Ethics & Law in Dental Hygiene, 4th Ed.

Ethics and Law in Dental
Hygiene
FOURTH EDITION
Kristin Minihan-Anderson, RDH,

MSDH
Clinical Dental Hygienist
Adjunct Faculty
University of New Haven
West Haven, Connecticut
Copyright
Elsevier
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St. Louis, Missouri 63043
ETHICS AND LAW IN DENTAL HYGIENE FOURTH EDITION
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Contributors
Phyllis L. Beemsterboer, RDH, EdD

Professor Emeritus
School of Dentistry
Oregon Health & Science University
Portland, Oregon
Associate Director
Center for Ethics in Health Care
Portland, Oregon
Linda D. Boyd, MS, EdD
Associate Dean, Professor
Forsyth School of Dental Hygiene
Massachusetts College or Pharmacy & Health Sciences
Boston, Massachusetts
Michele P. Carr, BS, MA, EdE(c)
Associate Professor Emeritus
Dental Hygiene
The Ohio State University
Columbus, Ohio
Frank Catalanotto, DMD
Community Dentist and Behavioral Science
College of Dentistry
University of Florida
Gainesville, Florida
Gary Chiodo, DMD
Professor and Dean
School of Dentistry
University of Washington
Seattle, Washington
Matt Crespin, MPH, RDH
Executive Director
Children's Health Alliance of Wisconsin
Milwaukee, Wisconsin
Laura Fassacesia, RDH, BSDH, MSDH
2nd-year Clinic Coordinator
Professor of Periodontology & Oral Pathology
Plaza College Dental Hygiene Program
Forest Hills, New York
Deirdre M. Fiorini, MSDH, RDH
Professor
Dental Hygiene
Plaza College
Forest Hills, New York
Shavonne R. Healy, MSDH, RDH
Contributor
Dental Hygiene
Fones School of Dental Hygiene
Bridgeport, Connecticut
Monica L. Hospenthal, RDH, BS, MEd
Director
Dental Hygiene
Pierce College Fort Steilacoom
Lakewood, Washington
Donna Lesser, RDH, EdD
Retired Educator, Consultant
Kristin Minihan-Anderson, RDH, MSDH
Clinical Dental Hygienist
Adjunct Faculty
Dental Hygiene
West Haven, Connecticut
Pamela Overman, BS, MS, EdD
Professor Emerita
School of Dentistry
University of Missouri-Kansas City
Kansas City, Missouri
David Ozar, PhD
Professor Emeritus
Philosophy
Loyola University Chicago
Chicago, Illinois
Toni M. Roucka, RN, DDS, MA
Associate Professor and Associate Dean for Academic
Affairs
Restorative Dentistry
University of Illinois Chicago
Chicago, Illinois
Alexandra D. E. Sheppard, RDH, BA, DipDH, MEd
Clinical Professor
Dentistry
University of Alberta
Edmonton, Alberta, Canada
Sandra Stramoski, RDH, MSDH
Associate Professor
Dental Hygiene
University of Bridgeport
Karen S. Williams, BS, MS
Associate Professor
Dental Hygiene
Pamela Zarkowski, JD, MPH
Provost and Vice President for Academic Affairs
University of Detroit Mercy
Detroit, Michigan
Professor
Practice Essentials and Interprofessional Education
University of Detroit Mercy School of Dentistry
Detroit, Michigan
Reviewers
Lezlie M. Cantrell, RDH, BSDH, MSDH, PhD

Associate Professor
Dental Hygiene
Missouri Southern State University
Joplin, Missouri
April Catlett, PhD, MDH, BHSA, RDH, EDA
Program Chair
Dental Hygiene
Central Georgia Technical College Pomona
Warner Robins, Georgia
Tammy S. Clossen, RDH, BS, MS, PhD
Assistant Professor
Dental Hygiene
Pennsylvania College of Technology
Williamsport, Pennsylvania
Kathleen Feres-Patry, RDH, Dip DH, BEd
Ethics & Jurisprudence Educator, Privacy Officer
Canadian National Institute of Health (CNIH)
Ottawa, Ontario, Canada
Brenda H. Fisher, RDH, BSDH
Associate Program Director
Dental Hygiene
Asheville-Buncombe Technical Community College
Asheville, North Carolina
Lisa Graciana, RDH, EdM
Associate Professor
Dental Hygiene
Rock Valley College
Rockford, Illinois
Kristin M. Hofer, RDH, MSDH
Assistant Professor
Dental Hygiene
SUNY Broome Community College
Binghamton, New York
Adjunct Professor
Dental Hygiene
Christine Patel, RDH, BSDH, MA
Associate Professor and Instructor-in-Charge
Dental Hygiene
St. Petersburg College
St. Petersburg, Florida
Cynthia Senior, RDH, BS, MEd
Assistant Professor and Clinic Director
Department of Dental Hygiene
University of Mississippi Medical Center School of
Dentistry
Jackson, Mississippi
Ancillary Writers
CASE STUDIES
Christine Nathe, RDH, MS
Professor and Director
Division of Dental Hygiene
Vice Chair
Department of Dental Medicine
University of New Mexico
Albuquerque, New Mexico
TEST BANK
Jennifer Zabel, MS, BS, RDH, CDA
Developer
Senior Allied Health Program
MedCerts (A Stride Company)
Livonia, Michigan
Dedication
This book is dedicated to my sons, Cody John and Colton Robert

Anderson, and my granddaughters, Charlee Rae and Callie Rose
Anderson. May I always make you proud.
To Peter L. Bonagura, for his undying support, encouragement,

and love, all of which mean more to me than words could ever
express.
To my mentor and dear friend, Olga A.C. Ibsen, who inspires me

to believe I can achieve the unthinkable professionally and
personally.
Preface
When Alfred Civilion Fones graduated from dental school in 1890,

he went home to Bridgeport, Connecticut, to practice dentistry with
his father, also a dentist. The overwhelming majority of patients
treated within their practice required the extraction of decayed
teeth.
Dr. Fones was convinced that if the public were educated about
how to prevent dental disease, fewer would require treatment
resulting from the progression of disease. Furthermore, Dr. Fones
understood that oral and systemic health were inextricably linked,
requiring the need for a distinct profession within dentistry focused
on prevention and oral health education.
Irene E. Newman, Dr. Fones's dental assistant and cousin, began
to provide dental hygiene services within his practice in 1907.
Undeterred by the ridicule of his peers, in 1913 Dr. Fones, with the
help of Irene Newman, opened the first school of dental hygiene
and began teaching the first class of dental hygienists, with Irene
Newman receiving the first dental hygiene license in the world in
1917 from the State of Connecticut. His vision was for dental
hygienists to provide education and preventive care where the
public was easily accessed, such as public schools, public clinics,
and institutions, in addition to private dental practices.
The profession of dental hygiene has evolved tremendously from
its inception, as have the needs of the public. The complexity of
cases treated and work settings within which dental hygienists
practice creates the need for a resource targeting the potential
ethical dilemmas and legal liability these professionals encounter on
a daily basis.
Background and Importance to the

Profession
It is essential for dental hygienists to understand and appreciate the
ethical and legal obligations faced in the provision of care to the
public.
Audience
This textbook provides content related to ethics and law as they
apply to the practice of dental hygiene. Within this fourth edition of
Ethics and Law in Dental Hygiene, future and current dental hygiene
professionals can benefit from not just the coverage of ethics and
law but also the relevant connections between the two.
Organization
This textbook is organized into three sections, with the first two
sections focusing on content and the third devoted to application.
The first section begins with the topic of risk management, presents
the foundational aspects of ethics, and introduces an ethical
decision-making tool for the analysis of ethical dilemmas. Legal
concepts are discussed in the second section and provide
information on state practice acts, an overview of the legal system,
and the dental hygienist's relationship with the patient and
employer.
The third section provides 30 case scenarios for the reader to
discuss and analyze that are authored by various contributors with
expertise in their respective content areas. Questions are provided to
stimulate thought and discussion, including opportunity to use the
ethical decision-making model to work through dilemmas proposed
in case studies. The cases are hypothetical, providing a range of
materials to facilitate meaningful discussion, and the situations
presented are relevant to those experienced in dentistry and dental
hygiene.
Ten “testlets” are also included to help prepare students for the
National Board Dental Hygiene Examination (NBDHE). (A testlet is
a short clinical scenario with a series of associated test items that
focus on critical thinking and problem-solving skills.) Last, a listing
of suggested activities and projects helps expand upon the topics
presented in the textbook and encourages additional thought and
discussion.
Key Features
• Coverage of ethics and law and how they apply to risk
management.
• Concepts are discussed in the context of real-world relevance
to help readers apply the knowledge to daily situations.
• A six-step decision-making model provides the framework to
allow readers to take on ethical situations.
• Contributors include educators, administrators, and clinicians
who are renowned leaders in their respective fields of ethics,
dentistry, and dental hygiene.
• Readers can sharpen their ethical and legal decision-making
skills using the multitude of case studies covering a wide
range of situations.
New to This Edition
• The topic of risk management has been moved to the
beginning of the textbook and vastly expanded upon to
provide context regarding why dental hygienists must possess
a deep knowledge of the ethical and legal obligations
associated with daily practice. Discussion of the Standards of
Care related to dental hygiene help to emphasize the
inextricable link between ethics and law.
• Returning chapters are revised, with expanded coverage of
content related to the current practice of dental hygiene.
• Many new case studies have been provided by experts within
a variety of dental and dental hygiene settings as well as
ethics. These allow the reader to apply concepts learned
throughout the textbook. Returning case studies have been
revised and updated.
• “Testlets” have been revised and are available to encourage
critical thinking, challenge problem-solving skills, and help
students prepare for the National Board Dental Hygiene Exam
(NBDHE).
• For instructors, the Evolve Resources website provides
teaching resources, case study answers and rationales, and
access to a test bank utilizing NBDHE format questions with
answers. All have been updated to correspond with this
edition of the textbook.
• For students, the Evolve Resources website includes practice
quizzes and new case studies for additional studying.
Future and current dental hygiene professionals will find Ethics

and Law in Dental Hygiene, 4th edition, to be a valuable resource as
they navigate the complexities presented in the provision of care.
Acknowledgments
Many of us in dental hygiene education have used this textbook as

an invaluable resource as we teach future dental hygienists how to
navigate the ethical and legal obligations related to the practice of
dental hygiene.
Phyllis L. Beemsterboer created this textbook to meet the need for
content related to ethics and law specifically for the profession of
dental hygiene. Her vision, knowledge, and passion have been the
driving force behind the success of this textbook.
I would like to express my deepest gratitude to Phyllis for
entrusting me with the responsibility of bringing forward the fourth
edition of this textbook. It is my hope that this edition meets the
benchmark she has set for this subject matter.
To say the collaborators for this textbook are renowned in their
disciplines would be an understatement. Phyllis Beemsterboer and
David Ozar are bioethics experts who have shared their knowledge
to create the ethics section. Frank Catalanotto leads the discussion of
social responsibility, discussing emerging provider models such as
dental therapists and landmark government publications and
initiatives related to access to care. All aspects of the law section of
this textbook were provided by Pamela Zarkowski and Michele
Carr. Pam, a lawyer, and Michele, a professor of dental hygiene, are
experts in the laws governing the practice of dental hygiene. I am
humbled to be associated with these incredible professionals.
A special thank you and acknowledgment goes to the contributors
who provided case studies for this edition. Their contributions are
greatly appreciated and help provide a method to apply the
concepts presented in this textbook in a relevant way.
It truly takes a village to bring forward a textbook such as this.
Thank you to everyone involved. Dental hygienists, current and
future, will benefit from our efforts.
Kristin Minihan-Anderson
Table of Contents
Cover Image
Title Page
Copyright
Contributors
Reviewers
Ancillary Writers
Dedication
Preface
Acknowledgments
Table of Contents
Section I Ethics
Chapter 1 Risk Management
Chapter Outline
Learning Outcomes
Risk Identification
Risk Reduction
Individual Risk Management
Summary
References
Chapter 2 Ethics and Professionalism
Chapter Outline
Learning Outcomes
The Healthcare Provider
The Dental Hygienist
Professionalism
Interprofessionalism
Competency in Dental Hygiene
Standards for Clinical Dental Hygiene Practice
Professional Traits for the Dental Hygienist

Legal Requirements for the Dental Hygienist
Summary
References
Chapter 3 Ethical Theory and Philosophy
Chapter Outline
Learning Outcomes
Moral Development
Theories of Cognitive Moral Development
Character
Overview of Ethical Theories
Summary
References
Chapter 4 Ethical Principles and Values
Chapter Outline
Learning Outcomes
Ethical Dilemmas
A Principle
Principle of Nonmaleficence
Principle of Beneficence
Principle of Autonomy
Principle of Justice
Values and Concepts
Applying Principles and Values
Summary
References
Chapter 5 Codes of Ethics
Chapter Outline
Learning Outcomes
Professional Codes in Health Care
Ethical Code for Dental Hygiene
Summary
References
Chapter 6 Ethical Decision Making in Dental Hygiene and Dentistry
Chapter Outline
Learning Outcomes
Learning Ethical Decision Making
Ethical Awareness
Moral Distress
Ethical Decision-Making Models
Ethical Dilemmas for the Dental Hygienist
Solving a Dilemma Using the Ethical Decision-Making Model
Summary
References
Chapter 7 Social Responsibility
Chapter Outline
Learning Outcomes
Disparities in Oral Health Care
Health Disparities and Professionalism
Dental Therapists as Part of the Oral Healthcare Workforce
Summary
References
Section II Law
Chapter 8 Society and the State Dental Practice Act
Chapter Outline
Learning Outcomes
Statutory Law
State Dental Boards
The Practice of Dental Hygiene
Rules and Regulations
Display of License
License Renewal
Standards of Practice
Continuing Education Requirements
Licensing Fees
Other Selected Statutory Provisions
Due Process
Summary
References
Chapter 9 Dental Hygienist–Patient Relationship
Chapter Outline
Learning Outcomes
Legal Framework of the Relationship
Overview of the Legal System
Civil Law
Rights and Responsibilities of the Dental Hygienist and Patient
Legal Actions for Healthcare Injuries

Informed Refusal
Summary
References
Chapter 10 Dental Hygienist–Dentist-Employer Relationship
Chapter Outline
Learning Outcomes
Seeking and Obtaining Employment
Employment Relationship
Employment Laws
Employment Environment
Bullying and Cyberbullying
Summary
Reference
Section III Simulations and Applications
Case Studies, Activities, and Testlets
Cases for Study and Discussion
Case 1 Mario and the School-Based Sealant Program

Case 2 To Sell or Not to Sell
Case 3 Trevor and the Technology
Case 4 A Great Boss
Case 5 Patients with Special Needs
Case 6 Standard Precautions
Case 7 Warming Up
Case 8 Patient Confession
Case 9 Guidelines or Mandates?
Case 10 Misdiagnosis
Case 11 Medical Clearance and the Student Dental Hygienist
Case 12 The Dental Therapist
Case 13 Summer Employment
Case 14 Questionable Case Selection

Case 15 The Code
Case 16 Systemic Racism
Case 17 The Maxillary Bridge
Case 18 The Independent Contractor in Accelerated Hygiene
Case 19 The Dropoff
Case 20 Integrity Protocol
Case 21 Natural or Negligence?
Case 22 Penny Wise, Pound Foolish
Case 23 Fitting In
Case 24 New Skills
Case 25 No Openings Today
Case 26 Just Clean His Teeth
Case 27 Breach of Contract?

Case 28 The Dentist Dental Assistant
Case 29 Agnes Day
Case 30 Cyberbullying
Suggested Activities
Testlets
Answers to Testlet Questions
Appendix A American Dental Association Principles of Ethics and

Code of Professional Conduct With Official Advisory Opinions
Revised to November 2020
Bibliography and Suggested Readings
Glossary
Index
SECTION
I
Ethics
CHAPTER 1
Risk Management
Kristin Minihan-Anderson, Pamela Zarkowski and Michele P. Carr
Chapter Outline
Risk Identification 4
Risk Reduction 6
Documentation 6
Communication 9
Individual Risk Management 11
Social Media 12
Summary 12
Learning Outcomes
• Describe the concept of risk management and its place in the practice
of dental hygiene.
• Identify the strategies that can be used to identify and reduce risk in
dental practice.
• List the elements of recommended dental record keeping, and
describe practices that should be considered in maintaining dental
documentation.
• Distinguish between paper and electronic dental record keeping.
• Discuss the role of verbal and nonverbal communication in the
patient–provider relationship.
• Explain how dental hygienists should manage their own professional
credentials and competency.
• List recommendations for the appropriate use of social media both
personally and professionally.
Throughout this textbook, the subjects of ethics and law will be discussed and
applied to the profession of dental hygiene. Risk management is the
intersection of ethics and law and thus will be introduced first to provide the
“big picture” as knowledge of the ethics and law components develops. As a
dental hygienist, you are a licensed professional and responsible for your
actions, as well as your inactions. It is imperative for the dental hygienist to
understand how ethics and law apply to daily practice and to actively expand
this knowledge throughout their career to provide exemplary patient care.
The dental hygienist’s primary goal is to provide patient care that promotes
the prevention of oral disease and the maintenance of oral and overall health.
However, as with most goals, the delivery of dental hygiene services brings
the potential for unanticipated and untoward outcomes. For example,
periodontal therapy is intended to help prevent the progression of the disease
and restore the patient to a state of oral health, but the tip of a curette
breaking subgingivally during root debridement would certainly be
considered an untoward outcome of periodontal debridement. For another
example, pain management through local anesthesia is intended to maximize
a patient’s comfort during the delivery of services, but a provider
experiencing a needlestick during recapping would unquestionably be an
unwanted event.
The dental hygienist must anticipate potential untoward outcomes and
implement strategies to minimize their occurrence. Risk management is a term
that describes a philosophy of risk identification and a system of risk
management for injury prevention. The term is also applied to other private
and public business entities but is most frequently used in health care. As part
of the term, management means that once risk is identified, it is measured for
the seriousness of the potential outcome and the likelihood of its occurrence.
A strategy is then created to manage the risk in such a way as to minimize it
or, in some cases, to eliminate it altogether.
Risk management programs generally focus on operational safety and
compliance, product and equipment safety, and quality assurance.1 The focus
of operational safety and compliance programs is to maintain a safe
environment for personnel, patients, and others to function, as well as
compliance with applicable standards of care, regulations, guidelines, and
recommendations from agencies such as the following:
• U.S. Department of Labor (DOL) Occupational Safety and Health

Administration (OSHA)
• Bloodborne Pathogens and Needlestick Prevention
• U.S. Department of Health & Human Services (HHS) Health
Information Privacy
• The Health Insurance Portability and Accountability Act of 1996
(HIPAA) requirements for protected health information and
patient confidentiality
• HHS Centers for Disease Control and Prevention (CDC)
• Infection Prevention Practices in Dental Settings
For this discussion, it is important to provide context regarding the terms

standards of care and regulations. Standards of care are established by a
profession and set the expectations of the provider–patient relationship. They
are basically a set of expectations—or standards—describing the level of skill
and care a reasonably competent and prudent provider should exhibit and, in
turn, can be expected of all providers in a similar situation. If a provider
deviates from the standards of care, exposure to liability and litigation may
result, resulting in the provider being named as a defendant.
Typically, during malpractice litigation, the judge and jury require technical
information from an expert in the field. Expert witnesses provide testimony
regarding and opinions about the incident by reviewing the patient record,
the outcomes, and whether or not the care provided met the acceptable
standards of care.
Regulations are defined as a rule or order issued by an executive authority
or regulatory agency of a government and having the force of law.3 These are
laws and are enforceable if not followed. These concepts will be discussed in
depth in Chapters 8, 9, and 10.
Product and equipment safety programs ensure that personnel are updated
regarding the safe use, storage, and maintenance of current products,
materials, and equipment utilized within the practice.1 Quality assurance
programs evaluate and seek to improve processes and outcomes of patient
care.
It is imperative that anyone charged with creating and implementing a risk
management program in a dental setting possesses knowledge of the
standards of care and scope of practice for the various providers employed by
the practice, CDC infection prevention and control protocols, and OSHA and
HIPAA requirements. In addition to enhanced patient and dental healthcare
provider (DHCP) safety, effective risk management education combined with
competent practice help to reduce allegations of malpractice and litigation.1
According to the National Practitioner Data Bank, between the years 2011 and
2021 28,573 Adverse Action and Medical Malpractice Payment Reports
involved dentists and 4406 were reported for dental hygienists and dental
assistants.2 All DHCPs have a vested interest in adhering to a risk
management program.
Risk Identification
DHCPs encounter legal, ethical, and safety risks through daily interactions
with the public and the completion of job-related tasks. The development of
well-targeted procedures for minimizing adverse outcomes requires an
awareness of the most frequently occurring negative incidents. Familiarity
with the professional literature can support the dental hygienist in
anticipating possible undesired situations that can occur most frequently in a
dental practice. The literature shows that one of the primary reasons dental
providers are sued in a court of law is failure to diagnose and/or treat disease.
An assessment of a practice’s policies and procedures (P&P) manual,
including standard operating procedures, should be conducted and followed
by a comparison to current standards related to facility operations,
administration, personnel training, patient care, and scopes of practice to
determine if updates are needed. A clear understanding of the risk exposure
of a practice setting provides an opportunity for targeted problem-solving
and corrective actions necessary to improve safety, patient care outcomes, and
protection from legal liability.
A system of incident reporting provides valuable information during the
risk identification process by pinpointing specific deficiencies in existing
processes. This requires members of the dental team to complete a report for
all adverse events or unusual incidents. Reporting may include issues related
to patient care, patient complaints, and standard negligence such as “slip and
fall” incidents. Occupational exposure by personnel to bloodborne pathogens
and other potentially infectious material (OPIM) must also be reported. Such
a report should focus on the concise recounting of facts rather than subjective
assessments and should provide details of the event, including who, what,
where, when, and why. These reports should not be retained in the patient
record but, rather, maintained in a risk management portfolio. An incident
reporting system permits the systematic tracking of adverse events.
As part of the risk identification process, a formalized quality assurance
program that results in an improvement in the quality of patient care and
overall organizational functioning should be implemented. The purpose of a
quality assurance program is to assess patient care–related operations and
administration of the practice setting as well as the delivery of patient care.
This should be done systematically and continuously through the collection
and analysis of reliable information, as described previously. The quality
assurance process is an ongoing evaluation system that focuses on patterns of
behavior rather than on isolated instances of behavior (i.e., incident
reporting). It is a mechanism for assessing the quality of care and
implementing and evaluating changes in the patient care delivery system to
maintain or improve the quality of care.
In 1966, Avedis Donabedian published a groundbreaking paper titled
Evaluating the Quality of Medical Care.3 The Donabedian model describes three
dimensions that provide the framework for healthcare quality measurement by
which quality assurance programs can be modeled. A quality assurance
program should include the assessment of these three dimensions of
healthcare delivery: structure, process, and outcome (Box 1.1). The structure
dimension considers components that contribute to the delivery of care such
as administration, products and equipment, personnel, and facilities. The
process dimension considers issues related to the delivery of clinical patient
care, such as the process of care, standards of care, technical skill, and
timeliness of care. The outcomes dimension considers the result of care, such
as improvements in the health status and oral health literacy of patients as
well as patient satisfaction. When risks are identified and quality is assessed
in these domains, improvement can be expected regarding patient care and
patient and DHCP, safety which ultimately provides protection from liability.
Identifying risks related to the three quality assessment domains can be
accomplished using a risk assessment form such as the one provided in Box
1.2.4 The results provide an opportunity to create a formal quality assurance
process to address the problems identified.
Box 1.1
Dimensions of Quality Assessment
Structure Process Outcomes

Structures that The delivery of clinical Outcomes of
contribute to careProcess of care care, health
the delivery of (assessment, dental status, and
careOrganizat hygiene diagnosis, behavior of
ion and planning, implementation, patientsOral
administratio and evaluation: ADPIE) health
n Technical skill improvement
Products and Timeliness of care General
equipment health
Personnel improvement
Facility Patient
satisfaction
Box 1.2
Risk Assessment and Reduction Template
Practice Name: Assessment completed by:

Assessment date: Date of next review:
Ri Q W Cur Addi D D Dat P&
sk ua h rent tiona H a e P
bei lit o pro l C t com man
ng y m cess actio P e plet ual
as do a (s) n(s) t b ed upd
ses m y use requi o y ated
se ai b d to red c w and
d n e con to a h DH
h trol contr r i CP
a risk ol r c trai
r risk y h ning
m o a com
e u c plet
d t t ed
a i
c o
t n
i i
o s
n n
e
e
d
e
d
Adapted from: Health and Safety Executive, Managing Risks and Risk Assessment
at Work.www.hse.gov.uk/simple-health-safety/risk.
The first step in a quality assurance process is the assessment of quality in

one or more of the dimensions of healthcare delivery. The practice’s P&P
manual provides detailed instructions outlining processes that can be used to
create an assessment checklist that identifies evaluation criteria applicable to
the process to be assessed. The individual tasked with this job will use the
checklist to collect data, analyze data, report results, and respond to results.
Errors can be categorized according to severity (critical, noncritical, or minor)
and handled accordingly.
A critical error is any error in a patient record that has the potential to
adversely impact patient safety or alter care or treatment; noncritical errors
impact document integrity but do not have the potential to alter patient
safety, care, or treatment and do not alter the author’s intended meaning.
Minor errors have no impact on patient safety or care and do not diminish the
integrity of the document.5 The next step is to design and implement
strategies intended to improve the quality of the healthcare delivery system.
The final step is to evaluate the effect of these strategies on improving and
maintaining quality. Quality assurance is a continuous, cyclic process of
assessment, planning, implementation, and evaluation.
From: https://www.istockphoto.com.
Risk Reduction
Following risk identification within the three domains, two universally
accepted strategies are used to minimize the risks associated within dental
settings: (1) comprehensive documentation and (2) effective communication
with personnel and in the care and treatment of the patient.
Documentation
Documentation as part of the provision of oral healthcare services is
important to protect the patient, provider, and practice. Documentation
occurs at all levels within a practice, both administratively and clinically.
Effective communication ensures that the needs of the patient and dental
hygienist are clearly conveyed. Communication among the dentist/employer,
personnel in the dental office, and other healthcare providers also is essential.
The dental hygienist uses various levels of communication skills on a daily
basis, constantly adapting, changing, and adjusting to the needs of patients
and personnel in the dental environment. The ultimate success of verbal
communication depends on the way the material is presented, the attitude of
the speaker, the tone and volume of the voice, and the degree to which the
individuals involved are able and ready to listen effectively.6 Some examples
of documentation and communication within the three quality domains will
be discussed here.
Within the structure domain of quality assessment, administration
encompasses criteria such as policies and procedures, compliance with
applicable regulations and guidelines, standards of care, products and
equipment personnel, and issues related to the facility. Administratively, a
practice must have a well-written P&P manual. The purpose of a P&P manual
is to define and reinforce the standard operating procedures in a practice. This
document clearly communicates policies to the employee: the expected
behaviors and procedures along with the steps required to meet the policies.
This helps to reduce confusion, misunderstandings, and errors and to ensure
consistency in operational procedures, decision making, and outcomes.
Policies and procedures are grounded in best practices, standards of care, and
regulations set by state and federal agencies. All aspects of this documented
manual must also be reviewed and discussed with each employee to ensure
concise communication and understanding. A P&P manual should contain
information related to the following:
• Practice mission statement

• Basic employment information: Definitions of employee status (full-
time/part-time), hours of operation, job descriptions, compensation
and benefits, attendance, performance reviews, office meetings, office
closings, employee time away (including paid time off), and
discussion of employee files
• Employee professional conduct: Communication/interaction with
patients, fellow personnel, and other healthcare providers; use of
social media; misconduct and dishonesty; personal appearance and
dress code; expectations of professional behavior
• Documentation protocol: Basic information and role-specific
requirements
• Product and equipment use and maintenance: Manufacturer
recommendations and instructions for the safe use of products and
equipment as well as applicable maintenance information
• Employee grievances and termination: Discussion of how grievances
and complaints are handled, definition of voluntary termination,
discussion of severance pay if applicable
• Workplace legislation and regulation:
• State laws related to scope of practice, licensure, supervision
requirements, abuse/neglect reporting (maltreatment), basic life
support, professional liability coverage, continuing education,
other as applicable by state
• Federal laws related to equal opportunity and employment,
discrimination, harassment, Americans with Disabilities Act
(ADA), Family Medical Leave Act (FMLA), compliance with
OSHA, HIPAA, and CDC Infection Prevention and Control in
Dental Settings
• Attestation by employee: Employee signature acknowledging
information contained within the P&P manual and expectations of
employee
Establishment of policies and procedures for compliance with OSHA,

HIPAA, CDC, and exposure of dental radiographs does not need to be a
complex undertaking. Many resources are available for the adaptation and
adoption of risk management and quality assurance programs in practices.
OSHA provides access to model plans and programs that include exposure to
bloodborne pathogens, hazard communication, and needlestick prevention as
well as other resources.7,8 HIPAA compliance resources are available online
via the HHS website.9 CDC infection prevention and control procedures that
outline expectations for safe care in dental settings and provide answers to
frequently asked questions can be accessed online.10,11 Additionally, the CDC
offers an infection prevention checklist for dental settings that was created to
be adapted for use in a risk management program.12 This checklist contains
sections that outline policies and procedures as well as methods for direct
observation of personnel and patient-care practices. The American Dental
Association (ADA) in conjunction with the HHS Food and Drug
Administration (FDA) created a guide titled Dental Radiographic Examinations:
Recommendations for Patient Selection and Limiting Radiation Exposure.13 This
document details patient selection criteria based upon the type of encounter,
patient age, developmental stage, and clinical situations impacting the need
for radiographs. Discussion of the expected diagnostic quality of the
radiographs exposed should also be included. Again, the processes detailed
within the P&P manual can be utilized to create quality assurance checklists
for specific tasks.
Patient records are included within the structure domain. The goals of
efficient documentation are to maintain continuity of care, facilitate
communication among providers, and ultimately reduce exposure to risk and
litigation.14 The patient record includes the baseline data gathered at the first
encounter as well as a chronologic history of subsequent patient visits. All
patient contacts, both oral and written communications, should be recorded,
including cancellations/failed appointments, requests for information,
referrals to and notes from conversations with other healthcare professionals
regarding the patient, and noncompliance with treatment recommended and
agreed upon. Box 1.3 identifies recommended contents for a patient record.
All information regarding patient encounters should be recorded using
objective, professional, and nonjudgmental terms. Abbreviations and
professional jargon not identified in a formal documentation protocol should
be avoided. A simple note such as “prophy” is not appropriate because it
does not convey what procedures were performed, what products were used,
or how the patient responded to treatment and patient education. A
description of all treatment provided is required, including materials,
products, and medicaments, when applicable.15 Documentation should be
completed by the provider of the care and completed in a timely manner
following the patient visit as delaying the entry may cause incomplete and
inaccurate documentation due to confusion with information about other
patients treated that day. To ensure continuity of care it is essential that all
providers adhere to the documentation protocols outlined in the P&P manual
—any other provider should be able to review the patient record and easily
continue the patient’s treatment.15 Additionally, healthcare providers must
recognize the importance of confidentiality and guard this special trust and
the patient’s protected health information (PHI), which is both an ethical and
legal requirement.
Box 1.3
Components of the Patient Record
The patient record should contain the following current and historical
items:
• Signed acknowledgment of HIPAA policies

• Signed patient bill of rights and responsibilities
• Health history: current and past
• Clinical assessments: current and past
• Exams of head, neck, oral cavity, hard tissue, and periodontal charts
• Diagnostic radiographs, intra-/extraoral images, all diagnostic imaging
and tests, study models, risk assessment findings, and dental hygiene
diagnosis
• Planned treatment with signed informed consent and refusal forms
• Treatments and services rendered
• Communication with other healthcare providers
• Objective record of patient communication and interactions: telephone
calls, emails, text messages, prescriptions, referrals, canceled/failed
appointments, noncompliance with recommendations
The patient record is not simply the documentation mentioned previously

