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What Are My Ethical Obligations When I Learn That My Local Dental Laboratory Has Been Subcontracting With Offshore Laboratories Without My Knowledge?

2013; Elsevier BV; Volume: 144; Issue: 10 Linguagem: Inglês

10.14219/jada.archive.2013.0039

1943-4723

Ethan A. Pansick,

Dental Implant Techniques and Outcomes

Q I have been using the same local dental laboratory to fabricate years with great success. I have a good relationship with the laboratory owner. Last week, I received a package containing laboratory work and noticed an invoice showing that my local laboratory had sent my work to an offshore laboratory for completion. Although I specified high-noble gold alloy for the fixed bridge on my laboratory prescription, the offshore laboratory invoice contained no such itemization. In fact, although my laboratory charges me by the pennyweight for precious metals, the offshore laboratory just listed a flat fee that was far too low to include precious metal. I telephoned the owner of the local laboratory and expressed my dismay. The owner told me that he had been sending all of his work to subcontractor laboratories since the economic downturn had forced him to lay off most of his employees. At this point, I realized that I faced a significant ethical dilemma. I had told my patients that they had received porcelain-fused-to-high-noble-alloy prostheses when, in fact, I had no idea what kind of alloy actually had been used. In addition, I submitted dental insurance claims for high-noble alloys. While I want to give my patients the best possible treatment and highest-quality prostheses, is it necessary for me to notify them of this issue if they are not experiencing any obvious problems with their crowns and bridges? Removing and remaking all of the prostheses fabricated by the laboratory would be a huge financial and time burden for my patients and my practice. What should I do? A You are faced with a dilemma. The American Dental Association Principles of Ethics and Code of Professional Conduct1American Dental Association American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar (ADA Code) will help you determine your ethical responsibility. The first issue that must be addressed relates to Section 2, Principle of Nonmaleficence (“do no harm”). The dentist has a duty to refrain from harming the patient. Because these prostheses may contain impure alloys, it is possible that the patient may be at risk. Because the metallurgic content of the alloy is unknown, there is potential for allergic reaction, greening of porcelain and undesirable soft-tissue reaction adjacent to these prostheses. Section 5, Principle of Veracity (“truthfulness”), also applies to your situation. “The dentist has a duty to communicate truthfully.”1American Dental Association American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar Given that your patient expected one thing and actually received something else, you may be required to discuss this with him or her. “Under this principle, the dentist’s primary obligations include respecting the position of trust inherent in the dentist-patient relationship, communicating truthfully and without deception, and maintaining intellectual integrity.”1American Dental Association American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar If you have concerns about the safety of the prosthesis, you should discuss this with the patient and make appropriate recommendations about replacing the prosthesis. You should inform your affected patients that the alloy used in their prostheses may not, in fact, be what had been specified when the treatment was performed. In doing so, you may have several options, including offering to monitor the clinical appearance of these prostheses and remove and remake them if allergic reactions or unfavorable soft-tissue responses are detected in the future. You also should give your patients the option of having the prostheses removed and replaced if they are uncomfortable in taking a wait-and-see approach. Another issue relating to veracity that you may need to address has to do with your obligations to third-party payers. Section 5.B.5, Dental Procedures, states a dentist who incorrectly describes on a third party claim form a dental procedure in order to receive a greater payment or reimbursement or incorrectly makes a non-covered procedure appear to be a covered procedure on such a claim form is engaged in making an unethical, false or misleading representation to such third party.1American Dental Association American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar This ethical principle may apply in this situation if you filed dental insurance forms for high noble–alloy prostheses when other types of alloys actually were used. With the assistance of your attorney, you should send a letter to the third-party payers involved, detailing what has occurred. Your attorney also can assist in negotiating with the affected insurance companies once the discrepancy in reporting has been disclosed. The dental laboratory and dental laboratory technician are integral to the dental partnership that delivers excellence to our patients each and every day. Like all good relationships, a foundation of trust and respect is needed for this partnership to succeed and flourish. Dentists and their laboratory technicians should have an open dialogue regarding how and where their work is fabricated so that incidents such as the one you describe are not repeated.