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In an ethical dilemma? Untreated dental disease remains difficult to reconcile

Jan. 16, 2017
Jannette Whisenhunt, RDH, suggests untreated dental disease remains one of the most difficult ethical issues to reconcile.

By Jannette Whisenhunt, RDH, BS, MEd, PhD

Integrity is a characteristic that we hope people notice in us. Doing the right thing can sometimes be very easy, but it can also be very difficult. I received an e-mail from a former student regarding a situation that had her puzzled, and she wanted advice. She had been put in the middle of an ethical dilemma, and as a new hygienist she wasn't sure how to handle it. I'm sure many of you have been put in the middle of something uncomfortable, but you had to figure out the best course of action.

Here is her dilemma in a nutshell: Her patient wants a "regular prophy only," even though scaling and root planing is what is indicated from her bleeding points and perio chart readings. The dentist has the patient sign a "waiver" that states she agrees to a regular cleaning only. The hygienist has to respect the patient's wishes and do a regular prophy.

According to Kimbrough and Walls, an ethical dilemma is defined as "A conflict between moral obligations that are difficult to reconcile."1

The dilemma that this hygienist faces is that as a dental professional, she is not providing the treatment that is indicated for the patient's disease process. This is something that is drilled into us in school, that we treat each patient individually for their present symptoms. In this case, the patient has calculus in 5-6 mm pockets that needs to be removed in one quadrant. But if the hygienist removes it, she is performing a scaling and root planing procedure that is not what the patient wants or is paying for (insurance or not).

So I asked her some questions to start her thinking: Does she go ahead and remove the calculus? Does she leave the calculus knowing that it's going to cause more issues? If she removes the calculus, the patient gets more than what her insurance covers and the office will not get compensated for the work done. The patient may be getting the best treatment, but it is not what she agreed to. Does the hygienist go ahead and clean the pockets and look the other way about the insurance fees for scaling and root planing? Does she have a legal obligation when it comes to the insurance company? It is wrong to do one thing and charge for another, even when it's for the "patient's good"? By the way, yes, that is wrong! It's called fraud.

So, what was my advice? We have to look at our ADHA Code of Ethics and our obligations as oral health professionals.3 I told her that this situation needed to be discussed in the office to see what was legal and binding.

Will the "waiver" hold up in court if the patient comes back in a few years with advanced periodontal disease and says, "I didn't know I would lose my teeth," and now she wants to take legal action against the dentist?2 Should the dentist tell the patient that she will have to go somewhere else because she will not accept the diagnosis and treatment that is required? This will cause the office to lose a patient and will lead to bad feelings with the patient. Is it right to let patients dictate their treatment instead of the dental professionals?

I asked the new hygienist all these questions and told her I hope she makes the correct decision, and that she and the staff can live with that decision. We all must go through these situations and figure them out. We try to do the right and ethical things, but often it is not easy. We are all going to be put in these tight places at some time.

Another thing I told her is that it sounds like the patients in this office need a lot of dental education. Hygienists need to explain the disease process to patients and try to put it in language they can understand. We should present posters and materials that patients can take home to help them understand what's going on in their mouths. The more they realize that we're there to help them, the more willing they will be to accept our treatment plans that are in their best interest. Education is the key, and it's something that every hygienist can do more of.

I hope you don't find yourself in an ethical dilemma any time soon, but if you do, I hope you can get out of it painlessly. Happy scaling! RDH


1. Kimbrough-Walls VJ, Lautar CJ. Ethics, Jurisprudence and Practice Management in Dental Hygiene, 3rd Ed. 2012. Pearson Publishing. Boston.
2. Beemsterboer PL. Ethics and Law in Dental Hygiene 2nd Ed. 2010. Saunders. St. Louis.
3. ADHA Code of Ethics. Adha.org

Jannette Whisenhunt, RDH, BS, MEd, PhD, is the Department Chair of Dental Education at Forsyth Technical Community College in Winston-Salem, N.C. Dr. Whisenhunt has taught since 1987 in the dental hygiene and dental assisting curricula. She has a love for students and served as the state student advisor for nine years and has won the student Advisor of the Year award from ADHA in the past. Her teaching interests are in oral cancer, ethics, infection control, emergencies and orofacial anatomy. Dr. Whisenhunt also has a small continuing education business where she provides CE courses for dental practices and local associations. She can be reached at [email protected].