ETHICS

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Dentist / patient
relationship
What’s Special About the Dentist/Patient
Relationship?
It is the cornerstone of dental practice and therefore of
dental ethics.
The traditional interpretation of the dentist-patient
relationship as a paternalistic one, in which the dentist made
the decisions and the patient submitted to them, has been
widely rejected.
In recent years, in ethics and in law, in favor of an equal
partnership.
 Duties of Dentist towards Patients:

•The relation between a oral healthcare

practitioner and patient is based on trust and
honesty.
•It is the duty of the oral healthcare practitioner
to deliver comprehensive dental care to patients
according to their dental needs
Duty of Care/Standard of Care
*The concept of duty of is commonly misunderstood among
dental professionals. Many assume that it is a law or regulation
and that it provides specific steps that a dentist must follow.

*It is, in fact, not a black-and-white rule at all. Instead, it is a

legal concept that provides general boundaries within which a
dentist must perform in a given situation.

*The standard of care that a dentist must meet is simply the

customary practice of reputable dentists who have similar
training and experience, who practice in similar disciplines,
or who practice in the same area or a similar locality (e.g.,
urban, remote rural).
*When a dentist fails to meet the standard of care
and the patient is injured, the dentist may be
held liable for malpractice. Competent and
experienced dentists are often called as
witnesses to testify in court
(Health care Practitioner-Patient Relationship) will
deal with topics that pose particularly challenging
problems to dentists in their daily practice:
1. Respect and equal treatment.
2. Communication and consent.
3. Decision-making for incompetent patients.
4. Patient referral
5. Confidentiality.
6. Financial restraints on treatment.
1- Respect and Equal Treatment

Compassion
Abandonment
Refuse the treatment
Compassion is one of the core values of dentistry and is an
essential element of a good therapeutic relationship.
Compassion is based on respect for the patient’s dignity and
values but goes further in acknowledging and responding to
the patient’s vulnerability in the face of illness and/or
disability.
If patients sense the dentist’s compassion, they will be more
likely to trust the dentist to act in their best interests, and this
trust can contribute to the healing process.
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II. The American Dental Association’s Principles of Ethics
and Code of Professional Conduct states:
“Once a dentist has undertaken a course of
treatment, the dentist should not discontinue that
treatment without giving the patient adequate
notice and the opportunity to obtain the services of
another dentist.
“ Care should be taken that the patient’s oral health
is not jeopardized in the process.”
Abandonment. Refers to discontinuation of
care after treatment has begun, but before it has
been completed. The dentist may be liable for
abandonment if the dentist ends the dentist-
patient relationship without giving the patient
reasonable notice.

Even if a patient refuses to follow instructions and

fails to keep appointments, the dentist may not
legally refuse to give the patient another
appointment.
The dentist may not dismiss or refuse to treat a
patient of record without giving the patient written
notification of termination. After notification, care
must continue for a reasonable length of time, usually
30 days, to allow the patient time to find another
dentist. It could even be considered abandonment if
a dentist left the area for a weekend without making
arrangements with another dentist to be available for
emergencies, or without leaving a number that the
patient can call for care.
There are many situations for a dentist wanting to
terminate a relationship with a patient, for example,
1. The dentist’s moving or stopping practice,
2. The patient’s refusal or inability to pay for the dentist’s
services,
3. Dislike of the patient and the dentist for each other,
4. The patient’s refusal to comply with the dentist’s
recommendations.
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The dentist should help the patient find
another suitable dentist or, if this is not
possible, should give the patient adequate
notice of withdrawal of services so that the
patient can find alternative dental care.

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III. According to the FDI’s Policy Statement
on Human Immunodeficiency Virus Infection and
Other Blood Borne Infections, “Patients with HIV
and other blood borne infections should not be
denied oral health care solely because of their
infections.”

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The Statement recommends that “Universal infection
control procedures should be employed for all patients
irrespective of their health status” in order to prevent
transmission of infectious diseases from patients to
dentists or other oral health care providers or from
them to patients.

Dentist should be treat all patients equally

regardless race , gender , traditions ............
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2- Communication and
Consent
Ø Informed consent is one of the central
concepts of present-day dental ethics.
Ø The U.K. General Dental Council (GDC)
advises dentists that: “It is a general legal and
ethical principle that you must get valid consent
before starting treatment or physical investigation,
or providing personal care, for a patient.
Ø This principle reflects the right of patients to
determine what happens to their own bodies,
and is a fundamental part of good practice”.
Ø Consent form consisted of dentists telling
their patients what treatment they were going
to perform ,They must provide all the
information patients need to make their
decisions.
The form should include
1. Explaining complex dental diagnoses, prognoses
and treatment regimes in simple language.
2. Confirming or correcting information that the
patients may have obtained elsewhere (e.g.,
from another health practitioner, magazines or
the Internet)
3. Ensuring that patients understand the
treatment options (including the option of
no treatment and its consequence) and the
costs, advantages and disadvantages of
each.
4. Answering any questions they may have.
5. Understanding whatever decision the
patient has reached.
Informed consent types
*When a patient enters a dentist’s office, the patient gives
implied consent, at least for the dental examination.
Provided the patient is capable, implied consent is given
when the patient agrees to treatment, or at least does not
object to treatment.

