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Abstract

It is important to understand the scope of dentistry and dental professions all over the world, in a global perspective. In dental practice, there are not only dentists but also other dental professionals that vary according to the country. The scope of practice of dentists and other dental professions may also vary depending on the country. Dentists do not work only in intraoral structures but also in the maxillofacial region. Besides the dental professionals, there are other people related to the dental activities – as patients, their family, other health professionals (physicians, nurses, physiotherapists, radiology technicians, etc.), and professionals of other areas (anthropologists, lawyers, etc.). It is worth bearing in mind the main differences among morality, ethics, and law, to reﬂect about dental ethics. In dental practice, there is an enormous quantity of different issues that can raise moral, ethical, and legal concerns. It is impossible to describe and/or comment on all of them. Thus, in this entry only few subjects were highlighted, as ethics education, advertisement, promises of result, patients’ images and media, informed consent, autonomy, professional secrecy, communication and relationship, biosafety, and researches with animals and human beings, always under a global perspective.

Introduction

It is important to understand the scope of dentistry and dental professions all over the world, in a global perspective. This is fundamental to discuss and reﬂect about dental ethics.

In dental practice, there are not only dentists but also other dental professionals that vary according to the country, as dental hygienists/ oral hygiene technicians, dental assistants/oral health assistants, dental prosthetists, assistants of dental prosthetists, dental therapists, oral health therapists, etc.

The scope of practice of dentists and other dental professions may also vary depending on the country. Dentists do not work only in intraoral structures but also in the maxillofacial region. The dental specialties also vary. For instance, oral and maxillofacial surgery is a dental specialty in some countries (as Brazil, USA, Canada, Australia, etc.), and it is a medical specialty in other countries (as France, Portugal, etc.). And in Switzerland, for example, the oral and maxillofacial surgeons are dentists and physicians.

A dental specialty that is growing all over the world is forensic dentistry, part of forensic sciences, that has a very important role in human identiﬁcation. So, the scope of practice of dentistry ranges from prevention, dental ﬁllings, crowns, root canal treatment, periodontal treatment, orthodontics, and dental implants to orthographic surgeries, panfacial trauma surgeries, maxillofacial implants, maxillofacial prosthesis, and human identiﬁcation, among others.

Besides the dental professionals, there are other people related to the dental activities – as patients, their family, other health professionals (physicians, nurses, physiotherapists, radiology technicians, etc.), and professionals of other areas (anthropologists, lawyers, etc.). There are ethical concerns involving all of them and their relationships.

Therefore, dental ethics involves many professionals and venues – as dental ofﬁces, clinics, hospitals, and morgues.

There are professionals who leave their countries of origin and go to work in other countries or even those who are called to act in emergency situations or disasters in a country other than theirs. It is important to have a global perspective of these situations. Many ethical questions can be raised.

Dental ethics is not a subject only related to the so-called professional ethics codes. These codes are related to deontology or professional ethics. Of course it is very important to know, respect, and discuss these codes, which are professional rules determined by the Dental Council (or other similar entities) of each country. But dental ethics is much broader.

Morality, Ethics, And Law

Before reﬂecting about dental ethics, it is worth bearing in mind the main differences among morality, ethics, and law.

Morality refers to a set of deeply held, widely shared, and relatively stable values within a community. Ethics as a philosophical enterprise involves the study of values, and the justiﬁcation for right and good actions, as represented by the classic works of Aristotle (virtue ethics), Kant (duty-based ethics), and Bentham and Mill (utilitarian and consequentialist ethics). Applied ethics, in contrast, is the use of ethics principles (e.g., respect for autonomy, beneﬁcence, and nonmaleﬁcence, justice) in actual situations, such as in professional and clinical life. Finally, law is comprised of concrete duties established by governments that are necessary for maintaining social order and resolving disputes, as well as for distributing social resources according to what people need or deserve. (Horner 2003, p. 263)

Thus, morality consists of a set of principles, rules, precepts, and values that guide people’s and individuals’ lives. Every culture and every society establishes moral values concerning good and evil, the permitted and the forbidden – in other words, the societies establish the correct conduct valid for its members. And the members of the society act according to the determined moral values (if they don’t, they are punished). Normally there are values transmitted across generations – as the concepts of correct and wrong, good and bad.

