Chapter

7

Ethical Considerations in Dentistry

Jonathan Rudin, DDS, MS, MPH

Treat your patients as you would like to be treated, you are a potential patient!

Dr. Olugbenga Ogunlewe, Lagos, Nigeria

Introduction

What can help create a good night’s sleep for you as a dentist? I would suggest that when you believe you are doing right by both your patients and yourself, you would be going far to ensure profound rest and pleasant dreams. What do I mean by “doing right by the patient?” You can answer that by asking yourself if the treatment you provide coincides with what you believe to be in your patients’ best interest. And what is meant by “doing right by yourself?” That is answered in part by your belief that you are earning a good living.

This chapter deals with the first part of the formula for sleeping well at night. Doing right by your patients—that is, practicing dentistry in an ethical way. This practice entails listening to your patients about what is important to them, addressing their expressed needs, educating them about what dentistry can offer to fulfill their desires, honoring informed consent, and delivering the highest quality service possible.

Everyone has faced and will face ethical challenges. I offer a framework for ethical practice, developed from my own experience over years of practice. First, I’ll present several true scenarios from my professional experience that I found to be ethically challenging. Then, I will introduce you to an ethical practice framework and illustrate it with a simple but realistic example. Before getting started, however, I want to provide insight into an underlying belief that I think is all too common in our profession and presents a considerable challenge to ethical practice:

Table 7.1 Relationships Between Ability to Make a Comfortable Living and Providing Ethical Patient Care

To make a comfortable living, dentists must make ethical compromises in patient care.

It may be tempting to think that to make a lot of money, a dentist needs to cut corners. In other words, to practice in an ethical way will lead to struggling financially. I invite you to consider the idea that it is not only possible to make a comfortable living practicing in an ethical way but is actually the only way to do so in the long run. These choices are illustrated in Table 7.1.

Ethical Challenges—Real-World Examples

The following examples of ethical challenges in dentistry are taken from my own experience with the exception of the last example. As you read through these vignettes, consider how you would handle similar situations.

Language Barrier

While staffing at a community clinic, I examined Ms. Nguyen, who did not speak English. She pointed to her lower anterior bridge, which was so mobile I was surprised it was still in her mouth. I planned to extract the abutment teeth. I administered local anesthetic and wanted to verify that my patient would be comfortable for the extraction. I summoned the supervisor for help in assessing the adequacy of anesthesia. He told me that everyone understands the word “pain.” Consequently, he yelled (in English) “Are you in PAIN???” The patient, saying nothing, looked bewildered as her eyes darted back and forth between us. The supervisor turned to me and said (as though the conclusion he was about to state was patently obvious), “See? She’s not in pain.” I wondered how in the world he could know that. I extracted the teeth despite being unsure that my patient was comfortable. In hindsight, I recognize that, among other things, informed consent had not been obtained for this procedure.

How would you handle a similar situation?

Obligating a Patient to Follow Through on Full Mouth Reconstruction

As a contractor in a general dental practice, I was assigned to Mr. Jones and told that he had agreed to full mouth reconstruction. Before Mr. Jones could leave the office, the owner dentist asked me to quickly prep all the teeth and place temporary crowns on them. When I responded that prepping the teeth was an involved process and I would need a significant amount of time to accomplish that, the owner stated that all I needed to do was a 30-second prep on each tooth. He acknowledged that the preps would be rough but they would be refined at future appointments. I asked the owner why he wanted me to buzz down all the teeth in this way. He stated that initiating irreversible treatment on a large scale would obligate Mr. Jones to follow through on his decision to have full mouth reconstruction—it would prevent him from backing out. I told the owner that I was uncomfortable with his request and left that practice soon afterward.

How would you respond to a similar request?

Keeping the Patient Flow Moving

While working in a military clinic, I was assigned Recruit Smith and told to restore tooth #20 with an amalgam crown—essentially an MODFL restoration placed on a tooth following root canal treatment. An amalgam crown typically entails removing gutta percha from the occlusal two-thirds of the root, cementing a pin into the prepared root canal space, shaping the remaining coronal structure, placing amalgam, and carving the amalgam to correct anatomical and functional form. This time-consuming process is not easily reversed if retreatment of the root canal filling becomes necessary.

Typically, when faced with placing a coronal restoration following root canal treatment (especially when a post would be cemented in the root canal space), I examine the tooth to make sure that it is asymptomatic. This practice is to rule out the persistence of pulpal or periapical pathology. When I tapped on tooth #20, Recruit Smith virtually jumped out of the chair—indicating that further evaluation of the root canal and possible retreatment were needed. On reporting this finding, the managing dentist complained about the patient flow being slowed down and insisted that I comply with his request. I responded that I could not in good conscience put the patient’s well being at risk. So, the managing dentist reassigned Recruit Smith to another dentist, who placed the amalgam crown on tooth #20 as ordered. Recruit Smith was deployed soon thereafter and essentially relegated to experience whatever symptoms associated with unresolved pathology might arise—whenever and wherever that may occur, including while engaged in military action.

