ethics in aesthetic dentistry part 1: the complex...
TRANSCRIPT
ETHICS IN AESTHETIC DENTISTRY
PART 1: THE COMPLEX ETHICAL ARENA OF AESTHETIC DENTISTRY
Johan Hartshorne
B.Sc., B.Ch.D., M.Ch.D., M.P.A., Ph.D. (Stell), FFPH.RCP (UK).
Private practice, Intercare Medical and Dental Centre, 43 Old Oak Road, Tyger
Valley, Bellville, 7536.
The changing face of dentistry
Dentistry is a dynamic profession that is continually being reshaped by new
scientific evidence, and advances in technology and materials.
Treatment options have increased and the approach to care is now aimed more
towards prevention and conservation than mere repair. Treatment is
increasingly patient-driven rather than entirely dentist-directed, with a greater
emphasis on informed consent. The focus and scope of dentistry has also
undergone a metamorphosis. Active and aggressive media, which were almost
absent 50 years ago, has made our society more aware of appearance and
globalised the perception of what is attractive, desirable, and appealing
(Mousavi , 2010). Collectively, this has prompted a greater demand for elective
aesthetic services such as tooth-whitening, tooth colored restorations, ceramic
veneers and crowns, dental implants, and “braceless” orthodontics.
This trend has led to an increasing number of dentists positioning their practices
to appeal to the aesthetic and dental implant market (Newsome, 2003). The
trend towards greater ‘specialization’ by general dental practitioners in aesthetic
and implant dentistry combined with increasing patient expectations and
demands is likely to set off an increase in complaints, negligence claims and
litigation cases. This is clearly reflected by the number and severity of claims that
have grown by more than 50% in the last few years (Tiernan, 2010).
What is aesthetic /cosmetic dentistry?
Nash (1988) defines ‘aesthetics’ as: “a branch of philosophy dealing with
beauty.” It can be both enjoyable (subjective and cosmetic e.g. look better and
feel better) and/or admirable (objective and definable e.g. whiter and straighter
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teeth). The formulae for marketing or presenting beauty and attractiveness in
the cosmetic industry are simply: “Look better, then everybody treats you better,
you will then feel better.”
Facial appearance, specifically the oral region, is of considerable importance in
the realm of attractiveness and appearance in contemporary society. Many
people seek aesthetic restorative treatment for the same reasons they pursue
plastic cosmetic surgery: to enhance social acceptance, self-esteem, and to
improve their quality of life (Davis, Ashworth and Spriggs, 1998; Mousavi,
2010).
Aesthetic dentistry is essentially elective procedures performed on normal
tissue(s) in order to enhance appearance whilst maintaining functional integrity.
The scope of aesthetic dentistry includes procedures such as teeth whitening
(bleaching), resin bonded restorations, ceramic veneers and crowns, reshaping
and recontouring teeth, orthodontic therapy, implants, periodontal plastic
surgery and orthognathic surgery. Aesthetic dentistry is multidisciplinary and
includes the oral hygienist, dentist, specialist and laboratory technician. (The
achievement of aesthetic enhancement goals in an ethical manner is only
possible through patient participation, a multidisciplinary treatment approach
and excellence in treatment performance) (Nash, 1988).
Ethically achieving aesthetic enhancement goals is only possible through patient
participation, a multidisciplinary treatment approach and excellence in
treatment performance.
The aesthetic dentistry revolution and its ethical challenges
There is no doubt that an aesthetic revolution has occurred in the dental
profession due to changing and increasing demands for elective aesthetic
procedures (Priest and Priest, 2004), primarily popularized by the media and
television (Gold, 2002). Access to the internet and various forms of media has
increased the public’s knowledge and fuelled its obsession and awareness with
image and appearance. In the present, consumer driven society, patients ask
their dentist not only for conventional dental therapy for the purpose of
restoring oral health (teeth) but also for newer aesthetic procedures that create
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beauty and enhance appearance e.g. teeth whitening and replacement of
amalgam fillings with resin bonded composites.
Advances in aesthetic and reconstructive dentistry have revolutionized the
management of patients with disfigured (malformed), discolored, worn and mal-
aligned teeth, inter-dental spacing and disproportioned gums. The dramatic
development and improvement in restorative materials and techniques in recent
decades has led to an impressive range of capabilities and techniques for
restoring these conditions and enhancing an aesthetically impaired dentition or
smile. Advanced reconstructive aesthetic procedures such as dental implants,
periodontal plastic surgery, orthodontic therapy and orthognathic surgery are
also increasingly being used for restoring and reconstructing aesthetically
impaired dentitions, jaws and faces.