Morality asks “What should we do?,” while ethics asks “Why should we? What arguments support and sustain the moral code that we are accepting as a guide of conduct?” (Cortina and Martínez 2005, p. 14).

Law usually reﬂects the morality of the society a certain country. Normally it is forbidden or allowed what that society understands that is right or wrong. And as the values change, laws also change. Law reﬂects the morals of a certain society and has positive norms (Serra et al. 2014).

Ethics corresponds to the study of what is considered good or bad. Ethics looks for justiﬁcations for the proposed rules by morality and law. However, it differs from both – morality and law – because it does not establish rules. The reﬂection on the action of humans characterizes ethics (Serra et al. 2014).

In a globalized world, the role of global bioethics is very important:

(…) On the one hand, there is a set of minimum standards on which traditions and cultures agree; this is expressed in international human rights language and elaborated into speciﬁc bioethics principles. On the other hand, there are many efforts to articulate more speciﬁc bioethics standards in the context of speciﬁc religious and cultural traditions. Members of these traditions also bring their views in the global debate through constructive dialogues and sometimes negotiations, so that the dialectic of global and local also helps to construct and produce global bioethics. Thus, the universal principles of global bioethics are the result of continuous and multilateral articulation, deliberation, and production.

Global bioethics is the result of continuous and multilateral articulation, deliberation, and production. It is both a herald and a witness of the rise of a global community of shared values. (ten Have and Gordijn 2014, pp. 7, 9)

UNESCO has recently launched a publication concerning global bioethics (Solinis 2015), in which authors of different nationalities write about various issues.

Finally, deontology or professional ethics – professional codes of conduct – as a set of rules for a given profession, also reﬂects the morality of those professionals in a certain place/ country. In dentistry, there are dental ethics codes elaborated usually by the National Dental Councils, which determine rules and punitions for those who do not obey or follow them.

Dental Ethics

As dentistry involves different professionals and specialties, there are various different ethical dilemmas faced in dental practice. Usually they are solved according to the values of the people/ place where they occur and also according to law and deontology.

Ethics Education

Teaching ethics for dental students (and also for dental coprofessional students) can reﬂect in the future professionals’ activities. This involves clinical ethics and research ethics (many of them will become teachers and scientists).

Ethics teaching does not correspond to a deontology course. It is not teaching the dental code of conduct and its rules.

Besides technical and clinical teaching, dental students may be encouraged to reﬂect and discuss about dilemmas they face and they will face during their professional career. However, the ethics teachers cannot be alone – in other words – it is important that all teachers behave ethically. Teachers are mirrors for the students; their behaviors are examples for them.

The core of medical practice is related to practical wisdom and virtues. The focus of bioethics education therefore should go beyond problem solving and applying principles. (ten Have and Gordijn 2012, p. 101)

There are international initiatives to have an exchange of educational experiences and a global platform for ethics education. In this sense, the International Association for Education in Ethics was created (ten Have and Gordijn 2012). UNESCO also is concerned with this issue and elaborated a bioethics core curriculum (UNESCO 2008, 2011).

Some Dilemmas

There are many different ethical dilemmas in dentistry. The daily dental activities involve many factors, areas, and professionals, which raise various and different concerns. Dentists face ethical dilemmas in their clinical routine, but there are also situations where the habit does not justify ethically – and even legally – the attitudes.

Unethical And Illegal Cases

Unfortunately, there are cases in which dental professionals indicate unnecessary treatments, for many unjustiﬁed reasons. The most common reason is to earn money – if they do more treatments, they earn more money. This occurs in private cases and in cases of patients with health insurance coverage. This is unethical and illegal.

Charging for treatments that were not carried out is also unethical and illegal (sometimes the patient does not know whether the treatment was actually carried out – such as in dental restorations and endodontics).

With regard to healthcare access, there are different types of systems employed in different countries all over the world: (1) totally free of charge public health system (the patient pays nothing), universal healthcare system; (2) public health system in which the patient pays moderating fees; (3) private health insurance that covers everything and in which the patient pays nothing for healthcare; (4) private health insurance in which the patient pays some fees according to the treatment; and (5) totally private healthcare.

There are situations where professionals charge patients assisted in the public health system – in which no fees are supposed to be paid. They charge to prioritize the treatment, to jump the queue – which is obviously unethical and illegal. This also occurs with private health insurance patients (when the health insurance pays for the whole treatment). In these cases, the professionals are used to say that the fees paid by the health system are too low and they need a “ﬁnancial complementation.”

