12.5 Standard of Care: Overtreatment, Unnecessary Treatment, and Undertreatment
Key Takeaways
California B&P § 1685 makes it unprofessional conduct to require or allow, directly or through office policy, clearly excessive or unnecessary treatment, or care that discourages necessary treatment.
Clearly excessive prescribing, treatment, or diagnostic procedures is unprofessional conduct and a misdemeanor under California B&P § 1680(p).
California B&P § 725 makes repeated acts of clearly excessive treatment or diagnostic procedures unprofessional conduct for dentists.
ADA Advisory Opinion 5.B.6 says recommending or performing unnecessary services is unethical regardless of practice arrangement or contract.
The CDA Code, Section 1C, says it is unethical for a dentist to render, or cause to be rendered, substandard care.
Definitions (K2172, K2173)
- Standard of care: what a reasonably careful dentist would do in the same or similar circumstances. Negligence falls short of it, and gross negligence is an extreme departure from it.
- Unnecessary treatment: treatment no diagnosis supports. Examples include restoring sound teeth, replacing intact restorations without cause, or scaling and root planing healthy periodontium.
- Overtreatment: treatment beyond what the diagnosed condition reasonably requires. Examples include crowns where conservative restorations would do, full-mouth rehabilitation when targeted care would meet the patient's goals, or radiographs more often than the patient's risk warrants.
- Undertreatment: failing to recommend or provide necessary care, sometimes driven by capitation or cost. The law treats this seriously too.
The law
| Provision | Rule |
|---|---|
| B&P § 1685 | Unprofessional conduct for a licensee to require, directly or through an office policy, or knowingly permit care that discourages necessary treatment or permits clearly excessive, incompetent, grossly negligent, repeatedly negligent, or unnecessary treatment, judged by the standard of practice in the community |
| B&P § 1680(p) | Clearly excessive prescribing or administering of drugs or treatment, or clearly excessive use of diagnostic procedures or facilities, judged by the dental profession's customary standards, is unprofessional conduct and a misdemeanor ($100–$600 fine and/or 60–180 days in jail) |
| B&P § 725 | Repeated acts of clearly excessive prescribing, treatment, or diagnostic procedures are unprofessional conduct for a dentist, and repeated excessive prescribing or treatment is a misdemeanor |
| B&P § 1670 | Incompetence, gross negligence, or repeated negligent acts are grounds for discipline |
| B&P § 810 / Penal Code § 550 | Billing an insurer for unnecessary services as if necessary is a false claim |
§ 1685 reaches owners and managers. A dentist-owner who sets production quotas that push associates to diagnose more crowns, or a policy that bonuses staff for selling treatment regardless of need, can be disciplined even if the owner never touched the patient. It also covers the opposite case: an office policy that discourages necessary but poorly reimbursed care.
The ethics codes
- ADA 5.B.6: recommending or performing unnecessary services is unethical, "regardless of the type of practice arrangement or contractual obligations."
- ADA Section 3 (Beneficence): contract obligations "do not excuse dentists from their ethical duty to put the patient's welfare first."
- ADA 5.A (Representation of Care): don't misrepresent the care being provided.
- CDA 1C: it is unethical to render, or cause to be rendered, substandard care, and CDA defines standards of care where the law does not.
- ADA 2.A: keep knowledge and skills current so that recommendations reflect current evidence.
Keeping recommendations honest
- Diagnosis first. Every treatment item should trace to a charted finding: a radiograph, probing depth, fracture line, or symptom.
- Use evidence-based thresholds. Consider caries risk, periodontal classification, and radiograph selection criteria based on the patient's individual risk, not a fixed schedule.
- Offer the conservative option. Present less invasive alternatives, including monitoring, alongside more extensive ones (Section 10.4).
- Don't let pay rules drive diagnosis. Associates facing quotas can document their reasoning, decline to diagnose unsupported treatment, and raise concerns. Firing an employee for trying to comply with the Dental Practice Act is itself unprofessional conduct (§ 1680(q)).
- Welcome second opinions on large treatment plans (ADA 2.B.1).
- Review your own patterns. A sudden rise in root canals per new patient, or in quadrant scaling on every adult, should prompt self-review.
Diagnostic procedures count too
Section 1680(p) and § 725 reach the "clearly excessive use of diagnostic procedures," not just treatment. Taking full-mouth radiographs at every visit regardless of risk, repeating cone-beam CT without a clinical question, or ordering tests that will not change management all expose patients to cost and, for imaging, radiation without benefit. The ADA and FDA's radiographic selection recommendations tie imaging to each patient's history, risk, and clinical findings. Following them, and charting why each image was taken, is the best defense.
How excessive treatment is judged
In a Board investigation, a dental consultant or expert compares the records with the standard of practice in the community. Did the findings support the diagnosis? Was the chosen treatment within the range reasonable dentists would select? Were alternatives offered? Thin documentation makes appropriate treatment look excessive, so the records should show the evidence behind every recommendation.
Worked scenario
A dental support organization's management contract sets a monthly production target for each associate, and a regional manager emails associates a list of patients with "unscheduled treatment" to "convert." An associate finds that several listed "crowns" are for teeth with small, arrested lesions.
- The associate must not perform unnecessary crowns (ADA 5.B.6; B&P § 1680(p)), and should document her own diagnosis and the conservative plan.
- Any licensee who requires unnecessary treatment through an office policy, or knowingly permits it, commits unprofessional conduct under § 1685. An unlicensed manager who directs clinical decisions may also be practicing dentistry without a license (§ 1625(e)).
- The associate may raise the concern with the owner, and a Board complaint is available if the practice continues.
A practice owner adopts a policy that every adult new patient must be scheduled for quadrant scaling and root planing, regardless of periodontal findings. Which statute most directly makes this unprofessional conduct?
B&P § 1611.5, which governs Board inspections
B&P § 680, which requires name tags
B&P § 1685, which prohibits requiring, through an office policy, clearly excessive or unnecessary treatment
Health and Safety Code § 123110, which governs records access
A dentist in a capitation plan tells patients who need root canals that "extraction is the only option," because endodontics pays poorly under the plan. Which statement is correct?
It is acceptable, because the plan's reimbursement controls clinical options
It is acceptable, if the patient signs a consent for extraction
It is required, because capitation plans prohibit referral
This may violate B&P § 1685, which also prohibits policies or care that discourage necessary treatment, and the duty to present reasonable alternatives
What makes clearly excessive treatment a crime, not only a disciplinary matter, under the Dental Practice Act?
Clearly excessive treatment is only an ethics violation
B&P § 1680(p) makes it a misdemeanor punishable by a $100–$600 fine and/or 60–180 days in jail
It becomes a crime only if the patient dies
It becomes a crime only if billed to Medi-Cal
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