—it also includes radiographs, intraoral and extraoral images, three-
dimensional scans, study models, referrals made to and reports back from
other healthcare providers, and results of diagnostic tests. A patient may
request that a copy of his or her record be transferred to another provider; a
signed formal release-of-records document should be obtained. A dental
office may charge a reasonable fee to duplicate the records and forward them
—however, withholding the transfer of records because of lack of receiving a
fee is not legally permitted.
Most patient records are created electronically using a practice management
software program. These programs automatically record a date-and-time
stamp for entries, identify the provider entering the information, and track
any changes to existing data. A records management system should be
established to ensure that all required documentation is recorded and
maintained according to current standards and laws since the patient record
is considered a legal document. As mentioned, practices should institute a
documentation protocol to ensure that all providers are recording data in the
same manner in order to decrease risk to the patient, practice, and provider. If
any type of legal action is initiated, the dental record, which contains the
details of patient care, is the vital document that can (or cannot) protect the
oral healthcare provider. It is important to note that time and resources must
be provided to train clinical personnel to properly utilize the practice
management software program chosen by the practice. It is imperative that
clinical personnel understand and know how to fully utilize the practice
management software and how to document all required aspects of patient
care in accordance with the practice’s documentation protocol and standards
of the profession.
The American Dental Hygienists’ Association (ADHA) published the
Standards for Clinical Dental Hygiene Practice, which provides a concise listing
of documentation required at each phase of the dental hygiene process of
care: assessment, dental hygiene diagnosis, planning, implementation, and
evaluation (ADPIE).14 These standards can be used when creating the
documentation protocol specific to dental hygiene care. Once created, the
protocol can be converted into a quality assurance audit: a quality assurance
checklist to assess the overall effectiveness of each dental hygiene provider in
relation to documentation within the patient record. For example, the
standards itemize the required components of a comprehensive clinical
assessment to be completed by the dental hygienist. As stated in the
standards, “[C]omponents of the clinical assessment include an examination
of the head and neck and oral cavity including an oral cancer screening,
documentation of normal or abnormal findings, and assessment of the
temporomandibular function. A current, complete set of radiographs
provides needed data for a comprehensive dental and periodontal
assessment”. A comprehensive periodontal examination and hard-tissue
evaluation that includes charting of existing conditions and habits and
necessary radiographs and intraoral photographs are also part of the clinical
assessment.14 Criteria for the periodontal examination and hard-tissue
evaluation are succinctly defined. Box 1.4 illustrates the criteria for a
comprehensive periodontal examination.
Box 1.4
ADHA Standards of Clinical Dental Hygiene Practice
Comprehensive Periodontal Examination Assessment Criteria
A comprehensive periodontal examination is part of clinical assessment. It
includes the following:
A. Full-mouth periodontal charting, including the following data points

reported by location, severity, quality, written description, or
numerically:
1. Probing depths
2. Bleeding points
3. Suppuration
4. Mucogingival relationships/defects
5. Recession
6. Attachment level/attachment loss
B. Presence, degree, and distribution of plaque and calculus
C. Gingival health/disease
D. Bone height/bone loss
E. Mobility and fremitus
F. Presence, location, and extent of furcation involvement
In 2011, the American Academy of Periodontology (AAP) published a

statement that is in agreement with the ADHA criteria, including that patients
should receive a comprehensive periodontal evaluation annually, at a
minimum, and more frequently if the patient’s status dictates.16 Therefore, a
practices documentation protocol for a periodontal examination during the
assessment phase of care should include the ADHA components and should
be updated annually as per the AAP statement.
A quality assurance audit schedule should be established for the patient
record. These “chart audits” must be formalized, objective, and completed to
verify compliance with the documentation protocol, to ensure that the
treatment delivered to patients meets the standards of care, and to protect the
practice and providers from potential litigation.
The process domain of quality assessment includes the technical skills of
the provider. A dental practice must apply the quality assurance mindset and
verify the skills of all clinical personnel upon hire and periodically thereafter.
In research, this process would be referred to as interexaminer reliability.
Simply stated, this is a determination of the consistency of assessment
findings among multiple (more than one) examiners. This quality assurance
audit would include visual observations and outcome verification of findings
to determine consistency among providers.
Documentation and communication within the outcomes domain include
patient satisfaction surveys. Ultimately, if a patient is not satisfied with the
overall experience with practice and the outcomes of care, they will find
another dental practice. Patient satisfaction surveys should assess all aspects
of the patient experience, including the facility itself, interactions and
communication with personnel in administrative and clinical positions, and
perceptions of clinical care received. These assessments are subjective but can
provide valuable feedback regarding how the practice is viewed from a
patient perspective.
Communication
Communication is defined as a process by which information is exchanged
between and among individuals using a common system of signs, symbols, or
behaviors.3 We communicate in four basic ways, although there is often
overlap and interaction among them: verbal, nonverbal, visual, and written.
Verbal communication can be conducted face-to-face, via the telephone, or by
using electronic conferencing. Nonverbal communication can involve facial
expressions, gestures, eye contact, posture, body movements, and touch.
Examples of visual communication include presentations, images,
demonstrations, videos, and animations. Written communication involves
interactions that utilize written words, such as emails, letters, postcards,
Internet websites, manuals, brochures, and newsletters. No matter the type of
communication chosen, it is imperative to convey information at a level and
in a manner that the audience can understand and receive.
Effective communication ensures that the needs of the patient and dental
hygienist are clearly conveyed. Communication also is essential between the
dentist/employer, personnel, and other healthcare providers. The dental
hygienist uses various levels of communication skills on a daily basis—
constantly adapting, changing, and adjusting to the needs of patients and
colleagues in the dental environment.
Lack of appropriate vocabulary and the use of words that are unfamiliar to
the individual are frequent complaints regarding communication in the
dental office. Providers must consider the oral health literacy (OHL) of the
audience and adjust accordingly. The ADA defines OHL as the degree to
which individuals have the capacity to obtain, process, and understand basic
health information and services needed to make appropriate oral healthcare
decisions.17 Clarity and a well-organized progression of ideas can help ensure
an adequate level of understanding. This may require additional time, and the
dental hygienist may need to stop periodically to check whether the receiving
party comprehends the information being given. The attitude and tone with
which the spoken words are presented also can influence the effectiveness of
the communication. Judgmental or negative attitudes and tone can influence
the patient’s response to the information or can distract the patient from the
educational message the hygienist is trying to convey.
Careful attention to the volume of the voice also is important. Volume
should be adequate to ensure that the parties involved can hear what is being
said without the information being overheard by uninvolved parties. Every
patient wants to have the full and complete attention of the individual
providing care, and many misunderstandings stem from the perception that
the caregiver is not listening to the patient’s issues.
After performing dental procedures, written instructions commonly are
provided to the patient. This usually is done to reinforce verbal instruction.
These written messages should be clear, concise, and accurate. Distribution of
printed information, such as materials from the ADHA, ADA, AAP, and
National Institutes of Health (NIH), is quite acceptable, but these materials
should be similar to the instructions provided, not contradictory or confusing.
Additionally, written materials should be offered in other languages or a
means of translating material should be used if possible so that information is
accurately conveyed.
Providing an opportunity for questions and answers enhances and verifies
patient understanding. It is beneficial to create a post-procedure/appointment
template that can be provided to the patient outlining the treatment and
procedures provided and recommendations given during the encounter for
the patient to reference later.
Nonverbal communication is critical in a patient–provider interchange, as is
the spoken word. This is especially true in the dental setting, in which the
patient often is unable to ask a question because of hands or instruments in
the mouth. Facial expressions and gestures often communicate a great deal,
and the dental hygienist must be sensitive to the messages sent through this
avenue. Reading the patient’s expressions is a common method for gauging a
patient’s reactions to diagnostic or treatment methods. Reassurance that a
patient’s response to a procedure is within the range of normal can be a
welcome message, especially when dental hygiene treatments may be
unfamiliar to them. Nonverbal communication is a two-way form of
communication that warrants monitoring by the dental hygienist. Patients
also receive communication, accurate or not, from the dental hygienists’
nonverbal communication during treatment, which can be misunderstood as
concern or criticism.
Cultural sensitivity and awareness are essential aspect of healthcare
delivery. Healthcare providers must exhibit both when interacting with
patients. The American Psychological Association (APA) defines cultural
sensitivity as awareness and appreciation of the values, norms, and beliefs
characteristic of a cultural, ethnic, racial, or other group that is not one’s own,
accompanied by a willingness to adapt one’s behavior accordingly.18
Learning about differences in cultures can help the dental hygienist broaden
his or her knowledge and perspectives and provide truly patient-centered
care, honoring the autonomy of each person receiving dental hygiene
services.19
To help an individual improve their oral health, providers must understand
what best motivates behavioral change. Health behavior theories based on
psychosocial ideology aid providers in developing a better understanding of
how to effect change and motivate patients. The transtheoretical model of
change states that individuals move through stages of readiness to change.
The dental hygienist can assess the stage a patient is in to develop a homecare
plan for the patient. The health belief model proposes that when a person
believes they is susceptible to disease, behavior will change.
Electronic communication between patients and healthcare providers is
commonplace. Any electronic communication, such as email and automated
messages, should comply with good practices for professional
communication. This communication must be clear, concise, and accurate.
The “voice” of an electronic communication can be more easily
misunderstood, so messages should be reviewed carefully before they are
sent to ensure that they are professional, comprehendible, appropriately
compassionate, and culturally sensitive.
Individual Risk Management

The individual dental hygienist is responsible for managing their own
professional competency, adhering to the standards of care, and maintaining
the appropriate credentials associated with being a licensed professional.
Each dental hygienist must be familiar with the scope of practice allowed by
the state dental practice act. Familiarity with the requirements for continuing
education also is important. All continuing education courses should be
carefully evaluated in terms of the quality of the information presented,
compliance with the content required by the practice act, and the credentials
of the presenters. Poor-quality continuing education that provides outdated
or incorrect information may cause the dental hygienist to alter standard
practices, putting him or her at risk. Belonging to a professional association,
such as the ADHA and its related state and component societies, provides an
additional source of continuing education and publications to keep the dental
hygienist current. A dental hygienist also can become a member of other
organizations, such as the Special Care Dentistry Association and the
American Association of Public Health Dentistry, or other groups that
support a particular interest or focus. Professional dental groups as a course
of business offer publications and annual meetings that serve as sources of
up-to-date information. Dental and dental hygiene education programs can
be other sources of up-to-date continuing education opportunities.
Most state practice acts require that any licensed dental health provider
inform the monitoring agency within a certain period of any address or name
changes. Renewal of a dental hygiene license usually is accomplished by
paying a fee and providing documentation of continuing education. As
requirements for licensure renewal, many states require providers to be
current with basic life support (BLS) and automated external defibrillator
(AED) training. Additionally, some states may mandate continuing education
in specific areas that affect the practice of dentistry and dental hygiene, such
as infection prevention, OSHA training, human trafficking, domestic or child
abuse, pain management, and/or substance misuse. State-regulated
continuing education course requirements are updated as public health issues
and crises demand, and professionals must stay abreast of these changes.
Each dental hygienist should maintain a file of related professional
documentation that includes licensure, liability insurance, and continuing
education information.
A dental hygienist should consider other strategies to reduce individual
risk. Maintaining a good working relationship with colleagues in the dental
office is critical. Reading the practice’s P&P manual and, when appropriate,
suggesting updates and risk management strategies that should be included
are also important. Being respectful to patients and cautious about personal
conversations, jokes, and inappropriate behavior that may be misinterpreted
are equally important. Dental hygienists should never provide treatment for
which they are not qualified, educated, experienced, or licensed to perform.
Dental hygienists should carry adequate professional liability insurance and
be familiar with the policy and its coverage, terms, and requirements.
Understanding the nature of the coverage provided by a policy is essential.
Claims-made coverage is limited to protection for allegations that arise from
treatment rendered and reported while the policy is in force. Policy terms to
consider include liability limits and deductibles. The types of insurance
available and requirement for coverage can be different from state to state,
and insurance policies must be carefully inspected so that the dental hygienist
is fully aware of coverage and limitations. Many policies have restrictions or
mandates for reporting if and when the hygienist is faced with a potential
lawsuit. It also is advisable to contact an attorney for advice before entering
into any binding agreement or when confronted with situations that have
legal implications.
Social Media
The various types of electronic communications that are used in today’s
world have benefits and risks in both personal and professional settings.
Blogs, microblogs, social networking, and media sharing are all considered
types of social media.20 These tools can be used for networking, promoting
oral health, and increasing knowledge about oral health approaches and
products as well as for everyday communications.
The same ethical and legal standards and practices applied in dental clinical
settings should be adhered to when utilizing social media. The gift of trust
that patients extend to their oral healthcare professionals must be treated with
the utmost care. Confidentiality of patient information must be maintained
and any breach of privacy could result in civil and criminal penalties. Every
digital action, including a visit to a website, leaves a digital footprint that
cannot be erased.21 Keeping that fact uppermost in any electronic interaction
will help in monitoring communication since publicly available content can
reflect on an individual both personally and professionally. Numerous
authors provide cautions that can guide the dental hygienist when utilizing
social media20–23:
• Carefully view anything and everything that is posted online for its
communication value and tone.
• Pause before posting. Strive to maintain personal and professional
integrity at all times.
• Postings can be considered harassing or discriminatory in nature if
they violate legal norms.
• Be vigilant about safeguarding health information privacy. Do not
post any patient information.
• Do not give professional advice over social media platforms. You do
not know the clinical circumstances, and doing so can be held against
you.
• Do not “friend” or “like” patients on any social networking site.
Keeping those boundaries is respectful and prudent.
• Know the rules and policies on social media of employers and related
institutions.
• Do not post defamatory remarks about your employer, patients,
colleagues, or other healthcare providers.
• Cyberbullying can occur either from peers or patients. Any bullying
behavior should be reported and addressed.
Summary
The dental hygienist has the ability to consider and apply numerous
strategies that can identify and reduce the risk of unwanted consequences that
may occur in dental hygiene practice. Risk management and quality
assurance practices, established as a system or individually, can enhance the
health and safety of dental healthcare personnel and the dental patient and
can support the ultimate goal of promoting oral health.
Practice Pointer
As licensed dental health professionals, dental hygienists are legally and
ethically required to adhere to the standards of care related to patient care.
Licensed individuals are expected to be well versed regarding regulations
governing their profession and to function within the state’s practice act.
References
1. Zarkowski P. Legal and ethical issues in the dental business
office. In: Finkbeiner BL, Finkbeiner CA, eds. Practice
Management for the Dental Team. 8th ed. Mosby; 2016:60–61.
2. Singh H. National Practitioner Data Bank. Generated using
the Data Analysis Tool at
https://www.npdb.hrsa.gov/analysistool. Data source:
National Practitioner Data Bank (2021): Adverse Action and
Medical Malpractice Reports (2011–March 31, 2021).
3. Donabedian, A. (1966). Evaluating the quality of medical
care. Milbank Memorial Fund Quarterly, 44(3). (pp. 166-206).
Reprinted in Milbank Quarterly 2005;83(4):691-729.
4. Health and Safety Executive (HSE). Risk Assessment
Template 2019. https://www.hse.gov.uk/simple-health-
safety/risk/risk-assessment-template-and-examples.htm.
Accessed June 11, 2021.
5. American Health Information Management Association.
Healthcare Documentation Quality Assessment and
Management Best Practices. 2017.
https://www.ahdionline.org/page/qa. Accessed July 2021.
6. Purtilo RB, Haddad AM, Doherty R: Health professional and
patient interaction, ed 8, St. Louis, MO, 2014, Saunders
Elsevier.
7. United States Department of Labor, Occupational Safety and
Health Administration (OSHA). Model Plans and Programs
for the OSHA Bloodborne Pathogens and Hazard
Communications Standards.
https://www.osha.gov/sites/default/files/publications/osha31
86.pdf. Accessed June 11, 2021.
8. United States Department of Labor, Occupational Safety and
Health Administration (OSHA). Safety and Health Topics:
Dentistry. https://www.osha.gov/dentistry. Accessed June 11,
2021.
9. United States Department of Health and Human Services.
Health Information Privacy.
https://www.hhs.gov/hipaa/index.html. Accessed June 11,
2021.
10. United States Department of Health and Human Services,
Centers for Disease Control and Prevention (CDC). Infection
Prevention Practices in Dental Settings: Basic Expectations for
Safe Care.
https://www.cdc.gov/oralhealth/infectioncontrol/summary-
infection-prevention-practices/index.html. Accessed June 11,
2021.
Prevention and Control in Dental Settings: Frequently Asked
Questions.
https://www.cdc.gov/oralhealth/infectioncontrol/faqs/index.h
tml. Accessed July 13, 2021.
Prevention Checklist for Dental Settings.
https://www.cdc.gov/oralhealth/infectioncontrol/pdf/safe-
care-checklist.pdf.
13. American Dental Association (ADA) and United States
Department of Health and Human Services, US Public Health
Service, US Food and Drug Administration (FDA). Dental
Radiographic Examinations: Recommendations for Patient
Selection and Limiting Radiation Exposure. 2012.
https://www.fda.gov/media/84818/download. Accessed June
11, 2021.
14. American Dental Hygienists’ Association (ADHA).
Standards for Clinical Dental Hygiene Practice. 2016.
https://www.adha.org/resources-docs/2016-Revised-
Standards-for-Clinical-Dental-Hygiene-Practice.pdf.
15. Royal College of Dental Surgeons of Ontario. Dental
Recordkeeping. 2019.
https://az184419.vo.msecnd.net/rcdso/pdf/guidelines/RCDSO
_Guidelines_Dental_Recordkeeping.pdf.
16. American Academy of Periodontology: Comprehensive
periodontal therapy: A statement by the American Academy
of Periodontology. J Periodontol 82:943-949, 2011.
17. American Dental Association. Glossary of Dental
Administrative Terms. Definition of Oral Health Literacy.
2022. https://www.ada.org/publications/cdt/glossary-of-
dental-administrative-terms.
18. American Psychological Association. APA Dictionary of
Psychology. Definition of Cultural Sensitivity. 2022.
https://dictionary.apa.org/cultural-sensitivity.
19. Institute of Medicine (IOM) and National Research Council
(NRC). Improving Access to Oral Health Care for Vulnerable and
Underserved Populations. The National Academies Press; 2011.
20. Sams LD: Understand the world of social media. Dimens
Dent Hyg 11(12):57–63, 2013.
21. Oakley M, Spallek H: Social media in dental education: a call
for research and action. J Dent Educ 76:279–287, 2012.
22. Henry RK: Maintaining professionalism in a digital age.
Dimens Dent Hyg 10(10):28–32, 2012.
23. Carr MP: Lawsuit pending against Florida dental hygienist.
Dimens Dent Hyg 2018. Retrieved from
https://dimensionsofdentalhygiene.com/lawsuit-pending-
against-florida-dental-hygienist/
CHAPTER
2
Ethics and Professionalism
Phyllis L. Beemsterboer
Chapter Outline
The Healthcare Provider 16
The Dental Hygienist 17
Professionalism 18
Commercial Model 18
Guild Model 18
Interactive Model 18
Interprofessionalism 19
Competency in Dental Hygiene 20
Standards for Clinical Dental Hygiene Practice
21
Professional Traits for the Dental Hygienist 22
Honesty and Integrity 23
Caring and Compassion 23
Reliability and Responsibility 23
Maturity and Self-Analysis 23
Loyalty 23
Interpersonal Communication 23
Tolerance for Others 24
Respect for Self 24
Legal Requirements for the Dental Hygienist 24
Summary 25
LEARNING OUTCOMES
• Describe the role of the dental hygienist in healthcare.
• Explain the relationship between the healthcare provider and
the patient.
• Describe the aspects of a true profession as they apply to
dentistry and dental hygiene.
• Explain interprofessionalism and its impact on healthcare
education and practice.
• Discuss the theory of competency and skill acquisition for the
dental hygienist.
• Compare educational competencies and practice standards.
• Identify the traits of a professional dental hygienist.
From its inception in the early 1900s, the profession of dental

hygiene has been concerned with the public good and with
advocating methods of preserving oral health. The first oath written
for dental hygienists called upon Apollo, the god of health, and
Hygeia, the goddess of health, to help each practitioner in
performing the “sacred duty of teaching to the public, particularly
children and young people, by precept, lecture and every other
available mode of instruction, the value of dental health as a
priceless possession.”1,2
The dentists who pioneered the special field of dental hygiene
positioned the dental hygienist as the oral preventive therapist
because of their vision of the day when dental disease could be
prevented by following a system of treatment and cleanliness.
The original intent of the first oath was preserved in a revised and
modernized version adopted by the Board of Trustees of the
American Dental Hygienists’ Association (ADHA) in 1979 and is
still in use today. This oath, which is affirmed by numerous dental
hygiene students before or at the time of graduation from their
formal education and training program, captures the essence of the
public mission of the profession. The following, reprinted from
Steele,1 recalls that original oath, which has been updated since by
the ADHA (http://www.adha.org/aboutadha/dhoath.htm):
In my practice as a dental hygienist,

I affirm my personal and professional commitment
To improve the oral health of the public,
To advance the art and science of dental hygiene,
And to promote high standards of quality care.
I pledge continually to improve my professional
Knowledge and skills, to render a full measure
Of service to each patient entrusted to my care,
And to uphold the highest standards of professional
Competence and personal conduct in the interest
Of the dental hygiene profession and the public it serves.
Over the years, the profession of dental hygiene has evolved and
changed with requirements for formalized education, regulation by
licensure, and increased scope of practice. In addition, the public
served by all healthcare providers has changed with the advent of
new diseases, the development of advanced treatment methods,
and a continually increasing human life span. However, dental
hygiene retains its original focus on the public good, as well as its
primary role in the prevention of dental disease and promotion of
oral health.
Society recognizes that healthcare providers, by virtue of their
education and special skills, are appropriately held to a higher
standard than can be expressed exclusively by legislative mandate.
Thus, these higher standards are expressed in professional codes of
ethics and are enforced by those within the profession. This is
called self-regulating or self-policing behavior and represents an
increased level of trust on the part of the public. In essence, the
public agrees that it is neither qualified nor in a position to evaluate
the adequacy of treatment provided by healthcare professionals.
Therefore, the public trusts these professionals to perform their
own evaluations. Ethical dental hygienists willingly accept the duty
of self-regulation, both in judging their colleagues and in
submitting to peer review, to ensure quality care for the public.
The Healthcare Provider

All healthcare providers are granted special rights and
responsibilities when they choose and enter a career in the
biomedical field. In the past, becoming a professional in medicine,
dentistry, or the allied disciplines was considered a calling. Once
specialized training was completed, the individual became a
member of a profession, defined as a limited group of persons who
have acquired some special skill and are therefore able to perform
that function in society better than the average person (Box 2.1).2 In
the corporate world, success is measured by financial gain. For the
healthcare professional, the patient’s welfare is placed above profit.
Because of this ideal, society has granted the healthcare
professional a certain status that carries prestige, power, and the
right to apply specialized knowledge and skill.
Box 2.1
Characteristics of a True Profession
• Specialized body of knowledge of value to society

• Intensive academic course of study
• Standards of practice
• External recognition by society
• Code of ethics
• Organized association
• Service orientation
Data from: Motley WE. Ethics, Jurisprudence and History for the
Dental Hygienist. 3rd ed. Lea & Febiger; 1983.
When patients seek care from any healthcare provider, they

expect to receive the best care from a professional and ethical
practitioner. The healthcare services provided involve technical
skill, appropriate knowledge, critical judgment, and—most
importantly—caring. Patients perceive this essence of caring and
respond to it. In the delivery of health care, trust is the critical
foundation for the relationship that develops between the person
seeking services—the patient or client—and the healthcare provider
—the professional. The patient is aware that the healthcare provider
has certain knowledge and skills; the graduation certificate and
state license hanging on the wall are proof of that fact. However,
the caring that the patient seeks gives the provider of dental
hygiene services the greatest opportunity for professional service
and satisfaction. An understanding of ethical issues and an
awareness of the ethical obligations inherent in the provision of
health care enable the dental hygienist to deal effectively with the
problems of patients and their communities.
The importance and need for professionalism in all areas of health
care have been extensively discussed and written about. Educators
in medicine, dentistry, and dental hygiene have shared the
importance of fostering professionalism and the fact that students
must be immersed in clinical learning environments that model the
highest principles.3
A number of medical organizations have focused on how to
reemphasize the essence of professionalism in health care. The
Institute of Medicine (now called the National Academy of
Medicine) has produced several reports on this topic, and a project
by a consortium of internal medicine groups led to the publication
“Medical Professionalism in the New Millennium: A Physician
Charter” (Physician Charter).4 The authors advocated that
everyone “involved in health care” use the charter to engage in
discussions to strengthen the ethical underpinning of professional
relationships. The Physician Charter sets out three fundamental
principles that are not new but reinforce the foundation of the
medical profession as one of service to others. The ethical principles
of the primacy of patient welfare (beneficence and nonmaleficence)
and patient autonomy are listed first; the principle of social justice
is the third main tenet. The desired goal was to reinvigorate the
value of professionalism that includes social responsibility: the ethic
of care, and access to that care, for all members of society.
Professionalism is rooted in a relationship or contract with
society. Ministry, medicine, and law grew from medieval guilds
that were established in universities centuries ago. Entrance into
these fields was controlled through the awarding of educational
credentials. Early dental practitioners were itinerant barbers, and
the road to professional status moved from apprenticeship to
education through the establishment of professional schools.5
Developing an educational process gave the members control over
entry into the occupation and the size of the labor force. Because of
their smaller number and their education, professionals became
trustees of the community and took leadership positions in their
societies.6 This led to the public understanding that the professional
person’s knowledge is linked with service in the interest of the local
community. Ultimately, the professional came to be defined as
someone learned, publicly licensed, and supported by a collegial
organization of peers committed to an ethic of service to clients and
the public.7 The professions then are much like universities and
colleges in this sense—given a unique charter that grants autonomy
and special status for a public purpose.
Irene Newman, the nation’s first licensed dental hygienist.

The Dental Hygienist
The dental hygienist is a professional oral healthcare provider—an
individual who has completed a required higher-education
accredited program; demonstrated knowledge, skills, and
behaviors required by the college or university for graduation;
passed a written national board examination; and successfully
performed certain clinical skills on a state or regional examination.
Because of these accomplishments, the state then grants this
individual a license to practice the profession for which he or she
completed training and education. By taking this step, the state is
assuring the public that this licensed individual is competent to
practice. That is the reason that a board of dentistry or a dental
practice act exists: to protect the public’s health and safety.
A dental hygienist provides educational, clinical, and therapeutic
services supporting the total health of the patient through the
promotion of optimal oral health. Because of these functions, the
dental hygienist has been defined as a preventive oral healthcare
professional.
To be considered a profession, a specific field or area of study
traditionally must have several characteristics. These include a
specialized body of knowledge and skill of value to society, an
intensive academic course of study, set standards of practice
determined and regulated by the group, external recognition by
society, a code of ethics, an organized association, and a service
ethic. What separates the professional from the layperson is this
specialized knowledge, which is exclusive to the professional
group. Because being a professional is considered desirable, many
careers and occupations aspire to this level. Real estate agents, auto
mechanics, and culinary chefs all use the term professional to
indicate a desired level of competency and quality performance.
However, the true professions are still considered to be medicine,
dentistry, ministry, and law because they possess all the
characteristics previously listed.
Moreover, a profession incurs an obligation by virtue of its
relationship with society—something that is affirmed and
reaffirmed over time. When an individual enters a course of
professional study, learning about the tenets of the profession and
its inherent obligations is part of the educational program. The
Hippocratic Oath, the dentist’s pledge, and the dental hygiene oath
are examples of outward signs that reflect acceptance of the
professional obligation. Professionalism is demonstrated through a
foundation of clinical competence, communication skills, and
ethical and legal understanding, upon which is built the aspiration
to and wise application of the principles of professionalism. These
principles are excellence, humanism, accountability, and altruism.8
Professionalism
The expectations of the public regarding health care have changed
and evolved over the years. People have become increasingly
knowledgeable, involved, and active in their own healthcare
decisions. This change evolved from a traditional relationship
between the practitioner and the patient. Ozar described this
evolution in his classic article in which he developed the three
models of professionalism: the commercial model, the guild model,
and the interactive model.9 These models are not intended to reflect
how dental care has been delivered in the past but to provide an
examination of how the obligations of provider and patient should
be established from a moral perspective.
Commercial Model
The commercial model describes a relationship in which dentistry
is a commodity: a simple selling and buying of services. The patient
is the consumer, and the dentist is the producer. The dental needs
of the patient are not as important as what the patient is willing to
pay for or what gives the dentist the greatest return on time, effort,
and materials. The patient, as the consumer, weighs needs and
discomfort against the cost of the purchase of dental services. A
dentist with a new technique in esthetic dentistry would present it
in such a way as to attract patients and build his or her business,
thereby keeping it from other dentist competitors. In this model, all
dentists are in competition, selling the same commodity to the
public for the best price, creating a true marketplace. In this
commercial model, no obligation exists between the dentist, the
patient, other dentists, or the community.
Guild Model
The second model, the guild model, presents dentistry as an all-
knowing profession. It is called the guild model because it resembles
the medieval guild of old in which those who were members of the
group controlled knowledge, skill, and competency. In this model,
the patient has dental needs and the dentist, as a member of the
profession, provides care to meet the needs of that patient, who is
uninformed and passive in the process. This is a paternalistic
undertaking in which the obligation to provide care comes from the
dentist’s membership in his or her chosen profession.
Interactive Model
In the third model, the interactive model, the patient and the dentist
are equals and have roles of equal moral status in the process of
dental care delivery. According to this model, patients determine
their own needs and healthcare choices on the basis of their
personal values and priorities but seek the care of the dentist
because of his or her knowledge and skill. Thus, the status of the
dentist and that of the patient are essentially equal; however, their
equality is based on their distinctive roles. Patients needing services
and dentists who are able to provide those services are both bound
by the common values of health and comfort. The obligation for care
in this relationship holds both parties as equals because neither can
achieve these values without the other. A delicate balance must be
maintained in this model between the expertise of the professional
and the choice of the patient based on the patient’s own values and
purposes. Ozar describes this subtle partnership in decision making
as the dental professional’s first responsibility.9 The fundamental
obligation in the interactive model is for the dentist to treat each
patient well and to support the profession. This obligation derives
from the larger community sanction that is granted upon
graduation and licensure and that is voluntarily accepted upon
entrance into the profession.
The three Ozar models provide insight into the moral basis of the
relationship between patient and provider in dental care. The
interactive model is preferable because it presents the patient and
provider as partners who make different contributions to the
partnership. This equal moral status creates an obligation for equal
respect as partners working together toward attaining and
maintaining oral health.
Dental hygiene and other healthcare professions students collaborate
on patient care treatment plans. From: @ iStock.com/Cecilie_Arcurs.
Interprofessionalism
As gains in the acknowledgment of the patient as a partner in
health and wellness grew, it became clear that building and
empowering all members of the healthcare team could increase
safety, efficiency, and patient outcomes. Previous Institute of
Medicine reports on the quality of care, access to care, and
preparing future healthcare teams underscored the need to improve
collaboration among clinicians.10,11 Communication skills and the
understanding of aging and medically complex populations are
among the acknowledged competencies required for highly
effective teams. This led to various academic health centers
establishing curricula in interprofessional education (IPE).
The term IPE refers to occasions when students from two or more
health professions learn together during all or part of their
professional training with the objective of cultivating collaborative
practice to improve the quality of patient care at the individual and
population level.12 In 2011, six major health education
organizations—the American Association of Colleges of Nursing,
American Association of Colleges of Osteopathic Medicine,
American Association of Colleges of Pharmacy, American Dental
Education Association, Association of American Medical Colleges,
and Association of Schools of Public Health—came together as the
Interprofessional Education Collaborative (IPEC) and published
core interprofessional competencies that could be embedded in all
curricula and provided a foundation for interprofessional learning
and collaborative practice. These core competencies are expressed
in four interprofessional competency domains that are
recommended by IPEC.13 The four domains are these:
• Values and ethics for interprofessional practice to maintain a

climate of mutual respect and shared values
• Roles and responsibilities for assessing and addressing the
healthcare needs of patients and populations
• Interprofessional communication to support a team approach
for the maintenance of health and treatment of disease
• Teams and teamwork to apply values and principles of team
dynamics for the delivery of care that is safe, efficient, and
equitable
Various educational programs will choose goals and objectives

within these domains as fits their settings and the types of
professionals who are training together. The idea of training
healthcare team members together has been met with great interest
by students and faculty alike. Dental and dental hygiene educators
have long acknowledged that oral health care is advanced when all
members of the dental team are working together collaboratively.
The preventive role of the dental hygienist is an excellent
foundation for establishing oral and general community public
health programs. Communicating with clinicians from all aspects of
health care can only improve the outcomes for health, wellness, and
treatment of diseases. Ethical issues will be encountered in
interprofessional collaboration, and all members of healthcare
teams will need to be aware of and trained in the complex
dynamics of relationships.
Competency in Dental Hygiene

A basic attribute of professionals is that they have achieved
competency in the scope of practice that is legally granted to that
particular discipline or field. Competencies are the essential
knowledge, skills, and abilities that are performed by a healthcare
provider.14 For a dental hygienist, competencies are skills regularly
used in real practice settings to meet the oral health needs of
patients. In addition, these competencies have been examined and
endorsed by dental hygienists, dentists, and dental educators as
valid and appropriate.
The Commission on Dental Accreditation, which is the authorized
agency that accredits all dental hygiene education programs in the
United States, publishes standards and competencies that all dental
hygiene programs must meet or exceed in their educational
programs (Box 2.2).
Box 2.2
Patient Care Competencies: Accreditation
Standards for Dental Hygiene Education
Programs
The Commission on Dental Accreditation is the agency that
conducts the accreditation program for all dental education
programs. The Commission is the nationally recognized
accrediting body for dentally related fields and receives its
authority from acceptance by the dental community and by being
recognized by the US Department of Education (USDE). The
standards for dental hygiene are reviewed and revised
periodically through an open and contributory process that
includes representatives from the discipline of dental hygiene.
The following standards may change because of this ongoing
cycle of review but will include competencies in these areas:
1. Providing dental hygiene care for the child, adolescent, adult,

geriatric, and special needs patient populations
2. Providing the dental hygiene process of care, which includes:
• Comprehensive collection of patient data to identify the
patient’s physical and oral health status
• Analysis of assessment findings and the use of critical
thinking in order to address the patient’s dental hygiene
treatment needs
• Establishment of a dental hygiene care plan that reflects
the realistic goals and treatment strategies to facilitate
optimal oral health
• Provision of patient-centered treatment and evidence-
based care in a manner minimizing risk and optimizing
oral health
• Measurement of the extent to which goals identified in the
dental hygiene care plan are achieved
• Complete and accurate recording of all documentation
relevant to patient care
3. Providing dental hygiene care for all types of classifications
periodontal disease, including patients who exhibit
moderate to severe periodontal disease
4. Communicating and collaborating with other members of
the healthcare team to support comprehensive patient care
5. Assessing, planning, implementing, and evaluating the
health-promotion activities of community-based health-
promotion and disease-prevention programs
6. Providing appropriate life-support measures for medical
emergencies that may be encountered in dental hygiene
practice
7. Applying the principles of ethical reasoning, ethical decision
making, and professional responsibility as they pertain to
the academic environment, research, patient care, and
practice management
8. Applying legal and regulatory concepts to the provision
and/or support of oral healthcare services
9. Applying self-assessment skills to prepare for lifelong
learning
10. Evaluating current scientific literature
11. Problem-solving strategies related to comprehensive
patient care and management of patients
Data from: Commission on Dental Accreditation (CODA).

