DENTISTRY

Most dentists in the United States practice as independent entrepreneurs either individually or in small groups. Nevertheless, dental care generally is not viewed as an ordinary commodity in the marketplace. Instead, the vast majority of dentists and most people in the larger community think of dentistry as a profession. That is, they consider dental care to be a component of healthcare and consider dentists to be experts in the relevant knowledge and skills, committed individually and collectively as professionals to giving priority to their patients' well-being as they practice their expertise. Consequently, when a person becomes a dentist, he or she makes a commitment to the larger community and accepts the obligations and ethical standards of the dental profession. Those obligations and standards are the subject matter of the subdiscipline called dental ethics.

Ethical Dilemmas

Because dentists rarely make life-or-death decisions, some people are unaware that the professional obligations of dentists require careful study. Important human values are at stake in dental care: relieving and preventing intense pain as well as less intense pain and discomfort; preserving and restoring patients' oral function, on which both nutrition and speech depend; preserving and restoring patients' physical appearance; and preserving and restoring patients' control over their bodies. These matters are important, and as a result dentists who are committed to responding to them in accordance with ethical standards often face complex questions.

Ethical dilemmas such as the following are faced regularly by almost every dentist:

1. When examining a new patient, a dentist finds evidence of poor earlier dental work. What should the dentist say to the patient? Should the dentist contact the previous dentist to discuss the matter? Should the dentist contact the local dental society?
2. May a dentist ethically advertise that his or her practice will produce "happy smiles" as well as quality dental care, or is such advertising false or significantly misleading?
3. May a dentist tell a patient that the patient's teeth are unattractive with a view to recommending aesthetic treatment when the patient has not asked for an opinion and has indicated no displeasure with his or her appearance?
4. May a dentist ethically decline to treat a patient with a highly infectious disease? What obligations does the dentist have regarding the information that this patient is a carrier of infection?
5. How should a dentist deal with an adult patient who cannot participate fully in making decisions about about care? Do treatment considerations depend on the reason for that inability? What should a dentist do when the guardian of a minor or an incompetent adult patient refuses to approve the best kind of therapy?
6. What may a dentist do to obtain cooperative behavior from a young or developmentally disabled patient who needs dental care but is uncontrollable in the chair?
7. What obligations does a dentist have and to whom when that dentist learns that another dentist is substance-dependent in a manner that probably affects the care he or she is providing?

Issues and Themes in Dental Ethics

The specific requirements of a dentist's ethical commitments in any aspect of professional practice depend on the specific facts and circumstances of the situation. However, the principal categories of dentists' professional obligations can be surveyed under nine headings:

1. Who are dentistry's chief clients?
2. What is the ideal relationship between a dentist and a patient?
3. What are the central values of dental practice?
4. What are the norms of competence for dental practice?
5. What sacrifices is a dentist professionally committed to, and in what respects do obligations to the patient take priority over other morally relevant considerations?
6. What is the ideal relationship between dentists and coprofessionals?
7. What is the ideal relationship between dentists, both individually and collectively, and the larger community?
8. What should members of the dental profession do to make access to the profession's services available to all those who need them?
9. What are members of the dental profession obligated to do to preserve the integrity of their commitment to its professional values and educate others about them?

THE CHIEF CLIENT. For every profession there is a person or set of persons whose well-being the profession and its members are committed to serving. The patient in the dental chair is the most obvious chief client of a dentist, but dentists also have professional obligations to the patients in the waiting room and all their patients of record, to patients who present with emergency needs, and arguably to the entire larger community, especially in matters of public health. The relative weight of a dentist's obligations to each of these entities when those obligations come into conflict ordinarily is considered to favor the patient in the chair over the others, but comparative judgments of the respective degrees of need also must be made.

THE IDEAL RELATIONSHIP BETWEEN PROFESSIONAL AND PATIENT. What is the proper relationship between the dentist and the patient in the chair as they make judgments and choices about the patient's care? There are a number of different ways of conceiving this ideal relationship when it involves the dentist and a fully competent adult: with the dentist alone making the judgment that determines action, with the judgment resting with the patient alone, and with the judgment shared by both parties.