*In a court of law, implied consent is a less reliable form of

consent in a malpractice suit.

*Written consent is the preferred means of obtaining and

documenting the patient’s consent to and understanding of
the procedure.
 Documenting Informed
Consent
*At minimum, the patient’s record should indicate that the
patient received information about risks, benefits, and
treatment alternatives and consented to or refused the
proposed treatment.

*When treatment is extensive, invasive, or risky, a written

informed consent document is recommended. The patient,
the dentist, and a witness should sign the written consent
form. The patient should receive a copy of the form, and the
original should be kept in the patient’s chart
Clinical Situations that Require
Written Informed Consent

1. New drugs are used

2. Experimentation or clinical testing is involved
3. Patient’s identifiable photograph is used
4. General anesthesia is administered
5. Minors are treated in a public program
6. Treatment takes longer than 1 year to complete
 Informed consent refusal

• Obtaining the patient’s informed refusal does not release

the dentist from the responsibility of providing the
standard of care.

• A patient may not consent to substandard care, and the

dentist may not legally or ethically agree to provide such
care.
For example, if a patient refuses radiographs, the dentist
may refer the patient to another provider because the
dentist believes radiographs are a necessary standard of
care. Another dentist, however, may be willing to treat the
patient without radiograph films and may request that the
patient sign a written and dated informed refusal for
radiographs. This statement is then filed with the patient’s
record.
 Guarantee

*Outcomes of dental care cannot be completely

predicted.

*Neither the dentist nor the staff should make a

promise or a claim about the outcome of care
because this could be interpreted as a “guarantee.”

*It is unethical to make guarantees; in some

countries, it is illegal.
3- Decision-making for
incompetent patients.
*Although the term ‘consent’ implies agreement to
treatment, the concept of informed consent
applies equally to refusal of treatment or to choice
among alternative treatments.

*Competent patients have the right to refuse

treatment, even good communication between
dentists and patients is essential for understanding
and evaluating reasons that patients may have for
their treatment preferences.
v patients are given the opportunity to name
their own substitute decision-makers to act
for them when they become incompetent.

For incompetent
1. For minor children, the parents, grandparents,
custodial parent, or legal guardian must give consent for
minor children.
ü When parents live separately, the child’s personal
information form should indicate which parent is the
custodial parent.
ü When separated parents share custody, the child’s record
should contain letters from both parents providing consent
and authorization to treat.
ü Asking in advance for a parent’s or a custodial parent’s
“blanket” consent for emergency treatment avoids
confusion and delays should the child require emergency
care when a parent or guardian is not present
2. For adults, husband or wife, adult children,
brothers and sisters, etc.).
In such cases dentists make
decisions for patients only when the
designated substitute cannot be
found.
4. Patient Referral
*Dentists usually refer a patient who has an unusual
case or a condition beyond their scope of expertise.

*The dentist must inform the patient that the needed

treatment cannot be performed properly in the
dentist’s office and that the services of a specialist
are required.

*The dentist should assist the patient in finding an

appropriate specialist.
 Failure to Refer

*Many malpractice claims involve failure of the general

dentist to refer the patient to a specialist when the
patient’s oral condition requires special attention.

*Failure to recognize periodontal disease and refer the

patient to a periodontist is a very common cause for this
type of malpractice suit. Periodontal disease is a silent
disease; patients rarely experience pain and often are
not even aware that a problem exists
*Therefore it is important that the general
dentist establish a patient’s baseline oral
condition and record changes in periodontal
health over time.

*It is also important to make an entry in the

chart each time that the patient has been
informed of the condition and the need for
treatment and/or referral.
*When a patient is referred to a specialist,
the referral should be thoroughly
documented in the patient’s chart.

