An Introduction to Ethical Issues in Dental Hygiene
Dentists and hygienists are taught to be perfectionists, to offer the best care possible for their patients. We are taught to go above and beyond the standard of care expected and to consider ourselves perfectionists. But when is it not appropriate? At what point do we cross the line between offering the best for our patients and being on the edge of ethics and the law? In this course we will discuss the topic of ethics and laws for the dental hygiene profession and how intertwined they are with one another.
If we consider what our professional ethics is, it is a code of conduct that we as professional hygienists have. When we choose to treat our patients according to the ethical guidelines we have established then we are acting as a professional should. This means: However, if you choose to violate your code of ethics, even with the best of intentions, then you are acting unethically. All of us have had patients that we thought needed "a crown" but let the patient know that they seem to be able to eat and function so there is no need for a crown just yet. However, if the dentist chooses to do the crown anyway this would be considered unethical on their part . If you were to scale the calculus/biofilm off the patient and charge them for the visit and then the dentist tells them that they need antibiotic premedication before routine dental treatment this would be an ethical violation.
As dental professionals, we have been trained that our professional conduct must meet the expectations of the community and the professional standards of education and experience. But what if our students don’t have the same values or motivation to be the perfectionists that we expect? What do we do in a legal sense? Are we responsible for their lack of professionalism? What is the ethical obligation we have to our students? We must discuss the fact that as instructors we have an obligation to provide a quality education, but that if we do not enforce the requirements of the curriculum that we are violating our own code of ethics. Students who seem to have difficulty in upholding their professionalism while in clinic must be let go and possibly remediated at a later date.
As we move further into the course we hope to give you a better understanding of how ethics and law effects your daily patient care. We want to give you a basic understanding of this topic and also how this may relate to you and how you practice as a dental hygienist.
Legal Considerations for the Dental Hygienist
The legal responsibilities of a dental hygienist are vast and include obtaining and renewing state licensure, signing practice agreements with dentists in the office, documenting patient records, reporting and/or treating suspected abuse or neglect of patients, reporting communicable diseases, following OSHA guidelines to provide the safest possible environment for patients and co-workers, just to name a few….
Licensure: Every state requires a dental hygienist to be licensed before he or she can practice. Only one state, Alaska, offers licensure by endorsement to people who have been out of dental hygiene school for more than 2 years. In other states, a hygienist needs to pass a board exam and pass a jurisprudence exam. Please check your state’s Board of Dental Examiners website for more information on how licensure works in your state.
Practice Agreements: Hygienists are employees of a dentist and are always subject to the rules laid out in the employment contract or agreement. This may include contractual limits on producing periodontal care, such as scaling deeper than 4mm. An agreement to perform duties that exceed a hygienist’s scope of practice can have serious consequences. For one thing, it places the dentist in an ethical dilemma and can result in disciplinary action against a hygienist. It can also lead to a civil action for damages resulting from malpractice if a hygienist performs a service beyond their scope of practice and injury results. This narrow scope of practice means a hygienist who comes to a new practice even for a day or two must be educated about the limits and requirements of the state’s scope of practice to avoid any inadvertent mistakes.
Patient Records: A dental hygienist’s most important legal obligation is documenting the care given to his or her patients. For the most part, this is accomplished through existing patient records, but hygienists may be called upon to produce them on request. The U.S. Health Information and Accountability Act of 1996 (HIPAA) provides a compendium of guidelines to follow while keeping in mind that patients have certain "protected health information rights" that are protected. These rights extend to minors, and in some states to adults if a power of attorney authorization has been signed. Consent, refusal to give consent, access to records if requested by the patient, and a patient’s right to an amendment of his or her medical condition information should be given by the patient upon request. An authorized person must be chosen by a patient to have access to the medical records if the patient has previously authorized it, such as a spouse or parent.
Abuse and Neglect: The fact that dental hygienists see both adults and children with injury patterns that suggest they may have occurred intentionally, hygienists must know how to recognize and document these signs, report them, and then treat their patients. This is also true for hygienists who suspect a patient is being abused or neglected at home, possibly by a family member. Each state has its own definitions of abuse and neglect, but these are typically outlined by their Board of Dental Examiners. A hygienist is obligated by law to report abuse or neglect in a timely fashion to authorities, such as the police, social services, the child protective agency or others responsible for investigating or recording child abuse and neglect.
Sources for more information on the laws that govern dental hygiene and the practice of dental hygiene are the American Dental Association’s Center for Professional Success, state dental hygiene and dental associations, and state Boards of Dental Examiners.