Since the late 1960s the accepted norm of dental practice in the United States has shifted toward the third type of relationship: shared judgment and shared choice regarding treatment. The legal doctrine of informed consent identifies a minimum standard of shared decision making for dentists and their patients, but it is important to ask whether informed consent fully expresses the ideal relationship between a dentist and a fully capable patient (Segal and Warner; Ozar, 1985; Hirsch and Gert; Ozar and Sokol, 2002).

What is the appropriate relationship between the dentist and a patient who cannot participate fully in treatment decisions? What is the dentist's proper role in this relationship? What is the role of the patient up to the limit of the patient's capacity to participate? What is the proper role of other parties?

In practice most dentists depend on choices made by the parents and guardians of such patients when they are available and when these choices do not involve significant harm to the patients' oral or general health. However, there is no clear consensus about how dentistry should proceed when these conditions are absent. The dental ethics literature has begun a careful discussion of the dentist's relationship with patients of diminished capacity or no capacity for decision making (Bogert and Creedon; Ozar and Sokol, 2002).

A HIERARCHY OF CENTRAL VALUES. Regardless of many professions' rhetoric on the subject, no profession can be expert in fostering the complete well-being of those it serves. There is instead a certain set of values that are the appropriate focus of each profession's particular expertise. These values can be called the central values of that profession. They determine and/or establish parameters for most aspects of a professional's judgments in practice. They are the criteria by which a person is judged to need professional assistance in the first place and by which that need is judged to have been met properly through the professional's intervention.

What, then, are the central values of dental practice, and if there is more than one, how are those central values ranked? One proposal is that the central values of the dental profession are, in the following order:

1. the patient's life and general health;
2. the patient's oral health, which is understood as appropriate and pain-free oral functioning;
3. the patient's autonomy—to the extent that the patient is capable of exercising it—over what happens to his or her body (including the patient's ranking of health, comfort, cost, aesthetic considerations, and other values);
4. preferred patterns of practice on the part of the dentist (including differing philosophies of dental practice);
5. aesthetic considerations from the point of view of skilled dental practice and from the point of view of patients' aesthetic values; and
6. considerations of efficiency, which may include considerations of cost, from the dentist's point of view. (Ozar and Sokol, 2002)

A particular dental intervention may achieve each of these values to a greater or lesser degree, and each value is more or less urgent for a particular patient. The ethical dentist takes the details of each situation into account and attempt to maximize dentistry's central values in accordance with their ranked priority in every encounter with every patient.

COMPETENCE. Every professional is obligated to acquire and maintain the expertise required to undertake his or her professional tasks. Every professional also is obligated to undertake only the tasks that are within his or her competence. Consequently, dentists must be constantly attentive to whether they have sufficient competence to make each specific diagnosis and perform each particular procedure for each patient in light of the clinical circumstances, especially when this involves something nonroutine.

Of necessity the dental community, not the community at large, determines the details of standards of competence because doing this requires dental expertise. However, the larger community is justified in demanding an explanation of the reasoning involved, especially regarding the trade-offs between quality of care and access to care that the setting of such standards inevitably involves.

SACRIFICE AND THE RELATIVE PRIORITY OF THE PATIENT'S WELL-BEING. Most sociologists who study professions and most of the literature of professions speak of "commitment to service" or "commitment to the public" as one of the characteristic features of a profession. Dentistry's self-descriptions are similar in this respect, but these expressions allow many different interpretations with different implications for practice. What sorts of sacrifices, for example, are dentists professionally committed to make for the sake of their patients? What sorts of risks to life and health, financial well-being, and reputation may a dentist be obligated to face?

The related question of the proper relationship between entrepreneurship and commitment to the patient, along with the sacrifice of self-interest this can involve, has been discussed in every age of the dental profession. The consensus is that especially in emergency situations, the patient's oral health and general health require significant sacrifices of personal convenience and financial interest on the part of a dentist. Since the arrival of HIV and AIDS, even more urgent implications of the obligation to give priority to the patient, including accepting an increased risk of infection, also have become part of this discussion.

