I.1.), 16
General practitioner announcement of services, 16
General standards (for announcement of specialization and limitation of practice), 15
Government of a profession, 7
Gross or continual faulty treatment (reporting), 9
H
HIV positive patients (4.A.1.), 9
HIV post-exposure obligations, 6
HIV test results (advertising) (5.F.5.), 14
I
Impaired dentist, 6
Infectious disease test results (5.F.5.), 14
Interpretation and application of Principles of Ethics and Code of Professional Conduct, 17
19
J
Justifiable criticism, 9
Justifiable criticism (meaning of “justifiable”) (4.C.1.), 9
Justice, 8
L
Law (and ethics), 3
Limitation of practice, 15
M
Marketing or sale of products or procedures (5.D.2.), 12
N
Name of practice, 14
Nonhealth degrees, advertising (5.F.3.), 13
Nonmaleficence, 5
O
Overbilling (5.B.2.), 11
P
Patents and copyrights, 7
Patient abandonment, 6
Patient autonomy, 4
Patient involvement, 4
Patient records, 4
confidentiality (1.B.2.), 4
furnishing copies (1.B.1.), 4
Patient selection, 8
Personal impairment, 6
Personal relationships with patients, 6
Practice
ability to (2.D.1.), 6
dentist leaving (5.G.1.), 14
name of, 14
Preamble, 3
Principles of ethics (definition), 3
Principles
beneficence, 7
justice, 8
nonmaleficence, 5
patient autonomy, 4
veracity, 10
20
Procedures (marketing or sale) (5.D.2.), 12
Products (marketing or sale) (5.D.2.), 12
Professional announcement, 12
Professional demeanor, 8
Published communications (5.F.1.), 13
R
Rebates and split fees, 10, 14
Records (patient), 4
confidentiality (1.B.2.), 4
furnishing copies (1.B.1.), 4
Referral, 5
Referral services (5.F.4.), 14
Reporting
abuse and neglect (3.E.1), 7
adverse reactions (5.D.1.), 12
gross and continual faulty treatment, 9
personal impairment, 6
Representation of care, 10
Representation of fees, 11
Research and development, 7
S
Sale of products or procedures (5.D.2.), 12
Second opinions (2.B.1.), 5
Specialist (announcement and limitation of practice), 15
Specialist (announcement of credentials in non-specialty interest areas) (5.H.2.), 16
Split fees, 10, 14
Standards for multiple-specialty announcements, 15
T
Treatment dates (5.B.4.), 11
Therapeutic methods, 12
U
Unearned, nonhealth degrees (5.F.3.), 13
Unnecessary services (5.B.6.), 11
Unsubstantiated representations (5.A.2.), 10
Use of auxiliary personnel, 6
V
Veracity, 10
W
Waiver of copayment (5.B.1.), 11
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American Dental Association
Council on Ethics, Bylaws and Judicial Affairs
211 East Chicago Avenue
Chicago, Illinois 60611