Counseling principles for more effective patient education.

Patients often fail to progress in preventive dentistry behavior. Greater success will be realized if the dentist uses a counseling approach based on basic theoretical principles of psychological counseling. Humanistic and behavioral counseling theories are adaptable to the dental environment. An approach modeled on the exploration, understanding, and action phases of counseling is practicable for the clinical dentist.

Dental treatment during pregnancy: a preventive approach.

Applying the basics of preventive dentistry at the primary level will broaden the scope of prenatal care. Dentists should encourage all patients of childbearing age to seek oral health counseling and examination as soon as they learn they are pregnant. Specific printed information on pre- and postnatal fluoride, plaque control, nutrition, and tooth development should be available for pregnant patients. Recall systems should allow for pregnant patients. Emergency problems should not be deferred for treatment in the second trimester but should be alleviated immediately. Indicated medications should not be withheld because of pregnancy but patients must be informed of benefits and risks. Consultation with the patient's physician is always appropriate.

Rapidly progressive periodontal disease associated with HIV infection: report of case.

A case of rapidly progressive periodontal disease associated with human immunodeficiency virus (HIV) infection is presented. Rapid horizontal bone loss, with only moderate inflammation, occurred during a 13-month period. Pocket depth was significantly less than anticipated, given the degree of bone loss. The patient had no signs or symptoms of acquired immune deficiency syndrome (AIDS). The cause, features, diagnosis, and management are discussed.

Addressing family violence among dental patients: assessment and intervention.

Health care professionals increasingly encounter family violence victims, but often do not recognize the signs of abuse. A mailed survey and personal interviews with dental health care workers reveal an uncertainty about intervening when abuse is suspected. The authors examine DHCWs exposure to family violence among their patients, educational history and thoughts about intervention.

Oral cancer detection. The importance of routine screening for prolongation of survival.

The incidence of oral cancer has increased in the past ten years. Early diagnosis and treatment are essential to long-term survival; however, patients at highest risk visit the dentist infrequently. The reddish, velvety or erythroplakial lesion at the base of the tongue or floor of the mouth is highly suspicious in any patient and requires further evaluation. High-risk patients with less suspicious appearing lesions must be reevaluated on close recall. Prognosis improves vastly when the lesion is detected and treated early. One study demonstrated a 64% five-year survival rate for patients with oral cancer that was diagnosed before regional lymph node involvement versus a 15% five-year survival for patients whose lesions were diagnosed after regional lymph node involvement. By including an oral cancer examination in routine physical examination of patients, the physician and public health nurse can increase the likelihood of early detection of oral cancer.

Sexual advances by patients in dental practice: implications for the dental and dental hygiene curricula.

The occurrence of patient initiated sexual advances toward dental health professionals has not previously been examined. Information from other health care specialties and reports from dental and dental hygiene students indicate that such advances do occur and that providers are rarely educated to deal effectively with them. Utilizing an anonymous survey of 300 Oregon dentists and 300 dental hygienists, this study sought to quantify the frequency of patient initiated sexual advances toward dental professionals and to survey practitioners as to their reactions to and methods of dealing with such advances. The information provided by the 483 (81 percent) respondents indicates that up to 44 percent of providers experience one or more patient verbal advances and up to 23 percent of providers experience one or more patient physical advances during a five year period. These advances are a significant source of concern for many dental professionals. Based upon this information, implications for the dental and dental hygiene curricula are considered.

Patient death and bereavement: what is the dentist's role?

The dentist's role following a patient's death has not been examined to date; neither has the attrition rate of a dental practice because of deaths of patients belonging to that practice. This topic was explored through a survey of 400 Oregon dentists. Seventy-two percent of dentists in active practice who participated in the survey had at least one patient death each year; the mean number of patient deaths per year was five. Following these deaths, most dentists reported providing some type of emotional support to the bereaved survivors. Dentists send sympathy cards 72% of the time and attend funerals 27% of the time; 55% of dentists regard the majority of their patient deaths as unexpected. These deaths are a source of emotional stress for dentists, as are subsequent discussions with survivors. Only 3% of the respondents reported having received formal education in death and bereavement, and 66% of dentists believe that some type of education in dying and bereavement should be included in dental school.

Ethical duties when patients make suspicious narcotic requests.

Practicing dentists are likely to be familiar with the prospect of patients who request controlled substances for doubtful indications. Torn between ethical obligations of beneficence and nonmaleficence, the dentist may be uncertain whether to prescribe a medication with the intention of alleviating pain or to refuse the prescription due to concerns related to chemical dependency, underlying emotional illness, or ulterior motives on the part of the patient. Pharmaceutical choices often do not provide a mechanism for sidestepping this dilemma as chemically dependent patients may be quite sophisticated in their knowledge of drugs and the ways in which to couch their requests. Dentists have an ethical obligation to move beyond simply refusing prescriptions for patients suspected to be chemically dependent; they should sensitively discuss the issue with these patients and be prepared to offer referral for intervention. However, dentists must always be open to the possibility that a particular patient's assertion of chronic physical pain may be of complex origin. When this is the case, appropriate treatment is essential and may involve referring the patient to others with specialized skills. Dentists should not withhold pain medication from patients with uncontrolled pain in the final stages of life.