RELATIONS WITH COPROFESSIONALS. Each profession has norms, usually largely implicit and unstated, concerning the proper relationship between the members of a profession. Should a dentist relate to other dentists as competitors in the marketplace, as cobeneficiaries in the monopoly their exclusive expertise gives them in the marketplace, or in some other way? What is the ideal relationship between dentists, and how is it connected with the fact that they are members of a profession, not only entrepreneurs in the same marketplace?

How should a dentist deal with another dentist's inferior work when its consequences are discovered in the mouth of a new or emergency patient or a patient referred for specialty care? The discovering dentist could inform the patient that bad work has been done or could hide that judgment from the patient. The discovering dentist could contact the dentist whose work had a bad outcome or possibly the local dental society. What is the proper balance between obligations to patients and obligations to one's fellow dentist? As in other professions obligations to the patient ordinarily take priority in dentistry, but this principle does not supply simple or automatic answers to the complexities of such situations.

There are also situations in which members of different professions are caring for the same patients. Many dentists, for example, work very closely with dental hygienists, whose professional skills and central professional values are closely related to but significantly distinct from those of dentists. In the best relationships those differences complement each other to the benefit of the patient, but in other situations the skills of the dental hygienist may be demeaned or the dental hygienist's status as a professional may be challenged. The ethical commitments of these professions imply an obligation to develop a working relationship that is conducive to mutual respect and focused on the well-being of the patient.

RELATIONS BETWEEN DENTISTS AND THE LARGER COMMUNITY. Every profession is involved in numerous relationships with the larger community and with important subgroups in it. Both the dental profession and individual dentists must monitor the quality of dental work and practice and report and address instances of inferior work and unethical practice. They also relate to the community as dental-health educators both through direct educational efforts and by monitoring the dependability and effectiveness of dental-care products offered to the public. Dentistry's relationships with the larger community also include developing proper standards for professional advertising. Dentists play an important role in public-health efforts, preserving public oral health, and addressing serious epidemic diseases such as HIV.

ACCESS TO THE PROFESSION'S SERVICES. Individual dentists and the dental profession as a whole have responsibilities in regard to access to dental care for people with unmet dental needs. Dentists also may be obligated to be educationally and politically active when policies are being made to determine how society will distribute its healthcare resources. Also, organized dentistry has an obligation to monitor access issues and use its resources to promote access for those whose dental needs are not being met.

INTEGRITY AND EDUCATION. A dentist who made no effort to influence patients to incorporate the central values of dental practice into their lives and educate them about how to do that would be falling short as a professional committed to these values. However, dentists influence and educate patients not only through their words and professional interventions at chairside but also by the way they live and act. Thus, there is a ninth category of questions to ask about dentists' professional obligations. What are dentists required to do and what might they be required to avoid to preserve the integrity of the values to which dentistry is committed and to educate others by living in a manner consonant with those values?

Organized Dentistry and Ethics

Ultimately, the content of a profession's obligations is the product of a dialogue between the profession and the larger community that entrusts the profession and its members with a high degree of autonomy in practice, including the power of self-regulation. In the case of dentistry this dialogue is often subtle and informal. Codes of ethics formulated by professional organizations such as the American Dental Association's Principles of Ethics and Code of Professional Conduct (American Dental Association, 2002) play an important role in articulating the most fundamental principles of dentistry's professional ethics within American society. However, such codes, like state dental-practice acts, can never articulate more than a small part of the content of a practicing profession's ethics. It therefore is incumbent on both individual dentists and organized groups of dentists to monitor this ongoing dialogue continuously and offer representative statements of its content as they are needed.

If the larger community had no part in this ongoing dialogue, its trust of the dental profession would make no sense. Nevertheless, the community exercises its role in the dialogue more often through passive tolerance than through active articulation. Therefore, the initiative ordinarily falls first to the members of the profession to articulate in word and action the current understanding of the profession's ethical commitments.

