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Practice Management and Human Relations
Ethical decision-making for multiple
prescription dentistry
Kevin Huff, DDS, MAGD  n  Marlene Huff, PhD, RN  n  Constantin Farah, DDS, MSD
Technology provides a selection of treatment choices for dental This article presents four case studies that illustrate the process of problems. Dental ethics must be applied to the development of a ethical decision-making for the appropriate treatment.
treatment plan and the selection of methods. Treatment options Received: August 2, 2007 should consider the patient's circumstances and desires as well Accepted: September 19, 2007 as the dentist's decision as it relates to best practices in dentistry. The art and science of dentistry a given patient may be different for mendations. The American Dental has progressed very rapidly the same patient at different times Association's Code of Ethics lays since the introduction of the in his or her life.
the groundwork; how the Code is high-speed handpiece in the 1950s.1 Recognizing the importance of applied reflects the dentist's indi- There has been a paradigm shift optimal oral health, coupled with vidual values (see the table).3 from paternalistic management the rapid advancements in technol- It often is possible to achieve of obvious problems to a medical ogy, may lead the practitioner to similar results from the application model of dental care, which includes be overzealous in treatment. A of different approaches to treatment prevention and management comprehensive plan of care that is or prevention.4 Having multiple of dental disease and prosthetic appropriate for the patient should options leads to what Sadowsky rehabilitation to restore normal include the application of ethical cal ed the "moral dilemma of the oral function. Discovery of the principles in the development, multiple prescription in dentistry."5 relationship between oral health and acceptance, and implementation of One approach may be considered systemic disease has raised awareness treatment. The science of dentistry more beneficial than another at concerning the importance of oral makes it possible to offer multiple a given time. The options that a health. In 2000, the U.S. Surgeon options to patients; however, the dentist offers and a patient selects General cited oral health as a major art of dentistry includes the need can be influenced by changes in the concern.2 Advancements in tech- to communicate with the patient patient's lifestyle or physical condi- nology offer a variety of solutions and to apply ethical principles tion or a change in terms of available for managing similar dental situa- when making treatment recom- treatment methods. The clinician tions and it is incumbent upon each practitioner, as a member of an ethi- cal profession, to educate patients about their appropriate treatment Table. Ethical principles.3 options, allowing them to make autonomous treatment choices that are in their best interest.
Patient autonomy ("self-governance") The dentist has a duty to respect the patient's It generally is understood that rights to self-determination and confidentiality many treatment options are avail- Nonmaleficence ("do no harm") The dentist has a duty to refrain from harming able for any given dental condition. A definite decision-making process Beneficence ("do good") The dentist has a duty to promote the patient's helps to determine the appropriate- ness of each treatment modality. It Justice ("fairness") The dentist has a duty to treat people fairly also must be acknowledged that the Veracity ("truthfulness") The dentist has a duty to communicate truthful y ethically appropriate treatment for 538 September/October 2008 General Dentistry www.agd.org should share his or her reasons col to matters of human concern. Informed consent is an important for recommending one treatment Normative ethics refers to an area component of decision-making; option over another; however, other of inquiry that investigates right or however, sharing all of the details reasonable treatment options should wrong conduct, looking at ethical about a case may complicate the be presented as well. An ethical principles and rules commonly process. The dentist must decide decision-making process is necessary associated with the situation and how much information to share when discussing the risks and ben- assessing duties and obligations. with the patient. For example, fair efits for the patient and arriving at an Autonomy includes self-determi- fee structures are included in the appropriate decision for treatment. nation, confidentiality, and the right principle of veracity; misrepresenta- Professional responsibility includes to select and/or to refuse treatment. tion is considered to be untruthful. acting in a manner that promotes The dentist must inform the patient Beneficence and nonmaleficence "good" for the patient. Ethical prin- of all reasonable and appropriate include benefits versus harm. Com- ciples should be the underpinning treatment options. This way, the bined, this dichotomy is a utilitarian for the plan of care and should affect patient is actively involved in