The dentist's role in bereavement support.

An aging population that is retaining more dentition and an increasing number of persons affected by terminal illnesses have resulted in dentists encountering dying patients and patient deaths with increasing frequency. These events call upon dentists and their staffs to provide support for the terminally ill and for survivors of the deceased. Dentists are effective in providing bereavement support and survivors benefit greatly from it. However, this type of support is stressful for dentists and many report the need for more formal education in this area. The ethical basis for dealing effectively with a dying patient's need for open and honest discussion derives from the obligations of the doctor-patient relationship. These ethical requirements carry over to providing some level of bereavement support for the surviving loved ones of the deceased and address the professional duties of compassion and care. Sending a sympathy card with a personal note, attending the patient's funeral, or making a follow-up telephone call to the patient's survivors are all appropriate, beneficial, and appreciated.

Treatment recommendations: "doctor knows best".

Patients often develop an abiding trust in their health care providers and may agree with any recommendations that a dentist offers. This level of trust is a compliment to the dentist and the profession. However, patients who request that a doctor perform the treatment that he or she feels is best and who prefer to avoid an informed consent process must be educated as to the role of informed consent and their part in the process. Even when a patient is adamant in refusing information about his or her condition or states a clear reason as to why he or she does not desire to know a diagnosis or treatment plan (for example, dental phobia or fear of cancer), the dentist has an ethical and legal obligation to work with an appropriate surrogate of the patient's choice and make reasonable attempts at including the patient in the discussion. These patients should be offered the option of discussing the diagnosis and treatment alternatives with a family member or friend present and may include such a surrogate in the informed consent process. When patients clearly lack capacity to consent, the process of informed consent will revert automatically to appropriate surrogates. Finally, patients from different cultures may bring a new set of considerations to the process of informed consent and may require that a modification of the Western tradition be considered, allowing a significant role for the family of the patient in making treatment decisions.

The ethical foundations of a duty to treat HIV-positive patients.

Unfortunately, those who commit the most egregious acts of HIV-related discrimination may not be motivated to change either by fines and sanctions, or by educational programs. Perhaps the best solution to dealing with the small, but significant, number of health care providers who discriminate against HIV-positive patients is the action of the majority. Most dentists are ethical and concerned health care professionals, who willingly care for patients with a wide array of medical problems. This majority must continue to serve as an example to those who refuse to care for HIV-positive patients, and must make it clear that such actions are professionally intolerable.

Self-effacement in dental practice.

Self-effacement is a difficult challenge for some providers. When their professional ehtics and personal morals conflict, health care providers may feel trapped in a dilemma that has no acceptable resolution. In some instances, legal requirements bolster the ethical requirement to be self-effacing. For example, according to the ADA Code, "dentists shall not refuse to accept patients...or deny dental service to patients because of the patient's race, creed, color, sex, or national." Discriminating against patients because of these attributes is unethical and violates civil rights. Providers are held to the highest standards of ethics and should tolerate differences in values. Patients who are morally reprehensible to dentists must be treated with the same degree of care and compassion as other patients receive.

Chemically dependent doctors.

Overcoming denial and admitting to having a chemical dependency problem is a hurdle that is extraordinarily difficult for anyone to handle without professional assistance. Addicted health care professionals often become even more deeply enmeshed in denial of their problem. They refuse help because they see themselves as educated beyond the level of those who are attempting to help them, and because they fear professional humiliation. Dental professionals who become aware of a colleague's chemical dependence, have an ethical duty to intervene in a constructive way. Reporting to a dental society wellness committee will accomplish this goal while protecting patients, the profession, the addicted provider, and the provider's family. Nonetheless, assisting chemically dependent colleagues to seek treatment can be an enormous burden. Thus, the dental hygienist in the case presented has few choices. She clearly has sufficient evidence of the dentist's chemical dependency problem and, ethically, she must act to prevent harm to patients. If a wellness program is available, it will help her. However, she should not expect gratitude from the dentist at the time of her intervention. Addicted persons rarely thank those who try to help them until much later and whistle-blowers are rarely appreciated. As is often the case, doing the right thing may be a challenge that risks losing a relationship or, as in the case presented, a job.

Confidentiality and the curb-side consultation.

Dentists who encounter friends or relatives who request professional opinions about oral health problems are placed in difficult positions that may impose a duty to provide some advice or intervention. Even more awkward is the situation in which a dentist recognizes a pathosis in a nonpatient who is not seeking advice. The ethical principle of beneficence may confer an obligation upon the dentist to act in a professional role even though no professional relationship exists. There are criteria that guide providers in establishing that such a duty of specific beneficence is present; dentists must meet this duty while not violating the same principle of doctor-patient confidentiality that would exist if the nonpatient were, in fact, a patient.

Ethics and insurance consultants.