Although the dental profession includes every dentist who practices competently and ethically, those who speak for the profession most articulately and are heard the most widely are dentistry's professional organizations. Therefore, those organizations have a special responsibility to foster reflection on and contribute to discussion of dental ethics (Ozar and Sokol, 2002).

Some dental organizations, such as the American Dental Association (ADA), the American College of Dentists (ACD), and some specialty organizations, have contributed actively to the articulation of dentistry's professional standards. Particular issues have temporarily focused the profession's attention on dentistry's ethical commitments. This occurred when the ADA's Council on Dental Therapeutics first awarded its Seal of Approval to a commercial dentifrice (Dummett and Dummett) and when the ADA first issued a policy statement regarding dentists' obligation to treat HIV-positive patients (American Dental Association, 1991; Ozar, 1993).

Until the late 1970s most dental organizations fulfilled this responsibility chiefly through editorials and other hortatory articles in their journals and sometimes through a published code of conduct. Detailed, carefully reasoned discussions of ethical issues in which assumptions were explicit and alternative points of view were accounted for or that articulated the profession's ethics in more than broad generalities were few and far between. Even the published codes of conduct, significant as they have been as representative articulations of dentistry's professional commitments, have not exhausted the contents of dental ethics, much less effectively addressed new and specific issues as they have arisen.

Since the late 1970s, however, the level of interest in and sophisticated discussion of ethical issues within organized dentistry have increased steadily. Responding to newly significant ethical issues in a rapidly changing social climate, the ADA's Council on Ethics, Bylaws, and Judicial Affairs has regularly prepared, after considerable debate in print and other forums, a number of revisions and amendments of the ADA's Principles of Ethics and Code of Professional Conduct (2002). The ADA and its council also have sponsored national workshops and other educational programs on specific ethical issues facing the dental community.

The ACD sponsored several national workshops and a national grassroots educational program to train dentists in more sophisticated forms of reflection on ethical issues as well as national conferences, Ethics Summits I and II, in which representatives from every part of the oral healthcare community worked to develop common understandings of the ethical issues they face and respectful collaboration in dealing with them (American College of Dentists, 1998,2000). Many other dental organizations have incorporated programs on dental ethics into their meetings and published scholarly and popular articles on those topics in their journals. A number of them also have made major revisions of their codes of ethics.

An organization specifically focused on dental ethics and its teaching, the Professional Ethics in Dentistry Network (PEDNET), was founded in 1982 by a group of dental school faculty members and has grown into a national organization with additional members in full-time practice as well as representatives from organized dentistry, dental hygiene, and the larger healthcare ethics community. The International Dental Ethics and Law Society (IDEALS) was established in 1999 to facilitate dialogue on dental ethics and law around the world.

The literature of dental ethics has grown significantly. In 1988 the Journal of the American Dental Association initiated a regular feature on dental ethics, "Ethics at Chairside," which moved in 1991 to General Dentistry, the journal of the American Academy of General Dentistry, and a similar series of ethics cases and commentary has appeared in the Texas Dental Association Journal. A peer-reviewed series, "Issues in Dental Ethics," supervised by the editorial board of PEDNET began publication in 2000, appearing as a special feature in each quarterly issue of the Journal of the American College of Dentists. Also since 2000, the dental journal Quintessence has published a series on ethical heroes in dentistry.

Dental Education

The changing climate of dental practice from the late 1970s into the 1980s and a heightened awareness of ethical issues throughout the dental profession in that period also brought about changes in dental schools. Until that time few dental schools had formal programs in dental ethics. Inspirational lectures by respected senior faculty members or local or national heroes were the standard fare (Odom). However, with prompting from the American Dental Education Association (ADEA), then called the American Association of Dental Schools, as well as the ACD, and the ADA, many dental schools began offering formal programs in dental ethics. They identified faculty members with an interest in dental ethics who began to develop curricular materials and network with the faculty in other institutions. For example, the University of Minnesota pioneered an innovative four-year curriculum in dental ethics in the early 1980s. With the founding of PEDNET, dental-ethics educators acquired a major resource for their teaching and a locus for scholarly discussions of issues in dental ethics at the national level both at annual meetings and at biennial workshops on teaching dental ethics.