Essential Ethical Principles in Dental Hygiene Practice
Autonomy: the principle of autonomy as related to dental hygiene is providing at the onset of an exam, a financial estimate for the treatment and providing an estimated time frame for the completion of the treatment. This collaborative exchange empowers the patient and enables an informed decision. A patient’s right to autonomy must never result in the revealing of confidential information.
Beneficence: "Do good" Every clinical procedure (within the practice acts) supports and protects the health status of the oral cavity. Even more importantly is the protection of the overall health of the patient. There are many times in practice where the hygienist waiver may come into play, e.g. the diabetic patient that has no appointment for six months, comes in with six carious lesions, puts off treatment, (understanding the consequences of treatment by this professional).
Non maleficence: "Do no harm." The professional as well as the patient have to believe in this concept. The foundation of which is an extensive grounding of knowledge and understanding of the interventions and having the skills to deliver. The basic operational procedures are a non-maleficent as well. Every stage of instrumentation, operator to patient to instrument are developed to ensure no harm.
The Ethical Questions Dental Hygienists Must Answer
Dental hygienists frequently encounter challenging ethical dilemmas during their career. Here are some common scenarios and how to resolve them.
Scenario 1: Patient Consent
A situation could arise where a patient in your chair is very nervous about getting their teeth cleaned. They’re convinced that it’s painful and unnecessary. You take the time to explain that it shouldn’t be painful at all, and that it’s in their best interests to go through with the procedure. They refuse your treatment anyway—what should you do?
It’s the patient’s ultimate choice. If they refuse your recommended treatment, you cannot perform the procedure. Always make sure to document your patient’s refusal in their file, so you have a record if any questions arise later.
Scenario 2: Professional Boundaries
Your office has a strict no-gift policy for referring offices. You get a fruit basket and a handwritten thank you note from an orthodontist whose office you’ve been sending patients to for years. You know that the referral has gone both ways, so there’s no favoritism, but it’s still a gift. Do you accept it?
An appropriate way to handle this situation is to thank the orthodontist for the thought, and explain that your office maintains a strict no-gift policy for any of your referring offices. Then, send them a healthy food gift basket in return—something that shows you’re not interested in accepting their $100 basket of Lindt truffles in exchange for your clients.
Scenario 3: Conflicts of Interest
As a savvy professional, you always recommend the best products and suppliers to your patients. Does that mean you can accept the free case of toothpaste your supplier shows up with? What if they give you a discount on your next order, or a pair of tickets to the Canucks game?
It’s completely acceptable to learn about a great new product from industry sales representatives. It’s healthy for your business. But learning is one thing, and accepting gifts that could interfere with your objectivity is another.
The best way to avoid conflicts of interest is to never recommend products you haven’t tried for yourself first. Once you can vouch for their quality, feel free to endorse them to your clients. And while you can definitely call up your full-size shampoo supplier to ask them to help you get some of their product on TV, you should stick to their professional samples for your client education.
Professional Associations and the Ethical Landscape
In addition to licensure and the associational codes of ethics, another mechanism for promulgating and regulating the practice of certain professions, including dental hygiene, is through membership in a professional organization. These organizations serve as both a collective voice for the profession and a place where members can turn for resources aimed at advancing their practices.
For many, the most well-known professional organization in dental hygiene is the American Dental Hygienists’ Association (ADHA). Founded in 1923, it is "the largest national professional association representing the interests of more than 185,000 licensed dental hygienists." ADHA defines its mission as "to lead the advancement of the dental hygiene profession to ensure access to quality oral health care for the public and to enhance the professional success of our members."
This mission is accomplished in part by gathering groups of dentists and dental hygienists who discuss the standard of care and use that information to develop rules and guidelines for the profession. Subsequently , these groups work with state legislators to enact statutes that reflect the regulations developed by these professions.
In 2016, ADHA published a paper titled "ADHA Policy on Professional Responsibility: Recognition of Responsibilities Related to Professional Judgment." The document discussed what constitutes appropriate professional judgment for a dental hygienist, making it a potentially useful tool for hygienists considering or involved in an ethics investigation. However, the document is merely a paper, and does not have the same effect as state statutory law, or even an ethical guideline or code. All members of ADHA must adhere to and are disciplined according to ADHA’s formal grievance process, but the group cannot actually discipline a member, or revoke and suspend a member’s license.