Accreditation Standards for Dental Hygiene Education Programs. 2022.
https://legacy.ada.org/en/coda/current-accreditation-standards.
Accreditation in the United States is a system that has been

developed to protect the public welfare and provide standards for
the evaluation of educational programs and schools. Regional
accrediting agencies examine colleges and universities, whereas
specialized accrediting agencies focus on a particular profession or
occupation. A specialized accrediting agency recognizes a course of
instruction composed of a unique set of skills and knowledge,
develops the accreditation standards by which such educational
programs are evaluated, conducts evaluation of programs, and
publishes a list of accredited programs that meet the national
accreditation standards. Accreditation standards are developed in
consultation with those affected by the standards as well as those
who represent the communities of interest.
The Commission on Dental Accreditation is the specialized
accrediting agency recognized by the US Department of Education
to accredit programs that provide basic preparation for licensure in
dentistry, dental hygiene, and all related dental disciplines.15 The
commission consists of 30 members and includes a representative
of the ADHA. The commission uses a peer-review process to ensure
that the dental hygiene standards are met in each program, and a
formal, on-site review is conducted every 7 years.
Patient care competencies, sometimes called graduation
competencies, are standards that must be met by graduates of any
educational program accredited by the Commission on Dental
Accreditation. In states in which mastery of additional skills is
mandated by the dental practice act, accredited programs also offer
training opportunities in those competencies. An example of such a
skill or function is the administration of local anesthesia or nitrous
oxide analgesia.
Acquisition of dental hygiene skills is a process guided by
educational theory and experienced dental hygiene educators.
General education, biomedical science, dental science, and dental
hygiene science content areas provide the core of knowledge in a
dental hygiene program. Educational theory categorizes the process
of skill performance into five stages of competency, also termed the
expert learning continuum (Fig. 2.1). The five stages are novice,
advanced beginner, competency, proficiency, and expertise.16,17
FIG. 2.1 Competency continuum.
When a student begins preclinical activities and progresses to

caring for clinical patients under the supervision of faculty, that
stage of learning is called novice or advanced beginner. At or even
before graduation, the student will have achieved competency—
that is, the ability to perform skills without faculty supervision and
with confidence. After graduation, the dental hygienist works
toward proficiency and continues working, throughout his or her
professional life, toward becoming an expert. Becoming an expert is
not an endpoint; rather, it is something a true professional
constantly strives for in practice. An analogy is a professional
athlete who constantly practices a sport, seeking improvement and
even greater ability. Perhaps that is why the term practice is used, as
in the practice of dental hygiene or the practice of dentistry.
Professionals constantly seek to perform at increasingly higher
levels, perfecting the art and science of dental hygiene for every
patient treated.
Standards for Clinical Dental
Hygiene Practice
The ADHA established standards for clinical dental hygiene practice
in 1985 to outline the expectations for the practicing dental
hygienist.18 In its role as the organized voice for dental hygiene, the
ADHA advocates quality care, health promotion, and enhanced
oral health, with the ultimate goal of improving overall health for
all individuals and groups. The revised Standards for Clinical
Dental Hygiene Practice were validated in 2008 and reaffirmed in
2016 to lay out a framework for clinical practice that focuses on the
provision of patient-centered comprehensive care.16 The six
standards of practice are assessment, dental hygiene diagnosis,
planning, implementation, evaluation, and documentation (Box
2.3). Establishing, reviewing, revising, and publishing these
standards are professional responsibilities that the ADHA assumes
for its members to ensure that professional practice is based on the
best and most scientifically accurate evidence and practice
approaches.
Box 2.3
Highlights of the Standards for Clinical Dental
Hygiene Practice
Standard 1: Assessment
Assessment is the systematic collection, analysis, and
documentation of oral and general health status and patient
needs. It is comprised of collecting the patient history, performing
a comprehensive clinical evaluation, and measuring risk
assessment.
Standard 2: Dental Hygiene Diagnosis
The dental hygiene diagnosis is the identification of an individual’s
health behaviors, attitudes, and oral healthcare needs for which
the hygienist is educationally qualified and licensed to treat. This
aspect of practice requires evidenced-based critical analysis and
interpretation of assessments in order to reach conclusions about
the dental hygiene treatment needs.
Standard 3: Planning
Planning is the establishment of goals and outcomes based on
patient needs, expectations, values, and current scientific
evidence. The dental hygiene plan of care is based on the
assessment and dental hygiene diagnosis within the context of
ethical and legal principles and the overall dental treatment plan.
Standard 4: Implementation
Implementation is the delivery of dental hygiene services while
minimizing risk and optimizing oral health. Communication with
between the patient and dental hygienist is critical and must be
appropriate for age, language, culture, and learning style.
Standard 5: Evaluation
Evaluation is the measurement of the extent to which the goals in
the dental hygiene care plan have been achieved. Evidenced-
based criteria are used to continue, discontinue, or modify the
care plan based on ongoing reassessments and diagnoses.
Standard 6: Documentation
Documentation is the complete and accurate recording of all
collected data, treatments planned and provided,
recommendations, and other relevant information. This
information is recorded appropriately and should meet all state
regulations and ethical guidelines.
Data from: American Dental Hygienists’ Association. Standards for

Clinical Dental Hygiene Practice. 2016.
https://www.adha.org/resources-docs/2016-Revised-Standards-
for-Clinical-Dental-Hygiene-Practice.pdf.
Professional Traits for the Dental

Hygienist
The professional traits or attributes of a successful dental hygienist
are found in the basics of professionalism. These traits are nurtured
in the dental hygiene student and then carried into clinical practice
or other practice settings.
The attributes that have been identified as those of a healthcare
professional are the same whether that individual is a physician,
nurse, dentist, dental hygienist, or other allied healthcare provider.
All these traits are rooted in beneficence: the core of health care that
places the needs of the patient or client ahead of those of the
provider. Society expects and demands this behavior from
individuals who choose to pursue a career in the health fields. From
the perspective of the general population, the term professional has
evolved to mean an individual who demonstrates certain attributes,
traits, and behaviors that embrace the best qualities of care and
service.
The ethicist Laurence McCullough has stated that two virtues are
required in a professional person. The first is self-effacement, which
means putting aside all notions of self as better educated, socially
superior, or more economically well off and focusing on the needs
of the patient. The second is self-sacrifice, or putting aside or giving
up one’s own interests and concerns.
The professional traits that a dental hygienist must demonstrate
and a dental hygiene student should strive to develop are listed in
Box 2.4 and discussed in the following section. Dental hygienists
who demonstrate these traits will experience a positive level of
satisfaction in the practice of dental hygiene and will be able to
recognize their contributions to the overall benefit of society.
Box 2.4
Professional Traits of the Dental Hygienist
• Honesty and integrity

• Caring and compassion
• Reliability and responsibility
• Maturity and self-analysis
• Loyalty
• Interpersonal communication
• Respect for others
• Respect for self
Honesty and Integrity

A relationship of trust is essential to providing care when personal
health information is shared. The patient should be confident that
information given in the written and verbal form is held in the
confidence and handled appropriately.
Patients and colleagues must be able to depend on the words and
actions of individuals who treat and work with them. Professional
integrity is a commitment to upholding the profession’s code of
ethics and standards of care.
Caring and Compassion

The ability to care for and be compassionate to each and every
patient is a critical trait expected of all individuals who seek a
career in a healthcare profession. Caring means demonstrating the
empathy necessary to comfort and guide the patient in the health
promotion process. Persons who exhibit compassion are merciful to
all patients, including those who are unlike themselves or who are
possibly difficult to understand and treat.
Reliability and Responsibility

The dental hygienist must accept responsibility for performing all
services to the best standard of care. Sound judgment must be
applied in every patient encounter, keeping in mind the technical,
scientific, and ethical dimensions of the case. Maintaining current
knowledge of dental hygiene theory and technique is part of that
responsibility. Most states have a legal requirement for continuing
education for those who hold a dental hygiene or dental license.
The goal of mandated continuing education is to ensure that
optimal health services are delivered to the public by fostering
continued competence. A reliable individual meets the obligations
of time and duty: keeping appointments and meeting established
schedules.
Maturity and Self-Analysis

A mature individual works efficiently and effectively toward the
goals of attaining and maintaining oral health for each patient. The
dental hygienist often seeks employment in solo or group dental
practices in which a small number of individuals must work as a
team, relying on each person to perform his or her assigned role
and to always keep the needs of the patient primary to all activities.
Self-analysis is the trait in which the dental hygienist assesses his or
her skills and takes responsibility for changing and improving
those skills when necessary.
Loyalty
Protecting and promoting the interests of a person, group, or
organization constitute the definition of loyalty. Any relationship
between a healthcare provider and a patient is a special affiliation—
all professional decisions must be unencumbered by conflicting
personal interests. Promises should be carefully made and kept.
Interpersonal Communication
The foundation of trust lies in communication and the ability of the
patient to speak and be heard. Listening to the overt and subtle
cues provided by patients allows the dental hygienist to develop a
relationship that fosters an open exchange of information. Patients
expect that personal, intimate facts and impressions about them
will be kept in confidence by the dental hygienist.
Tolerance for Others

Treating all patients without discrimination is a basic ethical and
legal requirement. This behavior goes beyond the legal warning to
not discriminate based on race, creed, color, age, sex, ethnicity, or
disabilities to include occupation, financial status, personality, and
oral conditions. It means caring for all individuals who seek
treatment whether or not they are likeable. Patients occasionally
will prove difficult and hostile during the course of treatment, but
dental hygienists must still treat such persons to the best of their
ability.
Respect for Self

Dental hygienists should maintain their own physical and mental
health so that the patient’s needs can remain the primary focus.
Working while under the influence of alcohol, drugs, lack of sleep,
or emotional distress does not allow the healthcare provider to
focus on the needs of the patient. Each patient deserves the
complete attention of the dental hygienist while being treated.
Legal Requirements for the

Dental Hygienist
Dental hygienists are subject to the rules and regulations of the
jurisdiction in which they practice dental hygiene. When a license is
granted to an individual, that person becomes responsible for
knowing and upholding all the statutes and laws set down in the
legal document, usually called the state dental practice act or the code
of dental practice. Ignorance of a portion of the law or code is no
excuse for noncompliance by a dental hygienist or any other
healthcare provider. The responsibility and power for legislative
protection of the public rest with each individual state or territory.
Licensure is designed to enforce practice codes, establish standards,
and sanction incompetent practitioners, all for the purpose of
protecting the health and safety of the public.
The scope of practice of a dental hygienist was first established by
law in Connecticut in 1915 at the urging of Dr. A. C. Fones, the
father of dental hygiene.2 The Connecticut dental law delineated
the practice parameters of the dental hygienist and subsequently
served as a model for the states that later adopted similar
legislation. All state boards, as well as those in the Virgin Islands
and Puerto Rico, grant a license to practice to the dental hygienist.
An unlicensed person may not provide dental hygiene care.
Legal statutes periodically change in response to many factors,
both to protect the public and advance the interests of the health
professions. The process for any legal change is arduous,
complicated, and costly in time and effort. Most legislative changes
related to dental health care are driven by individuals in the dental
and dental hygiene professions. For the most part, the public
remains unaware of the intricacies of the process or its effect on the
delivery of their dental healthcare. Some of the factors that
influence legislative changes in a state include the following:
• Need and demand for dental care

• Distribution of dental healthcare providers
• Federal health legislation
• Goals of organized dental and dental hygiene associations
advocacy groups
Increases in the scope of practice for the dental hygienist have

occurred over the years but usually have been accompanied by a
great deal of controversy and consternation. The services
performed by the dental hygienist usually are classified as either
traditional duties, such as scaling, root planing, and education of
the patient, or expanded functions, such as the administration of
local anesthesia and placement of restorative materials. Some states
have implemented an additional practice level for dental hygienists,
termed an expanded- or extended-duty dental hygienist. Individuals
pursuing this level of practice must complete additional training in
periodontal or restorative functions and must be sanctioned to
perform these skills by the particular state in which they practice.
The exact duties and services that may be performed by the dental
hygienist in a particular state are based on customary parameters of
practice, dental statutes, and the state dental practice act. Only
duties or functions allowed in a particular state may be performed
by the licensed dental hygienist, even if that individual is trained
and licensed in another state where the practice act is more
expansive.
The legal mandates in each state use terms that differentiate the
level of supervision set out by that particular body. Some states are
more liberal than others in their dental practice acts. Several states
have adopted mechanisms to allow a dental hygienist to practice
without the supervision of a dentist after gaining a special license
or credential. These allowances are granted after additional training
or testing, often with the goal of improving public access to
appropriate care.
Summary
The profession of dental hygiene was established with the goal of
providing oral health education and services to the public so that
dental disease could be prevented. As a healthcare professional, the
dental hygienist is given the trust of society, and with that special
trust comes rights and responsibilities. Attaining and maintaining
competency in dental hygiene are among the obligations that the
dental hygienist accepts in completing a formal education program
and passing the state licensure examination. The traits that
characterize a successful dental hygienist are the same traits found
in any successful healthcare professional: placing the needs of the
patient first and aiming to provide the best care to every patient as
well as society at large.
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Education: A Bridge to Quality. National Academy
Press; 2003.
12. Formicola, AJ et al Interprofessional Education in
U.S. and Canadian Dental Schools: An ADEA Team
Study Group Report. J Dent Educ Sept. 2012.
13. Interprofessional Education Collaborative Expert
Panel. Core Competencies for Interprofessional
Collaborative Practice: Report of an Expert Panel.
Interprofessional Education Collaborative. 2011.
https://www.aacom.org/docs/default-
source/insideome/ccrpt05-10-11.pdf.
14. Beemsterboer PL: Competency in allied dental
education, J Dent Educ 11:19, 1994.
15. Commission on Dental Accreditation (CODA).
Accreditation Standards for Dental Hygiene
yg
Education Programs. 2022.
https://legacy.ada.org/en/coda/current-accreditation-
standards.
16. Chambers DW. Toward a competency-based
curriculum. J Dent Educ. 1993;57:790.
17. Chi MT, Glaser R, Farr M, The Nature of Expertise.
Lawrence Erlbaum; 1988.
18. American Dental Hygienists’ Association. Standards
for Clinical Dental Hygiene Practice. 2016.
CHAPTER
3
Ethical Theory and Philosophy
Phyllis L. Beemsterboer and David Ozar
Chapter Outline
Moral Development 27
Theories of Cognitive Moral Development 28
One View: Male Justice Orientation 28
An Alternate View: Female Ethic of Care 29
Cognitive Development Theory 30
Character 30
Overview of Ethical Theories 31
Consequentialism, or Utilitarian Ethics 31
Deontology, or Nonconsequentialism 32
Virtue Ethics 33
Summary 34
LEARNING OUTCOMES
• Explain the main components of moral growth.
• Describe the theories of moral development and the role of
cognitive growth.
• Discuss the character and the contribution of character
development to ethical conduct for the healthcare provider.
• Compare the three theories of ethical thinking, and give
examples of each from oral health care.
The dental hygienist will be faced with numerous professional

and personal problems in everyday life. Many of these problems
arise in the kind of familiar situations in which we easily determine
what we ought to do, but determining what is the ethical action in
other situations takes careful reflection. For both types of situations,
an introduction to the foundation of ethical theory is important to
guide ethical decision making as well as to assist in understanding
the process by which such decisions are made. Ethical decision
making is behavior, and as a behavior, it is something that can be
done well or done poorly and something that can be taught and
learned. Thus, this chapter begins with an overview of moral
development and then examines three broad approaches from
moral philosophy that should enhance the understanding of how
ethical theory lays the foundation for ethical decision making.
Chapter 4 builds on ethical theory by introducing conceptual tools
that can be applied in real-life situations.
Moral Development
How do individuals become moral? Are we born moral, or do we
learn to be moral? If morality is something that must be learned, how
is it learned? Do all persons learn morality at the same rate and to
the same degree? If human beings are born capable of becoming
moral and therefore must learn to be moral, how do individuals
learn to differentiate right from wrong, and how do they
incorporate this skill in life?
A number of authors have focused on moral development as a
process. Just as each individual develops physically and
intellectually, moral development also has been shown to typically
occur in progressive steps or stages. Some researchers have related
age, maturation of components of personality, and increased
experience with moral development, whereas others have stressed
that moral development has a cognitive component as well. That is
why differentiating right from wrong, which is a cognitive matter, is
different from incorporating right and wrong into life—that is, into
moral development overall. The examples of saints and heroes,
including highly admirable members of one’s own profession, as
well as moral growth by ordinary people every day, can give clues
about the causes or mechanisms of moral development. Since
psychological research on moral development is a fairly new field,
from a scientific point of view much of what is involved remains
unclear.
What has become clear is that a strong relationship exists between
education and the development of moral judgment, which is the
cognitive aspect of moral development. One of the strongest and
most consistent correlates with the development of moral judgment,
even stronger than chronologic age, is years of formal education.1,2
For many people, moral development continues as long as the
person is in a formal education environment, but then it plateaus
upon leaving school. This provides an important lesson: If you want
to keep growing as a moral human being, keep learning, though not
necessarily in school. Instead, never stop observing and reflecting
on what is going on around you and people’s reasons for their
actions. Keep asking questions, read and discuss with others to keep
your learning vital, and above all do so in aspects of your life in
which moral matters are at stake. Professional life obviously is one
of those aspects.
Various educational programs and interventions have been used
to facilitate the development of moral judgment by providing
enriched and stimulating educational experiences. A review of
moral education programs revealed that almost half were effective
in promoting moral development, especially if the program lasted
longer than a few weeks and involved the participants in
discussions of controversial moral dilemmas.3 Adults also seemed
to gain more from such programs than did younger children, most
likely because a wider range of life experiences typically enriches a
person’s awareness of the moral aspects of situations.
These findings have implications for persons preparing for a
career in dental hygiene because they emphasize several things
about learning to make moral decisions. First, findings suggest that
the capacity for moral judgment is not as rigid as some have argued
—that is, neither a person’s cognitive moral development nor their
ability to employ what they understand in actual decisions is frozen
at some specified age. Rather, individuals can continue to learn, and
research has supported the idea that adults make greater gains than
children. Second, individuals who are still in formal education
programs will likely benefit from advanced training, especially
when expected to exercise their ethical decision-making ability by
considering a variety of dental hygiene case scenarios. Third, these
findings suggest that participation in continuing education courses
after graduation may reinforce an individual’s ability to make
sound ethical judgments and also have a positive impact on the
person’s commitment to practicing in an ethical manner.
Devil and Angel balancing. From: https://www.istockphoto.com.
Theories of Cognitive Moral

Development
One View: Male Justice Orientation
Psychologists have done some of the most important work in
developing our knowledge about moral development and how it
influences our actions in adulthood. Two of the most famous
developmental psychologists, Piaget4 and Kohlberg,5 categorized
stages in the moral development of male children. Piaget and
Kohlberg both stated that moral development is sequential and
depends on an individual’s level of cognitive development. Piaget’s4
model consisted of four stages (Table 3.1), whereas Kohlberg5
defined moral development according to both levels and stages
(Table 3.2).
Table 3.1
Piaget’s Four-Stage Model of Moral Development

S Characteristics of Moral Development
t
a
g
e
1 Amoral stage (ages 0 to 2 years)
2 Egocentric stage (ages 2 to 7 years); bends rules and reacts
to environment instinctively
3 Heteronomous stage (ages 7 to 12 years); accepts the
moral authority of others
4 Autonomous stage (ages 12 and older); a morality of self
based on cooperation; rules tested and become
internalized
Table 3.2
Kohlberg’s Three-Level Model of Moral Development

L Level of Reasoning Stage
e
v
e
l
e
v
e
l
1 Preconventional reasoning (stages 1 and 2), Stage 1:
in which externally established rules punish
determine right and wrong action ment
and
obedien
ce
orientati
on
Stage 2:
instrum
ental
relativis
t
orientat
ion
2 Conventional reasoning (stages 3 and 4), in Stage 3:
which expectations of family and groups are interper
maintained and where loyalty and sonal
conformity are considered important concord
ance
orientati
on
Stage 4:
law and
order
orientat
ion
e
v
e
l
3 Postconventional or principled (stages 5 and Stage 5:
6), in which the person autonomously social
examines and defines moral values with contract
decisions of conscience dictating the right legalistic
action orientati
on
Stage 6:
univers
al
ethical
principl
e
orientat
ion
Each stage in the process of cognitive moral development involves

judgment skills that are more complex, comprehensive, and
differentiated from the preceding stage. The process also is
sequential, with an individual moving from simple to more complex
stages. Kohlberg’s stages follow the Piagetian view that justice is the
core of morality; however, because this was first demonstrated
empirically only in male subjects, it is important not to generalize
more broadly at this point. Kohlberg’s theory focuses primarily on
cognitive processes, which is consistent with his belief that
understanding guides behavior. He asserts the moral superiority of
his stage 6, where what he considers to be genuine moral judgments
are made and where genuine moral judgments are defined as
judgments about the good and right of actions based on objective,
impersonal, or ideal grounds.6 Thus, cognitive moral development
for Kohlberg is a progression toward increasingly valid or universal
moral thought. There are other accounts of genuine moral
judgments besides Kohlberg’s, however, so the healthcare provider
should consider what more there is to cognitive moral development
than Kohlberg has discussed and what else besides the cognitive
aspects goes into moral development more broadly.
An Alternate View: Female Ethic of Care

Among the criticisms of Kohlberg’s work is the challenge that his
model reflects a male-oriented perspective of morality. Gilligan,7 in
her classic book In a Different Voice, states that women tend to see
morality in the context of a relationship she calls the ethic of care. She
proposes that feminine moral reasoning is typically different from
masculine moral reasoning. To survive evolutionarily and
practically, female individuals have had to develop a sense of
responsibility based on the universal principle of caring, which
Gilligan sees as quite different from universal justice. Like
Kohlberg’s model, Gilligan’s model also has three levels (Table 3.3);
unlike Kohlberg’s model, Gilligan includes noncognitive growth in
her model of moral development.
Table 3.3
Gilligan’s Model of Moral Development

L Care Orientation
e
v
e
l
L Care Orientation
e
v
e
l
1 Orientation to individual survival and being moral is
surviving by being submissive to society
2 Goodness as self-sacrifice, in which being moral is first
not hurting others with no thought of hurt to self
3 Morality of nonviolence; avoiding hurt becomes the
moral guide governing all moral reasoning
Gilligan believes that complete moral development occurs in the

context of two moral orientations—a male justice orientation and a
female ethic of care—and, therefore, that Kohlberg’s measurement
of moral development only in a justice-oriented scoring system is
biased toward the male. Gilligan’s work, which focuses on sex
differences within the study of moral judgment development, has
received much interest and support.8 As a much-oversimplified
example of her model, the male healthcare provider, when
discovering a case of suspected child abuse, would acknowledge his
duty to report, would report the suspicious case, and would move
on. For the female healthcare provider, however, even if her actions
turned out to be identical to those of the male, the basis of those
actions being ethically required would be different; the duty to
report—and her actually reporting if she determines this is her most
important duty—is derived from the relationships surrounding the
child and the need to protect the interests of the child. One reason
for this difference in Gilligan’s theory of moral development is that
it is based on the way girls are raised. The care orientation is a
parallel path of moral development and perhaps one that will
provide further insight into justice orientation. In any case, in
Gilligan’s description of moral development, both perspectives are
accepted as crucial to the understanding of moral development.
Cognitive Development Theory

The basic tenet of cognitive development theory is that people
operate on their experiences to make sense of them, and those
experiences, as we make sense of them, in turn, change the basic
conceptual structures by which we construct meanings. Researchers
studying the relationship between moral judgment and behavior
can see that many factors determine behavior. For example, studies
link moral perception with actual, real-life behavior as well as moral
judgment. In addition, the literature suggests that students pursuing
professional education are “in an important formative period of
ethical development and that formal schooling is a powerful catalyst
to ethical development,”9 as is the motivation to become an excellent
member of the profession. Rest10 and his coworkers have explained
this by saying that people who develop moral judgment are those
who love to learn, seek challenges, are reflective, set goals, take
risks, and profit from stimulating and challenging environments.
These are characteristics frequently found in professional students
who are working hard to become excellent professionals.
Character
The issue of character in an individual and the process of character
education are topics that have gained significant attention in recent
years, primarily because of a perceived lack of emphasis on
character development in today’s society. Character usually is
defined as qualities or dispositions that are consistently practiced.
The term comes from a Greek term meaning “a constellation of
strengths and weaknesses that form the person.” Many times when
we act “without having to think about it,” our actions are the
product of the habits of perception, valuing, and judgment (some of
them excellent, some of them less so) that make up our character.
Some colleges and several philanthropic foundations have
established character development or a character focus as their
mission. These groups aim to improve the ethical quality of society
by teaching principled reasoning and ethical decision making.
Programs are targeted at children in schools, legislators, lawyers,
journalists, and leaders in the corporate, public, and nonprofit
sectors. One example is the Jubilee Center at the University of
Birmingham in England. Another example is the Templeton
Foundation, in Radnor, Pennsylvania, which sponsors character
education programs. All these efforts are grounded in the belief that
positive traits of character can be forged through educational
experiences, whether in elementary or high school or professional
school. They also presume that character can be shaped and
influenced by a good example at every level of learning.
The reason for mentioning the character here is twofold. First, as
noted, the cognitive aspects of moral development are only part of
the story. Incorporating the skill of differentiating right from wrong
into life is a matter of building habits—habits of carefully
perceiving, carefully judging, and consistently acting in accordance
with one’s moral judgments. One of the best ways to appreciate the
value of a habit is to see how it operates in someone we admire,
which is why living human examples of good habits are so
important to moral development. On the cognitive side (the focus of
this chapter), much can be learned about the different ways in
which moral thinking can be achieved so that one has the
conceptual tools to make well-reasoned moral judgments—an
important first step. In the academic world, examining the different
ways in which moral thinking can be done is called a study of moral
or ethical theory. To keep matters simple, an “ethical” or “moral”
question (compared with a question that has nothing to do with
ethics or morality) is a question in which a person’s well-being or
rights or duties are at issue or at stake. In addition, because the
meanings of “ethical” and “moral” are not carefully distinguished in
a manner that is widely and consistently used, these terms often are
treated as synonyms and used interchangeably.
Sign: “Ethics, Integrity, Respect, Honesty.” From:

https://www.istockphoto.com.
Overview of Ethical Theories

The role of ethical theories is to lay a cognitive foundation for ethical
decision making. A system of moral reasoning or moral thinking is
important because it provides a frame of reference that will help the
individual respond in morally appropriate ways to moral dilemmas.
Although multiple theories have been proposed to explain how
people direct their actions when faced with a moral dilemma, three
broad-based classic views or philosophies of moral reasoning will
be reviewed here; they are known in the academic literature as
consequentialism, deontology or nonconsequentialism, and virtue
ethics.11
Consequentialism, or Utilitarian Ethics

Consequentialist Ethics
An action or rule is right insofar as it produces or leads to the
maximization of good consequences.
Consequentialism refers to the kind of moral thinking that is

predicated on the idea that the rightness or wrongness of any action
is determined and justified by the consequences of the act being
considered, judged in comparison with the consequences of the
other possible acts that might be performed in the situation.
Consequentialist thinking is always comparative because it aims at
maximizing good consequences (and minimizing harmful ones).
Thus, consequentialists consider the consequences of each
important alternative course of action available to them in the
situation before deciding on a right action. Thinking morally in this
way means considering all relevant consequences (potential
outcomes) of potential actions in the situation; identifying and
evaluating them in terms of benefit and harm in order to determine
the action(s) that, compared with the alternatives, yield the best
outcomes; and doing so before making a choice about which action
to take. For example, a dental hygienist may observe that his/her
employer routinely leaves overhangs on restored teeth. Because
overhangs may negatively affect the patient’s periodontal health, the
hygienist must determine what, if any, action to take and begins by
identifying her alternatives and examining the benefit or harm that
will most likely result from each one. First, the hygienist could take
no action. One consequence of inaction might result in some
patients developing severe periodontal disease and/or losing teeth.
Second, the hygienist could remove the overhangs. One
consequence of this action would be enhanced oral health for the
patient. However, in some states removal of overhangs may be
illegal for a hygienist, and doing so could put a professional
reputation in jeopardy or make employer communication difficult.
Third, the hygienist could discuss with the employer the fact that
overhangs are frequently present. The consequences could be that
the dentist would restore teeth more carefully. However, another
consequence might be that the dentist simply tells the hygienist to
just do her job. If the hygienist persists, the employer may decide to
terminate employment. All these are consequences to consider
because they are important alternatives for the dental hygienist in
this situation. However, notice that the consequential reasoning
approach would require the hygienist to do what is the best action
for good even when it might not be in the hygienist’s own best
interest. Being ethical is not always easy, and most versions of
consequentialism stress that in good moral reasoning the effects of
the alternative actions for everyone affected, not just oneself, must
be taken into account.
John Stuart Mill was one of the most famous proponents of
utilitarianism, a version of the consequentialist approach to moral
decision making, who stressed that in consequentialist reasoning,
every person affected by an action should be considered.11 Mill
often is described as saying that an action should be judged to be
moral on its capacity to provide the greatest good for the largest
number of people. However, his teacher Bentham said that, not Mill,
and Bentham himself eventually repudiated the phrase because it
misled people into thinking that, for a utilitarian, whatever
benefitted the majority was the right thing to do. Both men did teach
that the moral action is the one (of the alternative actions available)
that maximizes good and minimizes harm when the consequences
for every affected person are considered. Obviously, one place
where utilitarian reasoning might be appropriate is when ethical
matters must be decided (e.g., by a legislator or officer of
government) that affect large social systems, a community, or even a
nation. A public health dentist or a hygienist with a master’s degree
in public health would be more likely to use this approach in public
health thinking than would others. Thus, one of the best examples
of utilitarianism in dentistry is the application of fluoride to
community water systems. The consequence was a benefit through
caries reduction, provided at a relatively low cost, and available to
all members of a community regardless of social status or income,
and with almost no possibility of causing harm. The alternative,
going on without fluoride, was a situation in which many people
would have had many more carious lesions and other dental
problems because their oral hygiene was typically not dependable
enough to prevent these harms.
Deontology, or Nonconsequentialism
Nonconsequentialist Ethics
An action is right when it conforms to a principle or rule of
conduct that meets a requirement of some overriding duty.
The expression deontological ethics is derived from the Greek word

deon, meaning “duty.” Deontologists state that some actions are
required by the rightness or wrongness of the action, regardless of
the consequences of the action. Whereas consequentialists focus on
the consequences of an act, deontologists argue that some acts are
right or wrong independent of their consequences (thus the term
nonconsequentialism). Some acts are right because they have a direct
relation to some overriding duty, or they are wrong because they
directly violate some overriding duty, but not because of
consequences. For example, a deontologist might believe that a
healthcare provider, as a moral person, has a duty to tell the truth in
all circumstances and therefore has a specific duty to tell the truth to
patients. With this view, a professional’s duty to tell the truth to a
patient is not founded on the consequences of telling the patient the
truth, but on the belief either that an absolute duty exists never to lie
or that the patient is entitled by reason of a fundamental right to
receive the truth. According to deontology, then, moral standards
exist independently of the particular circumstances of an action and
do not depend on consequences. Duty and the relation of a person’s
actions to duty are the only relevant considerations.
Immanuel Kant12 is credited for establishing one of the most
detailed nonconsequentialist or deontological theories of ethical
thinking. Kant held that the test of any rule of conduct is whether it
can be a duty for all human beings to act on—what he called a
universal law. That test is, for Kant, what tells us whether an action is
directly related to an overriding duty. Kant also stressed that all
human beings (as adults) are free, are worthy of respect, and are
their own choosers of their purposes and actions. Many
deontological theories of human rights have been built by later
thinkers on this basis.12 This school of thought has had a significant
effect on biomedical ethics. It places primacy on the right of the
individual to act autonomously—that is, to make his or her own
decisions on the basis of his or her own values, goals, principles,
and ideals. Autonomy as an important principle of healthcare ethics
is further explored in Chapter 4.
Kant’s test for correct moral reasoning was called the categorical
imperative, which means a rule or standard of conduct that is
absolutely binding for all human beings under all circumstances in
which the rule or standard applies. Kant held that some of the moral
rules we are familiar with (e.g., Do not lie) have this character of
overriding duty. Most of the rules with this character are negative,
in that they tell a person what not to do—for example, one must not
lie, cheat, or steal. Borrowing an old Latin word, perfectum, which
means “binding unconditionally,” Kant categorized the negative
rules having this character as “perfect duties.” Perfect duties are
always binding. Kant also talked about “imperfect duties,” which
refer to moral obligations to act in certain ways during our lives but
leave it to each person to judge when and in what situation to fulfill
the obligation (imperfect here meaning “conditionally binding”—that
is, depending on the actor’s judgment to determine when to fulfill
the obligation). Thus, a perfect duty requires one not to kill an
innocent human being. The prohibition against murder is binding
because it is right and directly connected to an overriding duty, not
because of the consequences. An example of an imperfect duty is an
obligation to help another person in need or to be compassionate.
We all have an overriding duty to pay attention to people’s needs,
but we are not obligated to try to meet them in every situation in
which someone is in need. It is a matter of moral judgment that a
person must carefully make to determine for whom and in which
situations to fulfill this duty.12
Sometimes Kant’s categorical imperative is compared with the
golden rule, which cautions individuals to “Do unto others as you
would have others do unto you.” As Kant stated it, “Act that you
can will the maxim of your action to be a universal law binding
upon the will of every other rationale person.”12
An example of the deontological approach as it applies to dental
hygiene is that a hygienist has a duty to maintain patient
confidentiality in the provision of oral health care for his or her
patient. Other than sharing information appropriately with other
healthcare providers, information acquired while providing patient
care must remain private unless the patient’s express permission has
been granted. If an adult patient’s relative or a representative of a
finance company asks questions regarding the patient, for example,
confidentiality must be maintained. It is right because respect for
others’ autonomy is an overriding duty, and a patient’s revelation of
personal information to the hygienist for purposes of oral health
care does not include permission to use it for any other purpose. If
this philosophy were strictly held in health care, public health
reporting of communicable diseases would seem to not be
permitted. However, Kant expanded his moral theory to cover
societal rules in ways that could make such reporting morally
acceptable if one could reasonably argue that any rational person
would want such information communicated to avoid harm to
others. Just as consequentialist thinking can get quite complex when
many alternative actions must be compared, when consequences are
hard to predict, and when different kinds of benefits and harms
affect different persons as a consequence of an action, so
deontological thinking—though it may appear simple at the start—
can be complex when trying to determine what social standards
could reasonably be willed by rational people to be universal
standards to live by. No moral philosopher has ever claimed that
moral thinking is like solving a simple equation in mathematics.
One reason theories have been offered is to help us understand how
complex making good moral decisions can be, and then to try to
help us think about them more clearly.
Virtue Ethics
Virtue Ethics
Character or virtue and the goodness of the person in living a
good life is acquired by a person through learning and reflection
and repetition (based on the Greek traditions of Plato and
Aristotle).
Character, or virtue, refers to stable patterns of perceiving,