During the 1990s, several new textbooks were published (Rule and Veatch; Weinstein; Ozar and Sokol, 1994,2002) and additional educational programs and materials were developed for use in the classroom, in the clinic, and in continuing education programs. By the beginning of the new millennium, most dental schools had multiyear curricula in dental ethics in place (Zarkowski and Graham) and significant efforts were under way to integrate dental ethics education into the innovative patient-centered and problem-based-learning curricula that are the hallmark of contemporary dental school education.

Dentistry in the Twenty-First Century

As dentistry moves into the twenty-first century the focus on ethics will have to be even greater. Two of dentistry's greatest success stories of the twentieth century will yield two of its most important ethical challenges in the twenty-first.

Dentists deeply committed to preventive healthcare for the whole community lobbied successfully during the twentieth century for the fluoridation of water supplies. As a consequence most twenty-first-century dentists' patients will need much less restorative work to remedy the effects of caries than their predecessors' patients did. In these circumstances how will dentists maintain their practices fiscally and still remain true to their fundamental ethical commitments? For many patients and dentists the answer has been an increasing interest in aesthetic dentistry. However, there is a risk here. Too strong a shift in the focus of dental care in this direction could bring about a significant change in the community's view of dentistry, seeing it much more as a taste-driven commercial enterprise and much less as an expertise-grounded, value-based health profession.

The second success story concerns the tremendous advances made in dental research in recent decades. For example, the ways in which laser technology can be used in dental practice have multiplied at least tenfold since the early 1990s. However, these new technologies frequently require extensive training as well as new forms of theoretical understanding so that dentists can employ them safely and skillfully. Because so many patients are fascinated with new technologies, dentists, often fascinated themselves, feel strong pressure to purchase and employ them. The ethical standard of employing only those therapeutic techniques in which one is expert and that truly produce a marginal benefit for the patient compared with older technologies often is strained in these circumstances, and commercial pressures on dentists, both direct fiscal issues within their practices and the pressure of skillful marketing by manufacturers, enhance the challenge for twenty-first-century dentists to choose new technologies wisely and with their patients' best oral healthcare as the goal.

Further complicating both of these issues is the extent to which managed care has had an increased impact on oral healthcare since the early 1990s. More and more frequently dentists must negotiate with patients about treatments in circumstances in which a patient's insurance will pay only for the cheapest acceptable intervention and in which the patient has been poorly informed. The dentist or dental office staff frequently is the bearer of this bad news. Dealing with such situations in a way that preserves an appropriate dentist-patient relationship is often very challenging (Ozar, 2001).

Dentistry as a profession has always taken its professional ethics seriously. However, as a field of study and as a subdiscipline within the study of moral theory and professional ethics dental ethics is still a young field. Nevertheless, as reflection on ethical issues is taken more seriously and participated in more widely by practicing dentists and dental hygienists, dental school and dental hygiene faculty and students, and the leaders of organized dentistry, the dental profession's ethical standards and their implications for daily practice will be understood more clearly and creative dialogue about the ethical practice of dentistry will be more widespread and sophisticated.

david t. ozar (1995)

revised by author

SEE ALSO: Conflict of Interest; Healthcare Resources; Informed Consent; Profession and Professional Ethics; Professional-Patient Relationship; Public Health; Trust

BIBLIOGRAPHY

American Association of Dental Schools. 1989. "Curriculum Guidelines on Ethics and Professionalism in Dentistry." Journal of Dental Education 53(2):144–148.

American College of Dentists. 1998. "Ethics Summit I." Journal of the American College of Dentists 65(3): 5–26.

American College of Dentists. 2000. "Ethics Summit II." Journal of the American College of Dentists 67(2): 4–22.

American Dental Association. 1991. AIDS Policy Statement. Also incorporated into the ADA Principles of Ethics and Code of Professional Conduct at 4A1.