treat- principle that includes acting in a al choices made concerning care ment decisions. Dentists serve not manner that promotes the good only as diagnosticians but also as of the patient. Even though a Dentistry is a moral profession, educators. Trust may be weakened particular technique could address guided by normative principles.4 if dentists limit the amount of infor- an immediate problem, the overall As a result, dentists are obligated mation patients receive. effect may harm the patient in a way to choose a course of treatment Too much information also can that is not immediately apparent. that allows them to be "caring present a problem.9 The dentist Weinstein has proposed a process and fair in their contact with must use good judgment when for making ethical decisions for patients."3 Although increased obtaining informed consent. patient care. This process involves commercialism may be difficult to Education may inform patients as gathering relevant facts, including avoid, patient autonomy should to what they need but that may medical history and social factors, be the overwhelming decision- not be what they want. Autonomy ascertaining possible treatment making principle. Preservation involves decision-making from both options, and answering questions of the profession of dentistry and the patient and the dentist. The concerning what course of treat- the self-policing autonomy that it right to refuse treatment is inherent ment should be followed and why.7 enjoys necessitates adherence to the in the principle of autonomy.10 The first step involves gathering normative picture.7 Members of the Justice includes trust and kind- all of the relevant facts, including dental profession and of the com- ness. Trust is built upon being medical history, dental history, and munity at large expect dentists to honest; patients trust that dentists social factors. Relevant ethical prin- act ethically, according to a balance have a current working knowledge ciples are identified and a decision of certain norms: nonmaleficence, of modern dental techniques. As a is made regarding conflicts. For beneficence, justice, veracity, and result, continuing education is an example, when a patient requests respect for patient autonomy.3 The ethical obligation of the dental pro- a treatment that would knowingly personal virtues of the dentist and fession (one which may or may not render his or her condition more the intrinsic values of the profession, be required by law). If the patient unstable or uncertain than at the the patient, and society must be requires treatment that is beyond time of the initial visit, the personal considered when choosing appropri- the skill of the primary dentist, virtues of the dentist and the ate treatment for any given situation it is expected that the dentist will principles of nonmaleficence may (see the table).3 refer the patient to more qualified conflict with the need to respect the Codes of ethics describe expected clinicians. Ethical decision-making patient's autonomy. standards of behavior for self- reduces the tendency toward over- Next, all of the treatment options policing professions (dentistry, treatment; that is, a dentist should available for the given situation medicine, nursing, and so forth). not perform a procedure that is should be ascertained (for example, Ethics also may be considered a not indicated simply to please the a Class II carious lesion may be mode of inquiry for processing the treated with an interim glass moral dimensions of an issue.8 To Veracity includes judgment ionomer restoration, an interim engage in ethics is to apply a proto- concerning what to tell the patient. zinc oxide/eugenol restoration, www.agd.org General Dentistry September/October 2008 539

Practice Management and Human Relations Ethical decision-making
a composite resin restoration, an amalgam restoration, a porcelain inlay, a resin inlay, or a gold inlay). Finally, the dentist selects the appropriate treatment option by answering the questions "What should be done?" and "Why should it be done?" Although it is inherent in the process, perhaps a fourth step should be added: to arrive at a treatment option that is acceptable to both the patient and the dentist. Autonomy, or the patient's decision about treatment, is an important This article presents four case reports that illustrate how ethical Fig. 1. A 45-year-old woman with a loose maxil ary anterior FPD from teeth No. 6–9.
principles were applied in the deci- sion-making process to determine the most appropriate treatment. The authors acknowledge that the treatment rendered is not consid- ered to be ideal in these situations according to accepted standards. However, in each case, ideal treat- ment options were presented as part of the informed consent process. Weinstein's model was used to guide Case report No. 1
A 45-year-old woman sought treat-
ment for a failing four-unit fixed Fig. 2. A radiograph and occlusal view of the patient, indicating the recurrent caries that caused partial denture (FPD) that had the existing FPD abutment to fail. The cavosurface of the healthy tooth after excavation is at the been placed more than ten years osseous crest.