thinking, and acting rightly. A person cannot stop and carefully
weigh possible actions in terms of ethical standards hundreds of
times a day even though hundreds of opportunities for action each
day are ethically significant. Therefore, most of our actions are the
product of our character, or the stable patterns perceiving, thinking,
and acting that are part of us. If those patterns are perceiving,
thinking, and acting rightly, we call them virtues and we say the
person has a “good character” or is a “good person.” When we
speak of professionalism in any profession, we are talking about
stable patterns of perceiving, thinking, and acting in accord with the
profession’s ethical standards. Character and virtue, therefore, are
central themes in any discussion of ethics for professionals.
Virtue ethics was first articulated as a moral theory in the Greek
tradition of Plato and Aristotle, who emphasized that the cultivation
of virtuous traits of character is the primary function of morality.
Aristotle wrote that virtue is a stable state of character and is the
result of practice—that virtue is something acquired by a person
through learning, reflection, and repetition. When trying to describe
the virtues of good persons, he looked for a balance between
intellect and commitment in action (just as moral development is
understood today to involve both cognitive and noncognitive
components). He also stressed that the person who is virtuous has
developed the ability to perceive, judge, and act rightly as a
dependable habit; the ideal is stability in these patterns so that the
virtuous person would act in a virtuous manner in all situations.
Aristotle also recognized that we are all fallible in achieving this
ideal and stressed the value for each of us to identify role models
whom we can learn from in order to become more virtuous and do
the right thing in each situation more easily and regularly.
Each of the virtues is a habitual disposition to perceive, judge, and
act rightly. Virtue ethics focuses not so much on the rightness or
wrongness of a given act or whether it conforms to duty, but rather
on the goodness of the person who habitually chooses to act in that
way or see such acts as proper responses to duty.13 Rather than
focusing first on consequences or nonconsequentialist factors such
as duty or rights, philosophers of the virtue ethics tradition urge us
to reflect on what kind of person we ought to be (and ought not to be)
and not the ethical characteristics of the acts we ought to do. A
dental hygienist could treat a hostile and unhappy patient with
extra kindness and caring to maximize good and reduce harm or
because he/she considers it her duty. But in the rush of daily
professional life, a dental hygienist will more likely do this in order
to be a good professional and a good caring person. When this is the
ethical perspective, they clearly are striving to be virtuous and is
doing day-in/day-out ethical thinking according to the virtue ethics
approach.
Thus, virtue ethicists believe that individuals make most of their
choices on the basis of virtue and character. The focus is on the
character of the person. If a person has good character, that person
will make choices that produce good. In an ideal world, of course,
all people would be of good character and would make good
choices easily and habitually in every situation. However, we know
that few, if any, of us have completely arrived at that point. Even if,
speaking ideally, all people of good character have good ethical
decision-making abilities, in the real world we have to work to
develop these abilities first and then make them into habitual
patterns of perceiving, judging, and acting in our lives.14
Summary
Rarely does a person embrace one ethical philosophy exclusively.
More than likely an individual is influenced by more than one
ethical system as well as by a number of other factors, including
religion, culture, and environment. However, knowledge of these
philosophical frameworks for ethical thinking helps healthcare
providers understand their professional commitments more clearly
and understand their patients and coworkers better, as well as their
own personal philosophy while dealing with problems and
dilemmas in the delivery of health care. The profession of dental
hygiene needs people of good character who can, as a result of
education, experience, and careful reflection, acquire more skills in
making ethical decisions and acting according to them.
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7. Gilligan C: In a different voice, Cambridge, Mass,
1982, Harvard University Press.
8. Nokes KM: Rethinking moral reasoning theory, J Nur
Scholar 21:172, 1989.
9. Rest JR. Can ethics be taught in professional schools?
The psychological research. Easier said than done
[newsletter]. Josephson Institute; 1988:22–26.
10. Rest JR. Moral Development: Advances in Research
and Theory. Praeger; 1986:57.
11. Beauchamp TL, Childress JF: Principles of biomedical
ethics, ed 6, New York, 2008, Oxford University Press.
12. Kant I [ Beck LW, trans]: Critique of practical reason,
Indianapolis, 1956, Bobbs-Merrill and Kant I,
Metaphysics of morals. Translated by TK Abbott. 2013.
13. Ozar DT, Patthoff DE, Sokol DJ. Dental Ethics at
Chairside: Professional Principles and Practical
Applications. 3rd ed. Georgetown University Press;
2018.
14. Beemsterboer PL, Chiodo, GC. The foundation of
integrity. Dimensions of Dent Hygiene. 2014;12(1):52–
52, 57–58.
https://dimensionsofdentalhygiene.com/article/the-
foundation-of-integrity.
CHAPTER
4
Ethical Principles and Values
Chapter Outline
Ethical Dilemmas 37
A Principle 38
Principle of Nonmaleficence 38
Application of Nonmaleficence 39
Principle of Beneficence 39
Application of Beneficence 40
Principle of Autonomy 40
Application of Autonomy 40
Principle of Justice 40
Application of Justice 41
Values and Concepts 42
Paternalism 42
Application of Paternalism 42
Veracity 43
Application of Veracity 43
Informed Consent 43
Application of Informed Consent 44
Capacity 45
Confidentiality 45
Application of Confidentiality 46
Applying Principles and Values 46
Prima Facie Duties 46
Summary 46
Learning Outcomes
• Identify the four fundamental ethical principles.
• Define the terms autonomy, confidentiality, societal trust,
nonmaleficence, beneficence, justice, and fidelity.
• Describe the difference between a choice and an ethical
dilemma.
• Explain the role of principles in the decision-making process
of the dental hygienist.
• Identify the components of informed consent.
• Discuss the three types of informed consent.
• Compare the values and ethical concepts that support the
principles of ethics.
Ethical principles guide the conduct of healthcare providers by

helping to identify, clarify, and justify moral choices. Principles
help address this moral question: What should I do in the situation
I now face? More specifically, what is good, right, or proper for a
person to do in this situation? Normative ethics seeks to classify
actions as either right or wrong and provide a set of norms for
action by developing rules that govern human conduct. Normative
principles provide a cognitive framework for analyzing moral
questions and problems. These principles are linked to commonly
expected behaviors because they are based on shared standards of
thinking and behaving. In health care, the main normative
principles are nonmaleficence, beneficence, autonomy, and justice.
These principles are associated with expectations for behavior, and
they provide guidelines for dealing with right and wrong actions.
These principles provide direction about what should and should
not be done in specific situations.
Ethical Dilemmas
A difference exists between addressing everyday problems and
addressing ethical dilemmas. An ethical dilemma occurs when one
or more ethical principles are in conflict. An example of a true
ethical dilemma is one in which the principle of nonmaleficence is
in conflict with the principle of autonomy in a specific situation.
Such a dilemma might occur, for example, when a patient who has
undergone heart valve replacement and who requires antibiotic
premedication tells the dental hygienist he does not want to take
any antibiotics and urges the dental hygienist to go ahead with
crown and root debridement. The patient is expressing his
autonomy by stating he does not wish to take antibiotic
premedication. The dental hygienist, however, has taken an oath to
do no harm (nonmaleficence). This is a genuine ethical dilemma
because two ethical principles (patient autonomy and
nonmaleficence) are in conflict. Resolving an ethical dilemma is
certainly a very different enterprise from solving daily problems,
such as which gloves to purchase or which instrument to choose for
debridement. It also is different from a situation in which a dentist
is knowingly and intentionally charging an insurance company for
procedures not performed. That action clearly involves unethical
and unlawful behavior, but it is not a true ethical dilemma because
principles are not in conflict: The dentist is wrong and committing
fraud. A discussion of which ethical principle takes precedence
over another is not necessary. The dentist’s behavior is wrong,
unjust, and unlawful.
In a perfect world, the needs and wants of the patient would
always come first, and no conflicts, disputes, or dilemmas would
exist for the dental hygienist or any healthcare provider to resolve.
However, that is not the case in the real world, where what is in the
patient’s best interest may be open to question depending on whose
perspective—that of the clinician, the patient, the patient’s family,
or other healthcare professionals—is being considered. Principles,
values, and rules in health care will help guide decision making in
the process of providing the best dental health care for the patient.
Weighing and balancing ethical principles are the major tasks
involved in ethical decision making. Chapter 6 discusses ethical
decision making in-depth.
A Principle
A principle is a general normative standard of conduct, holding
that a particular decision or action is true or right or good for all
people at all times and in all places. Principles derive from common
morality in and the traditions of health care, specifically from some
of the role obligations of practicing medical clinicians. Four
fundamental principles—nonmaleficence, beneficence, autonomy,
and justice—provide the comprehensive norms used in biomedical
ethical framework analysis.1
Principle of Nonmaleficence
The founding principle of all health professions is nonmaleficence.
This principle declares that a healthcare provider’s first obligation
to the patient is to do no harm (in Latin, primum non-nocere).
Patients place themselves in the care of another person and, at a
minimum, should expect that no undo harm will result from that
act. The patient grants a provider the privilege of access to a portion
of his or her body for an explicit purpose, a privilege founded in
trust. Fundamental to that trust is that the healthcare provider will
do no harm to the patient. This societal trust patients extend to
those in health care is based upon the behavior and actions of the
providers and must be valued and respected.
The Hippocratic Oath requires the healthcare provider to promise
to keep the sick from harm and injustice. In reference to
nonmaleficence, the American Dental Association’s (ADA)
publication Principles of Ethics and Code of Professional Conduct states
that “the principle expresses the concept that professionals have a
duty to protect the patient from harm.” Under this principle, the
dentist’s primary obligations include keeping knowledge and skills
current, knowing one’s own limitations and when to refer to a
specialist or other professional, and knowing when and under what
circumstances delegation of patient care to auxiliaries is
appropriate.2 For example, practitioners are required to maintain
their level of knowledge and skill through participation in
appropriate continuing education programs. Thus, a dentist who
has not performed an endodontic procedure since graduation from
dental school 25 years ago would be expected to refer patients to a
colleague for root canal therapy. Likewise, a dental hygienist also
has an obligation to stay up to date with the changing standards of
care in the profession. A dental hygienist who is unfamiliar with
the use of lasers in periodontal procedures or administering local
anesthesia should defer performing that service until competency is
achieved.
Although nonmaleficence primarily is concerned with doing no
harm, over time it has evolved to include preventing and removing
harm. (Think back to the discussion of risk management in Chapter
1.) Therefore, healthcare providers have an obligation to do no
harm as well as to prevent harm. Prevention of harm clearly is a
domain of dental hygienists. Dental hygienists are concerned with
preventing harm when standard precautions are observed when
crown and root debridement are performed to preserve teeth and
manage periodontal tissues, and when educating patients in home
health care. Similarly, dental hygienists mitigate harm when they
treat patients who have active periodontal disease.
Application of Nonmaleficence
Does prevention of harm mean all possible harm? Harm is defined
as physical or mental damage or injury.3 A narrow interpretation of
this principle would hold that complete avoidance of any physical
or mental pain in patient care must be maintained. A such strict
interpretation would mean that invasive diagnostic tests to locate
disease, as well as intraoral anesthetic injections to allow crown and
root debridement, could never be performed. Consequently,
patients could never benefit from treatment that would alleviate
current pain, and they could not benefit from the prevention of
future pain and suffering. This would seem to be an unrealistic
application of nonmaleficence. The fact is that a healthcare provider
may not always be able to avoid harm and cause some degree of
harm when that harm will lead to a greater good—restoring a
patient to health—may be desirable as well as necessary. This
conflict is referred to as the principle of double effect, and it requires
the healthcare provider to consider the risks and benefits whenever
treatment is provided.1 What comprises harm and good can be
delineated using the following classification system1,4:
1. One ought not to inflict harm.

2. One ought to prevent harm.
3. One ought to remove harm.
4. One ought to do or promote good.
The first entry refers to avoidance of harm (nonmaleficence),

which takes precedence over the second, third, and fourth entries,
which define beneficence, or the promotion of good. This hierarchy
of nonmaleficence and beneficence provides the clinician with a
guideline to follow in working through dilemmas in practice. Not
inflicting harm takes precedence over preventing harm, and
removing harm is a higher priority than promoting good. Ideally,
the dental hygienist would be able to implement all four parts of
this hierarchical relationship; however, when faced with constraints
and conflict, prioritization would be necessary. Avoiding harm and
promoting good in the practice of dental hygiene and dentistry are
not always possible.
Principle of Beneficence
Nonmaleficence is concerned with doing no harm to a patient,
whereas beneficence requires that existing harm be removed.
Beneficence focuses on “doing good” for the patient. Doing good
goes beyond doing no harm as it requires taking all appropriate
actions to restore patients to good health. Healthcare providers use
all reasonable means, based on their knowledge and skill, to benefit
the patient. Dentists and dental hygienists have acquired a body of
knowledge and corresponding skills that make them uniquely
qualified to assess patient needs, recommend actions, and provide
treatment to address those needs. These unique qualifications allow
them to benefit the patient by removing existing harm and assisting
in the prevention of future harm.
Beneficence and nonmaleficence often are linked because they are
both founded in the Hippocratic tradition, which requires the
physician to do what will best benefit the patient. This is a
consequentialist approach. Meeting the requirement to do what the
physician believes will best benefit the patient implies the need to
conduct a consequence analysis to determine the best possible
outcome for the patient.
Beneficence is found in all healthcare codes. By choosing to
become a dental hygienist, an individual assumes a responsibility
to help others and professes to be part of a profession. This means
that the dental hygienist’s actions, behaviors, and attitudes must be
consistent with a commitment to public service, which is a
commitment to benefit others. This commitment to help and benefit
others morally defines the healing professions and sets them apart
from nonhealth-related occupations, such as architecture or
engineering.5
Application of Beneficence
For dental hygienists, whose primary focus is preventing oral
diseases, promoting good is a daily purpose and goal. Indeed, for
any person who is in a position to promote good for the benefit of
others, as healthcare providers are, failure to increase the good of
others is morally wrong. The purpose and existence of biomedical
research, public health policies and programs, and preventive
medicine are the formalized aspects of this part of health care.
Through various federal, state, and community-based activities,
society attempts to meet this need for the good of the public. The
promotion of good becomes difficult, however, when good is
defined according to differing values and belief systems. The
teaching of careful oral hygiene self-care to maintain health and
function is an example of promotion of good to many people.
However, the removal of all carious teeth to eliminate pain and
suffering may be considered promoting good to other individuals.
In public health programs, the appropriation of limited resources to
meet the medical and dental needs of a given population can be a
challenging and frustrating exercise but also part of being a
healthcare professional who advocates for the betterment of society.
Principle of Autonomy
Autonomy is self-determination and the ability to be self-governing
and self-directing. An autonomous person chooses thoughts and
actions relevant to his or her needs, independent from the will of
others. In health care, autonomy gives rise to the concept of
permitting individuals to make decisions about their own health,
which is the heart of many ethical dilemmas that occur in
dentistry.6 When weighed against competing principles, autonomy
may be overridden. It also does not extend to persons who lack the
capacity to act autonomously, such as children and those with
certain intellectual and developmental disabilities (IDDs),
neurological disabilities, or mental illnesses.7 All healthcare
providers must respect the autonomy of patients and properly
inform them about all aspects of the diagnosis, prognosis, and care
being provided. Because dental hygienists have a wide range of
knowledge and skills, they must fully and adequately explain the
parameters of the services that can be performed, as well as the
consequences of performing or not performing those services.
Application of Autonomy
The application of autonomy is founded in deontology and is based
on respect for persons. Essentially, deontology expounds that lying
is always wrong because if everyone lied then human
communications would break down entirely.3 The deontologist
holds that the healthcare provider has a duty to allow patients to
make decisions about actions that will affect their bodies. The
healthcare provider also has a duty to provide patients with all the
unbiased information they would need to make a decision about
treatment options. This is an area in which potential for conflict
exists between what the provider believes is in the best interest of
the patient and what the patient believes is in his or her best
interest. Sometimes what the provider believes is best for the
patient is not what the patient elects to do. As long as the patient
selects treatment options that are consistent with accepted
standards of care, the professional may ethically act on the patient’s
choice. However, the professional practitioner also has the
autonomy to not provide a service requested by the patient if that
service is in conflict with the standards of patient care. Referring
back to the ethical dilemma presented earlier in this chapter,
refusing a patient’s request to proceed with crown and root
debridement without him taking the required antibiotic
premedication would be ethical even though that decision would
conflict with the patient’s autonomy. Dentists and hygienists must
avoid doing harm to a patient even if the patient is exercising
autonomy by asking to receive a potentially harmful treatment or
service. The provider’s obligation to adhere to the principles of
nonmaleficence and beneficence overrides the patient’s right to
autonomy. Additionally, refusing a patient’s request to provide
services not aligned with the standards of care protects the provider
from possible liability and litigation should harm come to the
patient.
Principle of Justice
The principle of justice is generally interpreted as fair, equitable,
and appropriate treatment of persons.7 Nonconsequentialists view
justice as a duty for healthcare providers. The most fundamental
principle of justice was defined by the Greek philosopher Aristotle:
Equals should be treated equally and unequals unequally.8 This
means that individuals should be treated the same unless the ways
in which they differ is relevant to the situation at hand. For
example, if a man and woman are doing the same job and no
relevant differences exist between the work they perform and
deliver, then it is just to pay them the same wages. If the man is
paid more than the woman simply because he is a man, this is
unjust as it constitutes discrimination.8 Providing special treatment
based upon race, sex, age, religious beliefs, or socioeconomic status
is considered unjust.
There are many categories of justice, and the one most applicable
to bioethics and most often discussed in terms of public policy
issues is referred to as distributive justice. It is believed by many
ethicists that the conflicts of interest that arise when resources are
scarce, and differing opinions exist as to how those resources
should be allocated have created the need for society to have
reasonable policies to determine what people deserve.8 Resources
can include facilities, materials, specially trained individuals,
money, or time. Distributive justice is concerned with the fair and
equitable delivery of healthcare resources determined by societal
norms that support social cooperation.7 Policymakers must
confront the issue of how society distributes its resources. Various
principles of distributive justice can be applied alone or in
combination to form balanced decisions, and some are deemed
justifiable and socially acceptable criteria for not treating people the
same. The following are some valid principles with examples for
distribution to each person7:
• An equal share: Following a natural disaster, everyone in the
community is provided the same quantity of bottles of
drinking water.
• According to need: The government provides benefits to
those who are in need according to the Federal Poverty
Guidelines. If the inclusion criteria are not met, then no
benefits are provided.
• According to effort: The person who wakes up early to be
first in line for tickets to a baseball game between their
favorite team and the team’s rival gets first choice of the best
seats.
• According to merit: Only those who contribute the most to
improving an organization receive a promotion and pay
raise.
Application of Justice
If resources were unlimited, the problem of just allocation would be
minimal. Unfortunately, that is not the reality of the world in which
we live. Choices must be made, benefits and burdens must be
balanced, and resources must be justly distributed. A lofty goal for
most organized societies would be the just application of health
care. However, no legal mandate exists for free medical and dental
care to be available to all persons, and decisions are made daily
according to the ability of the patient to pay for the services
rendered. This means the provision of dental care is applied
unequally. People who present for treatment are, for the most part,
granted access to care based on their economic ability and not their
dental needs. This creates access to care issues.
The question of who should provide dental care when an
individual of low socioeconomic status (SES) is in need of treatment
is difficult to answer. Many dental hygienists and dentists provide
charitable services on a regular basis, either in a private practice
office or through participation in a community-based service event,
because of their recognition of their obligation to serve society.
Unfortunately, although this is a lauded practice, it does not come
close to meeting the needs of those who cannot access dental care.
Many dental public health practitioners and leaders consistently
advocate for the profession to make oral health a much higher
priority for federal and state decision makers.
“Do what is right, not what is easy.” From: https://www.istockphoto.com.
Values and Concepts

Several values and rules support the principles of ethics and add
clarity to attempts to make ethical decisions. Many of the concepts
are related to the discussion of consequentialism and
nonconsequentialism presented in Chapter 3. Remember that an
ethical dilemma occurs when one or more ethical principles are in
conflict. Thus, values and concepts discussed in this section are
founded in ethical principles and the theory upon which those
principles are based. Conflict between or among some of these
values and concepts is to be expected. They do, however, add
clarity to attempts to identify ethical issues and resolve conflicts.
These terms and concepts are paternalism, veracity, informed consent,
capacity, and confidentiality and are rooted in healthcare principles.
Paternalism
Paternalism arises from the Hippocratic tradition and is closely
related to the principles of nonmaleficence and beneficence. It is
defined as an attitude or the assumption of an attitude of superior
authority.3 The Hippocratic approach is based on the healthcare
providers doing what they believe is best for their patients
according to their ability and judgment. After all, who knows more
about oral health prevention and disease than the dentist and
dental hygienist? This approach requires the dentist or dental
hygienist to undertake a role similar to that of a parent. Paternalism
means that the healthcare professional acts as a parent and makes
decisions for the patient on the basis of what the professional
believes is in the best interest of the patient. Paternalism should
never be applied primarily to benefit the professional at the expense
of the patient. In fact, many would argue that paternalism should
never be applied because it subverts the autonomous wishes of the
patient. Therefore, paternalism and autonomy are in conflict. A
provider cannot unilaterally act on behalf of the patient without
denying the patient’s right to exercise autonomy. The concept of
justifiable paternalism may come into play if an individual lacks the
capacity to effectively look after their interests. Some form of
protection is justified or even obligatory when people cannot make
decisions for themselves, suffer incapacitating illnesses, show
involuntary self-destructive behavior, or make choices so
inappropriate to their own established life goals that we doubt their
autonomy.9 An example of this would be the temporary
involuntary inpatient commitment of an individual (assisted
treatment) for psychiatric evaluation. The burden of proof required
to legally disrupt an individual’s liberty and autonomy is
considerable, and courts must be convinced that there is imminent
danger to the individual and/or others.
Application of Paternalism
In general, patients today are well informed about health,
treatments, and their rights as patients and want to participate in
the decision-making process. In years past, however, paternalism
(now commonly called parentalism for gender neutrality) was a
common practice partly because the healthcare provider had
superior knowledge and skills and partly because patients expected
the healthcare provider to make decisions in their best interests.
Patients often had no knowledge that alternative care options were
available. Furthermore, even if patients did know that other options
existed, many placed the professional in a parental role by asking
the professional what they should do. Patients frequently had so
much trust in the provider that they would do whatever was
suggested. Such paternalistic acts were carried out with good
intentions to benefit the patient and often became second nature to
the clinician. The historic benchmark for refuting paternalism was a
political philosophy essay written in the mid-1800s. John Stuart
Mill’s essay remains one of the hallmarks of liberal political theory
and is the basis for the societal presumption that individuals are
free to act as they see fit.10
The responsibility of the dental hygienist is to educate the patient
about the balance of benefits and risks of treatment, which often
creates a conflict between autonomy and beneficence. This aspect of
providing ethical care is most important and requires the dental
hygienist to take the time and effort to ensure that the patient has
all the knowledge required to make health decisions. A dental
hygienist or dentist also can refuse to perform a procedure that he
or she considers to not be in the best interest of the patient. Such a
decision, which is based on the autonomy of the healthcare
provider, often is done in practice. For example, many dentists have
been asked by a patient, and have refused, to remove healthy
dentition merely because the patient believes that taking care of
dentures would be easier than caring for their natural teeth.
Veracity
Veracity is defined as being honest and telling the truth. It is the
basis of the trust relationship established between a patient and a
healthcare provider. Veracity binds the patient and the clinician as
they seek to establish mutual treatment goals. Patients are expected
to be truthful about their medical history, treatment expectations,
and other relevant facts. Clinicians, for their part, must be truthful
and provide full disclosure about the diagnosis, treatment options,
benefits, and disadvantages of each treatment option, cost of
treatment, and the longevity afforded by the various treatment
options. This allows patients to exercise their autonomy to make
decisions in their own best interest and to provide consent for
treatment, which is the key to obtaining informed consent. The
obligation of veracity, based on respect for patients and autonomy,
is acknowledged in most codes of ethics, including the codes of the
American Dental Hygienists’ Association (ADHA) and the
American Dental Association (ADA).
Application of Veracity
Lying to a patient does not respect the autonomy of the patient and
can compromise any future relationships the patient may have with
healthcare providers. Because relationships are built on trust, lying
—even telling little “white lies”—easily erodes trust. Therapeutic
privilege (sometimes called benevolent deception) is the name given
to the practice of withholding information from a patient because of
the clinician’s belief that the information may harm the individual.
For a provider to invoke the therapeutic privilege, the threat to the
patient’s well-being should be so serious that disclosing the truth
would be deemed medically contraindicated. The ethical dilemma
faced by the provider would be that exercising nonmaleficence and
beneficence, to protect the patient from harm and safeguard her or
his well-being, is in conflict with respecting the patient’s autonomy.
Currently, there is no rule in bioethics stating that a patient’s right
to full disclosure of information and autonomy invalidates a
doctor’s duty to exercise sound judgment regarding the protection
of the patient from harm. That being said, therapeutic privilege
should only be used in extraordinary circumstances. Only a rare
case would justify deceit in the dental setting. The interactive
nature of the provider–patient relationship functions most
effectively when both parties are truthful and adhere to all
promises made in the process.
Informed consent. From: https://www.istockphoto.com.
Informed Consent
Informed consent has both ethical and legal implications in
medicine and dentistry and is based on the patient exercising
autonomy in decision making. The components of informed
consent are outlined in Box 4.1. Prior to initiating the process of
obtaining consent, the provider must ensure that the patient
possesses the decision-making capacity to consent to treatment and
is seeking treatment voluntarily, meaning of her or his own free
will and not being subjected to coercion.
Box 4.1
Components of Informed Consent 1
I. Threshold elements (preconditions)

1. Capacity (decision-making ability)
2. Voluntariness (voluntarily present, no coercion)
II. Information elements
1. Disclosure (of all aspects of proposed treatment)
2. Recommendation (of a treatment plan)
3. Understanding (comprehension of 3 and 4)
III. Consent elements
1. Decision (in favor of plan)
2. Authorization (of chosen plan, consent to treatment)
Informed consent is two pronged. First, the information

component involves discussion and full disclosure of all relevant
information needed to make a decision. This discussion should use
language that is easy to understand and discloses to the patient the
diagnosis, description, and purpose of the treatment planned,
benefits and risks of proposed treatment, alternative treatment
options, prognosis of no treatment, costs, and time frame of
treatment, and it should specify the provider of care. Second,
during the consent component, the patient makes a decision on the
basis of the information provided and authorizes the clinician to
proceed.
Several criteria are involved in informed consent, and it is an
ongoing process, meaning that the discussion between provider
and patient continues throughout the length of treatment. The
patient is informed of progress, lack of progress, and treatment
goals met. If any aspect of the treatment agreed upon is going to be
changed, the patient must be informed of the changes and provide
consent to those changes.
Application of Informed Consent

As previously noted in the discussion of autonomy, accepting the
decision of the patient when it is in conflict with what the
healthcare provider would most likely recommend is extremely
difficult for dental professionals. Dentists and dental hygienists
must recognize that the patient has a right to informed consent as
well as a right to make an informed refusal. Autonomy includes the
right for a patient to assess all the information provided by the
professional regarding the proposed treatment and to refuse the
recommendations in part or whole. This is known as informed
refusal. From a risk management standpoint, it is imperative to have
an office policy to ensure that the informed consent process is
carried out for all patients and to obtain a signed refusal-of-
treatment form if a patient declines the recommended
treatment.11,12 As discussed in Chapter 1, the principle of autonomy
cannot supersede the provider’s obedience to the standards of care.
If the patient’s refusal requires the clinician to deviate from the
standards of care, the clinician would risk exposure to liability as
that deviation could constitute negligence and/or malpractice.
When a patient’s values and expectations are in conflict with a
clinician’s legal and ethical duties, the provider must consider
dismissing the patient from the practice. Discontinuation of the
provider–patient relationship is discussed in Chapter 9.
Patients provide their authorization for a comprehensive
treatment plan when they grant the healthcare provider informed
consent for that treatment. There are basically three types of
informed consent:
1. Implied consent: Consent is not formal. Patient passively

cooperates without extensive discussion and is given simply
enough information for a process or procedure to be
understood. This type of consent is considered adequate for
the assessment, diagnosis, and planning components of the
dental hygiene process of care.
2. Verbal consent: Consent in which the patient verbally
consents to a process or procedure but does not provide a
signature on a form. Diagnostic procedures such as exposing
radiographs and routine prophylaxis, use of medicaments
such as topical anesthetic, noninjectable anesthetic, dentinal
desensitizers, and various forms of fluoride are considered
acceptable with verbal consent. These procedures are
documented in the patient record but do not typically require
a patient signature.
3. Written consent: This type of consent is necessary for any
procedures or treatments beyond those listed above. Use of
anesthesia, debridement beyond prophylaxis, and invasive,
irreversible procedures, and surgical procedures would
require written consent with a patient signature.
Not all individuals have the ability to make informed decisions

about their dental health. Children, people who have intellectual
and developmental disabilities, neurologic disabilities, or mental
illness typically have a parent or legal guardian who assumes that
function. Depending on the age and capacity of the child, certain
choices can and should be discussed with the younger patient, but
actual decisions regarding what types of services are rendered must
remain the purview of the legal guardian. When the patient does
not understand because of a language barrier, informed consent is
not possible, and steps must be taken to remedy the situation. The
use of a translator, family member, or other communication option
must be pursued to ensure that the patient fully understands the
choices and consequences. To do any less is unethical and illegal.
The only exception to this would be an emergency when delayed
treatment could put the patient’s life in danger and an immediate
procedure is required to save that life.
Capacity
When discussing the topic of decision-making from a bioethical
standpoint, capacity is the ability of a patient to understand the
benefits and risks of, and the alternatives to, a proposed treatment
or intervention, including no treatment.13 The terms capacity and
competency are often used interchangeably; however, there is a
difference in how each is determined. Capacity is determined by a
healthcare provider regarding an individual’s ability to make an
informed decision. Competency speaks to one’s ability to
participate in legal proceedings and is determined in the courts by a
judge. When evaluating capacity, four key components are usually
assessed: (1) understanding the situation, (2) appreciating the
consequences of one’s decision, (3) reasoning and rationalization in
one’s thought process, and (4) ability to communicate one’s choices
and wishes. A patient’s capacity is assessed informally during all
encounters but may need to be assessed formally if there is an acute
change in cognition and/or mental status. For an individual to give
informed consent, capacity is a prerequisite. This is a growing
concern with an aging population as older adults can exhibit a wide
range of cognitive function and neurologic disabilities. Older
individuals are not only becoming a larger percentage of the
population, but they are also living longer. The US Census Bureau
predicts that one of every five Americans will be 65 years of age or
older by the year 2030.14
Providers may also need to assess the capacity of a patient who
may be under the influence of substances such as illicit as well as
legally obtained alcohol and drugs. Use and misuse of substances
can affect the central nervous system and distort one’s perceptions
of situations and the environment due to the physiologic impact of
these substances. Following the ADHA’s health history criteria
outlined in the Standards of Clinical Dental Hygiene Practice can
help identify potential issues related to substance use and misuse.
These criteria include the assessment of demographic information,
vital signs, physical characteristics, social history, medical history,
and pharmacologic history. It is imperative for providers to engage
in meaningful continuing education regarding the recognition and
management of patients who may be misusing substances to ensure
that they are not exposed to undo liability.
Questioning the patient as to how he or she understands the risks
of treatment or why they are declining treatment are among the
ways to explore the capacity of a patient. Objective assessment
instruments can be utilized to help with this determination and are
routinely used by primary healthcare providers.15 Treating a person
with a cognitive impairment can present a range of ethical
dilemmas.
In the dental setting, ensuring that a patient has capacity may
often require reaching out to the family, primary care physician, or
surrogate decision maker. It is not uncommon for an individual to
have transient or diminished capacity, which is the ability to
express his or her wishes on one day and not the next. Awareness
of the issues of capacity will assist the dental hygienist in providing
ethical and legal oral health treatment to geriatric, and all,
populations.
Confidentiality
Confidentiality is a critical aspect of trust in the provider–patient
relationship and has a long history of use in health care.
Confidentiality is related to the obligation a provider has to keep
safe a patient’s protected health information (PHI) unless consent
has been provided by the patient to release information in a
controlled manner. The patient has a reasonable expectation that
PHI will be kept private. The requirement for confidentiality is
mentioned in all codes of ethics as well as in the Hippocratic Oath.
Trust is necessary for the exchange of personal and intimate
information from the patient to the clinician. A patient has a right to
privacy concerning his or her medical and dental history,
examination findings, discussion of treatment options and
treatment choices, and all records pertaining to dental and dental
hygiene care. This privacy extends to the way in which information
is gathered, stored, and communicated to other healthcare
professionals. Discussion about a patient’s history or treatment is
not to be shared with spouses, family, or friends—to do so is a
violation of confidentiality. Legal requirements regarding the
confidentiality of PHI are discussed in Chapter 1. Information
about a patient can be given to other healthcare professionals with
the patient’s permission. When a case is discussed in an educational
setting or a second opinion is sought, the clinician who first saw the
patient in question should protect the privacy of the patient.
Application of Confidentiality
Conflicts and exceptions will arise surrounding the principle of
confidentiality. There are instances when a provider can legally
breach confidentiality. In certain situations, legal requirements exist
to report diseases that can have an effect on the health of the public,
such as sexually transmitted diseases. Reporting suspected child
maltreatment (abuse and neglect), which is required as dental
hygienists are mandated reporters in most states, is a violation of
confidentiality. In dealing with minor children, divulging
confidential information to the parents may be necessary to protect
the child from harm. This is especially difficult with adolescents,
who may or may not be adults according to the legal system. The
patient’s right to confidentiality often must be balanced against the
rights of other individuals. In any situation, the healthcare provider
must communicate to the patient the professional and legal
responsibilities that exist for disclosure and work toward helping
the patient as much as possible.
Fidelity is the belief that it is right to keep promises, be faithful,
and fulfill commitments. Some philosophers consider this value as
stemming from autonomy and the basic idea of respect for persons.
Others denote it as a framework of confidentiality. For the
healthcare provider, it includes the duty to fulfill all portions of
expressed or implied promises made to the patient, in addition to
holding to contractual agreements, not abandoning the patient
before the completion of treatment, and keeping confidentiality.
Applying Principles and Values