There are cases where professionals make money when they use a speciﬁc material – as prefabricated prosthesis, plates and screws, implants, and biomaterials. The manufacturers or their representatives pay the professional for the indication and use of their product. Therefore, some professionals act unethically and illegally, using and/or indicating materials without good quality or unnecessarily.

Dentists should only use materials and techniques with scientiﬁc evidence (but even with this case, it is not ethical nor legal to receive beneﬁts to use or indicate materials). Professionals have the duty of being updated.

On the other hand – as some tests and imaging tests as CT scans or MRI (as examples) are expensive and they mean higher costs for health insurance companies – some companies give prizes (money prizes or trips, among others) to professionals who do not ask many tests, as a (unethical and illegal) way to stimulate the reduction of imaging test requests.

Advertisement And Promises Of Result

Aesthetic dental treatments are becoming more affordable and popular in many countries. Among treatments with aesthetic purpose, there are tooth whitening, composite ﬁllings, crowns made of different materials (such as resin and porcelain), dental contact lenses, and surgical procedures, such as periodontal surgeries to improve aesthetics (e.g., to correct a gummy smile). Even major surgeries, as orthognathic surgeries, have aesthetic implications – although, in these cases, function is the major concern.

There are different kinds of dental treatment advertisements in the various countries around the world. And the rules concerning advertisement are also different. In some places it is totally permitted; in other places there are restrictions. Advertisements can be carried out in magazines, newspaper, radio, television, Internet, and outdoors. Usually there are guidelines regarding advertising in dental ethics codes. Nevertheless, promising unrealistic results is something that should never be done.

Advertisements that promise perfect smiles, beautiful smiles, mainly with before and after photos (many of them edited in the computer), usually promise something that cannot be fulﬁlled. They are false or misleading advertisings.

Sometimes the promise of result is not divulgated in advertisements, but the dentist personally guarantees to the patient a result that cannot be achieved. This occurs in many different kinds of treatments – from tooth whitening to orthographic surgeries.

There are software that can simulate the results of an aesthetic treatment. For this, simple image editing programs can be used. But in real cases the result depends on many things and may not be as the software previewed. In surgical situations it is even worse; despite the surgical planning – which can be done by a computer – the ﬁnal result will not necessarily be the same as predicted in the computer.

Promising something that cannot be fulﬁlled is unethical. In these cases, it can also be illegal, depending on the countries’ legislation. It is a great disrespect to the patient.

Patients’ Images And Media

The last years have witnessed many changes – mainly in the ﬁeld of technology. Social media is getting more and more present in the daily life of many people, from children to the elderly. Posting photos and images on the web has become commonplace. People show what they do, where they go, and with whom they are. And health professionals and students often post photos taken in a professional environment – in ofﬁces, clinics, and hospitals. They post selﬁes of themselves only or selﬁes taken with colleagues, friends, and patients! Sometimes the patients agree, but other times patients do not even know the photos were taken. This can expose people who do not want to be exposed, who did not consent, and who may feel embarrassed by the publication of their images on social media. There are people who do not even want others to know they are undergoing some kind of treatment – whether something as simple as tooth whitening or even more complex treatments as orthodontic treatments, dental implants, and prosthetics. Some patients may feel uncomfortable. In some countries, it is forbidden to publish, in social media, photographs taken in professional environments. It is important to respect patients’ privacy.

Patients’ images can be used for many different purposes. Some photos can be taken exclusively to be placed in health records. But, to use patients’ photos for other purposes, even for scientiﬁc publications or in classes and lectures, it is necessary to obtain their consent.

Dental professionals may also work in forensic cases, in human identiﬁcation isolated cases, or even in mass disasters, where a large number of people/victims are involved. Forensic dentistry specialists can also work in criminal cases, as homicides. In such situations, great care must be taken to avoid breaching conﬁdentiality. In some countries, there are speciﬁc laws that directly address the disclosure of crime scene photos and autopsy reports and photos. And, although there is legislation on the subject – and even if there is not – this is also a matter of respect for people and families involved in the mentioned situations.

Interviews on television and radio (among other communication vehicles) of dental professionals are frequent. The dentists’ role in community education, clariﬁcation of problems, prevention, techniques, and treatments is important. However, the professionals must remember to preserve information and images of their patients and always transmit current and true information.