earlier (from teeth No. 6–9). She had recurring dental caries under the distal abutment crown that was inaccessible for repair without removing the FPD (Fig. 1). The contraindication to dental surgery. lengthening surgery, individual right maxillary canine abutment The patient wanted to receive the abutment crown therapy for teeth was mobile and fractured at the least costly restoration as quickly as No. 6 and 9, and removable partial gingival margin (Fig. 2); in addi- possible. The function, esthetics, denture (RPD) therapy. A second tion, the patient had an Angle's and durability of her previous FPD option involved the aforementioned Class I occlusion with stable centric were acceptable to her. She was endodontic therapy and crown- occlusion and anterior guidance. opposed to any type of removable lengthening surgery plus FPD The patient had received a nine- therapy, utilizing teeth No. 6 and 9 unit, four implant-supported FPD Based on the patient's wishes, three as abutments. A third option would (from teeth No. 19–27) more treatment options were available. involve extracting the right canine than a year earlier; it was in good One option involved endodontic and placing implants in the sites of condition. Medically, there was no therapy on the right canine, crown- teeth No. 6 and 8, with an implant- 540 September/October 2008 General Dentistry www.agd.org

that have improved the feasibility of fixed prostheses and in an era that places a high value on esthetics. The costs associated with complex restoration of severely compromised teeth, the associated morbidity, and the unfavorable comparative prognoses suggest a need to consider utilizing dental implant therapy and/or FPD therapy as alternatives. The decision should be based on the Fig. 3. The patient in Figure 2 after receiving appropriate endodontic therapy and phased FPD patient's medical history and socio- therapy. Note the favorable tissue response and esthetic appearance created by wel -developed economic status, as well as proper ethical principles. Ethical considerations
Autonomy
The patient was presented with all
supported FPD and an independent and a full-coverage restoration possible treatment options, includ- crown on tooth No. 9. After thor- subsequent to endodontic therapy. ing the option to do nothing with ough discussion, the patient chose For adequate retention, it generally her failing FPD. As with all of the the second of the three plans.
is understood that the final crown cases presented in this article, the The existing FPD was removed, margin should be at least 2.0 mm patient was well-educated through endodontic therapy was completed apical to the cavosurface margin of discussion and commercially on tooth No. 6, and a pre-fabricated the core, creating a ferrule. This prepared video presentations. In post and a bonded resin core were complex approach to restoration is addition, she had received implant placed. A provisional FPD was technique-sensitive and the progno- therapy on her mandibular arch fabricated and crown-lengthening sis for the tooth as an abutment for previously without complication.
surgery was completed from teeth No. 6–11. After ten weeks of tissue For healthy biologic width, there healing, a porcelain-fused-to-high must be adequate space between the The patient had been treated previ- noble metal FPD was fabricated crown margin and the crestal bone. ously with a very functional and and luted with resin-reinforced glass Osseous crown-lengthening surgery esthetic FPD. FPD therapy has ionomer cement (Fig. 3). is indicated when coronal tooth been utilized for many years in The patient had enjoyed acceptable structure loss is significant enough to conventional dentistry and there success with her previous four- compromise the biologic width when was no absolute contraindication unit FPD and understood that an an ideal restoration is placed. This for FPD therapy, since the abut- implant-supported prosthesis would procedure is a subtractive approach ment teeth were prepared and provide the best longevity and that that requires removing bone in an would have required crown therapy crown-lengthening surgery is a sub- era when efforts are conscientiously regardless of the therapy selected. tractive therapy rather than additive. being made to provide additive treat- The risks of crown-lengthening ments that regenerate bone.
surgery (and the fact that bone Dental considerations of
When a tooth is severely com- would need to be removed) were promised, an alternative to the discussed thoroughly. The patient Periodontally sound teeth that aforementioned therapy would be clearly understood her condition have endured severe structural to extract the tooth and replace it and made an educated choice. The loss (that is, more than 50% of with either an RPD or an implant- same clinicians who completed the the coronal tooth structure) and supported prosthesis. Although previous implant therapy and pros- still are deemed restorable usually RPDs once were common practice, thesis presented and performed this require either a prefabricated or they have fallen out of favor in light particular treatment, so the patient laboratory-made post and core of modern materials and techniques was not subjected to outside bias.
www.agd.org General Dentistry September/October 2008 541

Practice Management and Human Relations Ethical decision-making
Fig. 5. The patient in Figure 4, after receiving a zirconia-based FPD that replicated the original Fig. 4. An anterior view and a radiograph of a 64-year-old woman with failing restorations on her position of the natural dentition in accordance central incisors.
with the patient's esthetic demands.
a stable, esthetic solution for her in options were considered. The first Although it may be argued that accordance with her chief concerns.