Basic principles guide the dental hygienist and all healthcare
providers in determining what is right and wrong in the practice of
health care. From these principles are derived the rules laid out in
all codes of ethics and codes of professional conduct. How these
principles and codes are applied to decision making is the challenge
for each healthcare provider faced with a professional problem or
dilemma. What does a person do when duties conflict or when
more than one principle is involved in a situation?
Prima Facie Duties

Thiroux16 describes prima facie duties as duties that must be done
before any other considerations enter the picture. Prima facie means
“at first glance.” Thiroux established two rules to deal with the
conflict of prima facie duties:
1. Always do the act that is in accord with the stronger prima

facie duty.
2. Always do the act that has the greatest of prima facie
rightness over prima facie wrongness.
For example, the dental hygienist who suspects child
maltreatment should place the welfare of the child over the
autonomy of the parent. The stronger duty in this instance is the
good of the child—beneficence—not the right of the parent.
These rules, with their supporting principles and values, can
provide the dental hygienist guidance in the decision-making
process. However, although these are good guides to use, they do
not automatically provide correct ethical decisions because they
sometimes are in conflict with each other. A choice must be made
regarding which rule or value has precedence.
Summary
This chapter provides an introduction to the fundamental
principles of ethics (nonmaleficence, beneficence, autonomy,
justice) and several related values and concepts (paternalism,
veracity, informed consent, confidentiality) commonly used to
assist in ethical decision making. These principles and concepts are
intellectual tools that can guide the dental hygienist in making
difficult decisions when confronting an ethical dilemma or
problem.
References
1. Beauchamp TL, Childress J: Principles of biomedical
ethics, ed 8, New York, 2019, Oxford University Press.
2. American Dental Association. The ADA Principles of
Ethics and Code of Professional Conduct. 2020.
https://www.ada.org/about/principles/code-of-ethics.
3. Merriam Webster’s Dictionary.
https://www.merriam-webster.com.
4. Frankena WK: Ethics, ed 2, Upper Saddle River, NJ,
1963, Prentice-Hall.
5. Campbell CS, Rodgers VC: The normative principles
of dental ethics. In Weinstein BD, editor: Dental ethics,
Philadelphia, 1993, Lea & Febiger.
6. Rule JT, Veatch RM: Ethical questions in dentistry, ed
2, Chicago, 2004, Quintessence.
7. Varkey B: Principles of clinical ethics and their
application to practice. Med Princ Pract 30:17-28, 2020.
8. Velasquez M, Andre C, Shanks T, Meyer SJ, Meyer
MJ: Justice and fairness. Markkula Center for Applied
Ethics at Santa Clara University, 2018.
9. Kopelman L: On distinguishing justifiable from
unjustifiable paternalism. Medical Education 6(2),
2004.
10. Kahn JP, Hasegawa TK, Jr: The dentist-patient
relationship. In Weinstein BD, editor: Dental ethics,
Philadelphia, 1993, Lea & Febiger.
11. Watterson DG: Informed consent and informed
refusal in dentistry. RDH Sep 2012.
12. American Dental Association: Managing patients;
informed consent/refusal, ADA Center for
Professional Success, Chicago, 2021
13. Barstow C, Shahan B, Roberts M: Evaluating medical
decision-making capacity in practice. Am Fam
Physician 98(1):40-46, 2018.
14. Colby SL, Ortman, JM. Projections of the Size and
Composition of the U.S. Population: 2014 to 2060.
Population Estimates and Projections. Current
Population Reports. United States Census Bureau;
2015.
https://www.census.gov/content/dam/Census/library/
publications/2015/demo/p25-1143.pdf.
15. Moyer J, Matson D: Assessment of decision-making
capacity in older adults: an emerging area of practice
and research. J Gerontol B psychol Sci Soc Sci 62:3–11,
2007.
16. Thiroux JP, Krasemann KW: Ethics theory and
practice, ed 11, New York, 2015, Pearson.
CHAPTER
5
Codes of Ethics
Chapter Outline
Professional Codes in Health Care 49
Development of Ethical Codes 50
Ethical Code for Dental Hygiene 51
Summary 53
Learning Outcomes
• Discuss the role of a code of ethics for the healthcare
professions.
• Explain the value to the lay public of a professional code of
ethics.
• Describe how a code of ethics can assist in the professional
duty of self-regulation.
• Compare the 1927 version and the current version of the
ADHA Code of Ethics for Dental Hygienists.
• List and describe the nine sections identified under the
Standards of Professional Responsibilities of the Code of Ethics for
Dental Hygienists.
• Be familiar with the code of the American Dental Association.
A code of ethics is one of the essential characteristics of a true

profession. It is a guideline for members of a professional group
used for self-regulation of the group. A major purpose of a
professional code of ethics is to bind together the members of a
group by expressing their goals and aspirations, as well as to define
expected standards of behavior. The code is the contract the
profession makes with society outlining the standards it will adhere
to and uphold.
Professional Codes in Health Care

Ethical codes address the areas of personal integrity, dedication,
and principled behavior.1 Most healthcare providers cherish and
hold sacred the obligations that flow from the entrance into their
chosen profession. Acceptance and support of the prescribed
principles and standards of behavior help reinforce the significance
of being a part of a special group of people who are committed to
the same values and goals.
Professional groups and the public have sometimes questioned
the value of codes of ethics. Do codes of ethics really make a
difference in the way healthcare providers interact with and treat
patients and colleagues? If a member of a profession has seen
evidence of colleagues acting unethically and those colleagues have
not been punished, that question is legitimate. It would be the same
for a member of the public who has had a bad experience with a
healthcare provider. Patients may assume that they were treated in
a manner inconsistent with the standards of behavior in the
profession (even though the professional may have behaved
appropriately). Sometimes the act may be inappropriate behavior
by professionals; conversely, the frustration of patients may lead
them to believe unethical behavior occurred even when it has not.
How, then, does a person know whether codes of ethics are ever
effective? Three things demonstrate how codes can be effective in
shaping professional behavior. First, when professional schools of
healthcare screen applicants for admission to education programs,
integrity and character are important criteria for acceptance.
Admissions committees aim to select candidates who are the best
qualified academically as well as candidates of good character.
Virtue ethics, derived from the tradition of Plato and Aristotle, was
introduced in Chapter 3. Virtue is a character trait; the assumption
is that if someone is virtuous, they will act virtuously. Thus, part of
the selection process often focuses on identifying virtue in the
character of applicants.
Second, until proven otherwise, each entering student must be
assumed to have the character traits needed to be a true
professional. Educational institutions actively seek to indoctrinate
students into the goals of the profession and expected professional
behaviors. Learning what is expected of that professional person
reinforces character traits in the developing professional. This often
is accomplished by introducing students to the institution’s code of
conduct, by familiarizing them with the profession’s code of ethics
and professional conduct, by faculty serving as positive role
models, and by enforcing adherence to expected professional
behaviors when professional codes have been violated.
Third, after entering professional practice, it becomes the
obligation of those professionals to help regulate their profession.
When violations occur, members of the profession who become
aware of these violations have a duty to intervene in a substantive
way. This is a serious step and must be carefully considered; the
reputation of the profession and the well-being of the public
ultimately rest on a willingness to engage in meaningful self-
policing of the profession.
The degree to which codes are effective remains a difficult
question to answer completely. However, because health
professions invest so much effort in the development and
propagation of codes of ethics and standards of professional
behavior, an assumption that the professions find them to be
extremely valuable is reasonable. When violations of the code
occur, the profession is empowered to take action to resolve the
problem. Although codes alone do not guarantee that everyone will
behave with integrity, they do provide guidance and standards by
which professionals can be judged. Codes also serve as a
touchstone by which all members of a profession can judge the
acceptable parameters of behavior. This is why being a professional
person is a privilege and carries both benefits and responsibilities.
Development of Ethical Codes

The first ethical code dates back to the time of the Greek physician
Hippocrates, and the influence of the Hippocratic Oath is still
reflected today in modern versions of ethical codes (Box 5.1).
Traditional medical codes of ethics emphasize the physician’s (1)
duties in the individual patient–physician relationship, including
the obligation of confidentiality, (2) authority and duty of
beneficence (i.e., acting for the patient’s good), and (3) obligation to
each other.2 In return for the power and prestige granted to the
professions, a code of ethics is the promise to society to uphold
certain values and standards in the practice of the profession. As
noted, codes of ethics are aspirational in nature. They typically are
powerful ethical statements, but they are not legal mandates.
However, codes cannot easily be dismissed if there is a formal
structure for self-regulation. In recent years, evidence has been
increasing that state dental boards, which usually have authority
over both dentists and dental hygienists, are sanctioning
practitioners for legal violations as well as ethical violations.
Because these boards typically have the authority to suspend or
terminate a professional’s right to practice, the fact that more
attention is being given to ethical behavior makes the relationship
between ethical codes and enforcement stronger. Ideally, codes
should create a relationship among members of a profession that is
similar to the ties in a family, obviating the need for enforcement
outside the group. Additionally, there is often an inextricable link
between the ethical and legal obligations of healthcare
professionals. For example, a breach of confidentiality may
constitute a breach of the Health Insurance Portability and
Accountability Act (HIPAA), which could incur legal liability.
Professionals’ obligations to each other, to patients, and to society
should be similar to the strong obligations and emotional feelings
that attend belonging to a family, with the behavior of members
being monitored by the membership.
Box 5.1
Hippocratic Oath
I swear by Apollo Physician and Asclepius and Hygeia and
Panacea and all the gods and goddesses, making them my
witnesses, that I will fulfill according to my ability and judgment
this oath and this covenant:
To hold him who has taught me this art as equal to my parents
and to live my life in partnership with him, and if he is in need of
money to give him a share of mine, and to regard his offspring as
equal to my brothers in male lineage and to teach them this art—if
they desire to learn it—without fee and covenant; to give a share
of precepts and oral instruction and all the other learning to my
sons and to the sons of him who has instructed me and to pupils
who have signed the covenant and have taken an oath according
to the medical law, but no one else.
I will apply dietetic measures for the benefit of the sick
according to my ability and judgment; I will keep them from harm
and injustice.
I will neither give a deadly drug to anybody who asked for it,
nor will I make a suggestion to this effect. Similarly I will not give
to a woman an abortive remedy. In purity and holiness I will
guard my life and my art.
I will not use the knife, not even on sufferers from stone, but will
withdraw in favor of such men as are engaged in this work.
Whatever houses I may visit, I will come for the benefit of the
sick, remaining free of all intentional injustice, of all mischief and
in particular of sexual relations with both female and male
persons, be they free or slaves.
What I may see or hear in the course of the treatment or even
outside of the treatment in regard to the life of men, which on no
account one must spread abroad, I will keep to myself, holding
such things shameful to be spoken about.
If I fulfill this oath and do not violate it, may it be granted to me
to enjoy life and art, being honored with fame among all men for
all time to come; if I transgress it and swear falsely, may the
opposite of all this be my lot.
A sound and deep understanding of the moral responsibilities of

those entrusted with the health of others is essential.3 Healthcare
providers have a special responsibility to the patients they treat
because of their knowledge and the dependency of the patient on
that knowledge. A code of ethics also is a set of commandments
and, as such, has two principle functions. First, it provides an
enforceable standard of minimally decent conduct for those who
fall below that standard. Second, it indicates in general terms some
of the ethical considerations a professional must consider when
deciding on conduct.4 The code of ethics can and does serve as a
tool in the function of self-regulation.
The use of professional codes in health care has some limitations.
Not every situation can be addressed in an ethical code or fully
explained in an accompanying interpretation. Some philosophers
have noted that most codes stress the obligations of healthcare
professionals rather than describe the rights of those receiving
healthcare services.5 The current use of a patient’s bill of rights in
healthcare settings is an attempt to address this discrepancy.
Ethical Code for Dental Hygiene

The first code of ethics for dental hygienists was created at the
inception of the American Dental Hygienists’ Association (ADHA)
in 1927.6 The wording of the original code reflects the tone and
verbiage of the time and the fact that initially, only women were
dental hygienists. That code, developed in three sections that list
the duties of the profession to patients, reads as follows:
Section 1: The dental hygienist should be ever ready to respond to the

wants of her patrons, and should fully recognize the obligations
involved in the discharge of her duties toward them. As she is in most
cases unable to correctly estimate the character of her operations, her
own sense of right must guarantee faithfulness in their performance.
Her manner should be firm, yet kind and sympathizing so as to gain
the respect and confidence of her patients, and even the simplest case
committed to her care should receive that attention which is due to
operations performed on living, sensitive tissue.
Section 2: It is not to be expected that the patient will possess a very
extended or very accurate knowledge of professional matters. The
dental hygienist should make due allowance for this, patiently
explaining many things which seem quite clear to herself, thus
endeavoring to educate the public mind so that it will properly
appreciate the beneficent efforts of our profession. She should
encourage no false hopes by promising success when in the nature of
the case there is uncertainty.
Section 3: The dental hygienist should be temperate in all things,

keeping both mind and body in the best possible health, that her
patients may have the benefit of the clearness of judgment and skill
which is their right.
The code has been revised several times over the years, most
significantly in 1995 after a thoughtful review and the incorporation
of newer aspects of health care and changes in the profession.
Minor revisions have been undertaken in more recent years. This
version of the code is presented in several sections and
encompasses the areas of endeavor in which the dental hygienist
functions. The purpose, illustrated by four objectives of the code of
ethics, is listed in the beginning of the code, and these capture the
essence of why the code is important to dental hygienists and the
public who entrust themselves for care and services. The key
concepts, basic beliefs, fundamental principles, and core values are
established and explained in the code so that the standards of
professional responsibility can be fully understood by professionals
and public alike.
For dental hygienist students, the code of ethics for dental
hygienists is a vehicle for educating novices about the obligations of
the profession, informing them about the basic beliefs and
fundamental principles of the group, and providing guidelines
regarding the expected behavior of a dental hygiene practitioner.
The topic of ethics is usually integrated throughout the dental
hygienist entry-level curriculum both didactically and clinically.
The American Dental Association’s Commission on Dental
Accreditation (CODA), the agency that sets the standards for all
dental health-related education programs, requires graduates of
accredited dental hygienist programs to be “competent in the
application of the principles of ethical reasoning, ethical decision
making and professional responsibility as they pertain to the
academic environment, research, patient care, and practice
management.”7
All professional codes are evolving documents that embody the
contract between a particular profession and the public. For dental
hygienists, the code is maintained by the professional organization
(the ADHA) and is monitored by the executive staff of the
organization. When deemed necessary, the officers of the
association appoint a committee of members to review and revise
the document. The code can be amended at any meeting of the
ADHA House of Delegates by a two-thirds vote of that group. The
ADHA and all healthcare professional organizations have, as a
condition of membership, an agreement to uphold the profession’s
code of ethics.
The code of ethics that was first developed in 1995 is more
comprehensive than earlier versions and provides extensive
guidance for the dental hygienist working in a variety of healthcare
delivery settings. The current code lists the core principles
embraced and upheld in all healthcare professions and clearly
defines all the standards of professional responsibility that the
ADHA believes its members should adhere to in the performance
of their services. A code of ethics is a reference and a guide. It
should be studied by students and referred to for guidance by
working professionals (Figure 5.1). The ADHA Code of Ethics for
Dental Hygienists can be found on the organization’s website
(https://www.adha.org), the Core Values are presented in Table 5.1.8
FIG. 5.1 Visual representation of the American Dental Hygienists’
Association Dental Hygiene Code of Ethics. Although the specific
language of the code has been updated through the years, its basic
components and aims remain the same. From: American Dental
Hygienists’ Association. The Dental Hygiene Code of Ethics, as
appeared in the January 1995 issue of Access magazine. Reproduced
with permission of American Dental Hygienists’ Association in the format
Textbook via Copyright Clearance Center.
Table 5.1
American Dental Hygienists’ Association Code of Ethics for

Dental Hygienists Core Values8
We acknowledge these values as general for our choices and
actions.
Individual Autonomy and Respect for Human Beings
People have the right to be treated with respect. They have the
right to informed consent prior to treatment, and they have
the right to full disclosure of all relevant information so that
they can make informed choices about their care.
Confidentiality
We respect the confidentiality of client information and

relationships as a demonstration of the value we place on
individual autonomy. We acknowledge our obligation to
justify any violation of a confidence.
Societal Trust
We value client trust and understand that public trust in our

profession is based on our actions and behavior.
Nonmaleficence
We accept our fundamental obligation to provide services in a

manner that protects all clients and minimizes harm to them
and others involved in their treatment.
Beneficence
We have a primary role in promoting the well-being of
individuals and the public by engaging in health
promotion/disease prevention activities.
Justice and Fairness
We value justice and support the fair and equitable

distribution of health care resources. We believe all people
should have access to high-quality, affordable oral healthcare.
Veracity
We accept our obligation to tell the truth and expect that

others will do the same. We value self-knowledge and seek
truth and honesty in all relationships.
The dental hygienist is most often an employee of a dentist.

Individuals employed by a dentist should be familiar with not only
the ADHA Code of Ethics but also the ADA code.
Summary
Codes of ethics are the written standards to which healthcare
professionals agree to adhere before society, which grants certain
privileges to these groups. Among these privileges are societal trust
and self-regulation. Once individuals have gained the necessary
professional knowledge and skill and acquired their professional
license, which is an acknowledgment of this achievement, they are
accorded professional status. The responsibility that goes with this
status is to uphold the core values of the profession of dental
hygienists: professional autonomy, confidentiality, societal trust,
nonmaleficence, beneficence, justice, and veracity.
References
1. Edge RS, Groves JR. Ethics of Health Care. 3rd ed.
Delmar; 2006:84.
2. Kenny NP: Codes and character: the pillars of
professional ethics. J Am Coll Dent 65(3):5, 1998.
3. Jonsen AR: The sins of specialists. J Hist Dent
55(3):113, 2007.
4. Benjamin M, Curtis J. Ethics in Nursing. 2nd ed.
Oxford University Press; 1986:6.
5. Beauchamp TL, Childress JF. Principles of Biomedical
Ethics. 7th ed. Oxford University Press; 2012.
6. Steele PF. Dimensions of Dental Hygiene, 3rd ed. Lea &
Febiger; 1982:474.
standards.
8. American Dental Hygienists’ Association. Standards
for Clinical Dental Hygiene Practice. 2016.
CHAPTER
6
Ethical Decision Making in

Dental Hygiene and Dentistry
Chapter Outline
Learning Ethical Decision Making 55
Ethical Awareness 56
Moral Distress 57
Ethical Decision-Making Models 58
Six-Step Decision-Making Model 58
1. Identify the Ethical Dilemma or
Problem 58
2. Collect Information 58
3. State the Options 58
4. Apply the Ethical Principles to the
Options 59
5. Make the Decision 60
6. Implement the Decision 60
Ethical Dilemmas for the Dental Hygienist 60
Solving a Dilemma Using the Ethical Decision-
Making Model 61
Summary 62
Learning Outcomes
• Describe the difference between an issue of right and wrong
and a true ethical dilemma.
• Identify the goal for use of an ethical decision-making
process in dental hygiene.
• List the six steps provided in the ethical decision-making
model.
• List and discuss the categories of common ethical dilemmas
for dental hygienists.
• Apply the decision-making model to a hypothetical situation.
The student of dental hygiene studies and learns about the ethical
and professional responsibilities of a dental hygienist. As a clinician
providing care and services, the dental hygienist will be faced with
many choices and dilemmas. Some of these choices will be simple
issues of right and wrong, whereas others may be ethical dilemmas
that require careful decision making. The dental hygienist must be
aware of the ethical issues that can arise in dental hygiene and
dentistry and take appropriate action when necessary. Two aspects
are involved in ethics: the ability to discern right from wrong and
the commitment to act on a decision.
Learning Ethical Decision Making

Ethical problems arise for the dental hygienist in professional
practice when the dental hygienist is caught between two
competing obligations. Throughout their lifetimes, professionals
face situations that require carefully weighing options. Often no
right or wrong answer exists. Instead, a variety of answers may be
possible, each of which has an element of rightness about it. Most
decisions must be made in the context of professional, social, and
economic pressures, which may be in conflict with values and
principles. Determining what to do when faced with an ethical
dilemma can be a daunting challenge. Making such decisions can
be greatly facilitated by an ethical decision-making model.
Ethical decision-making models provide a suggested mechanism
for critical thinking and the resolution of ethical dilemmas. Odom
was the first to report that the usual approach to teaching ethics in
dental and dental hygiene schools is either the lecture format or the
lecture and case analysis format.1 He, as well as others, have
suggested and supported the concept that students need
opportunities to develop the analytical skills needed to assess
ethical dilemmas. Odom further suggested that posing ethical
dilemma cases when a panel of experts is available to help students
analyze and arrive at possible solutions to the hypothetical
dilemmas is a means of affording those opportunities.2,3 Kacerik et
al. found that ethics was overwhelmingly (98%) taught in the
didactic component of the curriculum in dental hygiene programs
with far fewer hours devoted to the clinical application of theory.4
This oftentimes leaves dental hygienists feeling ill-equipped to
handle ethical dilemmas they may encounter in the workplace.
The teaching of ethics in dental and dental hygiene educational
programs has been acknowledged as an essential part of the
education of the dental healthcare professional. As mentioned in
Chapter 5, the CODA Accreditation Standards for Dental Hygiene
Education Programs dictates that “Graduates must be competent in
the application of the principles of ethical reasoning, ethical
decision making, and professional responsibility as they pertain to
the academic environment, research, patient care, and practice
management.”5 However, these accreditation standards simply
provide general guidelines—dental hygiene programs vary related
to hours spent didactically and clinically on this topic.
In 1989, the American Dental Education Association (ADEA)
established guidelines for all dental-related educational programs
that stated that curricula should provide opportunities for refining
skills of ethical analysis so students are able to apply ethical
principles to new and emerging problems in the profession. The
goal for these curricula was to develop a commitment by the
students to the moral principles that are the basis of the
profession’s contract with society. The ADEA policy has been
revised since that time to include expanded statements on
professional behavior, societal obligations, access to care needs, and
community service.6 Within the Core Competencies domain of the
Competencies for Entry into the Profession of Dental Hygiene
published by the ADEA, “apply a professional Code of Ethics in all
endeavors” is listed first.7
Intellectual and clinical skills are essential to the competent
provision of oral health care, which is why ethics and
professionalism are required in the dental hygiene educational
curricula. Effectively fostering and evaluating the ability of students
in ethical reasoning and critical thinking are challenging tasks.
When faculty are trained in ethical reasoning skills and the
authentic evaluation of students, the outcomes are positive, faculty
are more comfortable evaluating professional judgment, and
students report being competent in the skills.8,9
Ethical Awareness
How the dental hygienist responds to ethical issues that arise in
practice depends on the ethical awareness of the individual (moral
sensitivity). A situation or problem can be perceived by one
individual as having an ethical component but not by another.
Campbell and Rogers categorized the kind of moral problems
encountered in life and dental practice (Table 6.1).10 Their first
category deals with problems of moral weakness, in which moral
responsibilities point in one direction and personal inclinations in
another. The dental hygienist who forgoes providing a patient with
needed dental health education because he or she wants to get to
lunch early is lacking in professional responsibility. Another
category is moral uncertainty, which is defined as the question of
whether a moral obligation exists and its scope. For a dental
hygienist, dealing with a noncompliant periodontal patient could
raise issues of uncertainty. How far should the dental hygienist go
to attain a level of health when the patient is unwilling or
uninterested in following good dental health advice and guidance?
The third category is composed of problems that are moral
dilemmas. A moral dilemma exists when obligations or
responsibilities are in conflict. A large portion of the bioethics
literature deals with moral dilemmas that often involve matters of
life and death.
Table 6.1
Categories of Moral Problems

Categ Characteristic
ory
Moral Moral responsibilities conflict with personal
weakn inclinations.
ess
Moral The question is whether a moral obligation exists.
uncert
ainty
Moral Obligations and responsibilities are in conflict.
dilem
ma
Moral Frustration results from perceived powerlessness
distres when what is happening appears to be wrong and
s one cannot to act ethically.
Data from: Campbell CS, Rogers VC. The normative principles of dental ethics. In:
Weinstein BD, ed. Dental Ethics. Lea & Febiger; 1993.
Moral Distress
The term moral distress is included here to acknowledge situations
in which the healthcare provider is frustrated by feelings of
powerlessness when a perceived wrong is occurring but is unable
to act. It is the feeling experienced when—because of a system
issue, the resistance of a powerful person, or a restraint in the
situation—an individual cannot do what is believed to be what
ought to be done. The use of this term came from the nursing
profession and describes situations in which the nurse feels
powerless to act ethically.11,12 Although this is a newer term, the
resulting distress, emotional toll, anger, guilt, and depression are
familiar to many healthcare providers who must balance conflicts
of conscience with professional expectations. An example of this for
the dental hygienist could be when treatment recommended by
another provider for a patient is deemed excessive or unnecessary.
The American Association of Critical Care Nurses (AACCN)
advocates a model for rising above moral distress called the “four
A’s.”13 The goal of this model is to preserve the integrity and
authenticity of the healthcare provider. Addressing moral distress
requires making changes (Table 6.2).
Table 6.2
The “Four A’s” to Rise Above Moral Distress

T Description
er
m
A Ask about distress. Are you showing signs of work-
sk related distress? Become aware of the problem.
T Description
er
m
A Affirm your distress and the commitment to take care of
ffi yourself. Affirm the professional obligation to act.
r
m
A Identify sources of distress and determine severity.
ss Analyze risks and benefits.
es
s
A Prepare personally and professionally to take action.
ct
Data from: American Association of Critical Care Nurses. AACN Public Policy Position
Statement: Moral Distress. AACN; 2008.
Morally courageous professionals are encouraged to persevere in

standing up for what is right even when it means they may do so
alone. Murray provided a listing of seven critical checkpoints to use
in ethical decision making.14 His guiding checkpoints start with
evaluating the need for moral courage and end with avoiding what
might restrain moral courage. In a clinical setting, whether it is a
small or large group of practitioners, there can be an unwillingness
to face the challenge of addressing unethical behaviors. Those who
have the courage to stand up and speak out need the support of
their peers.
The following are checkpoints to apply in ethical decision
making:
• Evaluate the circumstances to establish whether moral

courage is needed in the situation.
• Determine what moral values and ethical principles are at
risk or in the question of being compromised.
• Ascertain what principles must be expressed and defended in
the situation. Focus on one or two of the more critical values.
• Consider the possible adverse consequences and risks
associated with taking action.
• Assess whether or not the adversity can be endured.
Determine what support and resources are available.
• Avoid stumbling blocks that might restrain moral courage,
such as apprehension or other reflections leading to reasoning
oneself out of being morally courageous in the situation.
• Continue to develop moral courage through education,
training, and practice.
Ethical Decision-Making Models

An ethical decision-making model is a tool that can be used by the
dental hygienist or other healthcare provider to help develop the
ability to think through an ethical dilemma and arrive at an ethical
decision. A number of models are presented in the ethics literature,
all of which are somewhat similar in design and content.14,15 The
goal of each model is to provide a framework for making the best
decision in a particular situation with which the healthcare
provider is confronted. Most of these models use principle-based
reasoning, which is an approach derived from the work of
philosophers Beauchamp and Childress.
The model provided in this chapter is a simple six-step approach
derived from the decision-making literature as interpreted by
Atchison and Beemsterboer and used in the early 1990s with dental
and dental hygiene students in a combined ethics course. It is a
reasoned approach based on theory and principle. The model has
been diagrammed as a circle to emphasize the use of past
information and experiences in current and future decision making
(Figure 6.1).
FIG. 6.1 Ethical decision-making model.
The process of decision making is dynamic, evolving as

additional information comes into play. Dental hygienists are
confronted with myriad questions to consider, requiring them to
factor in the code of ethics and their own values and beliefs before
arriving at a decision. The evaluation process involved in an ethical
dilemma is not unlike what occurs when the practitioner is faced
with a clinical or scientific problem. Careful attention to and
systematic analysis of the evidence, facts, and details will help the
healthcare provider reach an appropriate decision. Applying the
decision-making model gives the dental hygienist a tool to use
throughout professional life (Figure 6.2).
FIG. 6.2 Worksheet for ethical decision making.
Six-Step Decision-Making Model

1. Identify the Ethical Dilemma or Problem
Step 1 is the most critical step in the process. Many situations are
simply never perceived to be ethical problems or dilemmas. Once
the problem has been recognized, the decision maker must clearly
and succinctly state the ethical question, considering all pertinent
aspects of the problem. If the ethical question does not place
principles in conflict, it is a simple matter of right and wrong, and
no process of ethical decision making is required. Proceeding to
step 2 is not necessary if a clear determination of right or wrong has
been made.
2. Collect Information
The decision maker must gather information to make an informed
decision. This may be factual information about the situation as it
developed, and it may come from more than one source.
Information regarding the values of the parties involved, including
those of the healthcare provider, is needed.
3. State the Options

After gathering all the necessary information, one may proceed to
the third step, which involves brainstorming to identify as many
alternatives or options as possible. Often the best decision is not the
first one that comes to mind. Also, a tendency exists to think that a
question has only one answer. This step forces us to stop and view
the situation from all angles to identify what other people might see
as alternative answers to the problem. An enlightened and open
mind is often required to recognize that more than one answer to a
problem exists.
4. Apply the Ethical Principles to the Options

Focus on the ethical principles (autonomy, beneficence,
nonmaleficence, and justice) and ethical values and concepts
(paternalism, confidentiality, and informed consent). In general,
one or more of these will be involved in any ethical decision. State
how each alternative will affect the ethical principle or rule by
developing a list of pros and cons. In the pro column, show
alternatives that protect or hold inviolate each principle or value. In
the con column, state how an alternative could violate the principle
or value. Do this for each option. This process will enable you to see
which ethical principles are in conflict in this situation. Refer to the
ADHA Code of Ethics for Dental Hygienists for guidance.
5. Make the Decision

When each alternative has been clearly outlined in terms of pros
and cons, a reasonable framework is apparent for making a
decision. Each option must then be considered in turn, with
attention to how many pros and cons would attend each decision.
The seriousness of the cons must then be weighed by the dental
hygienist, remembering that, as a professional, he or she is obliged
to put the patient’s interests first. Simply by examining the options
in a careful way, the best solution to an ethical dilemma frequently
becomes obvious. Before implementing the decision, the
practitioner should replay each principle against the decision to see
if the decision holds up to this evaluation.
6. Implement the Decision

The final step involves acting on the decision that has been made.
The decision process will have been futile if no action is taken.
Many appropriate decisions are never implemented because this
step is omitted. Remember that no action represents tacit approval
of a situation.
Ethical Dilemmas for the Dental

Hygienist
The dental hygienist may be faced with a wide variety of ethical
issues and moral dilemmas. A few studies have addressed the
responsibility of dental hygienists to report unethical practices. In
1990 Gaston and colleagues conducted a survey of ethical issues in
dental hygiene.16 They found that the three most frequently
encountered practice dilemmas were observation of behavior in
conflict with standard infection control procedures, failure to refer
patients to a specialist, and nondiagnosis of dental disease. One of
the conclusions drawn from this study was that serious ethical
dilemmas are encountered by most dental hygienists, prompting
the authors to advocate for increased education of hygienists in the
recognition and resolution of ethical problems.
The range and type of ethical problems have continued to
expand, and because most hygienists are employees, issues around
employment are commonplace. Unfair treatment involving
assignments of hours, compensation, benefits, unsafe work
environment, and noncompliance with state or federal regulations
are reported by dental hygienists.17
Dentistry, unlike medicine, usually is performed in small or large
group practices in which little, if any, institutional oversight is
provided by groups such as ethics committees or standard review
boards. Dental hygienists usually are employed by a dentist or a
group of dentists. This arrangement can place the hygienist in a
difficult situation when inappropriate care or unethical practices
are observed, especially when the dentist’s employer is involved in
the action. In these situations, if the dental hygienist advocates for
the good of the patient, continued employment may be in jeopardy
—thus causing moral distress. Conversely, if the hygienist remains
silent, professionalism is compromised and no one speaks for the
interests of the patient. This dilemma is similar to what many
registered nurses are subjected to when they become advocates for
a hospitalized patient.18 A conflict or dilemma can be intensified
when a subordinate observes an unethical action performed by an
individual in a position of power. Studies from the nursing
literature have reported such situations having a negative influence
on the healthcare environment and leading to burnout and
departure from the profession.18,19 Any type of an ethical dilemma
or problem can arise in the practice of dental hygiene. Box 6.1 lists
the categories of ethical dilemmas most frequently encountered by
dental hygienists.
Box 6.1
Categories of Ethical Dilemmas Most
Commonly Encountered by Dental Hygienists
1. Substandard Care
Situations in which there is failure to diagnose, failure to refer, or lack of proper
infection control or in which dental or dental hygiene services are provided that
do not meet the accepted standard of care.
2. Overtreatment
Situations in which excessive services or services that are unnecessary for a
particular case are provided. This category includes unduly influencing a
patient’s care decision as a result of one’s position of greater knowledge.
3. Scope of Practice
Instances in which the legally assigned scope of practice is exceeded by a dental
hygienist, dentist, or other member of the dental team.
4. Fraud
Situations in which an insurance claim or other reimbursement mechanism is
adjusted to favor the dental office or the patient’s financial situation. Other types
of false charting or other cost-containment efforts may be included in this
category.
5. Confidentiality Breaches
Situations in which patient and/or child–parent confidentiality is jeopardized or
the need and requirement for informed consent is not met.
6. Impaired Professional
Situations in which the dental hygienist or other dental team member cannot or
should not perform appropriate dental care because of a dependence on alcohol,
drugs, or other substances (impaired professional).
7. Sexual Harassment
Includes a wide range of behaviors that a dental team member may observe or
be subjected to that can be classified as harassment.
8. Abuse
Situations in which abuse of a child, elder, or spouse is observed or suspected.
Such situations have legal requirements as well as ethical considerations in most
states.
Additional types of dilemmas and problems can and will arise.