American Dental Association. 2002. ADA Principles of Ethics and Code of Professional Conduct, with Official Advisory Opinions. Chicago: American Dental Association.

Bebeau, Muriel J. 1991. "Ethics for the Practicing Dentist: Can Ethics Be Taught?" Journal of the American College of Dentists 58(1): 5, 10–15.

Bebeau, Muriel J.; Spidel, Thomas M.; and Yamoor, Catherine M. 1982. A Professional Responsibility Curriculum for Dental Education. Minneapolis: University of Minnesota Press.

Bogert, John, and Creedon, Robert, eds. 1989. Behavior Management for the Pediatric Dental Patient. Chicago: American Academy of Pediatric Dentistry.

Burns, Chester R. 1974. "The Evolution of Professional Ethics in American Dentistry." Bulletin of the History of Dentistry 22(2): 59–70.

Chiodo, Gary T., and Tolle, Susan W. 1992. "Diminished Autonomy: Can a Person with Dementia Consent to Dental Treatment?" General Dentistry 40(5): 372–373.

Dummett, Clifton O., and Dummett, Lois Doyle. 1986. The Hillenbrand Era: Organized Dentistry's "Glanzperiode." Bethesda, MD: American College of Dentists.

Hirsch, Allan C., and Gert, Barnard. 1986. "Ethics in Dental Practice." Journal of the American Dental Association 113(4): 599–603.

Horowitz, Herschell S. 1978. "Overview of Ethical Issues in Clinical Studies." Journal of Public Health Dentistry 38(1): 35–43.

Jong, Anthony, and Heine, Carole Sue. 1982. "The Teaching of Ethics in the Dental Hygiene Curriculum." Journal of Dental Education 46(12): 699–702.

McCullough, Laurence B. 1993. "Ethical Issues in Dentistry." In Clark's Clinical Dentistry, rev. edition, vol. 1, ed. James W. Clark and Jefferson F. Hardin. Philadelphia: Lippincott.

Odom, John G. 1982. "Formal Ethics Instruction in Dental Education." Journal of Dental Education 46(9): 553–557.

Ozar, David T. 1985. "Three Models of Professionalism and Professional Obligation in Dentistry." Journal of the American Dental Association 110(2): 173–177.

Ozar, David T. 1993. "AIDS, Ethics, and Dental Care." In Clark's Clinical Dentistry, rev. edition, vol. 3, ed. James W. Clark and Jefferson Hardin. Philadelphia: Lippincott.

Ozar, David T. 2001. "A Position Paper: Six Lessons about Managed Care in Dentistry." Journal of the American College of Dentists, special section, "Issues in Dental Ethics" 68(1): 33–37.

Ozar, David T., and Sokol, David J. 1994. Dental Ethics at Chairside: Professional Principles and Practical Applications. St. Louis: Mosby-Yearbook.

Ozar, David T., and Sokol, David J. 2002. Dental Ethics at Chairside: Professional Principles and Practical Applications, 2nd edition. Washington, D.C.: Georgetown University Press.

Professional Ethics in Dentistry Network. 1993. The PEDNET Bibliography, 1993. Chicago: Professional Ethics in Dentistry Network.

Rule, James T., and Veatch, Robert M. 1993. Ethical Questions in Dentistry. Chicago: Quintessence.

Segal, Herman, and Warner, Richard. 1979. "Informed Consent in Dentistry." Journal of the American Dental Association 99(6): 957–958.

Weinstein, Bruce D., ed. 1993. Dental Ethics. Philadelphia: Lea & Febiger.

Zarkowski, Pamela, and Graham, Bruce. 2001. "A Four-Year Curriculum in Professional Ethics and Law for Dental Students." Journal of the American College of Dentists, special section, "Issues in Dental Ethics" 68(2): 22–26.

INTERNET RESOURCE

American Dental Association. 2002. ADA Principles of Ethics and Code of Professional Conduct, with Official Advisory Opinions. Available from <www.ada.org/prof/prac/law/code/index.html>.