option involved endodontic retreat- crown-lengthening surgery removes ment, bonded resin cores, and crown bone, it also would allow the Case report No. 2
therapy on teeth No. 8 and 9. The dentist to save the canine. Since all A 64-year-old woman sought treat- second option involved extracting procedures were performed accord- ment for failing restorations of her teeth No. 8 and 9, fol owed by ing to accepted protocols (with maxillary central incisors (teeth No. phased FPD therapy. The third 2.5 mm of ferrule for abutment 8 and 9). External root resorption option involved extracting teeth No. retention on tooth No. 6, while the was evident (Fig. 4). The patient 8 and 9, followed by phased remov- abutment teeth had been prepared had an Angle's Class II Division able denture therapy. The fourth as abutments previously), no harm II occlusion and a moderate shift option involved extraction of teeth was caused to the patient. Healing from centric occlusion to maximum No. 8 and 9, fol owed by implant discomfort and surgical involvement intercuspal position without pain. replacement therapy for teeth No. 8 were similar to what would have There was steep anterior guidance and 9 and implant-supported crowns. resulted from implant therapy.
and a high maxillary lip attachment. The patient selected extraction The patient was in good health with and the FPD. Once that decision a history of seasonal sinusitis and was made, teeth No. 8 and 9 were The benefits of implant therapy was not taking any medications on extracted and the maxil ary lateral were superseded by the patient's a regular basis. Her dental history incisors were prepared for abutment concerns about the short-term cost included multiple minimally accept- crowns. Synthetic ridge preservation of therapy. A plan for failure was able alloy and resin restorations. material (Bioplant, Kerr Dental, discussed with the patient, who More than 40 years earlier, the Orange, CA; 800.537.7123) was clearly understood that the lifespan patient had received endodontic placed according to standard proto- of the FPD was expected to be therapy on teeth No. 8 and 9; this col and a provisional FPD was fab- shorter than that of an implant- therapy was followed by the placing ricated to al ow for adequate tissue supported prosthesis. The patient of porcelain veneers that had been maturation. The preparations on understood that failure could repaired multiple times. She had a the lateral incisors were refined and a require either a removable prosthesis history of sporadic recall visits and four-unit zirconia-substructure FPD or a more costly implant-supported poor oral hygiene. The patient said (Lava, 3M ESPE, St. Paul, MN; prosthesis. The patient benefited that she wanted "whiter" incisors 888.364.3577) was fabricated for from crown-lengthening, endodon- but she did not want the position or teeth No. 7–10. The FPD was luted tic therapy, and conventional FPD shape of her teeth to change.
with resin-reinforced glass ionomer therapy because this plan provided Given these factors, four treatment cement (Fig. 5).
542 September/October 2008 General Dentistry www.agd.org understood that the lifespan of an FPD therapy has been utilized in FPD most likely would be shorter conventional dentistry for many than that of an implant-supported years, with predictable outcomes. prosthesis. The patient understood No absolute contraindication that in the event of failure, her for FPD therapy exists in this only choices of therapy might be particular case, although it would a removable or implant-supported require altering the abutment teeth. prosthesis. The patient benefited However, when the patient's desired from phased FPD therapy in this esthetic outcome was considered case because it was the most predict- carefully, there were reasonable able treatment option for meeting contraindications for an implant- her demands and expectations. retained prosthesis or RPD therapy. The dentist and patient had a frank Case report No. 3
Fig. 6. A radiograph of a 62-year-old man with discussion about the difficulties that A 62-year-old man had a failing a failing cantilever FPD. No photograph was would be encountered in meeting cantilevered FPD that replaced the the patient's esthetic demands left maxillary central incisor (Fig. and the expected results of each 6). Tooth No. 8, the single abut- treatment option were reviewed. ment, was mobile and elicited pain The patient clearly understood her on percussion. An Angle's Class I condition and made an educated occlusion existed with stable centric The prognosis of re-restoring teeth choice. No guarantees or promises occlusion and anterior guidance. No. 8 and 9 was guarded due to the were made. It was made clear to The patient had a history of acid lack of substantial remaining root the patient that her home compli- reflux, asthma, chronic sinusitis, structure and external root resorp- ance would determine the success primary tension headaches, and tion. The patient's esthetic demands of any treatment option and the arthritis; his current medications and existing anatomy created a relative fees for each treatment included Prilosec (AstraZeneca, contraindication for RPD therapy. option were discussed openly and Westborough, MA; 800.236.9933) It was unclear whether the patient and lactase. The patient had a his- would be satisfied with implant tory of excellent oral hygiene and therapy due to the uncertain gin- compliance with recommended gival esthetic outcome, which cur- Since all procedures were performed dental treatment. Seven years rently is a risk factor for implants in according to accepted protocols earlier, the same dentist had placed a the esthetic zone. Since the patient and because the patient was clearly crown that was not esthetic on tooth desired an exact duplication of the informed about all procedures prior No. 7. Since the patient was an crowding of her original anterior to treatment initiation, no harm optometrist and had direct and close teeth, an FPD was considered to be was caused to the patient. Healing personal contact with the public, he the best course of therapy.