Health care professionals who serve as consultants for insurance companies provide an essential service in reducing health care costs and ensuring access to care for increased numbers of people. The role and function of these consultants is not always appreciated or welcomed by providers, who may view them as intruders to the doctor-patient relationship and feel that treatment plans are being second-guessed. Consultants, on the other hand, may be placed in uncomfortable positions when radiographically visible pathological conditions are not addressed on a treatment plan. Overlooking such conditions in hopes of not embarrassing the treating dentist is not an ethical option. When an isolated omission or error is encountered, it is best for consultants to contact the treating dentist and advise him or her of the disparity between planned treatment and observed pathology. Patients, providers, and the profession will benefit through this collegial exchange of information. When consultants observe continual omissions or errors, the stakes are much greater and the public's health must be protected through implementation of the peer-review system.

Professional conduct: when patient requests exceed the boundaries of dental care.

This discussion began with a question regarding the possibility of defining the elements of unprofessional conduct. It is likely that the many elements that may be intrinsic to this definition are, in part, temporally situated--that is, unprofessional behavior is defined somewhat differently today than in 1940. The three cases presented underscore this point. It is not likely that dentists of two or three decades ago were confronted with patients desiring pierced tongues, radio stations that saw dental offices as ideal participants in publicity stunts, or individuals admitting their dentist was an instrument of erotic pleasure. Despite this dynamic nature of new challenges to professional conduct, many elements are constant. Certainly the ethical obligations of beneficence, nonmalficence, respect for autonomy, and justice have remained since the time of Galen. We have proposed that one modern-day element of defining professional conduct is the performance of a professional action for a nonprofessional purpose. These types of actions can be harmful to patients and embarrassing to the profession. Finally, it is likely that the dentist who cooperates in any of the scenarios presented could be held to violation of malpractice standards and/or be reprimanded by state dental boards. In addition to these legal entanglements, it is clear that knowingly and willingly participating in any of the presented cases comprises unethical behavior.

Ethical issues in the acceptance of gifts: Part 1.

It brightens the day of any health care provider when a patient presents him or her with a personal gift. These thoughtful items express sincere appreciation and are evidence of a solid, trust-based provider-patient relationship. However, there is a significant ethical difference between accepting small gifts of appreciation versus gifts of great financial value. While the patient may be expressing the same appreciation with this substantial gift, he or she may also be attempting to curry special consideration or feel some pressure to please the provider. In addition, acceptance of these large gifts produces the appearance of an improper relationship between the doctor and the gift-giving patient. Patients who offer gifts of great value should receive a sensitive explanation as to why the gift cannot be accepted.

Sexual boundaries in dental practice: Part 1.

Sexual contact between doctors and patients is unethical, legally perilous, cause for professional discipline at times, and often viewed as an outrageous transgression by the public. While it is true that some provider-patient couples go on to get married and "live happily ever after," this is not always the case. However, if these relationships fail, a now embittered ex-paramour is empowered with the options of bringing legal and/or disciplinary action against the doctor and may be motivated by the distinct possibility of significant financial reward. Patients place enormous trust and respect in their health care providers. In addition, patients reveal sensitive, confidential information to doctors and do so with the expectation that it will be used only for their best interests. This dynamic creates a substantial power imbalance between doctors and patients and this power differential must never be exploited. Dentists who find themselves romantically attracted to patients must either avoid initiating a more intimate relationship or refer the patient to another provider. Dentists who are the recipients of romantic inquiries by patients should establish clear boundaries. If the dentist is available and interested in the patient, dating may occur only after the patient has been reassigned to another dentist and a suitable time period has elapsed.

Managed care--serving two masters.

It is likely that enrollment in managed care dental plans will continue to increase. Dentistry can respond to this trend by resisting it; however, just as the health care marketplace drove medical care into managed care mechanisms, so too will these forces impact dentistry. For those who are participating in managed care dental plans, it is heartening that current data indicate that most types of patient care are not adversely affected by reimbursement mechanisms. Dentistry, however, should seek out opportunities to shape the managed care format and must be at the table to assure that ethical principles and conflicts of interest receive due consideration. Dentists who treat patients under a managed care reimbursement system must be certain that the plan does not require providers to sacrifice patient autonomy or compromise care in the process of serving two masters.

Cosmetic treatment, autonomy, and risks: "if you don't do it, I'll go to a dentist who will".

Patient requests and treatment goals may exceed the limits of professional practice and may have an adverse effect on health. When doctors encounter these types of requests, they first must decide whether the patient has the capacity to consent to such care. In the case of child patients, no such capacity exists and surrogate consent to care must be, in the opinion of the doctor, in the child's best interests. Parents who request potentially harmful procedures for a child with no hope for any health care benefit should be refused politely. Adult patients who request harmful elective procedures for themselves also should be educated and helped to fully understand why the request represents substandard treatment. The long-term consequences of these requests must be detailed clearly for these patients. Elective cosmetic treatment that will lead to long-term adverse effects on function and health raises serious ethical concerns in which the principle of nonmaleficence likely will trump the patient's autonomy.