Informed Consent, Clarification, And Autonomy

The need of obtaining patients’ informed consent for treatment and for research is well known. It is necessary to clarify the patient about the alternatives, risks, costs, limitations, advantages, and disadvantages of each one. Then, exercising their autonomy, patients can decide.

However, the health professionals (or scientists) are the ones that have the technical and scientiﬁc knowledge. They have the responsibility to inform the patient. They must act honestly, clarifying correctly the patients. But sometimes, due to various reasons, health professionals do not clarify accordingly, i.e., they do not provide the necessary information and even deliberately omit information necessary for an informed consent.

Health professionals hold the clinical/technical/scientiﬁc knowledge to be transmitted to patients. In practice, they decide what to inform and are responsible for the information provided. There are professionals who strive at appropriately informing their patients. However, unfortunately, there are professionals who deliberately and consciously do not provide all necessary information to clarify their patients, these are professionals who manipulate the information to their own indulgence, with the intention of inducing the patient to take (or not) a decision in agreement with their own partisanship, according to their own interests. In this situation, the patient ends up forsaken – he/she places his/her trust on a professional who provides inaccurate information, or maybe even false, and based on this, takes a decision. (Serra et al. 2010, p. 161)

In dentistry, this situation can occur from more simple cases, related, for example, to small ﬁllings, to cases involving placement of dental implants, prosthesis, and major surgeries. For example, a dentist that does not work with dental implants receives a patient that needs such treatment, because he has lost some teeth. But the dentist offers him a traditional ﬁxed prosthesis – which the patient accepts, because he does not know there is another possibility. In this case, sound tooth structure needs to be removed, in order to receive crowns that will support the prosthesis (what would not happen with the use of dental implants).

In cases of major surgeries, as orthognathic surgeries or temporomandibular joint surgeries, e.g., if the surgeon does not provide the patient with the due information, the patient will decide without being adequately clariﬁed – and can decide for what the surgeon wants him to decide (what not necessarily is a good choice for the patient).

Intentional inadequate clariﬁcation, in order to make the patient take the decision that the professional desires, in which he/she has some kind of interest is unethical and illegal. The patient can suffer a permanent prejudice, depending on the involved treatment.

Moral values, culture, and religion vary around the world (ten Have and Gordijn 2014). Some countries tend to be more individualistic and others more beneﬁcent or paternalistic. This reﬂects in the professional deontological norms and in the general legislation. Similar situations can be morally, ethically (in a deontological sense), and legally understood and decided in different forms, in different countries.

As the world population is getting older, there are more elderly people – but this does not mean, necessarily, that all of them have good physical and/or mental health. Even if they do, in some cultures, families tend to “protect” their elderly relatives. Sometimes, a son/daughter, grandson/ granddaughter, or other younger relatives come with the elderly patient to the medical/dental consultation and want to decide for him/her – even if the patient has perfect mental health and conditions to decide. In some situations, in cases, e.g., of cancer diagnosis, the relative asks the dentist not to tell the truth to the patient. The resolution of these cases has not a “unique answer”; it depends on various factors.

Patients’ autonomy is not unlimited. That is, if the professional does not agree with the treatment request presented by the patient, he is not obliged to perform it. Sometimes patients can present some requests with which the dentist disagrees, for example, to endodontically treat healthy teeth (and even all teeth) or to extract all teeth without clinical indication. In these extreme situations, if the dentist does what was asked, even if a written, signed, and informed consent is obtained, in some countries, the professional can be sued in an ordinary justice court (criminal and civil liability) and in the Dental Council (Serra et al. 2014).

Nevertheless, less extreme situations also occur. Some of them are due to culture or even fashion. In some countries, or cultures, still now it is common (and sometimes it means social status) to have gold ﬁllings – and even crowns (not aesthetic) in anterior teeth. If a patient with caries in an anterior tooth does not agree with a composite ﬁlling but asks for a metallic restoration, what should the dentist do (supposing that the dentist does not agree or does not belong to nor share with the same culture)? And what if the patient asks for totally metallic crowns in the anterior superior teeth?

The placement of piercings in anterior teeth became a fad in some places. Sometimes dental piercings are “glued” on the teeth, but in other cases sound enamel is removed. If the patient asks for a dental piercing and assumes the responsibility of removing sound dental structure without clinical indication, should the dentist perform it?