discomfort and surgical involvement did not want any long-term remov- were within normal limits. able prostheses; he also was opposed to further tooth reduction unless it was absolutely necessary.
The patient was presented with Since the patient's home hygiene Three treatment options were con- all reasonable treatment options, practices were questionable, the sidered. The first option involved including the option to do nothing success of dental implant therapy endodontic therapy, with a new with her existing dentition. She was uncertain. The potential need crown for tooth No. 8 and a single- was made aware of the anticipated for future extraction might require a tooth RPD. The second option difficulty of fabricating a prosthesis multi-tooth RPD; the design of such involved performing endodontic that would comply completely with a prosthesis might be complicated therapy on tooth No. 8 and conven- her esthetic demands. The patient's by endosseal implants in the sites of tional FPD therapy from teeth No. desire to recreate her existing maloc- teeth No. 8 and 9. A plan for failure 8–10, replacing tooth No. 9 with a clusion was honored. was discussed with the patient, who pontic. The third option involved www.agd.org General Dentistry September/October 2008 543 Practice Management and Human Relations Ethical decision-making
Fig. 7. The patient in Figure 6, after receiving dental implants and an Fig. 8. The patient in Figure 6, after splinted, implant-supported crowns interim acrylic RPD. The existing crown on tooth No. 7 was made to were fabricated to replace teeth No. 8 and 9. The crown on tooth No. 7 match the existing cantilever FPD.
was replaced to provide a more esthetic result. extracting tooth No. 8 and utilizing nothing with his existing dentition. were within normal limits. An implant therapy to replace teeth No. He was made thoroughly aware of interim RPD was fabricated during 8 and 9. The patient selected the the difficulty of providing a prosthe- the healing period so that the patient third option; in addition, he wished sis that complied with his esthetic did not have to endure social stigma to replace the crown on tooth No. 7 demands. The dentist exercised due to missing central incisors.
with a more esthetic restoration. professional autonomy by replacing Once a treatment plan was the restoration on the lateral incisor selected, tooth No. 8 was extracted at no fee because he was not satis- Considerations for the patient's and bovine bone was grafted for fied with the result of his previous profession and psychosocial success ridge preservation. Two endosseous solidified the selection of implant dental implants were placed and therapy over other treatment alter- an interim acrylic RPD (with no natives. This treatment choice cre- contact over the implant sites) was There was no absolute contraindica- ated a situation that was more stable fabricated for esthetic function tion for FPD therapy but there and predictable than his original only (Fig. 7). Definitive implant- were relative contraindications for prosthesis. The dentist's decision supported crowns were fabricated an implant-retained or removable to replace the restoration on tooth to replace teeth No. 8 and 9 and the prosthesis. The patient was given No. 7 at no fee was made with the crown on tooth No. 7 was replaced the same options for treating his patient's best interest in mind.
(Fig. 8). The restorability of tooth condition as anyone else would have No. 8 was questionable and tooth received in a similar situation. He Case report No. 4
No.10 was virgin. Because of the also was clearly informed that his On two different occasions (two patient's profession and his desire home compliance would determine years apart), a 62-year-old woman to avoid a removable prosthesis, a the success of any treatment option.
sought treatment for maxillary definitive RPD was contraindicated. incisors that had fractured 2.0 mm The crown on tooth No. 7 was coronal to the free gingival margin. replaced at no fee to the patient.
