Some of the most influential and impactful lessons in health care are not found in textbooks. Through workplace culture, repetition, and the normalization of behaviors, health-care professionals adopt assumptions and attitudes that define what they accept, question, and advocate for within clinical practice.

The hidden curriculum of dentistry

“That’s how we’ve always done it.” At some point in our careers, many of us have heard this. Maybe it was directed to us or implied in workplace culture. “Hidden curriculum” can be defined as the behaviors and understandings established outside of traditional education.¹ Through repetition and professional socialization, health-care professionals tend to adopt hierarchical beliefs rooted in experience, skill, or educational background, where questioning those above them is discouraged. This develops the mentality of “if it has worked this long, why change it?”

Roughly half of adults ages 30 years or older in the United States have periodontitis.² Despite ongoing advancements in oral-systemic research and preventive technology, many clinical environments struggle to move beyond traditional philosophies and legacy approaches to treatment.

The moral question becomes: “Is what we’re doing really working?”

Moral distress and burnout

For many clinicians, identifying the factors influencing hidden curriculum creates emotional and ethical tension within the workplace. When health-care professionals are expected to follow outdated or production-driven policies and procedures, they may experience moral distress: feelings of anger, disappointment, and guilt resulting from frustrations directly related to moral choice.³ The wide range of definitions for the occurrence of moral distress makes analysis difficult, but a review of literature suggests that a combination of the experience of a moral event, “psychological distress,” and a direct causal relation between the two are necessary conditions to define moral distress.⁴

Repeated exposure to moral distress can result in discouraged clinician autonomy and overall patient care. Dealing with long-term exposure to moral distress has also been linked to physical and psychological effects. These effects can manifest as insomnia, excessive fatigue, depression, and helplessness. In addition, studies reveal a strong correlation between moral distress and clinician burnout.⁵

Approximately 70% of dental hygienists who reported thinking about leaving the profession within the next five years had significantly higher burnout.⁶ Burnout extends beyond the physical manifestations of moral distress, and the influence can impact how clinicians interact with patients, colleagues, and the profession. Environments that leave clinicians unheard, unsupported, or unable to choose ethical patient care may lead to feelings of reduced professional accomplishment and overall job satisfaction. As a result, workforce retention is impacted, ultimately affecting patient care delivery.

Impact on patient care and professional identity

In clinical environments where efficiency and production are prioritized, patients may receive care focused on resolving the immediate concern, rather than addressing the underlying systemic and behavioral factors contributing to disease. Preventive education, behavioral counseling, and comprehensive communication suffer when clinicians are pressured to remain on a strict schedule or conform to nonclinical expectations.⁷ This creates tension with the patient-centered and preventive foundations emphasized throughout dental hygiene education. Additionally, these challenges are further complicated when diverse patient needs, health literacy levels, and access barriers are not fully considered within rigid clinical structures.

Dental hygienists often serve as the first line of advocates and educators for preventive oral health care. However, when clinicians feel that they are unable to practice at the highest standard of care, professional autonomy may become limited.⁸ New graduates enter the workforce equipped with current research and evolving standards of care, often recognizing a disconnect between what is taught in formal education and what is accepted within clinical practice. In some environments, questioning existing protocol or introducing newer evidence-based approaches may be interpreted as challenging authority and status quo rather than contributing to professional growth. New clinicians may gradually conform to prevent conflict or maintain workplace acceptance.

The normalization of these behaviors significantly shapes professional identity, as professional socialization helps clinicians develop confidence, communication skills, and clinical judgment. However, if influence is rooted in hierarchy, fear, or resistance to change, it could lead to unhealthy expectations. If emotional exhaustion, understaffing, moral distress, or burnout is viewed as “part of the job,” we fail to identify the influences that are part of larger systemic conditions.

Recognizing these patterns is just the first step. Addressing them requires intentional reflection in both educational and clinical settings. Encouraging open discussions surrounding ethics, communication, evidence-based care, and overall clinician well-being may help bridge the gap of educational standard of care and workplace acceptance. By supporting environments where clinicians feel heard and supported, patients will benefit from higher standards of care and clinicians will avoid moral distress and burnout.

Ethical responsibility

Ethical practice is more than nonmaleficence and technical competence. Clinicians should remain open to evolving evidence, acknowledge when routines no longer serve the patient, and participate in conversations that improve standards of care. In environments where hierarchy and repetition can discourage questioning, maintaining professional integrity may involve difficult but necessary dialogue.

Advocacy takes many forms in everyday practice. Whether it’s strengthening informed consent, adapting communication to meet individual patient needs and lived experiences, supporting colleagues through collaborative discussion, or recognizing the barriers influencing access to trust in health care, remaining engaged, reflective, and willing to challenge complacency allows our profession to move toward true ethical, equitable, and patient-centered care.

Possible interventions

Addressing moral distress and burnout is more than individual resilience. Creating a psychologically safe workplace where everyone feels comfortable asking questions, discussing ethical concerns, and participating in collaborative decision-making may help reduce emotional exhaustion and professional disengagement.⁹

Open communication between team members can encourage reflection, strengthen trust, and support more patient-centered approaches to care.

Shifting the culture

Professional growth and ethical development should also be supported through mentorship, self-reflective practice, and continuing education. Engaging in conversations surrounding ethics, cultural awareness, communication, and evolving evidence-based care allows clinicians to remain adaptable and professionally fulfilled. Small intentional efforts to challenge complacency and encourage dialogue may assist in creating healthier clinical environments for both providers and patients.

Also by the authors: Who we are shapes how we practice: Cultivating ethical decision-making

Editor’s note: This article first appeared in RDH eVillage newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles and subscribe.

References

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2. About periodontal (gum) disease. Centers for Disease Control and Prevention. May 15, 2024. https://www.cdc.gov/oral-health/about/gum-periodontal-disease.html
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