Although advances in aesthetic dentistry have benefitted patients and improved
their quality of life, it has also brought some unique ethical challenges that dental
clinicians have to deal with.
Aesthetic services are desirable and lend themselves well to promotional efforts.
This trend, driven by the media and by the public demand has begun to foster a
practice model of commercialism previously unseen in dentistry (Leffler, 2008).
This trend towards commercialism has the potential to tilt the balance or focus
of services more towards business interests and profit rather than the patient’s
best interest. Dentists are taking advantage of the increasing demand for
aesthetic procedures by developing their skills and knowledge in this field and
promoting aesthetic procedures in their practice. This places a duty on dental
clinicians to reduce potential risks and harm by selecting and providing the most
appropriate treatment option for each individual case. Dental clinicians are
obligated to upgrade their knowledge and skills on all available treatment
options so that they are able to inform patients appropriately and adequately on
alternative options, the possible complications and associated risks and to
enable them to perform such procedures in a safe and effective manner.
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Defining ethics and the fundamental principles of ethics
Nash (1988) defines ethics as: “a branch of philosophy dealing with morality”.
Dentists assume unique moral duties in presenting themselves to society as
being uniquely qualified to care for their oral health. (Ethics is also used as a
generic term for various ways of understanding and examining moral behavior
The application of ethical principles provides various ways of understanding and
examining moral behavior, (Beauchamp and Childress, 2001), inquiring why
an individual action is right or wrong, or establishing the reasons why a person
is good or bad (Jessri and Fatemitabar, 2007).
Dentistry has historically been a caring profession with core ethical obligations
that center on the duty to treat and prevent disease and ultimately to promote
well-being (Simonsen, 2007). Our clinical decision-making, behaviour and
standard of care is guided by a professional or ethical code of conduct, which is
based on four fundamental ethical principles.
The four fundamental principles of ethics that set the moral boundaries and
ethical guidelines and duties that drive treatment decisions are (1) beneficence
(promoting or doing good), (2) non-maleficence (preventing harm), (3)
autonomy (patient right to make or participate in decision-making and make
their own choices) and (4) justice (fairness in treating each other justly)
(Beauchamp and Childress, 2001). Our duties to act in the best interest of the
patient, doing good, preventing harm, truthfulness and fairness reflect the
underlying nature of the dentist-patient relationship. Ethics help clarify the path
of what’s appropriate and what’s not.
Beneficence (To promote or to do good)
The principle of beneficence expresses the concept that professionals have a
duty to care for and to act in the patient’s best interest. Under this principle the
dentist’s primary obligation is service to the patient with the aim of benefiting or
improving the patient’s oral health condition. The most important aspect of this
obligation is the competent and timely delivery of appropriate and safe dental
care within the bounds of clinical circumstances presented by the patient
(American Dental Association, 2005). Patients rely on trust and on their
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dentist’s expert and professional diagnosis to assess their treatment needs. The
dentist, by virtue that he is also the ‘seller’, may use his information advantage to
induce overtreatment. Inappropriate or unnecessary care (overtreatment) is
usually based on wrong treatment decisions, giving more importance to the
interests of the dentist or his practice rather than serving the patient’s best
interests. The second part of this series: “Ethical considerations of
overtreatment – Patient interests vs. business interests” is based on the
principle of beneficence.
Non-Maleficence (Do no harm)
This principle expresses the concept that dental clinicians have a duty to refrain
from harming the patient e.g. doing irreversible harm or placing teeth at risk by
selecting appropriate therapies and informing patients of unavoidable risks
(ADA, 2005; Thomas and Straus, 2009). Under this principle the dentist’s
primary obligations include keeping knowledge and skills current, knowing
one’s own limitations and limiting and managing risks with the ultimate aim of
minimizing harms and maximizing benefits for the patient.
Quality and safe dentistry can only be provided when both the clinician and the
patient make treatment-planning decisions based on the patient’s general health
status and specific oral health and aesthetic needs. The treatment recommended
should be safe, predictable, cost-effective, and respectful of patient preferences,
aimed at preserving normal tissue and function and based upon current
scientific evidence (American Association of Endodontists, 2007).