Since al procedures were performed Tooth No. 7 was the first to fracture according to accepted protocols (Fig. 9); tooth No. 10 fractured two Ethical considerations
and because the patient was clearly years later (Fig. 10). An Angle's informed about al procedures prior Class I second premolar bilateral The patient was presented with to treatment initiation, no harm occlusion had been restored previ- all possible treatment options, was caused to the patient. Healing ously, with stable centric occlusion including the option to do discomfort and surgical involvement and adequate anterior guidance. 544 September/October 2008 General Dentistry www.agd.org therapy to replace tooth No. 20 without incident.
The first treatment option involved endodontic therapy on the involved lateral incisor, crown- lengthening surgery, fabrication of a post and core, and crown therapy. The second option involved extrac- tion of the fractured lateral incisor and phased FPD therapy, utilizing the lateral canine and central inci- sor as abutments. The third option involved extracting the fractured Fig. 9. A radiograph and anterior view of a 62-year-old woman with a fracture just above the lateral incisor and utilizing an gingival margin on tooth No. 7.
RPD. The fourth option involved extracting the incisor and utiliz- ing implant replacement therapy, replacing the lateral incisor with an implant-supported crown. Crown-lengthening therapy would alter the gingival profile significantly and expose the margins of the exist- ing adjacent crowns. FPD therapy was contraindicated at both visits due to the cost already invested in crown therapy on adjacent teeth. Implant therapy appeared to be the best treatment option. Although the patient was given the same four treatment options at both Fig. 10. A radiograph of the patient in Figure Fig. 11. A radiograph of the patient in Figure visits, she made a different choice 9 taken two years later demonstrates a similar 9, after receiving a dental implant to replace each time. At her first visit, the fracture on tooth No. 10.
tooth No. 7 while the gingival architecture was patient requested implant replace- ment therapy because she had been pleased with the results of previous implant therapy. At the second visit, the patient's situation had changed and she was concerned about under- The patient had a history of fibro- Inc.), Oxycontin (Purdue Pharma, going any additional surgery, leading myalgia, osteoarthritis, hypothy- Stamford, CT; 800.877.5666), her to choose the first option.
roidism, sleep apnea, hypertension, and aspirin with calcium. A his- Tooth No. 7 (the first fractured depression, anxiety, chronic sinus- tory of excellent home care and tooth) was extracted atraumatically itis, and primary tension head- compliance with dental therapy and an endosseous implant was aches. At the time of both visits, was obvious upon the initial visit, placed immediately at the time of she was taking Prinivil (Merck & but declining health and dexterity extraction. The patient declined to Co., Inc., Whitehouse Station, NJ; became evident by the time of receive a provisional restoration. An 800.444.2080), Zoloft (Pfizer, Inc., the next visit two years later. The implant-supported crown was fabri- New York, NY; 800.223.0182), patient was pleased with her smile cated (Fig. 11). When tooth No. 10 Xanax (Pfizer Inc.), Levoxyl (King and did not wish to alter her gin- fractured similarly two years later, Pharmaceuticals, Bristol, TN; gival profile; she had been treated endodontic therapy was completed, 800.776.3637), Neurontin (Pfizer, previously with dental implant a prefabricated post and resin core www.agd.org General Dentistry September/October 2008 545 Practice Management and Human Relations Ethical decision-making
Fig. 12. A radiograph of the patient in Figure 9, after conven- Fig. 13. An anterior view of the patient in Figure 9, after receiving a conventional tional therapy was completed to restore tooth No. 10. An ideal crown supported by a prefabricated post and core on tooth No. 10. The gingival ferrule was sacrificed to preserve biologic width.
architecture was maintained.
was placed (Fig. 12), and the tooth treatment option. She declined the best possible prognosis, based on was restored using a porcelain- crown-lengthening surgery with the patient's prior experience with fused-to-high noble metal crown the thorough understanding that it dental care and the fact that remov- without osseous crown-lengthening may be necessary in the future for ing the adjacent crowns to fabricate surgery. (The biologic width viola- optimal gingival health.
an FPD would subject those teeth tion was minimized to the greatest to unnecessary trauma and lead to extent possible.) The patient's additional expense. By the time esthetic and functional needs were All reasonable treatment options the patient sought treatment for met appropriately with two different were presented to the patient. Her tooth No. 10, it was apparent that approaches to care (Fig. 13).