*Documentation should include a description

of the problem, reasons for referral, the
name and specialty of the referral dentist,
and whether or not the patient has agreed to
the referral.
5. Confidentiality
v The duty to keep patient information confidential has
been a cornerstone of medical ethics since the time
of Hippocrates.
v The FDI’s International Principles of Ethics for the
Dental Profession requires that the professional
dentist “must ensure professional confidentiality of
all information about patients and their treatment.
The high value that is placed
on confidentiality has three
sources:

Autonomy, Respect and Trust

(ART)
Autonomy relates to confidentiality in that personal
information about an individual belongs to him or her and
should not be made known to others without his or her
consent.
When an individual chooses to reveals personal
information to another, a dentist, dental hygienist or nurse
for example, or when information comes to light through a
dental test, those in the know are bound to keep it
confidential unless the individual concerned allows them
to disclose it.
ü Confidentiality is also important because human
beings deserve Respect.
ü One important way of showing them respect is
by preserving their privacy. Care must be taken
to determine which personal information a
patient wants to keep secret and which he or she
is willing to have revealed to others.
ü Trust is an essential part of the health care
Practitioner -Patient Relationship.
ü In order to receive dental care, patients have to
reveal personal information to dentists and others
who may be total strangers to them, information
that they would not want anyone else to know.
ü They must have good reason to trust their caregivers
not to disclose this information.
The U.K. General Dental Council’s Principles of Patient
Confidentiality summarizes the dentist’s responsibilities
for respecting confidentiality as follows:
• Treat information about patients as confidential and
only use it for the purposes for which it is given.
• Prevent information from being accidentally revealed
and prevent unauthorized access by keeping information
secure at all times.
Ø In exceptional circumstances, it may be justified to
make confidential patient information known
without consent if it is in the public interest or the
patient’s interest.

EX : In cases of child abuse and HIV infection

6. Financial restraints on
treatment
FDI International Principles of Ethics for the

Dental Profession that “The needs of the patient

are the overriding concern” clashes with the

financial reality that dental services cannot be

provided free of charge to everyone in need.

The individual dentist has responsibilities towards their
patients who do not have sufficient means, either
through insurance or their personal assets, to pay for
needed dental care.This ways includes:
• Accepting patients covered by insurance that provides
compensation below the rate usually charged by the dentist;
• Allowing patients to pay over an extended period;
• Reducing or eliminating fees for some patients;
• Lobbying for better oral health insurance coverage for those
in need.
Malpractice and risk
management
Malpractice

• Although patients may bring a lawsuit against the dentist, this does
not mean that they will win.

• The following four conditions, sometimes called the “four D’s,”

must all be present for a malpractice lawsuit to be successful:

1. Duty. 2. Derelict.

3. Direct cause. 4. Damages.

1. Duty. A dentist-patient relationship must exist to establish
the duty.

2. Derelict. (lacking a sense of duty, negligent). Negligence

occurred because the standard of care was not met.

3. Direct cause. The negligent act was the direct cause of the
injury.

4. Damages. Pain and suffering, loss of income, and medical

bills are included in damages.
Example

• If a dentist injects local anesthetic on the wrong

side of a patient’s mouth:
1. Probably a grounds exist for a malpractice suit
2. No grounds exist for a malpractice suit
Examples
1. Improper extraction of teeth
2. Failure to diagnose various conditions (TMJ, oral
cancer)
3. Failure to properly treat complications of care (e.g.,
infection)
4. Failure to properly supervise or oversee actions of
employees (e.g., hygienists)
5. Wrongfully administered anesthesia
6. Failure to refer to a specialist
7. lack of informed consent.
Acts of Omission and Commission

• Malpractice is professional negligence, or failure to

provide due care, or the lack of due care.

• In dentistry, the two types of malpractice are acts

of omission and acts of commission.
 1. Due Care

• Is a legal term that means proper and sufficient care or

the absence of negligence.

• The dentist has a legal obligation to provide due care in

treating patients, this obligation applies to all
treatment procedures.
Example of due care
• When a drug is administered and prescribed, due care
implies that the dentist is familiar with the drug and its
properties.
• The dentist must also have adequate information regarding
the patient’s health to know whether the drug is suitable for
the patient, or whether the patient’s health record
contraindicates its use.
• Therefore a complete, up-to-date health history is essential.
2. Omission

• An act of omission is failure to perform an act that a

“reasonable and prudent professional” would
perform.

• An example would be a dentist who fails to

diagnose periodontal disease because the dentist
did not take radiographs or perform a periodontal
probing
3. Commission

• An act of commission is performance of an act that

a “reasonable and prudent professional” would not
perform.

• An example would be a dentist who administers 15

cartridges of a local anesthetic to a small child,
resulting in a life threatening overdose.
In most cases of malpractice
an expert dental witness is
necessary.
Sometimes an expert witness
is not necessary in a
malpractice suit.

“The act speaks for itself”,

the evidence is clear.
Unethical practices
1. Judgments in peer relations
2. Fee splitting
3. Luring patients from colleagues
4. Harassment