How would you respond to orders similar to those I received?

Fast-Paced Community Dental Clinic

As mentioned in the first example, a community clinic setting can present ethical challenges. The pace of work can be so intense that certain important responsibilities are not addressed as they should be. In the case of one such clinic, the managing dentist told the dental staff to prevent complaints from the patients and we had to work at such a pace that there was inadequate time to update the medical history, do a full examination and treatment plan, obtain informed consent, and provide treatment. Despite the managing dentist’s request to speed things up, I chose to take the time necessary to comply with all necessary steps before treating the patient. As a result, the manager reprimanded me for taking too much time per patient. Later on, I learned that had I not obtained informed consent for the procedures I performed, I could have been charged with assault and battery.

How would you handle a similar situation?

Nitrous Oxide for Everyone

I interviewed for a contractor position at a private practice office and noticed, while I was at that facility, that every patient presenting for treatment was given nitrous oxide—even those having dentures delivered. When I asked about this practice, the owner told me that giving nitrous oxide to everyone increased the chances that they would come back for further treatment and that it created a great referral source. I chose not to work in this office.

How would you handle a similar situation?

Maximizing Cash Flow

In his first year out of dental school, one of my classmates worked for another dentist. He was assigned to do root canal treatment on retained roots. Soon afterward, he discovered that these roots were extracted. He subsequently learned that the practice owner’s intention was never to rehabilitate those teeth but to maximize the income that could be generated by their being treated in multiple ways—with no benefit to the patient yet with all the risks associated with the dental treatment.

How would you respond to a similar situation?

Now that I’ve presented some of the ethical situations that challenged either me or my classmate, I will present a framework that I have conceptualized over time that has provided me with the ethical foundation for my practice. I will demonstrate a simple tool, the Importance-Performance Analysis, which you can use right away in the treatment planning phase of your practice. The following section will show you how the treatment planning phase fits into the greater context of what we do as dentists.

What We Do for Our Patients: Diagnosis, Treatment Planning, and Treatment

Essentially, when we see a patient, we can engage in 3 main activities: (1) the Diagnostic Phase, (2) the Treatment Planning Phase, and (3) the Treatment Phase. Each phase is based on the preceding step. Yet, these steps are totally distinct as far as execution is concerned. For example, consider a patient whom you diagnosed as being completely edentulous. Once you have arrived at that straight forward diagnosis, you can choose to present a treatment plan—or not. And following the treatment plan presentation, you may choose to provide the treatment itself—or not. It should be clear that there is nothing inherent in any one step that obligates you to move on to the next step. Your ability and willingness to refer a patient for whatever reason can be quite liberating (and contribute to sleeping well at night). The first two parts of this sequence, the Diagnostic and Treatment Planning phases, are discussed below. The third phase, Treatment, is beyond the scope of this chapter.

Diagnostic Phase

The diagnosis is arrived by collecting information during the following six steps:

1. Chief complaint
2. History of present illness
3. Medical history
4. Social history
5. Clinical examination
6. Adjunctive diagnostic examinations and testing

Chief Complaint

This term is borrowed from the symptom-reactive practices of our medical colleagues, where patients seek relief for an ailment. Dental patients may not be aware of any particular ailment. Thus, their Chief Complaint can range from an asymptomatic, “Doc, I think I’m OK but can you tell me how am I doing?” to a very symptomatic, “Doc, I have this horrible pain in my upper right molar!” You would record what the patients say in their own words as the Chief Complaint.

History of Present Illness

This step is also borrowed from medicine. In this step, you would elicit details about the Chief Complaint such as duration of pain, initiating factors, such as hot or cold temperatures, the character of the pain, and so on. You would record the patient’s answers to your questions in the oral health record.

Medical History

This step is necessary for all evaluations. The Medical History essentially reviews all the physiological systems (e.g., cardiovascular, neurologic, gastrointestinal, etc.), medications being taken, allergies to medications and other agents (e.g., latex), and surgical history. The Medical History also covers patient symptoms (e.g., weight gain/loss, chest pain, etc.) that may be indicative of undiagnosed and/or poorly controlled illnesses (e.g., diabetes and heart disease).

Social History

This step is a summary of lifestyle practices that may have an effect on your patients’ health. These practices can include occupation, habits such as alcohol, drug use, and smoking, interests/hobbies, diet, and exercise. It is also important to note communication issues such as hearing, visual and cognitive impairments, language barriers, and preferred communication style (e.g., verbal, visual, auditory, and kinesthetic).

Clinical Examination

In this step, you would look for clues that would help arrive at a diagnosis. Optimally, the Clinical Examination is comprehensive; you would examine everything in the oral cavity, head, and neck areas avoiding focusing initially on the patient’s Chief Complaint. The information gathered is primarily visual, but may also be tactile (e.g., fluctuant vs. indurated swelling) and auditory (dull vs. resonant sound when tapping on a tooth). During the Clinical Examination, the decision about the need for adjunctive diagnostic examinations and testing is made.

Adjunctive Diagnostic Examinations and Testing

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