The Effect of Ethics and Law on the Quality of Patient Care
The impact ethics and law have on patient care and how patient standards of care are an integral part of the dental hygiene process will be discussed in this section. When a dental provider such as a dentist or dental hygienist performs, or fails to perform, a treatment that does not meet the accepted standard of care, it can lead to complications for the patient and an increase in risk for the provider. Ethics and law are two different ideals. The laws and regulations of a health profession govern our actions and are set forth by the various state boards of dental examiners. The regulatory board reviews evidence and makes decisions when a complaint is filed against a licensee. If a licensee is sanctioned for a violation of a dental practice act, the public protection agency presiding over the licensee may require additional education or require them to perform community service, suspend the license, or terminate it altogether. When a license does not meet specified requirements, the holder may be fined, placed on probation, or suspended indefinitely. The degree to which the licensee suffers consequences for a violation depends on the severity of their actions and the number of offenses they have committed. There are many ethical conflicts in health care today. Dentists, dental hygienists, assistants, and other members of the oral health team, often struggle with ethical dilemmas such as seat time, treatment protocols, or time restraints. It is also difficult to find the right balance between treating patients who cannot afford certain treatment and enhancing one’s own economic status. Ethical issues may also occur, however, when state practice acts conflict with theory, equity, or public health. For example, a lack of awareness of the laws and regulations governing the practice of dental hygiene has resulted in dentists asking dental hygienists to perform procedures that are illegal and unethical. For example, dentists have requested hygienists to write standing orders for fluoride varnish in schools, apply fluoride to school-aged children, or perform selective polishing, all of which the hygienist knows are not legal tasks for an oral health provider who is subordinate to the dentist. A dental hygienist exercising her professional judgment and ethical decision making processes must be knowledgeable of her state practice act, which specifically outlines what constitutes the practice of dental hygiene and identifies those activities and procedures the state allows hygienists to perform under their dentist’s supervision and when they may be performed. She must also understand the legalities of the various dental treatment strategies offered and the impact these legal requirements have on the delivery of professional oral health care services. Finding local resources to obtain information regarding the laws and regulations that supervise a hygienist’s practice may help if conflicting situations arise or if dental hygienists are asked to perform an unsanctioned activity. Health care professionals working to safeguard the practice of dental hygiene positively contributes to the pursuit of oral care for the community and enhances the dental hygienist’s overall professional growth and potential contributions in impacting the oral health status in their communities.
Continuing Education and Ethical Practice
As an ever-evolving profession, dental hygiene provides a wide array of opportunities for career advancement. From private practice clinicians to corporate and industrial roles, from community outreach positions to advanced clinical practice and education, the options are as vast as the imagination of the practitioner. And yet, regardless of which path is taken, every practitioner is held to the same legal and ethical standards and faces the same dangers of stepping out of the bounds of expectations and into legal or ethical trouble. To be fair, sometimes crossing the line is unintentional; but knowing where lines are drawn is the ultimate responsibility of the practitioner. It is not enough for one to say "I didn’t know." For that reason, lifelong learning as a practitioner is essential, not simply to advance one’s career, but to sustain the highest possible level of respect and integrity for the profession as a whole. While some degree or certification might put a practitioner at the forefront of the profession, when it comes to the law and ethics, even the most seasoned veteran may be just as green as a new graduate. The laws governing any industry are constantly moving and changing. Legislative requirements can shift overnight, but the practitioner who has been in the field for years is still responsible for staying up to date on the current rules. That’s why education should never be a one-time thing. It should remain a top priority throughout a practitioner’s career and be revisited often. One of the best ways to do this is through continuing education (CE). Look at CE requirements not simply as hurdles to jump through every year, but as valuable opportunities to dig deeper into specific topics and address particular areas of concern with experts . Choose the courses that speak to you and offer you a chance to broaden your knowledge on topics you’re passionate about. Seek out resources that make sense for you and focus on the topics that are relevant to the path you’re taking. In addition to traditional CE courses, if you engage in self-study (and we hope you do!) make sure the material is coming from a reliable source. Auditing first-rate dental hygiene publications establishes a valuable connection between you and the experts in the field. You’ll still want to conduct your own research, but relying on peer-reviewed journals, legal experts and DNJ publications can put you on the right track. Keep in mind that sometimes the best learning experiences come from having frank discussions within your own team. When you have questions about an ethical or legal situation, don’t immediately seek outside counsel or go up the chain. Engage those closest to you in a discussion and work through the issue together. Chances are, you’re not the only one with questions. Take the time to come to an educated understanding as a team, and then present yourself as a united front to anyone asking for direction on the subject. If you find you need to reach out to outside sources, do so. But start with those closest to you whenever possible. Finally, always understand and follow the rules and regulations set forth by your state’s dental hygiene association. Local associations have their own engrained cultures and prerogatives that exist alongside the legal requirements, and state regulations are often shaped by more than just what is written into law. So if your particular state is known for more stringent requirements, abide by those standards – even if they are not covered in the law. Your local association can be a great resource both in person and online, so connect with them and trust their guidance in matters of law and ethics.