Professional Secrecy

Conﬁdentiality, privacy and professional secrecy need to be respected. Dental students have to learn about this very early, before starting to attend patients. Violating/revealing without justiﬁed reasons (there are exceptions) professional secrecy, in some countries, is considered as a crime, besides being ethically/deontologically prohibited.

There are various forms of revealing a professional secrecy, not only revealing the name of the patient or showing his or her image but also disclosing information that can lead to his or her identity.

Similar information disclosure might embarrass a person and not another. For example, revealing that a very elderly patient wears dentures may not cause embarrassment – but revealing that a young man or woman wears dentures can cause harm to him or her.

It is not rare to have cases in which a patient asks professionals not to tell their partners (husbands, wives) that they use dentures – or that they are being submitted to dental implant and prosthesis treatment. This is more difﬁcult when the partner is responsible for the payment of the treatment.

Often, when an employee does not go to work in order to attend a medical consultation, he requests an attendance certiﬁcate. And, if his employer requests, the patient asks the professional to include the International Classiﬁcation of Diseases (ICD) in the mentioned document. As the corresponding ICD code is easily found, inserting this codiﬁcation on a simple attendance certiﬁcate can be considered professional secrecy disclosure. So, to avoid being accused of professional secrecy revelation, the professional must ask the patient a written consent to disclose his or her diagnostic information.

There are exemptions for professional secrecy, depending on the country’s legislation. Usually communication of infectious diseases to health authorities, collaboration with justice, expert work, judicial recovery of professional fees, and denunciation of violence cases aren’t considered professional secrecy disclosure.

The dental profession, due to its characteristics of physical proximity, is on a privileged position to diagnose or suspect cases of domestic violence – violence against children, adolescents, women, and the elderly. When there is a suspect, in some countries, as in Brazil, the professional is obliged to report to the responsible authority that will investigate the case. This report, in some cases, can avoid future tragedies.

Professional Communication And Relationship

Good communication and relationship is fundamental in dental practice. They can even prevent complaints. And the opposite is true – bad communication and relationship can engender complaints (Serra et al. 2014).

The professional has to clarify the patient about treatment options and their characteristics, to obtain informed consent. But the patient trusts the professional, because often he or she has no technical knowledge to assess the quality of the dental care. The relationship between the dentist and his patient is mainly a trusting relationship.

It is very important to establish a good professional-patient relationship. And even with the best relationships, problems can occur – in this situation, the best to do is to talk honestly about them and try to ﬁnd a common resolution.

Not only the dentist-patient relationship is important. The relationship of the dental team with the patients and also the doctor-team relationship are very important, besides the dentist-dentist and dentist-other professionals relationship. But, focusing on the team-patient relationship, it is very important to train adequately the dental team to listen to the patients, to treat them well, and to communicate adequately. Sometimes patients do not tell the dentist about their dissatisfaction, but tell a dental assistant, for example, or comment on the problem with another patient in the reception room. The dental team has to be prepared not only for technical work, but it also has to have good communication skills.

Some Other Issues

There are many issues that can be discussed, concerning dental ethics. Biosafety is a very important subject, which also needs to be highlighted. Dental patients can be attended in ofﬁces, clinics, and hospitals or even in teaching environments such as universities, to undergo many different types of treatments. But always, everywhere, it is very important to respect the biosafety rules. Cross infection (i.e., contaminating patients under dental treatment) is a very serious problem and must be avoided. The dental team has to be adequately trained to follow the biosafety procedures – not only during the patient’s attendance but also before and after seeing the patient – with disinfection and sterilization of environments, instruments, and materials and medical waste disposal.

Dental professionals not only work as clinicians, but they can also develop other activities – as scientiﬁc research. In this case, it is very important to follow ethical and legal rules concerning animal research and research involving human beings. There are international guidelines, national deontological rules, and legislation to be followed. Also in regard to research, cultures have different customs, traditions, and moral values that have to be taken into account.

Conclusion

In dental practice, there is an enormous quantity of different issues that can raise moral, ethical, and legal concerns. It is impossible to describe and analyze all of them. Thus, in this entry only few subjects were highlighted and commented, always taking into account a global perspective. Different regions, countries, and cultures have different values and customs that also affect the dental practice. And even the scope of dental practice is not the same everywhere.

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