The third part of this series, based on this principle, will cover the topic of:
“Balancing benefits and risks”.
Autonomy (right to self-determination)
The principle of autonomy expresses the concept that dental clinicians have a
duty to respect the patient’s right to select or refuse treatment according to their
desires, within the bounds of accepted treatment. Dental clinicians’ primary
obligations include involving patients in treatment decisions in a meaningful way
with due consideration being given to the patient’s needs, desires and abilities,
facilitated by the process of informed consent (Leffler, 2008).
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Informed consent is obtained by conducting a structured, formal consultation
with a patient to explain the goals of treatment, alternative options, the probable
benefits (advantages) and risks (disadvantages) of treatment, alternative
options, prognosis or treatment outcome, costs and the risks of non-
treatment.(Nash, 1988). Dental health care providers are obligated to tell the
truth, protect confidentiality and respect privacy (Jessri and Fatemitabar,
2007). By communicating relevant information effectively, openly and truthfully,
dental practitioners assist patients to make informed choices about all treatment
options available and to participate in achieving and maintaining optimum oral
health, rather than promoting the most profitable option.
Part 4 of this series is based on the principle of autonomy, will discuss:
“Informed consent – How much information is adequate?”
Justice (fairness)
The fourth fundamental ethical principle is justice. Justice expresses the concept
of fairness in treatment, respect for people’s rights, and demands consideration
of fair distribution of scarce resources (Jessri and Fatemitabar, 2007). Justice
requires that dental healthcare providers ensure that patients are given the same
treatment options as anyone would receive in a similar position.
Conclusion
Dental clinicians that are providing aesthetic dental services that are evidence-
based; built on the foundational concepts of beneficence, non-maleficence,
truthfulness and respect for patient autonomy; and in keeping with professional
standards of care, are fulfilling their professional and ethical obligations. The
ethical principles are the moral rules, foundations and justification for our
treatment decisions and behavior. Failure to adhere to the fundamental ethical
principles not only violates the trust placed in the dental profession, but also
leaves the clinician vulnerable to litigation.
Dental practitioners should embrace this changing market as long as they leave
their patients in as good as, or better health than they found them in, while
meeting their demands. (Dental practitioners should embrace this changing
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market, attempting to meet their patients’ demands, but always leaving them in
as good as or better health than they found them in.)
References
1. Mousavi SR. The ethics of aesthetic surgery. J Cutan Aesthet Surg 2010; 3(1): 38-40.
2. Newsome P. From I don’t care to customer care. An evolution in patient
expectation. Dent Update 2003; 30: 488-490. 3. Tiernan JP. Editorial. Risk management from Dental Protection. Riskwise
South Africa, 2010; 14: p.3. 4. Nash DA. Professional ethics and esthetic dentistry. J Am Dent Assoc
1988; (4) 7E-9E. 5. Davis LG, Ashworth PD, Spriggs LS. Psychological effects of aesthetic
dental treatment. Journal of Dentistry 1998; 26: 547-554. 6. Priest G, Priest J. Promoting esthetic procedures in prosthodontic
practice. Jnl of Prosthodontics 2004; 13(2): 111-117. 7. Gold SA. Healing or hustling? Journal of the California Dental Association,
August 2002. Accessed on the Internet at: http://www.cda.org/library/cda_member/pubs/journal/jour0802/editor.html
8. Leffler WG. How do I justify my views on what I consider unnecessary
treatment. Ethical Moment in J Am Dent Assoc 2008; 139: 1546. 9. Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th ed. Oxford
University Press 2001. 10. Jessri M, Fatemitabar SA. Implications of ethical principles in chair-side
dentistry. Iran J Allergy Asthma Immunol 2007; 6(Suppl.5): 53-59. 11. Simonsen R. Commerce vs care: Troubling trends in ethics of aesthetic
dentistry. Dent Clinics of North Amer 2007; 281-287. 12. American Dental Association. Principles of ethics and code of professional
conduct. Chicago: ADA; 2005. 13. Thomas MV, Straus SE. Evidence-based dentistry and the concept of harm.
Dent Clin of North Amer 2009; 53(1): 23-32.
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14. American Association of Endodontists. AAE Position Statement, Implants. AAE Special Committee on Impants, American Association of Endodontists, Chicago, 2007. Accessed on the Internet at: http://www.aae.org/uploadedFiles/Publications_and_Research/Guidelines_and_Position_Statements/implantsstatement.pdf
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