Major advances in technology and the changes in delivery and
payment systems in dentistry will further alter the scope and depth
of ethical challenges facing dental hygienists and dentists.
Dental hygienists also are increasingly finding employment in
areas other than private practice, such as research, public health,
and corporate fields. These arenas will pose different ethical
dilemmas for these individuals.
Solving a Dilemma Using the Ethical

Decision-Making Model
The following hypothetical case is an example of a typical ethical
dilemma often faced by a dental hygienist in a private practice
situation. This case is presented to illustrate how the ethical
decision-making model can be applied to an ethical dilemma.
Joan Lakeside is a dental hygienist who graduated last year from
a dental hygiene program near her hometown. Since graduation,
she has been working for a dentist, Dr. Tom McVey, who has been
practicing for 20 years. The practice is growing, and Dr. McVey is
happy to have Joan working 4 days a week in his busy office. He
often tells her how pleased he is with her work and comments how
lucky they both were to attend State University Dental School, one
of the best in the country.
A patient of the practice, Steve Stafford, is scheduled for an
appointment with Joan for the first time. Steve is a 51-year-old
White male with normal vital signs, no current medications, and no
history of systemic disease. His periodontal condition is good
overall, but he does occasionally smoke cigars. Joan notices a small,
indurated, white and reddish, slightly raised lesion on the right
side of Steve’s tongue. On questioning her patient, Joan finds out
that he is unaware of the lesion or how long it has been present in
his mouth. Joan shows the lesion to Dr. McVey when he comes into
the room to chat with Steve. In earshot of the patient, Dr. McVey
tells Joan, “Not to worry. It is nothing. We’ll take a look at it in six
or seven months, or whenever Steve gets back in here for his next
cleaning.”
At the end of the day, Joan goes into Dr. McVey’s office and
shares with him her concern that the lesion in Steve’s mouth looks
suspicious and should be referred for biopsy. Once again, Dr.
McVey tells her not to worry, adding “It is my decision as to
whether or not we send Steve for a biopsy.” Joan is very
uncomfortable about the situation and wonders if she should call
the patient directly to advise him to seek further examination
regarding the lesion on his tongue.
Step 1 in the ethical decision-making model is to identify the
dilemma. Joan is concerned about her patient and believes that the
lesion on his tongue may be cancerous. Her employer tells her not
to be concerned because he does not believe the lesion requires
immediate attention. Joan is not reassured because she recalls
seeing slides in her pathology class that resemble the lesion on
Steve’s tongue. Should she call the patient and tell him to seek
further examination, or simply forget it and wait until he comes in
for his next appointment? That is Joan’s ethical dilemma—to call
the patient or not.
Steps 2 and 3 involve gathering all pertinent information and
listing possible options for action. Joan checks in her oral pathology
book and confirms that the lesion on Steve’s tongue looks very
much like the photographs of squamous cell carcinoma in her text.
She identifies the following as her options:
1. Go back to Dr. McVey with her textbook, and restate her

suspicions in an attempt to convince him to refer the patient
for a diagnostic biopsy.
2. Call the patient directly and advise him to seek another
opinion about his lesion.
3. Do nothing and wait until the patient comes in for his next
appointment.
Step 4 requires that Joan apply the ethical principles and rules to
each option she has identified. Option 1—talking to Dr. McVey and
convincing him to call the patient in for another examination—
applies the principles of nonmaleficence and autonomy. Removing
harm is in the patient’s best interest, which, in this case, is a
possibly cancerous lesion. Option 2—calling the patient directly
and advising him to seek care for the lesion—applies the principles
of autonomy and beneficence. Autonomy is involved because the
patient came in for an examination and has a right to know that he
may or may not have a disease. Beneficence—doing good for the
patient—is applicable because doing nothing could cause the
patient great harm if the lesion were found to be cancerous. Option
3—doing nothing and waiting for 6 or 7 months—may involve
respecting the autonomy of the dentist.
After completing steps 1 through 4, Joan is prepared for step 5:
the decision stage. Joan decides to approach Dr. McVey again and
try to convince him to call the patient in for another appointment. If
she is unsuccessful in convincing her employer, she will call the
patient directly.
Step 6 is implementation. Joan resolves to speak to Dr. McVey
first thing the next morning.
The process of ethical decision making can be facilitated by using
the decision-making model just described. Numerous other models
can be applied to problem solving. Many healthcare workers find
that talking to trusted colleagues and peers about ethical dilemmas
and work problems can be both beneficial and comforting. The
ethical decision-making model can be applied in a small group and
is equally effective for students and experienced practitioners. A
sample of a worksheet for assisting in the decision-making process
is provided in Figure 6.2.
Summary
Ethical choices and dilemmas inevitably occur during the career of
any healthcare professional. Ethical decision making, like other
aspects of dental hygiene care, is learned during the education of
the dental hygienist and then applied in the practice of dental
hygiene. The use of an ethical decision-making model can help the
healthcare professional think through an ethical dilemma and
arrive at a decision. The six-step model presented in this chapter
can provide structure and guide the dental hygienist when faced
with an ethical dilemma.
Practice Pointer
Use the six-step model when faced with an ethical dilemma in the
workplace. This will assist the dental hygienist to arrive at an
ethically sound decision and aid in avoiding potential liability.
References
1. Odom JG: The status of dental ethics instruction. J
Dent Educ 52:306, 1988.
2. Odom JG: Recognizing and resolving ethical
dilemmas in dentistry. Med Law 4:543, 1985.
3. Odom JG, Beemsterboer PL, Pate T, et al: Revisiting
the status of dental ethics instruction. J Dent Educ
64:772, 2000.
4. Kacerik MG, Prajer RG, Conrad C: Ethics instruction
in the dental hygiene curriculum. J Dental Hygiene 80
(1):9, 2006.
standards
6. American Dental Education Association: ADEA
policy statements. J Dent Educ 78:1057, 2014.
7. American Dental Education Association.
Competencies for entry into the allied dental
professions. 2011.
https://www.adea.org/about_adea/governance/docum
ents/competencydocs2011.pdf. Accessed September
29, 2021.
8. Christie CR, Bowen DM, Paarmann CS: Curriculum
evaluation of ethical reasoning and professional
responsibility. J Dent Educ 67:55, 2003.
9. Christie CR, Bowen DM, Paarmann CS: Effectiveness
of faculty training to enhance clinical evaluation of
student competence in ethical reasoning and
professionalism. J Dent Educ 71:1048, 2007.
10. Campbell CS, Rogers VC. The normative principles
of dental ethics editor. In: Weinstein BD, ed. Dental
Ethics. Lea & Febiger; 1993.
11. Corley MC: Nurse moral distress: a proposed theory
and research agenda. Nurs Ethics 9:636, 2002.
12. Hamric AB, David WS, Childress MD. Moral distress
in health care professionals: what is it and what can
we do about it? Pharos Alpha Omega Alpha Honor Med
Soc. 2006;69(1):16–23.
13. American Association of Critical-Care Nurses.
AACN Public Policy Position Statement: Moral
Distress. AACN; 2008.
14. Murray JS. Moral courage in healthcare: acting
ethically even in the presence of risk. Online J Issues
Nurs. 2010;15:3.
https://ojin.nursingworld.org/MainMenuCategories/E
thicsStandards/Resources/Courage-and-
Distress/Moral-Courage-and-Risk.html.
15. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A
Practical Approach to Ethical Decisions in Clinical
Medicine. 7th ed. McGraw-Hill, 2010.
16. Gaston MA, Brown DM, Waring MB: Survey of
ethical issues in dental hygiene. J Dent Hyg 64:216,
1990.
17. Majeski J: Ethical issues for the dental hygienist.
Access 27:16–20, 2013.
18. Redman B, Fry ST: Nurses' ethical conflicts: what is
really known about them? Nurs Ethics 7:360, 2000.
19. Kalvemark S, Hoglund AT, Hansson MG, et al:
Living with conflicts: ethical dilemmas and moral
distress in the health care system. Soc Sci Med
58A:1075, 2004.
CHAPTER
7
Social Responsibility
Frank Catalanotto and Kristin Minihan-Anderson
Chapter Outline
Disparities in Oral Health Care 65
Surgeon General’s Report on Oral Health
65
Oral Health Disparities 66
Health Disparities and Professionalism
67
Ethical Goals in Oral Health Care 67
Social Justice 68
Dental Therapists as Part of the Oral
Healthcare Workforce 69
Challenges to Ethical Practice and Social
Justice and the Role of the Dental
Hygienist 69
Summary 70
Learning Outcomes
• Describe the role of the dental hygienist in meeting
the oral healthcare needs of the public.
• Relate the importance of the Surgeon General’s Report
on Oral Health to the profession of dental hygiene.
• List several facts about oral health disparities in
America.
• Describe the issue of access to care and social
responsibility.
• Describe dental therapists and their role in addressing
access to dental care.
• Identify several strategies that a dental hygienist can
implement in striving for social justice.
The dental hygienist assumes the rights and

responsibilities of service in the greater good as a healthcare
provider and a professional. This chapter reviews the issues
of disparity in oral healthcare, access to care, and the
responsibilities of all oral healthcare professionals to
advocate the just distribution of resources to meet the oral
healthcare needs of the public.
In his March 1966 presentation to the Committee on
Human Rights Dr. Martin Luther King made the following
statement: “Of all forms of inequality, injustice in health
care is the most shocking and inhumane.”
Disparities in Oral Health Care

Surgeon General’s Report on Oral
Health
The first Surgeon General’s Report on Oral Health was
published in the year 2000. Major findings are listed in Box
7.1. This landmark report described the meaning of oral
health and explained why oral health is essential to general
health and well-being.1 The use of the term oral health and
not dental health was a deliberate choice because oral health
means more than healthy teeth. The report included
conditions and diseases such as oral cancers, lesions of the
head and neck, birth defects, and facial pain. The phrase
“the mouth is a mirror” of the body was used to emphasize
the oral-systemic connection as it relates to disease. The
report established the reciprocal relationship between oral
health and general health and that the two should not be
looked at separately. Oral health is a critical component of
overall health.
Box 7.1
Major Findings of Oral Health in America
• Oral diseases and disorders affect health and well-

being throughout life.
• Safe and effective measures exist to prevent common
oral diseases.
• The mouth reflects general health and well-being.
• Oral diseases and conditions are associated with other
health problems.
• Lifestyle behaviors that affect general health affect oral
and craniofacial health.
• Profound and consequential oral health disparities are
present in the population of the United States.
• More information is needed to improve oral health and
eliminate health disparities.
• Research is the key to a further reduction in the burden
of diseases and disorders that affect the craniofacial
complex.
Data from: U.S. Department of Health and Human
Services. Oral Health in America: A Report of the Surgeon
General. National Institutes of Health; 2000.
The surgeon general’s report also addressed the

disparities and inequalities that affect the most vulnerable
populations: the poor, children, the elderly, the disabled,
and racial and ethnic minorities. These groups often cannot
access care for financial reasons, but lack of access also can
be caused by fear and complex psychosocial or cultural
assumptions. How to address this need is a social
responsibility of all healthcare professionals working with
public and private agencies. It is a complex and challenging
problem in which the dental hygienist is well suited to be an
active participant.
The publication of the 2020 Surgeon General’s Report Oral
Health in America: Advances and Challenges sought to provide
answers regarding the current state of oral health, advances
made since the 2000 report, challenges that persist since the
last report, threats that are new and/or emerging, and
promising new directions for research and oral health
improvement. The guiding principle of the 2020 report is
“The report will describe and evaluate oral health and the
interaction between oral health and general health
throughout the lifespan, considering advances in science,
healthcare integration, and social influences to articulate
promising new directions for improving oral health and
oral health equity across communities.”
Introductory documents of this publication indicate the
following: many of the oral health disparities and access
problems discussed in 2000 are still present today, the aging
population in the United States is experiencing less
edentulism although disparities still exist among lower-
income adults and those in particular geographic areas, and
the cost is a major obstacle to Americans obtaining
necessary dental care.2
The first dental hygienists provided oral health education in

public schools in Bridgeport, CT. Courtesy: University of
Bridgeport, Fones School of Dental Hygiene.
Oral Health Disparities

The National Institute of Dental and Craniofacial Research
addressed the disparity issue by publishing A Plan to
Eliminate Craniofacial, Oral and Dental Health Disparities in
2002.3 This report listed many factors besides finances that
must be identified when determining why certain
populations become patients and others do not. By 2050,
racial and ethnic minority groups are expected to no longer
be “minorities” but will constitute the emerging majority of
the population of the United States. Social, political,
economic, and cultural factors clearly underlie the complex
social problem of inequality. Although these problems are
not new, they continue to confound and frustrate.
The Centers for Disease Control and Prevention (CDC)
provides data and resources outlining how
sociodemographic factors are significant risk indicators for
poor oral health:4
• Sex: Men experience head and neck cancers at twice

the rate of women.
• Race/ethnicity: Untreated dental caries significantly
impact members of particular racial and ethnic groups
of all ages.
• Socioeconomic status (SES): Previous research has
identified a strong association between low SES and
the severity and prevalence of oral diseases. Oral
diseases disproportionally impact children and adults
from low-income households.
• Age: Periodontitis in older adults (65+ years) occurs at
a rate of 60% compared to a rate of 42% in younger
adults.
The deaths of two children from dental abscesses made

headlines in 2006 and triggered some legislative actions to
attempt to prevent similar tragedies.5 Recent reports
document that the death of Deamonte Driver, one of the
children referenced here, was not an isolated event and that
there are significant morbidities and mortality associated
with severe dental problems such as dental infections.6,7
Health Disparities and
Professionalism
As a society, we are faced with disparities in health care and
in dental health care. More than 30 million people in the
United States under the age of 65 are estimated to have no
health insurance; this is a great concern for the public health
and well-being of the country.8 It has been estimated that
over 190,000,000 Americans do not access dental care on a
regular basis.9,10 Approximately 60,000,000 Americans live
in Dental Health Professional Shortage Areas (DHPSA).11
Dental hygienists are focused on prevention, a focus that
fits well with the goals of health promotion that have been
established by the US Department of Health and Human
Services and with the lack of access to dental care and the
resulting oral health disparities previously noted. Two
subsequent reports called for significant expansion of the
role of dental hygienists in meeting the challenges of oral
healthcare disparities. In celebrating the 100th anniversary
of the dental hygiene profession, in 2013 the ADHA
published a report entitled “Transforming Dental Hygiene
Education and the Profession for the 21st Century”12; this
report called for significant change in both the education
and future role of the dental hygienist in the oral healthcare
workforce. At about the same time, the National Governors
Association issued a brief entitled “The Role of Dental
Hygienists in Providing Access to Oral Health Care”13;
again, this report called attention to the role of dental
hygienists in addressing access to care, particularly for
underserved patients. These reports lay the foundation for
both oral healthcare workforce policy changes but also a
reminder of the ethical commitments of dental hygienists as
oral healthcare professionals.
The responsibility of all oral healthcare professionals to
assist and lead society in finding solutions to oral health
disparities is based on the historic definition of a
profession.14 This concept of service and the aspirations for
professionalism in dental hygiene are established in the
code of ethics and addressed in its fundamental principles
and core values. Listed under the ADHA Code of Ethics as
well as the Standards of Professional Responsibility, to the
Community and Society15 are several points that include
increasing access to care, promoting public health,
supporting justice, and recognizing an obligation to provide
pro bono service. As a group, dental hygienists aspire to
make a contribution to the public and to enhance all the
ability to seek and receive dental care resources. Dental care
is, by its nature, a social enterprise even when normally
provided on a one-on-one basis.16 The social contract made
between the public and healthcare professionals, such as
dental hygienists and dentists, is the basis of this
relationship.
Dental hygienists and dentists take pride in being
recognized as professional healthcare providers. Welie, in a
series of articles examining what it means to be a
professional, defined a profession as a “collective of expert
services providers who have jointly and publicly committed
to always give priority to the existential needs and interests
of the public they serve ahead of their own and who in turn
are trusted by the public to do so”.17–19 Thus, the benefit of
being called a professional also carries the burden of
addressing the needs of the public. How the dental
hygienist uses his or her skills and knowledge to advance
the public good is part of the obligation laid out in the code
of ethics and embraced in the essence of a professional
person. We must consider our obligations as a group, not
just individuals who are members of a group, by honoring
the justice principle in the code of ethics and sharing ethical
concerns as a moral community.20,21
Courtesy: Nichole Salazar.
Ethical Goals in Oral Health Care

The values of caring, stewardship, and justice are of great
importance for achieving ethical goals in healthcare—they
are the goals that focus on society. These are different from
the ethical principles that focus on the individual, such as
autonomy and self-determination.
Justice in dental care is a complex topic. What is just or
fair? What does the just distribution of dental healthcare
resources look like? For the parents of a child with a
toothache who can find a dentist and pay for dental
services, no dilemma exists. For the parents of a child with a
toothache who cannot find a dentist because they have no
ability to pay for services or have no access to a public
program, a dilemma certainly exists, as does the need to
examine the disparities of the situation. As discussed in
Chapter 4, distributive justice is the term used when
discussing allocation of resources in large social systems.
Saying that everyone should have access to dental care is
easy, but what kind of care are individuals entitled to when
resources are limited? The first response might be basic
dental care or adequate dental care. Defining what that
might be is a daunting task that challenges communities
and the federal government. Even the term access can be
misleading, with access defined as the freedom or ability to
obtain health care, and accessibility defined as the ease with
which health care can be reached in the face of barriers such
as finance or culture.22 As Garetto and Yoder stated, we also
have a responsibility to those who are unaware of need, do
not seek it, cannot get to it, or are afraid of it.23 Ethically, the
goal of improving the health of the population is a societal
greater good benefiting society at large.
Social Justice
Numerous authors and national reports have addressed the
importance of teaching social responsibility as part of
professionalism. Two reports from the Institute of Medicine
(IOM) in the early 2000s advocated increased
professionalism and social justice as a part of improving
quality and bridging the gaps in health care.24,25 The
American Dental Education Association (ADEA) defined its
role and responsibility with its member institutions in
improving the oral health status of all Americans in a report
in 2003 and is now an established association policy (Box
7.2).26 The findings stressed the importance of increasing the
diversity of the oral healthcare workforce and teaching and
exhibiting values that prepare future dental professionals to
commit to delivering oral healthcare to all populations,
including the underserved. The message from the
healthcare professions is that professionalism includes
social responsibility, an ethic of caring, and access to that
care for all members of society.27
Box 7.2
American Dental Education Association
Recommendations for Improving the Oral
Health Status of All Americans
Roles and Responsibilities of Academic Dental
Institutions:
• Monitor future oral healthcare workforce needs.

• Improve the effectiveness of the oral healthcare
delivery system.
• Prepare students to provide oral healthcare services to
diverse populations.
• Increase the diversity of the oral healthcare workforce.
• Improve the effectiveness of allied dental professionals
in reaching the underserved.
Modified from: Haden NK, Catalanotto FA, Alexander CJ,
Bailit H, Battrell A, Broussard J Jr, Buchanan J, Douglass
CW, Fox CE 3rd, Glassman P, Lugo RI, George M,
Meyerowitz C, Scott ER 2nd, Yaple N, Bresch J, Gutman-
Betts Zlata, Luke GG, Moss M, Sinkford JC, Weaver RG,
Valachovic RW, ADEA. Improving the oral health status of
all Americans: Roles and Responsibilities of Academic
Dental Institutions: The Report of the ADEA President’s
Commission. J Dent Educ. 2003;67:563.
Dental Therapists as Part of the

Oral Healthcare Workforce
Dental therapists are a relatively recent addition to the oral
healthcare team in the United States. Dental therapists have
been utilized for over 100 years in over 50 countries. They
were first introduced in the United States in Alaska in 2002
to provide dental care to indigenous populations. Their
introduction was met with fierce resistance by the American
Dental Association and affiliated state organizations, but
dental therapy legislation has been passed by 12 states with
several other states considering such legislation.28 Although
there have been unsupported claims about safety, quality of
care, and cost-effectiveness of dental therapists in providing
dental care, especially to underserved populations, all the
published evidence strongly counters these concerns.29,30 In
addition, in 2015 the American Dental Association’s
Commission on Dental Accreditation (CODA) approved
accreditation standards for dental therapy educational
programs31 that include 3 years of education. However,
dental hygienists can receive credit for their existing
education as “advanced standing” and can usually
accomplish the necessary additional education to become a
dental therapist in about 18 months of additional training.32
Challenges to Ethical Practice and

Social Justice and the Role of the
Dental Hygienist
A dentist’s decision to participate or not in safety net
programs such as Medicaid can be viewed as a fulfillment
of the social contract and maintaining a social justice
perspective. For example, a paper by McKernan and
colleagues showed that Iowa dentists who participated in
that state’s Medicaid program scored significantly higher in
altruistic attitudes.33 Similarly, a paper by Logan and
colleagues showed that dentists who participated in
Florida’s Medicaid program felt a sense of social stigma
from other dentists who did not participate in Medicaid.34
Because only 26.4% of dentists nationally accept Medicaid
patients,35 this can pose a challenge for the dental hygienist
who believes in a social justice perspective.
Most dental hygienists work in an employer/employee
setting in which a solo dentist or small group of dentists
owns and manages the dental care business. What can a
dental hygienist do to fulfill a commitment to social justice?
It is not prudent or feasible for a dental hygienist employee
in such a situation to provide free or discounted dental
hygiene care; this kind of “Band-Aid” approach would not
solve the greater problem anyway.36,37 However, the dental
hygienist can be a part of the movement to alleviate
disparities and develop effective care systems in many other
ways.
The following are some suggested activities to address
these societal disparities:
• Provide dental hygiene services at a safety net clinic.

• Work on a community campaign to install
fluoridation in the local water district.
• Participate in state-organized caries prevention
programs.
• Work with local dental groups to address oral health
disparities.
• Support school-based fluoride and sealant programs.
• Volunteer at general and dental health fairs.
• Provide dental hygiene services in mobile dental
vans.
• Support collaborations among community-based
programs and practitioners.
• Educate patients regarding the importance of public
programs and dental health.
• Educate local, state, and federal policymakers on
access to care issues.
• Become involved in discussions regarding public
health infrastructure.
• Support research on oral health and disparities.
• Recruit individuals to join the oral healthcare
workforce.
• Keep informed on care delivery systems,
reimbursement schedules, and changes in public
policy.
• Advocate improved funding and access for Medicaid
recipients.
• Advocate better dental insurance and the inclusion of
dental benefits in any new national health insurance
plans.
• Advocate increased scope-of-practice regulations, or
new workforce models, at the state or national level
that would allow dental hygienists to provide more
care to underserved patients in a variety of settings.
Dental therapy not only provides dental hygienists with

an opportunity for career advancement but also for
participating in a social good in addressing access to care
and oral health disparities.
The issues surrounding oral health disparities are complex
and confounding. Lee and Divaris have stated that the
ethical imperative of eliminating health disparities will
require bold policies and deep scientific study on the
elements of resources and power.38 The dental hygienist, by
education and practice, is positioned to be at the table in
addressing this global problem.
Summary
Improving oral health care can take many avenues in which
the dental hygienist can be an active and effective
participant. The dental hygienist, along with other
healthcare providers, must recognize the collective and
individual responsibilities held as health professionals to
address the oral health needs of the entire public.
Collaboration among many stakeholders in providing
access to dental care is part of being a professional and
caring member of society.
The test of our progress is not whether we add more to the
abundance of those who have much; it is whether we
provide enough for those who have too little.
Franklin D. Roosevelt
Practice Pointer
The standards of care apply in both private and public
practice settings. Those working in publicly funded
settings must meet the same ethical and legal obligations
as those in privately funded settings.
References
1. U.S. Department of Health and Human
Services: Oral health in America: a report of the
surgeon general, Rockville, MD, 2002, National
Institutes of Health.
2. Albino J, Dye BA, Ricks T. 2020 Surgeon
General’s Report. Oral Health in America:
Advances and Challenges. International
Association for Dental Research; 2019.
https://www.nidcr.nih.gov/sites/default/files/20
19-08/SurgeonGeneralsReport-
2020_IADR_June%202019-508.pdf.
Services: A plan to eliminate craniofacial, oral
and dental health disparities, Rockville, MD,
2002, National Institutes of Health.
4. Centers for Disease Control and Prevention
(CDC). Disparities in Oral Health. Author.
https://www.cdc.gov/oralhealth/oral_health_di
sparities/index.htm.
5. Otto M. For want of a dentist Pr. George’s boy
dies after bacteria from tooth spread to brain.
Washington Post; February 28, 2007.
6. Tomar, SL, Carden, DL, Dodd, CJ,
Catalanotto, FA, Herndon, JB. Trends in dental-
related use of hospital emergency departments
in Florida Journal of Public Health Dentistry 76
(2016) 249–257
7. Shah AC, Leong KK, Lee MK, Allareddy V.
Outcomes of hospitalizations attributed to
periapical abscess from 2000 to 2008: a
longitudinal trend analysis. J Endod
2013;39(9):1104–10
8. Gunja MZ, Collins SR. Who are the remaining
uninsured, and why do they lack coverage?
Findings from the Commonwealth Fund
Biennial Health Insurance Survey, 2018. The
Commonwealth Fund; 2019.
https://www.commonwealthfund.org/publicati
ons/issue-briefs/2019/aug/who-are-remaining-
uninsured-and-why-do-they-lack-coverage.
9. Vujicic M. State of the Dental Market: Outlook
2018 (webinar). American Dental Association,
Health Policy Institute.
www.ada.org/en/science-
research/healthpolicyinstitute/publications/we
binars/state-of-the-usdental-care-market-
outlook-2018.
10. Vujicic M, Buchmueller T, Klein R. Dental care
presents the highest level of financial barriers,
compared to other types of health care services.
Health Aff 2016;35(12):2176-82
11. Bureau of Health Workforce, Health
Resources and Services Administration
(HRSA), U.S. Department of Health & Human
Services. Designated Health Professional
Shortage Areas Statistics. 2022.
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https://data.hrsa.gov/Default/GenerateHPSAQ
uarterlyReport.
12. American Dental Hygienists’ Association.
Transforming Dental Hygiene Education and
the Profession for the 21st Century. 2015.
https://www.adha.org/resources-
docs/Transforming_Dental_Hygiene_Educatio
n.pdf.
13. National Governors Association. NGA Paper.
The Role of Dental Hygienists in Providing
Access to Oral Health Care. Author.
http://www.nga.org/files/live/sites/NGA/files/p
df/2014/1401DentalHealthCare.pdf.
14. Pellegrino ED: What is a profession? J Allied
Health 12(3):168, 1983.
ADHA Code of Ethics. Author. 2019.
docs/ADHA_Code_of_Ethics.pdf.
16. Ozar DT, Sokol DJ. Dental Ethics at Chairside:
Professional Principles and Practical Applications.
2nd ed. Georgetown University Press; 2002.
17. Welie JVM: Is dentistry a profession? Part I:
professionalism defined. J Can Dent Assoc
70(8):529, 2004.
18. Welie JVM: Is dentistry a profession? Part II:
hallmarks of professionalism. J Can Dent Assoc
70(9):599, 2004.
19. Welie JVM: Is dentistry a profession? Part III:
future challenges. J Can Dent Assoc 70(10):675,
2004.
20. Dharamsi S, MacEntee M: Dentistry and
distributive justice. Soc Sci Med 55:323, 2002.
21. Dharamsi S: Building moral communities?
First, do no harm. J Dent Educ 70(11):1235,
2006.
22. Crall JJ: Access to oral health care:
professional and societal considerations. J Dent
Educ 70(11):1133, 2006.
23. Garetto LP, Yoder KM: Basic oral health needs:
a professional priority? J Dent Educ
70(11):1166, 2006.
24. Institute of Medicine: Crossing the quality
chasm: a new health system for the 21st
century, Washington, DC, 2001, National
Academies Press.
25. Institute of Medicine: Health professions
education: a bridge to quality, Washington, DC,
2003, National Academies Press.
26. Haden NK, Catalanotto FA, Alexander CJ,
Bailit H, Battrell A, Broussard J Jr, Buchanan J,
Douglass CW, Fox CE 3rd, Glassman P, Lugo
RI, George M, Meyerowitz C, Scott ER 2nd,
Yaple N, Bresch J, Gutman-Betts Zlata, Luke
GG, Moss M, Sinkford JC, Weaver RG,
Valachovic RW, ADEA. Improving the oral
health status of all Americans: roles and
responsibilities of academic dental institutions:
The report of the ADEA President’s
Commission. J Dent Educ. 2003;67:563.
27. Beemsterboer PL: Developing an ethic of
access to care in dentistry. J Dent Educ
70(11):1212, 2006.
( )
28. Simon L, Donoff RB, Friedland B, Dental
therapy in the United States: Are developments
at the state level a reason for optimism or a
cause for concern? J Public Health Dent. 2021
Dec;81(1):12-20. doi: 10.1111/jphd.12388. Epub
2020 Aug 17. PMID: 32805762
29. Catalanotto, FA In Defense of Dental Therapy:
An Evidence-Based Workforce Approach to
Improving Access to Care. J Dent Educ. 2019
Feb;83(2 Suppl):S7-S15. doi:
10.21815/JDE.019.036. PMID: 30709933
30. Chi DL, Lenaker D, Mancl L, Dunbar M, Babb
M. Dental therapists linked to improved dental
outcomes for Alaska Native communities in the
Yukon-Kuskokwim Delta.J Public Health Dent.
2018 Mar;78(2):175-182. doi:
10.1111/jphd.12263. Epub 2018 Jan 29. PMID:
29377127
31. Commission on Dental Education. Dental
Therapy Education Standards.
https://www.ada.org/~/media/CODA/Files/den
tal_therapy_standards.pdf?la=en.
32. Self K, Brickle C, Dental Therapy Education in
Minnesota. Am J Public Health. 2017
May;107(S1):S77-S80. doi:
10.2105/AJPH.2017.303751. PMID: 28661792
33. McKernan SC, Reynolds JC, Momany ET, et al:
The relationship between altruistic attitudes
and dentists' Medicaid participation. J Am
Dent Assoc 146(1):34–41, 2015.
34. Logan HL, Catalanotto F, Guo Y, et al: Barriers
to Medicaid participation among Florida
p p g
dentists. J Health Care Poor Underserved
26(1):154–167, 2015.
35. Unpublished data from the survey of dental
practice. Health Policy Institute, American
Dental Association, 2015.
36. Mouradian WE: Band-Aid solutions to the
dental access crisis: conceptually flawed—a
response. J Dent Educ 70(11):1174, 2006.
Services. National Healthcare Quality Report.
National Institutes of Health; 2005.
38. Yee JY, Divaris K: The ethical imperative of
addressing oral health disparities: a unifying
framework. J Dent Res 93(3):224–230, 2014.
SECTION
II
Law
Chapter 8
Society and the State Dental