medical history, desires, and capa- elective surgical procedures should bilities were considered carefully be avoided due to medical risks. Ethical considerations
and independently at the time of Therefore, the patient's health at the each presentation.
time of each event was factored into In both scenarios, the patient was the selection of a treatment modal- presented with all possible treatment ity for each situation.
options, including the option to do Although the "ideal" protocol was nothing with her existing dentition. not followed in the restoration of She was made aware of the difficulty tooth No. 10, the patient was clearly In each of these case reports, ethical that would result from crown- informed about al procedures prior principles guided the plan of care. lengthening therapy. At her first to treatment initiation and no harm Patient autonomy was the last step visit, she was predisposed to dental was caused to her. Healing discom- in the ethical decision-making pro- implant therapy because of suc- fort and surgical involvement were cess. The dentist used knowledge cessful previous implant therapy; at within normal limits. The patient's and ability to answer the questions that time, she declined a provisional request for the course of therapy in regarding why treatment was neces- prosthesis to reduce the cost of ther- both scenarios was reasonable.
sary, enabling the patient to make apy. By the time of the second visit, a sound autonomous decision. The she was aware of the decline in her principle of veracity was not noted health and was willing to accept the Initially, implant therapy appeared for each case because it is a value of risks of a somewhat compromised to be the best treatment option with the authors to tell the truth about 546 September/October 2008 General Dentistry www.agd.org treatment options within the limits tion of technological advances in of the information that is available dental medicine integrates the art 1. A mil ennium of dentistry—A look into the and necessary to make a choice. and science of dentistry, personal past, present and future of dentistry. Available Trust is considered an integral values and beliefs, and a profes- part of the dentist-patient relation- sional code of ethics into a decision- Accessed July 20, 2007.
ship and is essential for informed making framework for providing 2. Healthy People 2010, vol. 2. Washington, DC: Department of Health and Human Services; appropriate care.
Even as technology advances 3. American Dental Association. Principles of eth- rapidly and aggressive marketing ics and code of professional conduct. Available practices appear to be increasingly The authors wish to thank the team ada_code.pdf. Accessed June 2007.
necessary, clinicians cannot be con- of technicians at BecDen Dental 4. Windholrn R, Cuenin M. An implant versus a sidered incompetent simply because Laboratory (Draper, Utah) for their conventional fixed prosthesis: A case report. Gen Dent 2007;55:44-47.
they make decisions that other cli- artistic talents demonstrated in each 5. Sadowsky D. The moral dilemmas of the multi- nicians may view as inappropriate, case and the staff in the Department ple prescription in dentistry. J Am Coll Dent provided there is sound scientific of Nursing at the University of 6. Ethics handbook for dentists. Gaithersburg, rationale behind the choice of treat- Akron for their assistance.
MD: American College of Dentists;2004.
ment rendered in good faith. Pro- 7. Weinstein B. Dental ethics. Philadelphia: Lea viding treatment without informed & Febiger;1993.
8. Huff KD, Leffler WG, Campbell D. Ethics are consent devalues patient autonomy. The authors have received no moral, but morality is not ethics. Gen Dent Because dentistry is an ethical financial reward from any of the profession, the ethical obligations products, companies, or laboratories 9. Kelley J. Ethical dentistry: A time proven solu- tion to a modern problem. J Am Coll Dent of the dentist must guide every mentioned in this article.
treatment decision. If neither the 10. Nichols P, Winslow G. What patients need ver- patient nor the dentist are comfort- sus what they want. Gen Dent 2003;51:503- able with the decision, there is no Dr. Kevin Huff is a clinical instruc- 11. Perel M. Endodontics or implants: Is it that obligation for the dentist to treat tor, Department of Comprehensive simple? Implant Dent 2006;15:111.
the patient beyond stabilizing a life- Care, Case School of Dental Medi- Published with permission by the Academy of General threatening urgent condition. A cine in Cleveland, Ohio, where Dr. Dentistry. Copyright 2008 by the Academy of dentist should not perform a treat- Farah is an associate clinical profes- General Dentistry. All rights reserved.
ment that would violate another sor. Dr. Marlene Huff is an associate ethical principle simply to support professor, Col ege of Nursing, patient autonomy. Ethical utiliza- University of Akron in Akron, OH. www.agd.org General Dentistry September/October 2008 547

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