Practice Act
Michele P. Carr and Kristin Minihan-Anderson
Chapter Outline
Statutory Law 76
State Dental Boards 76
The Practice of Dental Hygiene 77
Rules and Regulations 77
Licensure Provisions 78
Display of License 79
License Renewal 79
Standards of Practice 80
Continuing Education Requirements 80
Licensing Fees 81
Scope of Practice 81
Supervision Requirements 81
Other Selected Statutory Provisions 82
Abuse Reporting 82
Patient Records 82
Professional Liability Insurance 82
Cardiopulmonary Resuscitation Certification 83
Self-Referral and Kickbacks 83
Due Process 83
Summary 83
Learning Outcomes
• Describe the role of the state in the governing of
healthcare professions.
• Identify the provisions likely to be included in state
statutory law for the practice of dental hygiene.
• Describe the different categories of licenses available for
dental hygiene licensure.
• List the reasons that a dental hygiene license may be
denied, suspended, restricted, or revoked.
• Compare and contrast direct supervision, indirect
supervision, general supervision, and independent
practice.
• Recognize the responsibility of the dental hygienist for
understanding and observing the state statutory and
regulatory provisions.
State governments are given authority and responsibility to

protect the health, safety, and welfare of the state's citizens.
The practice of health professionals, including dental
hygienists, is governed under this authority. The structure of
each state's government is prescribed in the state
constitution. In general, state governments are divided into
three branches: (1) legislative, (2) executive, and (3) judiciary.
The legislative branch is authorized to enact laws or statutes
that prescribe or prohibit activities within the state. The
executive branch plays a major role in the implementation
and enforcement of the prescriptions and prohibitions
enacted into law. The judiciary branch is the final arbiter
regarding the rights and responsibilities of individuals
subject to the laws of the state. The practice of dental hygiene
is regulated through each of these branches of state
government. If left unregulated, the practice of dental
hygiene could have the potential to harm patients. Dental
hygiene is a highly skilled profession that requires
professional education for the achievement and maintenance
of competence. Government regulation is intended to
minimize the public risk of untoward healthcare outcomes.
The state dental practice act is the government regulation
that most specifically controls the practice of dental hygiene.
Statutory Law
The legislative branch of government generally is responsible
for the enactment of the state dental practice act, and state
dental practice acts are overseen by state dental boards. The
overall intent of state dental practice acts is to help ensure
the protection of the public's health. In a limited number of
states, the state constitution reserves for the people the right
to enact laws independent of the legislature. For example, in
the state of Washington, the constitution states,
“the people enacted Initiative Measure No. 607, known as the

Washington State Denturist Act, which established a
program of licensure for denturists which provides a
mechanism for consumer protection, and offers cost-effective
alternatives for denture care services and products to
individual consumers and the state” (WASH. REV. CODE
§18.30.005 [2014]).
The state dental practice act may be a single law or a

compilation of laws that regulate the practice of dentistry.
These laws regulate the practice of dentistry by dentists,
dental therapists, dental hygienists, denturists, dental
assistants, expanded function dental auxiliary, and dental
anesthesia assistants. Statutes that regulate the health
professions are generally not all encompassing. In other
words, dental hygienists must be familiar with the laws that
deal specifically with dental hygiene as well as the general
laws that protect the well-being of the state's citizens. For
example, most states have enacted laws that require
healthcare professionals to report suspected child abuse. This
law may be found in acts that focus on child protection
rather than on the practice of dental hygiene. Refer to the list
that follows for a list of issues applicable to healthcare
professionals that may be regulated by state law but may not
be specifically incorporated into the state dental practice act.
Issues That May Be Regulated by State Laws but May Not Be

Specifically Incorporated Into the State Dental Practice Act
• Abuse reporting requirements (e.g., child, dependent

adults, and domestic violence)
• Biomedical wastes and hazards management
• Business operation practices (e.g., rebating, credit
agreements, business license, and advertising)
• Consent to treatment and informed consent
• Criminal activity
• Disability accommodation
• Education and training requirements (e.g., bloodborne
pathogens)
• False healthcare claims
• Liability for volunteer services
• Malpractice or actions resulting from healthcare injuries
• Mandatory malpractice insurance
• Patient confidentiality and heightened protections (e.g.,
sexually transmitted diseases, mental health treatment,
and substance abuse treatment)
• Public health reporting requirements (e.g., contagious or
infectious diseases)
State Dental Boards

The governing bodies of dentistry may be referred to in
terms such as Board of Dental Examiners, Board of Dentistry,
State Dental Board, State Dental Commission, Dental Quality
Assurance Commission, or Board of Dental Health Care.
Dental hygiene representation in such regulatory bodies is
common. For example, most dental boards are comprised of
dentists, dental hygienists, and public members who are
appointed by the governor of each state for specific terms. In
Colorado, the dental board consists of seven dentist
members, three dental hygienist members, and three
members from the public at large. The governor appoints
each member for a term of four years with a maximum of
two consecutive terms (§12-220-105 [2021]). Alternatively, the
practice of dental hygiene may be the purview of an elected
regulatory body. In North Carolina, dental hygienists are
elected to the Board of Dental Examiners in an election as
opposed to being appointed by the governor (§90-22 [1987]).
The job of members of state dental boards is to interpret and
enforce the state dental practice acts, which are written by
the state legislature. Generally, state dental boards do not
have the power to change what is written in the state dental
practice act without the state legislature passing an
amendment. Additionally, as dentistry changes, state dental
boards may interpret the state dental practice act to keep
current with the profession, but they can only interpret this
with what is written in the dental practice act. Along with
interpreting and enforcing state dental practice acts, the
functions of state dental boards may include the examination
of dental hygienists for licensure; issuance, renewal, and
revocation of dental hygiene licenses; investigation of
disciplinary charges; and adoption of rules and regulations
regarding the practice of dental hygiene. In some states, the
regulatory body may be advised by a secondary body, which
has greater dental hygiene representation, such as a council,
as in Florida, or a Dental Hygienists Committee, as in New
Mexico. The American Dental Hygienists' Association
(ADHA) is a resource for information on states that utilize
bodies secondary to dental boards.1
Courtesy: Idaho State University Department of Dental
Hygiene.
The Practice of Dental Hygiene

In the United States, the practice of dental hygiene is not
nationally regulated. A movement towards an interstate
licensure compact is being considered which would allow
dental hygienists to work seamlessly within states that
choose to join the compact. Until this becomes a reality, the
practice of dental hygiene is different in each state. To obtain
a dental hygiene license, applicants must take and pass a
jurisprudence examination that delineates the laws and rules
specific to the state's dental practice act. The professional
obligation of dental hygienists is to be intimately familiar
with the laws and regulations of the state in which they
practice. A dental hygienist should, on an annual basis,
review the applicable state dental practice act as laws and
rules change to keep current with professional standards. A
good time to do this may be at the time of license renewal,
birth date, or another annually recurring date of significance.
The contact information for the state licensing agency can be
obtained from the American Association of Dental Boards at
https://www.dentalboards.org.
State statutory law that regulates the practice of dental

hygiene is likely to include provisions regarding the
following: (1) licensure requirements, (2) licensure
examination requirements, (3) licensure eligibility
requirements, (4) licensure by endorsement, (5) approval of
educational programs, (6) examination and disciplinary
authority, (7) scope of practice, (8) supervision requirements,
and (9) continuing education requirements. These laws
provide a general outline of requirements, provisions, and
limitations of the practice of dental hygiene and grant
authority to the executive branch of government to
implement administrative procedures and requirements.
Rules and Regulations
The executive branch of government is responsible for
implementing the statutory law and providing more specific
guidance and regulations regarding the practice of dental
hygiene. The executive branch includes the departments and
agencies of state government (e.g., Department of Health,
Department of Professional Regulation, Department of
Consumer and Industry Services, or Secretary of State). The
development of more specific requirements (e.g., rules) for
implementing statutory law is accomplished through a
process known as rule making, which is a public process that
provides the opportunity for input from interested persons,
including dental hygienists.
Licensure Provisions
To practice dental hygiene legally, individuals must have a
dental hygiene license in the state in which they practice. In
general, a condition of initial dental hygiene licensure is to be
(1) at least 18 years of age, (2) be of good moral character, (3)
graduate from a dental hygiene program accredited by the
Commission on Dental Accreditation (CODA), and (4)
successful completion of national, regional, and/or state
licensure examination. An exception to these general
conditions exists in Alabama, where the law allows that
applicant for examination and license as a dental hygienist
can be a “graduate of a school of dental hygiene which has
been approved by the board, shall have served as a dental
assistant for a period of time established by board rule and
shall have served at least one year as a dental hygienist
trainee under a training permit issued by the board to a
qualified dentist practicing in this state in accordance with
the dental hygienist training program established by the
board” (ALA. CODE §34-9-26 [2021]).
A dental hygiene license also may be issued on the basis of a

review of credentials, also known as licensure by endorsement
or reciprocity. Dental hygienists who have graduated from a
CODA-accredited dental hygiene program, who are licensed
in good standing in a state with similar or higher
requirements for licensure, and who have practiced dental
hygiene for a minimum prescribed period dictated by the
state may have examination requirements waived on the
basis of their credentials. For example, in Colorado the
dental board can issue a license to an applicant “duly
licensed as a dental hygienist in another state or territory of
the United States who has submitted credentials and
qualifications for licensure that include: (a) Verification of
licensure from any other jurisdiction where the applicant has
held a dental hygiene or other health care license; (b)
Evidence of the applicant's successful completion of the
national board dental examination administered by the joint
commission on national dental examinations; (c) (I)
Verification that the applicant has been engaged either in
clinical practice or in teaching dental hygiene or dentistry in
an accredited program for at least one year during the three
years immediately preceding the date of the receipt of the
application; or (II) Evidence that the applicant has
demonstrated competency as a dental hygienist as
determined by the board; (d) A report of any pending or
final disciplinary actions against any health care license held
by the applicant at any time; and (e) A report of any pending
or final malpractice actions against the applicant” (COLO.
REV. STAT. §12-35-127.5 (2) [2021]).
In North Dakota, to practice dental hygiene by credential

review, the applicant, for at least 3 years immediately
preceding application, must have a license in good standing
and have been actively practicing dental hygiene in another
jurisdiction where the requirements are at least substantially
equivalent to those of the state (N.D. CENT. CODE §43-20-
01.3 [2014]).
Some states provide for temporary or provisional licensure

of dental hygienists who are licensed in other jurisdictions,
are relocating to that state, and do not have the option of
licensure by credential available to them. A temporary or
provisional license is valid for a prescribed period or
purpose, or until the next scheduled licensure examination.
Typically the license must be in good standing with the
licensing requirements from the existing state being
substantially equivalent to the state in which the hygienist is
applying for a license. As with initial licensure requirements,
applicants for this type of license must be a graduate of a
recognized school of dentistry or dental hygiene accredited
by CODA and approved by the board and must have passed
a national or other examination recognized by the board
relating to the practice of dental hygiene. In addition, the
dental hygiene applicant must be sponsored by a person
who holds an appropriate license and with whom the
provisional license holder will practice during the time the
person holds a provisional license.
A volunteer license may be available to dental hygienists
who hold a dental hygiene license in good standing in
another jurisdiction, have passed an examination prescribed
by the dental board, have the minimum specified years of
clinical experience, and seek to provide volunteer services.
As documented in South Carolina statute, a person holding a
volunteer license is restricted to practicing in clinics
prescribed by the board and to only treating patients who do
not have dental insurance, are not eligible for financial
assistance for dental treatment, and do not receive
remuneration for providing dental hygiene services (South
Carolina Code of Laws, SECTION 40-15-177, [1994]).
Some states provide a faculty license for dental hygienists

whose practice of dental hygiene is limited to dental hygiene
education. Individuals for this type of license must be
endorsed by an accredited dental hygiene school in the state
where a license is being sought. The state dental board may,
without examination, issue a teacher's certification to a
dental hygienist who has been authorized to practice in
another state or country. In Ohio, the statute states, “A
teacher's certificate is subject to renewal in accordance with
the standard renewal procedures and holders of this type of
license are not authorized to perform any dental hygiene
functions other than teaching or demonstrating the skills of a
dental hygienist in the educational programs of the
accredited dental hygiene school which endorsed the
application” (OHIO REV. CODE ANN. §4715.27 [2021]).
These licensure provisions and descriptions are summarized

in Table 8.1.
Table 8.1
Types of Dental Hygiene Licenses

Type of Purpose
License
Full A full dental hygiene license may be granted
license on the basis of examination or endorsement of
credentials; such a license permits unrestricted
practice within the scope of the state dental
practice act.
Tempora A temporary dental hygiene license, granted on
ry the basis of licensure in another jurisdiction,
license permits practice within the scope of the state
dental practice act for a limited period of time
while the dental hygienist pursues full
licensure status.
Volunte A volunteer dental hygiene license, granted on
er the basis of licensure in another jurisdiction,
license permits practice within the scope of the state
dental practice act for the purpose of volunteer
(e.g., unremunerated) public service.
Faculty A faculty dental hygiene license, granted on
license the basis of prior licensure in another
jurisdiction, permits a faculty member to
practice within the scope of his or her
educational responsibilities.
Display of License
Dental hygienists generally are required to display a current
copy of their license or licensure renewal documentation at
their place(s) of practice. If working in multiple offices, a
copy of the original license or renewal documentation will
suffice.
License Renewal
Dental hygiene licenses expire and require renewal on a
schedule (e.g., annually or biennially) prescribed by state
law. When a dental hygienist experiences a limited lapse of
licensure (e.g., failure to renew the license before expiration),
state law may provide for reinstatement without
examination with proof of continued professional
competence and payment of renewal and penalty fees. For
example, in Alaska, a licensed dental hygienist who does not
pay the renewal registration fee forfeits their license. The
board may reinstate the license without examination within 2
years of the date on which payment was due upon written
application, proof of continued professional competence, and
payment of all unpaid renewal and penalty fees (Alaska
Statute Sec. 08.32.081[2022]).
If a dental hygienist does not renew their license but

continues to practice, this constitutes practicing without a
license and is a criminal offense. Depending upon the state
and type of criminal offense, the violation may constitute a
felony or a misdemeanor and is subject to disciplinary action.
Dependent upon the violation, the penalty for
noncompliance with licensure requirements may include a
monetary fine and/or imprisonment. In California, if a
person is found guilty of a misdemeanor and convicted, they
may be punished by imprisonment in a county jail of not less
than 10 days nor more than 1 year, or by a fine of not less
than one hundred dollars ($100) nor more than one thousand
five hundred dollars ($1,500) (CAL. BUS. & PROF. CODE
§1958 [2020]). In Connecticut, the fine cannot exceed five
thousand dollars ($5,000) and the term served cannot be
more than 5 years (CONN. GEN. STAT. §53a-41 [2014]).
Standards of Practice
Dental hygienists are obligated to comply with the accepted
standards of professional practice and conduct. The
standards may be specific to the practice of dental hygiene or
more generally applicable to healthcare professionals. Dental
hygienists are responsible for knowing the standards of
practice in their state and ensuring that they are competent
to engage in practice and comply with the provisions of their
licensure. The standards of practice for dental hygiene are
the minimum, competent, safe level of care provided by
dental hygienists when they apply dental hygiene
knowledge, skills, and attitudes to their practice. The ADHA
published Standards for Clinical Dental Hygiene Practice,
which can serve as a guideline for the most updated
standards of practice.2
Some states have uniform standards of professional conduct

for healthcare professionals, including the delineation of
conduct and acts and conditions that constitute
unprofessional conduct.
A dental hygiene license may be suspended or revoked on

the basis of unprofessional conduct, violations of the laws
and regulations governing the practice of dental hygiene,
and clinical incompetence or the delivery of substandard
care. Unprofessional conduct is a broad term that may
encompass, but is not limited to, acts of fraud,
misrepresentation, or deception; conviction of a felony;
aiding and abetting, in the practice of dentistry or dental
hygiene, any person not licensed to practice dentistry or
dental hygiene; sexual conduct with a patient; and violation
of state or federal laws. Dental hygienists also may have their
practice restricted or suspended if they become impaired by
reason of mental illness, physical illness, or habitual or
excessive use or abuse of alcohol or controlled substances.
Continuing Education
Requirements
Most states have continuing education requirements for
maintaining a dental hygiene license. Such provisions may
be found in state statutes or administrative rules, and they
vary in the number of hours required to renew a license, the
content of the course, and the course's presentation format.
For example, in Ohio, every person licensed to practice as a
dental hygienist and required to register with the state dental
board must certify to the board at the time of applying for a
renewal of registration in the two-year period preceding the
registration period for which renewal is sought, the
registrant completed a minimum of 24 hours of continuing
dental hygiene education (Ohio 4715.25 [2021]).
Documentation or certification of compliance with

continuing education requirements may be necessary when
renewing the license. If documentation is not required at the
time of license renewal, records of continuing education
completion should be maintained for at least 2 bienniums as
some states conduct random audits for compliance. In Ohio,
“A licensed dental hygienist shall retain in the dental
hygienist's records for a period of at least four years such
receipts, vouchers, or certificates as may be necessary to
document completion of continuing education programs.
With cause, the board may request such documentation from
licensed dental hygienists, and the board may request such
documentation from licensed dental hygienists at random
without cause” (Ohio 4714-25 ORC [2021]).
Licensing Fees
Initial licensure and renewal of the professional license
require payment of a licensing fee. Dental hygienists who are
not actively practicing dental hygiene and do not want to
maintain a current license may be able to apply for an
inactive license or retire their license. Although not all states
have provisions for an inactive status, when available, an
inactive or retired license may permit a dental hygienist to
avoid the expense of maintaining an active license. It also
permits the dental hygienist to maintain recognized
professional status as a dental hygienist and to reactivate the
license upon demonstration of professional competence (e.g.,
documentation of continuing education). Some states, such
as Arkansas, require that a dental hygienist be practicing to
maintain active licensure status. That law states, “Dental
hygienists are automatically forfeited if they cease to practice
either in the State of Arkansas or elsewhere for a period of
two (2) years” (ARK. CODE ANN. §17-82-314 (a) [2015]).
Scope of Practice
The scope of dental hygiene practice varies among the states.
The practice of dental hygiene includes educational,
assessment, preventive, clinical, and other therapeutic
services. The specific functions that can be legally performed
in each of these aspects of dental hygiene practice are
defined by state law. Examples of functions that are
routinely allowed to be performed by the dental hygienist
include the removal of deposits, accretions, and stains from
the supragingival and subgingival surfaces of teeth by
scaling, root planing, and polishing; the application of pit
and fissure sealants, fluoride, and other topical therapeutic
and preventive solutions; dental hygiene assessments and
the charting of oral conditions; obtaining intraoral
photographs; and exposing and interpreting oral
radiographs. The practice of dental hygiene may include
additional functions such as the administration of local
anesthesia and nitrous oxide sedation as well as the
performance of laser and restorative procedures. This
expanded scope of practice typically requires approved
instruction, formal endorsement, and/or heightened
supervision. Regarding the administration of local
anesthesia, in Ohio the law states that a dental hygienist may
administer intraoral block and infiltration local anesthesia to
a patient under direct supervision if the dental hygienist is in
compliance with the education requirements and rules set
forth by the dental board (Ohio 4715.230 ORC [2019]).
Additionally, in Oregon, “Expanded Functions of Dental
Hygienists must complete a course of instruction in a
program accredited by the Commission on Dental
Accreditation or other course of instruction approved by the
Board” (Or. ADMIN. R. §818-035-0072 [2015]). General
preclusions of dental hygiene practice include diagnosis for
dental procedures or treatments and the cutting or removal
of hard or soft tissues. The prescribing of drugs or
medications is allowable in some states dependent upon the
state's dental practice act. The ADHA provides a resource
where the scope of practice for each state is presented.3
Dental hygienists have a legal and professional obligation to

limit their practice to the scope of functions permitted by law
in the jurisdiction in which they are practicing. If asked by an
employing dentist or another licensed dental professional
(e.g., dental therapist) to perform services that are clearly
outside the legal scope of practice, the dental hygienist is
obligated to decline to comply with the request. If it is
unclear whether a procedure is within the legal scope of
practice, the dental hygienist or employing dentist should
seek clarification from the governing authority in the state of
practice (e.g., board of dentistry or state dental board).
Supervision Requirements
The level of supervision required for the practice of dental
hygiene varies by state, the scope of practice, and the
location of the practice. Although the specific definitions for
supervision are state specific, they can be generalized. Direct
supervision generally requires a prior diagnosis of the
patient's condition and authorization of a procedure by a
dentist, the presence of a supervising dentist on the
premises, and dentist approval of the work performed before
patient dismissal. Indirect supervision requires a prior
diagnosis of the patient's condition and authorization of a
procedure by a dentist and the presence of a supervising
dentist on the premises. General supervision requires that
the services being delivered be authorized by the dentist
along with other stipulations; however, the presence of the
supervising dentist in the treatment facility is not required,
but the dentist's availability for consultation may be
required.
Some states, including Colorado, Connecticut, New Mexico,

Minnesota, and Maine, permit the unsupervised practice of
dental hygiene. Practicing unsupervised allows the dental
hygienist to practice within the scope of their educational
training and experience without the supervision of a licensed
dentist. This type of practice may also be referred to as
independent practice. The independent practice licensee, as
described in Colorado, allows for the licensee to be the
proprietor of a place where independent practice dental
hygiene is performed and for the licensee to purchase, own,
or lease equipment necessary for the performance of
independent practice dental hygiene.
Other Selected Statutory Provisions

Not all laws governing the practice of dental hygiene are
encompassed in the state dental practice act. This does not
negate, however, the dental hygienist's obligation to comply
with such laws. This section provides examples of laws that
may not be incorporated in the state dental practice act but
instead may be located in other statutes that are universally
applicable to healthcare providers or by topic (e.g., child
protection statutes).
Abuse Reporting
The practice of dental hygiene focuses on the prevention of
dental diseases to promote oral and general health, and this
encompasses the prevention of child abuse through proper
identification and reporting of suspected cases. In all 50 US
states, healthcare providers are mandated to report
suspected cases of abuse and neglect to the appropriate
authorities, which can include social service or law
enforcement agencies.4 Dependent upon state law, members
of the dental team, including dental hygienists, are specified
as mandated reporters of suspicious cases. Reports must be
made when there is reasonable cause to suspect child abuse
or neglect in order to make state investigative and social
services available and to make sure investigations regarding
child abuse and neglect are conducted by trained
investigators.
In addition, several states have enacted similar legislation

that mandates or encourages the reporting of abuse of
vulnerable, dependent, and disabled adults. Dental
hygienists should be familiar with their personal
responsibility to report abuse as it has ethical and legal
professional demands. Child abuse and neglect are
widespread public health problems, and this problem spans
all socioeconomic, cultural, and ethnic aspects of society.5
The prevalence of elder abuse is also alarming, and although
no one knows precisely how many older Americans are
being abused, neglected, or exploited, evidence of such
issues is accumulating.6
Resources to aid the clinician in identifying and reporting

abuse should be available and reviewed often as dental
hygienists have an important role in the detection of abuse.
Patient Records
Although the maintenance of a patient record is
professionally prudent, it may also be mandated statutorily.
Some states have incorporated patient record requirements
within the state dental practice act or related regulations
(e.g., WASH. ADMIN. CODE §246-817-310 [2015]), whereas
others have enacted separate laws that broadly delineate the
requirements for maintaining healthcare information (e.g.,
ch. 50-16 MONT. CODE ANN. Uniform Health Care
Information and ch. 629 NEV. REV. STAT. ANN. Healing
Arts Generally). Healthcare records are generally recognized
to be confidential and protected against disclosure to
unauthorized third parties (e.g., ch. 5-37.3 R.I. GEN. LAWS,
Confidentiality of Health Care Communications and
Information Act).
Professional Liability Insurance

Dental hygienists in some states are mandated to maintain
professional liability insurance or other indemnity against
liability for professional malpractice. When mandated, the
law may prescribe the level of insurance that must be
maintained per incident as well as in the aggregate. In
Connecticut, for example, the law states that “every dental
hygiene licensee must maintain professional liability
insurance or other indemnity against liability for
professional malpractice. In addition, the amount of
insurance carried by each person against claims for injury or
death for professional malpractice must not be less than five
hundred thousand dollars for one person, per incidence,
with an aggregate of not less than one million five hundred
dollars” (CONN. GEN. STAT. §20-126x (a) [2014]).
Cardiopulmonary Resuscitation Certification

Maintaining current cardiopulmonary resuscitation (CPR) or
basic life support (BLS) certification is professionally
prudent. Some states have enacted legislation that mandates
that dental professionals be currently certified. Similar to
many jurisdictions, Illinois law states that a dental hygienist
must provide at the time of license renewal proof of current
BLS certification for healthcare providers. Dependent upon
state practice acts, CPR or BLS training may be counted
toward continuing education hours (ILL. COMP. STAT.
ANN. 25/16 [2015]).
Self-Referral and Kickbacks

State and local self-referral statutes have been enacted to
avoid the conflict of interest that may be inherent in the
referral of a patient by a healthcare provider to a provider of
healthcare services in which the referring provider has an
investment interest (e.g., fa. stat. ch. §456.053). Prohibitions
on kickbacks, or remuneration or payment as an incentive or
inducement to refer or solicit patients also have been enacted
at the federal and state levels (e.g., fa. stat. ch. §456.054 2008).
Due Process
In the event of threatened adverse actions by dental boards
against licensure status, dental hygienists should become
familiar with the available administrative procedures.
General due process provisions include notice and an
opportunity to be heard. Notice generally includes a
statement of the proposed action to be taken, the available
evidence supporting the proposed action, and the
opportunity for a hearing. The proposed action can be taken
uncontested if the dental hygienist fails to respond within
the time and in the manner specified in the notice. If a
hearing is requested, the dental hygienist will be notified, at
a minimum, of the time and place of the hearing and who
will conduct the hearing.
Summary
Dental hygiene is a state-regulated health profession because
of society's concern for the well-being of its citizens. The
dental hygiene professional is obligated to be intimately
familiar with the statutory and regulatory provisions of the
practice of dental hygiene. Noncompliance with these
provisions is not an excuse for failure to know or understand
one's professional responsibilities. Therefore, on an annual
basis, dental hygiene professionals should review the state
dental practice act for the jurisdiction(s) in which they are
licensed and practicing as laws and rules may change.
Practice Pointer
Boards are not to be feared. They exist to protect the public

and are willing to help dental professionals comply with
state dental practice acts. If a dental hygienist has questions
regarding the dental practice act, the scope of practice for
dental hygienists, or licensure procedures, they should
contact the state dental board or governing body for the
appropriate information and clarification. When licensure is
on the line, it is much better to ask for permission rather than
for forgiveness!
References
1. American Dental Hygienists' Association (ADHA). Dental
Hygiene Participation in Regulation. ADHA; 2019.
docs/75111_Self_Regulation_by_State.pdf.
2. American Dental Hygienists' Association (ADHA).

Standards for Clinical Dental Hygiene Practice. ADHA; 2016.
3. American Dental Hygienists' Association (ADHA).

Practice Act Overview. https://www.adha.org/wp-
content/uploads/2023/01/ADHA_Practice_Act_Overview_8-
2022.pdf.
4. Fisher-Owens, SA, Lukefahr, JL, Tate, AR. Oral and Dental

Aspects of Child Abuse and Neglect. Ped. Dent 39(4): 278-
283, 2017.
5. Jones ML, Francisco EF: Recognize the signs. Dimens Dent

Hyg 12(2):48–52, 2014.
6. Acierno R, Hernandez MA, Amstadter AB, et al:

Prevalence and correlates of emotional, physical, sexual, and
financial abuse and potential neglect in the United States:
The national elder mistreatment study. Am J Public Health
100(2):292–297, 2010.
CHAPTER
9
Dental Hygienist–Patient
Relationship
Pamela Zarkowski and Michele P. Carr
Chapter Outline
Legal Framework of the Relationship 86
Overview of the Legal System 86
Civil Law 86
Contract Law 86
Tort Law 87
Intentional Torts to Persons 87
Intentional Torts to Property 88
Unintentional Tort of Negligence 88
Rights and Responsibilities of the Dental
Hygienist and Patient 88
Legal Actions for Healthcare Injuries 89
Informed Consent 90
History 90
Elements of Informed Consent 90
Who Can Give Informed Consent? 91
Documentation of Informed Consent 91
Informed Refusal 92
Professional Malpractice 92
Malpractice Defined 92
Shared Responsibility 92
Statute of Limitations 92
Reporting Requirements 93
Breach of Contract 93
Summary 93
Learning Outcomes
• Describe the professional obligation that exists between the
dental hygienist and the patient.
• Recognize the difference between civil law and criminal law
in the US legal system.
• Compare intentional torts and persons, intentional torts and
property, and unintentional torts and negligence.
• List and evaluate the rights and responsibilities of the dental
hygienist in the provider–patient relationship.
• State the patient's responsibilities when receiving oral health
care.
• Describe the elements of informed consent.
• Define malpractice and contributory negligence.
The dental hygienist–patient relationship is a critical factor in the

delivery of quality dental hygiene care. The dental hygienist–
patient relationship is a two-party association that can only achieve
its fullest potential with the committed participation of each of the
parties. Patients enter into this therapeutic relationship with certain
expectations. Dental hygienists must understand these expectations
through communication with their patients. Suppose dental
hygienists are unable to meet their patients' expressed expectations.
In that case, the patients must understand this limitation and either
accept the limitation and alter their expectations or seek care from
an alternative provider who is able to meet the expectations. The
dental hygienist has a professional obligation in this relationship to
comply with the laws that govern the practice of dental hygiene
and to deliver oral healthcare services that meet the standards of
care of the profession. Failure to fulfill this professional obligation
can result in untoward consequences to the patient and dental
hygienist. The consequences to the patient may be substandard
and/or unauthorized care. Several consequences for the dental
hygienist, such as complaint review, sanctions, or even criminal
penalties, are possible. Three examples from state law demonstrate
the variation found across the United States.
Legal Framework of the Relationship

In addition to being a professional relationship, the dental
hygienist–patient relationship also is legally binding. Dental
hygiene professionals must be familiar with the legal principles of
the relationship to guide their actions, decisions, record-keeping,
and professional interactions. The legal principles are based on
society's general belief that citizens have a right to be protected and,
if they come to harm at the hands of another, they have a right to be
compensated.
Society provides justice to harmed citizens through civil and
criminal litigation (civil action or criminal action). A civil offense is
a wrongful act against a person that violates their person (body),
privacy, property, or contractual rights. A dental hygienist who
fails to provide appropriate periodontal therapy that results in a
condition of increased severity may have committed a civil offense.
An office manager who breaches confidentiality by discussing a
patient's medical condition with an unauthorized person without
the patient's consent may have committed a civil offense. A
violation of criminal law is a violation of a societal rule outlined by
statutory law. Physically harming someone with a weapon is a
criminal offense, as is practicing dental hygiene without a license.
Although civil offenses are most commonly litigated, both civil and
criminal offenses can be committed in the practice of dental
hygiene.
Practice Pointer
Dental professionals can be subject to both allegations of civil or
criminal offenses.
Overview of the Legal System

The legal system has a clearly outlined structure for dealing with
civil and criminal offenses, including filing, investigating, and
resolving claims and allegations. The party bringing a claim is
referred to as the plaintiff in a civil proceeding and the prosecutor in
a criminal proceeding. The party defending a claim is referred to as
the defendant. The investigation of claims and allegations includes
the discovery of evidence, which may be gathered through
interrogatories and depositions. In addition to the plaintiff (i.e.,
harmed party) and defendant, other individuals who may be
witnesses to events or recorders of information may be called on to
respond to requests for information. The resolution of claims and
allegations may require a court proceeding known as a trial. In a
trial, the plaintiff or prosecutor is given the opportunity to present
allegations, including evidence. The defendant is allowed to present
a defense, including evidence, to a panel of judges or jury.
Questions of law are decided by judges, whereas juries decide
questions of fact. In a criminal case, the establishment of guilt
requires a high level of certainty known as beyond a reasonable doubt.
In a civil case, the establishment of a claim may require a level of
certainty that is greater than 50 percent, known as the preponderance
of evidence. The nature of the claim or allegation influences the
determination of which party (plaintiff or defendant) bears the
responsibility for meeting the required level of proof.
Civil Law
The two major categories of civil law are contract law and tort law.
Contract Law
A contract is a legally binding agreement to keep a promise in
exchange for something of value. The courts view the relationship
between a healthcare provider and a patient in terms of a contract.
Simply stated, a dental provider agrees to deliver oral healthcare
services to a patient, and in return, the patient agrees to cooperate
in the care and arrange for appropriate payment. The exchange of
promises that creates a binding contract may be expressed or implied.
An express contract is an agreement that is stated in explicit
language, either orally or in writing. For example, a written
treatment plan that outlines the procedures to be performed and
associated costs may be viewed as an express contract. An implied
contract is recognized if, based on the circumstances surrounding a
particular event, the assumption that a contract exists between the
parties is reasonable. An implied contract can occur through
inference by signs, inaction, or silence. In a dental office, the
patient's action of arriving at the office at a scheduled time and
sitting in the dental chair and the dental provider's actions of
treating the patient may establish an implied contract. A
contractual relationship is a relationship that binds each of the
parties to fulfill their committed responsibilities. Failure to meet
one's contractual obligations is known as a breach of contract, which
may be remedied through the judicial system.
Justice Statue.
Tort Law
A tort is a civil wrong that results from the breach of a legal duty
that exists by virtue of society's expectations of performance, rather
than a contractual or privately created performance obligation.
Torts include two types: intentional and unintentional. An
intentional tort is a deliberate and purposeful act that has
substantial certainty of untoward consequences from the act.
Intentional torts relate to persons and property. Insurance policies
that protect healthcare providers against liability-associated
healthcare delivery may not provide coverage for intentional tort
liability. An unintentional tort includes no intent to cause harm,
although harm or injury does occur.
Intentional Torts to Persons

The intentional tort of battery is defined as harmful, nonconsensual,
or offensive contact with a person. An injury does not have to occur
—only a physical invasion of a person. Intentional torts are
differentiated from unintentional torts based on the state of mind of
the wrongdoer and their intent to cause harm. For example, a
dental hygienist who slaps a child on his buttocks with the intent to
make physical contact and punish the child for difficult behavior
may be guilty of battery. An assault is an action that causes
apprehension in a person. No physical contact occurs in an assault,
but the action may involve words and conduct. For example, a
dental hygienist who raises his or her voice and threatens to harm a
patient with a dental instrument, creating fear and apprehension on
the part of the patient that a battery may occur, may be guilty of an
assault. Therefore, dental hygienists must use caution in patient
management techniques to minimize the risk of being accused of
battery or assault. Methods of restraint should be selected carefully,
and permission should be granted before use.
Misrepresentation is another category of intentional tort.
Misrepresentation is an incorrect or false representation. Consider,
for example, the situation in which an office dental hygienist calls
in sick on a day that is completely scheduled with patients. If the
employer dentist allows the dental assistant, a dental hygiene
student, to be the “dental hygienist for the day,” this action is a
purposeful misrepresentation because patients believe they are
being treated by a dental hygienist who is licensed and qualified.
Other intentional torts include false imprisonment involving
restraint against a victim's will, intentional infliction of emotional
distress through an act of extreme and outrageous conduct, and
slander or libel resulting in defamation causing damage to the
reputation of another.
Intentional Torts to Property

The physical invasion of intruding on land without authorization is
a form of intentional tort. Interference with the possession of an
individual's property is another form of intentional tort. For
example, finding a colleague's lost handpiece and keeping it as
one's own property is interference.
Unintentional Tort of Negligence

Negligence is an unintentional tort that involves the failure to act
as a reasonable, prudent person under similar circumstances.
Malpractice is a form of negligence that, in the context of medicine
and dentistry, includes all liability-producing conduct resulting
from the delivery of healthcare services.
Rights and Responsibilities of the
Dental Hygienist and Patient
The dental hygienist–patient relationship includes a number of
rights and responsibilities for both parties (Boxes 9.1 and 9.2).
Failure by either party to meet its obligations can result in litigation.
Dental hygienists must become familiar with their responsibilities
to patients, which include the following:
• Dental hygienists must have a current license for the state in

which they practice and have it displayed as required. An
individual who fails to renew a license or who is denied a
license cannot practice. Dental hygienists must perform only
the legally allowed duties with appropriate supervision.
• Dental hygienists must deliver care that meets the standard
of a reasonable person in the profession. A reasonable person
is one who would use suitable judgment based on the
circumstances. A practitioner makes a judgment or decision
based on his or her educational training and experience. A
dental hygienist is held to the standard of a dental hygienist,
not a dentist or a physician.
• A dental hygienist must use medications, materials, and
techniques recognized by the profession. Patients trust that
the dental hygienist will recommend or use therapeutic
treatments recognized by professional groups, such as the
American Dental Association (ADA) or the American
Academy of Periodontology (AAP).
• An office must complete treatment in a timely manner. An
office that chooses to delay or extend treatment for any
reason, such as in the case of a patient with a difficult
personality, is at risk of extending treatment beyond an
acceptable time.
• An office should charge fees that are usual, customary, and
reasonable.
• An office cannot stop the treatment of a patient if harm will
occur. The discontinuation of the provider–patient
relationship requires appropriate notification to avoid
abandonment. The necessary notification includes informing
the patient in writing, allowing emergency care to be
provided for a specific period, suggesting that the patient
seek another provider, and providing the patient with an
opportunity to obtain a copy of their dental records. An office
also must have a policy for short-term absence. To meet this
obligation, a dental office may use an answering service,
voice mail, or pagers to allow for emergency contact.
• A dental hygienist has a duty to understand their abilities
and limitations and to collaborate with the dentist to
appropriately refer to other providers.
• A dental hygienist must respect a patient's right to privacy. A
patient's privacy is protected by specific laws such as the
Health Insurance Portability and Accountability Act (HIPAA).
Patient information cannot be shared with unauthorized
parties without the patient's permission. Office staff must be
careful not to divulge information without a patient's consent.
Office staff must be cautious not to have casual or public
conversations about a patient that would violate the patient's
privacy and must never post patient information on social
media.
• An office is required to record information received in a
logical, complete, and accurate manner. Records may include
written documentation (e.g., collected data, diagnoses,
treatment plans, and a description of the treatment provided),
radiographs, images, and models. Patients have the right to
obtain a copy of their records. State regulations may outline
fees to obtain medical and dental records.
• An office must give the patient appropriate and
understandable pretreatment and posttreatment instructions.
Instructions may be provided verbally and in writing. In
offices with diverse patient populations, instructions should
be available in commonly spoken languages to facilitate
understanding. Translation services are also available.
• Dental hygienists are required to remain current with all
aspects of patient care. It is important to attend continuing
education courses, read scientific literature, and use other
educational sources to keep knowledge and skill levels up to
date. In addition, an awareness of and adherence to a
professional code of ethics are imperative.
Box 9.1
The Dental Hygienist's Responsibilities When
Delivering Oral Health Care
• Possess a proper license and registration, comply with all

laws, and practice within the scope of practice as dictated by
state law.
• Exercise reasonable skill, care, and judgment in the
assessment, diagnosis, and treatment of patients.
• Use standard drugs, materials, and techniques.
• Complete treatment within a reasonable time.
• Charge reasonable fees.
• Never abandon a patient and always arrange for care during
an absence.
• Refer unusual cases to a specialist.
• Maintain patient privacy and confidentiality.
• Keep accurate records.
• Give adequate instructions to the patient.
• Maintain a level of knowledge and practice within the code of
ethics.
Box 9.2
The Patient's Responsibilities When Receiving
Oral Health Care
• Pay a reasonable fee in a reasonable time.

• Cooperate in care and keep appointments.
• Provide accurate answers about dental or medical history and
current health status.
• Follow instructions, including home care instruction.
Patients seek care, trusting that their legal rights will not be
violated and that their health and oral health status will not be
harmed. When harm or injury does occur, several remedies may be
available through the judicial system.
Legal Actions for Healthcare Injuries

When the care delivered by a dental hygienist results in injury, the
injured patient may seek compensation and justice through the
courts. The three most common actions relating to health care are
(1) failure to obtain informed consent, (2) professional malpractice,
and (3) breach of contract. At the core of each of these actions is the
question of whether the dental hygienist violated a duty owed to
the patient. The American Dental Hygienists' Association (ADHA)
recognizes that the dental hygienist has the following professional
responsibilities to patients*:
• Provide oral health care utilizing high levels of professional

knowledge, judgment, and skill.
• Maintain a work environment that minimizes the risk of
harm.
• Serve all [patients] without discrimination, and avoid action
toward any individual or group that may be interpreted as
discriminatory.
• Hold professional [patient] relationships confidential.
• Communicate with [patients] in a respectful manner.
• Promote ethical behavior and high standards of care by all
dental hygienists.
• Serve as an advocate for the welfare of [patients].
• Provide [patients] with the information necessary to make
informed decisions about their oral health, and encourage
their full participation in treatment decisions and goals.
• Refer [patients] to other healthcare providers when their
needs are beyond [the dental hygienist's] ability or scope of
practice.
• Educate patients about high-quality oral health care.
• Recognize that cultural beliefs influence [patient] decisions.
There are additional resources to guide the dental hygienist in

patient care. The American Dental Hygienists' Association's
Standards for Clinical Dental Hygiene Practice provide guidelines
for dental hygiene care and record keeping.1
Informed Consent
History
An essential step in understanding and meeting the expectations of
a patient involves obtaining the patient's informed consent before
the delivery of oral healthcare services. Informed consent is based
on the premise that every citizen has the basic right to be free from
invasions of their body without permission. The United States
Supreme Court strongly asserted this premise in 1891 in Union
Pacific Railway v. Botsford, 141 U.S. 250, 251 (1891), when it stated
that “No right is held more sacred, or is more carefully guarded, by
the common law, than the right of every individual to the
possession and control of his own person, free from all restraint or
interference of others, unless by clear and unquestionable authority
of law.” This position was extended to the delivery of health care in
1914 in Schloendorff v. Society of New York Hospital, 105 N.E. 92, 93
(1914), when the court opined that “Every human being of adult
years and sound mind has a right to determine what shall be done
with his own body; and a surgeon who performs an operation
without his patient's consent commits an assault.”
Over time, the concept of consent to health care evolved into the
concept of informed consent. Informed consent balances the
healthcare provider's unique knowledge and skill with the patient's
decision-making role by placing an affirmative duty on the
healthcare provider to disclose the nature of a procedure to be
performed as well as the risks and benefits of proposed and
alternative treatment. Although informed consent was first
addressed in common law (e.g., the reported opinions of courts,
also known as case law), the doctrine of informed consent also has
been codified through state statutory enactments. In addition to a
legal obligation to obtain informed consent, the ADHA also
recognizes an ethical obligation, as specified in the following
excerpt from its Code of Ethics for Dental Hygienists:
Individual autonomy and respect for human beings—People have
the right to be treated with respect. They have the right to informed
consent prior to treatment, and they have the right to full disclosure
of all relevant information so that they can make informed choices
about their care.
Elements of Informed Consent

Individuals who incur a healthcare injury and allege that they were
not adequately informed regarding the procedure to which they
consented may file a legal action against the dental hygienist for
failure to obtain informed consent. To be successful in establishing
a cause of action for failure to obtain informed consent, a patient
must generally establish (1) that the dental hygienist had a duty to
disclose sufficient information about the proposed treatment to
obtain the patient's informed consent, (2) that the dental hygienist
breached that duty, and (3) that the dental hygienist's breach of
duty was the cause of the injury sustained by the patient.
A duty to disclose information arises when a potential danger or
risk is associated with a proposed treatment that may influence
whether to proceed with the treatment. Two different standards
have emerged as the general measure of the duty to disclose: (1)
professional community standard and (2) materiality standard. The
professional community standard is based on the accepted practice
of the professional community, whereas the materiality standard is
based on the needs of the patient to make an autonomous and
informed treatment decision. The dental hygienist must be familiar
with the informed consent statutes in the jurisdiction of practice as
well as the judicial interpretations of the statutory language.
A dental hygienist's duty to disclose information generally
requires disclosure of the following: (1) the nature of the patient's
condition or diagnosis, (2) the nature and purpose of proposed
treatment, (3) the risks, consequences, and anticipated results of the
proposed treatment, (4) the alternative feasible treatment(s), (5) the
risks, consequences, and anticipated results of the alternative
feasible treatment(s), and (6) the probable or possible consequences
of accepting no treatment. The discussion of risks should include
the nature and severity of the risk and the likelihood of its
occurrence. For example, patients with active periodontal disease
may have a claim for failure to obtain informed consent if they are
not informed of the potential consequences of limiting care to only
the treatment covered by their insurance plan when additional
treatment is recommended.
A breach of the duty to obtain informed consent is not sufficient
to establish a claim of lack of informed consent if the breach was
not the cause of an injury to the patient. To establish a causal link
between the breach of duty and patient injury, both injury
causation and decision causation must exist. Injury causation
requires that the patient suffer an adverse consequence and that the
cause of the injury is an undisclosed risk. Decision causation
requires demonstrating that the patient would not have consented
to treatment (or in the case of no treatment, the patient would have
consented to treatment) had the disclosure been adequate.
Who Can Give Informed Consent?

Competent adults are solely responsible for the determination of
the healthcare services to which they are willing to consent.
Informed consent to the treatment of an adult patient may be
sought from an authorized person other than the patient only when
the patient is incapable of consenting because of incompetency or
incapacity. Guidance in determining who is an authorized person
to consent to care for an incompetent or incapacitated adult should
be sought from statutory law within a state.
Minor patients generally are unable to consent legally to health
care. In most jurisdictions, the age of majority is attained at the age
of 18 years. Therefore, consent to the treatment of persons younger
than 18 years generally should be sought from the minor's parents
or guardian. Parents who are themselves minors typically are
granted authority to consent to the healthcare needs of their
children. Other exceptions to the requirement of parental consent
for the treatment of minors are the treatment of a minor in an
emergency, the treatment of a legally recognized emancipated
minor or mature minor (i.e., a minor who is free from parental
control), or other statutorily authorized treatment of a consenting
minor. Guidance in determining who is an authorized person to
consent to the care of a patient under the age of majority should be
sought from statutory law.
As a reminder, the laws and regulations vary from state to state;
therefore, dental hygienists should be familiar with the
requirements of the jurisdiction within which they are practicing.
Documentation of Informed Consent

Informed consent is a process of communication between a dental
hygienist and a patient. The patient acquires adequate information
to make an autonomous and informed decision regarding his or her
treatment plan. The information must be effectively conveyed to the
patient to ensure comprehension. To ensure patient
comprehension, the dental hygienist must speak and write clearly,
using lay terminology. In addition, patients must be given the
opportunity to ask questions and receive adequate answers.
In general, consent does not need to be written to be valid.
However, from a practical perspective, consent that is not written
may be difficult to prove. Written documentation of consent may
take the form of an entry in the patient record, a consent document
that acknowledges the required disclosures were made and
understood, or a consent form that delineates the required
disclosures and acknowledges understanding. Electronic consent
software options are available and provide detailed patient
information packets that educate patients about planned
procedures. The type of procedure to be performed and the nature
and severity of risk, as well as the likelihood of its occurrence, can
be used as guides for the selection of the form of consent. The
patient's implied consent, by his or her presence in the dental chair,
may be adequate consent for the performance of a clinical
examination with minimal risk. Documentation of consent in the
patient record, dated and initialed by the patient either in writing
or electronically, may be sufficient for routine dental hygiene
procedures that are not part of a comprehensive treatment plan.
However, if anesthesia is used it is advised to get consent so that
the potential risks associated with the treatment can be explained.
A comprehensive treatment plan can be reviewed with patients and
verified in writing by them with an accompanying statement that
acknowledges that they have been informed of their condition and
consent to the plan of care. For high-risk procedures, such as
surgery, the use of a comprehensive and individualized consent
form is advisable.
Informed Refusal
Patients may refuse recommended treatment or referrals. They may
refuse radiographs, anesthesia for a root planing and scaling
treatment, or a referral to a periodontist. Patient refusals must be
documented in the patient record. This protects the provider if
there is future litigation because there is a record of a provider and
patient interaction. The informed refusal process parallels the
informed consent process. The patient must be informed of the
procedure or recommendation. The reason and need for the
procedure must be clearly explained. The oral and general health
risks should be described. For example, a patient refusing to agree
to radiographs must be informed that a lack of radiographs will
limit the dental hygienist's ability to evaluate periodontal status,
bone loss, and other oral health conditions. The dental hygienist
can also educate the patient about the relationship between oral
and systemic health conditions that may be impacted by less-than-
ideal oral health care. An informed refusal, sometimes referred to
as a declination of treatment, should be documented. It is important
to get the patient's signature and signatures from a provider and a
witness. It is advisable not to allow patients to consistently refuse
recommended treatment. An office policy should be determined
concerning patients who refuse recommended treatment as it may
be putting the dental hygienist and dentist at risk for allegations of
malpractice. Appropriate patient termination policies should be
developed.
Professional Malpractice
Professional malpractice had its beginning in common law, as did
informed consent. However, many jurisdictions have codified the
requirements of claims relating to health care.
Malpractice Defined
In general, dental malpractice is the failure of an oral healthcare
provider to exercise the degree of care, skill, and learning expected
of a reasonably prudent oral healthcare provider, in the class to
which he or she belongs within the state, acting in the same or
similar circumstances. Some states provide protection against
malpractice actions to providers delivering care as volunteers and
not for compensation.
Malpractice may be established when a provider is found to have
violated the standard of care. The standard of care can be
established legislatively, administratively, and through expert
testimony.
Dental hygienists violate the standard of care when they injure a
patient by not using the care, knowledge, skill, and ability
possessed by other dental hygienists. For example, a dental
hygienist would violate the standard of care if they failed to obtain
a comprehensive health history on a patient before performing
periodontal therapy. The dental hygienist may commit malpractice
if this violation of the standard of care results in injury to the
patient. For example, if a patient has a heart condition that requires
antibiotic premedication and the dental hygienist performs
periodontal therapy without knowing this condition, the dental
hygienist may commit malpractice if the patient develops bacterial
endocarditis. The standard of care for dental hygiene includes
responsibilities in patient assessment, treatment planning, patient
education, treatment, and evaluation.
Shared Responsibility
Healthcare injuries result from both the provider's failure to meet
the standard of care and the patient's failure to comply with the
treatment plan. In such situations, the responsibility for the injury is
shared by the patient and recognized as contributory negligence.
Responsibility for healthcare injuries also may be shared between
the provider and employer. The legal doctrine of respondeat superior
stands for the proposition that employers act through their
employees or agents and are therefore responsible for the negligent
acts of their employees or agents. As licensed professionals, a
dental hygienist and dentist may be jointly named in a lawsuit
alleging malpractice.
Statute of Limitations
A statute of limitations is a statutory provision that limits the
period within which an injured party can file a legal action. The
purpose of these time limitations is to protect against stale claims
that will be difficult to judge because of limited documentation and
undependable recollection of events. Statutes of limitations for
healthcare injury or malpractice actions vary by state; however,
they usually are in the range of 2 to 4 years from the date of the
alleged act, omission, neglect, or occurrence. Given that some
injuries are not known at the time of their occurrence, a statute of
limitations also provides for a period (1 to 2 years) for filing an
action after the discovery of an injury. For injuries to minors, the
statute of limitations is tolled until they reach the age of majority:
• A statute of limitation is the time allowed to file a court case.

Statutes of limitation apply in both civil and criminal cases.
The statute of limitations for some cases is as short as six
months, while some serious criminal offenses have no limit
and can be filed at any time, even decades after the crime
occurred. Most statutes of limitation range from one to eight
years.2
Reporting Requirements
Some states, such as Arizona and Oklahoma, require that
malpractice settlements and judgments against dental hygienists be
reported to the state health profession regulatory board. Such
notice may then serve as a cause for an investigation by the
regulatory board regarding the professional's practice. In addition
to state requirements, the National Practitioner Data Bank is a
national program that collects and discloses negative information
on healthcare practitioners, including malpractice awards and loss
of a license (https://www.npdb.hrsa.gov).
Breach of Contract
The most common breach of contract claim associated with
healthcare injuries is that the healthcare provider promised the
patient that the injury suffered would not occur. For example,
statements indicating that a proposed procedure will take care of
“someone's troubles” and that there is “nothing much to the
procedure” may represent promises that cannot be kept. Healthcare
providers are not expected to be guarantors of healthcare outcomes.
Therefore, the dental hygienist should be careful not to make
statements that a patient may interpret as a guarantee of outcome.
Summary
This chapter provides a general overview of the legal context of the
dental hygienist–patient relationship. The dental hygienist–patient
relationship is a two-sided relationship with rights and
responsibilities on each side. As a healthcare professional, the
dental hygienist has an ethical and legal obligation to uphold the
standards of the profession and avoid injury to the patient. When
injury that should have been avoided does occur, the legal system is
designed to provide retribution and compensation to the patient
and society. Dental hygienists are responsible for understanding
their legal obligations and are encouraged to seek legal counsel
when specific issues of concern arise.
Practice Pointer
During a recall appointment, the dental hygienist spends more
time with the patient than the dentist and other office personnel
do, and as such relationships are built. It is helpful to get
acquainted with and learn facts about patients to discuss at future
appointments. Showing interest in patients as individuals can be
beneficial for the practice and in turn, can play a role in the
patient's decision to accept recommended treatment and to return
for recurring appointments.
References
1. American Dental Hygienists' Association. Standards
for Clinical Dental Hygiene Practice; 2016.
Standards-for-Clinical-Dental-Hygiene-Practice.pdf
2. Utah State Courts. Statutes of Limitation; 2022.
https://www.utcourts.gov/en/legal-help/legal-
help/procedures/statute-limitation.html
*
Excerpted from: American Dental Hygienists' Association. Code of
Ethics for Dental Hygienists, Chicago; 2019. The use of the term client
in the code has been replaced with patient.
CHAPTER
10
Dental Hygienist–Dentist-
Employer Relationship
Pamela Zarkowski and Michele P. Carr
Chapter Outline
Seeking and Obtaining Employment 96
Employment Relationship 97
Employment Laws 98
Federal Laws Prohibiting Discrimination 98
Equal Pay Act of 1963 98
Age Discrimination in Employment Act of
1967 98
Americans With Disabilities Act of 1990
99
Uniformed Services Employment and
Reemployment Rights Act of 1994 99
State Laws Prohibiting Discrimination 99
Enforcement of Laws Prohibiting Discrimination 99
Other Laws Providing Employee Protections 100
Family Medical Leave Act of 1993 100
Occupational Safety and Health Act of
1970 101
Sexual Harassment 101
Categories of Harassing Behavior 102
Protection for the Dental Hygienist 102
Employment Environment 103
Cultural Competence 103
Bullying and Cyberbullying 103
Summary 104
Learning Outcomes
• Describe the legal parameters of the employer–employee
relationship, and state the two general categories of
employment.
• Identify the recommended strategies for preparing for a
dental hygienist employment interview.
• List the items that can and cannot legally be asked during the
application and interview process for a dental hygienist
position.
• Describe the federal laws prohibiting discrimination and
protecting worker safety.
• Explain the concepts of sexual harassment and hostile work
environment in the dental practice setting.
Employment settings for dental hygienists vary and may include

working for a dentist, group practice, or corporation, such as a
dental service organization (DSO). Dental hygienists may also be
employees in a public health setting, interprofessional clinic setting,
hospital, or dental industry. As an employee, the dental hygienist
must understand the legal parameters of the employer–employee
relationship. Numerous federal and state laws protect the interests
of employees. Familiarity with these laws may help ensure a safe,
productive, and professionally rewarding work environment for the
dental hygienist.
The dental hygienist is an integral member of an oral healthcare
team and deserves to be treated with respect, dignity, and
professionalism. Dental hygienists, together with the practices in
which they are employed, will prosper when recognized for their
professional contributions and acknowledged as valued members of
a team. Compliance with federal and state employment laws is one
way for an employer to give dental hygienists the professional
recognition they deserve.
Although an employer should be familiar with and comply with
legal employment obligations, uninformed and unintentional
violations can occur. Questions, potential oversights, and
unintended violations should be brought to the employer’s attention
for resolution. However, when this does not result in a satisfactory
resolution and a dental hygienist suspects that their employment
rights have been violated, an attorney or appropriate agency should
be contacted for guidance and possible legal resolution. Such action
should be viewed as the ethical and professional obligation of a
dental hygienist.
Seeking and Obtaining Employment

When seeking employment, a dental hygienist may explore several
different forums. Dental hygienist positions frequently are
announced in classified advertisements in local newspapers and
professional publications, such as newsletters and journals. Dental
hygienist job placement services, which may be advertised in
professional newsletters or online, are another source for identifying
available positions. Examples include professional Facebook groups,
LinkedIn, and Monster.com. Word of mouth and networking with
fellow professionals at meetings, continuing education programs,
and community service events also can be valuable mechanisms for
finding well-suited employment opportunities. Formal job
announcements generally indicate the application procedure and
provide details regarding the preferred mode of contact (telephone,
email, or in person) and résumé submission.
The selection process generally includes an interview with the
employer. The interview may be limited to a review of the résumé
and job description followed by a question-and-answer period
between the interviewer and the dental hygienist. In some
situations, it may include a working interview, which provides an
opportunity for the employer to assess the applicant’s professional
competence. A working interview provides an opportunity for the
licensed dental hygienist to assess the office environment, including
scheduling, record-keeping practices, disinfection and sterilization
protocols, and other aspects of the business. A dental hygienist
should be paid for a working interview to comply with labor laws.
Frequently the employer or staff will meet with the dental hygienist
to provide feedback. However, it is important to recognize that this
is not a one-sided event and that the dental hygienist should be
assessing whether or not they are satisfied with the office climate
and delivery of oral healthcare services.
When preparing for an interview, the dental hygienist should
consider the following strategies:
• Prepare a concise, accurate, and professional résumé that

highlights the educational background, employment history,
licensure, and professional experiences, such as association
membership, presentations, and honors.
• Obtain a job description and develop questions concerning
practice philosophies and protocols, referral strategies,
documentation guidelines, performance evaluation, and other
pertinent information.
• Anticipate questions and plan responses to inquiries about
career goals, professional skills and judgment, commitment to
lifelong learning, and potential contributions to the practice.
• Be familiar with proper and improper employment inquiries
during the interview process.
Limitations exist regarding the questions that may legally be
asked during the hiring process. The following list provides
examples of permissible inquiries during the application and
interview process:
• Full name and any different names necessary to verify

employment history
• Date of birth
• Length of residency in a particular state or city
• Name of relatives already employed by the employer
• Ability to perform the duties of the position with or without
accommodation
• Ability to meet specified work schedules and attendance
requirements
• Legal eligibility to work in the United States
• Languages that can be spoken and written fluently
• Education and employment history
• Criminal conviction history
• Emergency contact
The application and interview process is intended to support the

selection of an applicant who can perform the functions of the
available position. Questions are classified as impermissible when the
information sought could be used in a discriminatory manner and is
irrelevant to assessing an applicant’s qualifications for a position.
However, once a hiring decision is made, certain additional
information may be necessary for personnel records and employee
benefit programs. The following list provides examples of inquiries
not permitted during the application or interview process:
• Age, only if the candidate is 18 or older

• Original name when changed by court order or marriage
• Marital and family status or related questions
• Number of children and their ages or related questions
• Sex orientation or gender identity
• National origin, ancestry, or descent
• Religion or creed
• Race or color
• Height and weight
• Disability status
• Arrest record
• Required list of affiliations and memberships
• Garnishment of wages
• Native language
During the application and interview process, applicants should

be cautious not to offer information voluntarily that cannot be
solicited legally by the employer. Although a dental hygienist who
is the proud parent of two fabulous children might be inclined to
comment on the children after noticing pictures of the employer’s
children, the dental hygienist should think twice about doing that.
A discussion of children could raise concerns about child care
arrangements and a sick child’s impact on the employee’s
attendance record. Personal information can be shared following the
hiring decision.
Practice Pointer
Employees should use caution in sharing personal information at
work that could influence an employer’s attitude about the
employee and potentially be used for discriminatory reasons.
Employment Relationship
There are two general employment categories: (1) at will and (2)
term. The at-will category is best described as employment with an
indefinite duration. This means that the employment relationship
can be terminated at the will of either the employer or employee for
any or no reason with or without an explanation or warning. A
dentist can inform a dental hygienist at the end of a workday that
his or her employment in the office is terminated, effective
immediately. Termination decisions customarily are accompanied
by notice (e.g., 2 weeks before the end of the employment
relationship) or severance pay. However, the termination of an at-
will employment relationship can legally occur without notice,
severance pay, or a statement of cause as long the decision was not
made for a discriminatory or retaliatory reason. In an at-will
situation, an employee can resign at any time.
The category term is best described as employment with a definite
duration. For example, a dental hygienist may sign an employment
contract for 12 months. An employment contract generally has
language that specifies the conditions under which the employment
relationship can be terminated before the completion of the
duration. The legal term for these conditions is just cause or good
cause. Cause is reasonable job-related grounds for dismissal based
on, for example, failure to satisfactorily perform job duties. The
employment relationship cannot be terminated without breaching
the contract unless just cause exists, which is a specified (i.e.,
contractually agreed upon) and nondiscriminatory reason for
termination. Some states have wrongful discharge protections
which specifically state that an employee can only be terminated for
good cause.
Employment Laws
Federal and state employment laws are designed to protect the
interests of employees and employers. Although the employer may
have an obligation to inform employees of various state and federal
laws, dental hygienists should be independently familiar with and
know how to access additional information about their rights as
employees.
Federal Laws Prohibiting Discrimination

Title VII of the Civil Rights Act of 1964, 42 U.S.C. §2000e et seq., is a
federal law that protects against discrimination based on race,
color, religion, sex, or national origin. This act applies to employers
with 15 or more employees. Discrimination is prohibited in any
employment action including, but not limited to, hiring and firing,
compensation and salary raises, promotions, fringe benefits, and
retirement plans.
The Pregnancy Discrimination Act (PDA) was an amendment to
Title VII of the Civil Rights Act of 1964, 42 U.S.C. §2000e (k). This
amendment prohibits employment discrimination on the basis of
pregnancy, childbirth, or related medical conditions. The PDA
forbids discrimination based on pregnancy when it comes to any
aspect of employment. This includes hiring, firing, pay, job
assignments, promotions, layoff, training, fringe benefits such as
leave and health insurance, and any other term or condition of
employment. An employer cannot refuse to hire a qualified
applicant on the basis of pregnancy. An employer cannot treat
pregnancy-related conditions differently by requesting that only
pregnant employees undergo medical evaluation regarding their
ability to work. Suppose an employer requires that all employees
with a medical condition undergo a medical evaluation to establish
the ability to work. In that case, a pregnant employee can be
required to comply with the same procedure (e.g., providing a
statement from a healthcare provider documenting the need for
leave). If a temporary inability to work occurs, the pregnant
employee must be treated like any other temporarily disabled
employee in terms of available options, such as leave or leave
without pay. An employer cannot have a policy that prohibits an
employee from returning to work for a predetermined time after
childbirth. Health insurance coverage provided by an employer
must cover expenses for pregnancy-related conditions. Pregnancy
benefits cannot be limited to married employees (e.g., 29 CFR
§1604.10). Most states have enacted their own pregnancy
discrimination laws and lowered the threshold for the number of
employees, for example, Iowa law mandates that employers with
four or more employees grant pregnant employees leave.
Equal Pay Act of 1963

The Equal Pay Act of 1963, 29 U.S.C. §206(d), is a federal law that
protects men and women who perform substantially equal work in
the same establishment from sex-based wage discrimination. An
employer cannot reduce the wages of either a man or a woman to
equalize pay inequities (e.g., 29 CFR §§1620).
Age Discrimination in Employment Act of 1967

The Age Discrimination in Employment Act of 1967, 29 U.S.C.
§§621-634, is a federal law that prohibits discrimination based on
age against any employee or applicant for employment who is at
least 40 years old. The act applies to employers with 20 or more
employees. For example, a dental practice violated the federal law
when it fired eight dental hygienists over the age of 40 and the
terminated dental hygienists were replaced over the next 2.5 years
with a majority of employees under the age of 40. Examples of age
discrimination would also include a job advertisement that indicates
age preferences and denial or cessation of benefits to older
employees (e.g., 29 CFR §§1625).
Americans With Disabilities Act of 1990

The Americans with Disabilities Act of 1990, 42 U.S.C. §§12101 et
seq., is a federal law that prohibits discrimination against qualified
individuals with disabilities in all aspects of employment. This law
applies to employers with 15 or more employees. A disability for
purposes of the ADA is a physical or mental impairment that
substantially limits a major life activity. What constitutes a major life
activity is broadly defined to include basic tasks such as walking,
reading, bending, and communicating, as well as major body
activities such as normal cell growth and immune, digestive, bowel,
bladder, neurological, brain, respiratory, circulatory, endocrine, and
reproductive functions. The inability to perform a single, particular
job does not constitute a substantial limitation in the major life
activity of working. Although a history of drug addiction is
recognized as impairment, individuals currently using illegal drugs
are not protected by this act.
Disabled individuals can qualify for protection under the
Americans with Disabilities Act if they satisfy the skill, experience,
education, and other job-related requirements of a position and also
can perform the job with or without reasonable accommodation.
Employers are required to provide reasonable accommodation to a
qualified disabled employee or job applicant. Three categories of
reasonable accommodation exist: (1) changes to the job application
process, (2) changes to the work environment or the way a job is
usually performed, and (3) changes that allow an employee with a
disability to enjoy equal benefits and privileges of employment.
Reasonable accommodation can include making existing facilities
accessible, modifying schedules, or modifying equipment. For
example, an office manager with hearing loss may need telephones
equipped with sound amplification to function in the position.
Determining the accommodation is an interactive process that
requires a dialogue with the employee about the accommodations
that will meet that person’s needs. Reasonable accommodations do
not include modifications that would cause an undue hardship to
the employer.
Before making a job offer to a potential employee, an employer
cannot ask an applicant about the existence, nature, or severity of a
disability. However, the employer can and should inform the
applicant of the essential functions of the position and inquire
whether the applicant is able, with or without accommodation, to
perform those job functions (e.g., 29 CFR §§1630).
Uniformed Services Employment and Reemployment

Rights Act of 1994
The Uniformed Services Employment and Reemployment Rights
Act of 1994, 38 U.S.C. §§4301-4334, is a federal law that protects
civilian job rights and benefits for veterans and members of Reserve
components called to active duty. This law is administered and
enforced by the US Department of Labor and can be accessed at
https://www.dol.gov/agencies/vets/programs/userra.
State Laws Prohibiting Discrimination

States may enact laws that extend the provisions of the federal laws
against employment discrimination. Such state laws may extend the
reach of the nondiscrimination provisions (e.g., redefining
“employer” to require fewer employees to be bound by the
employment discrimination laws). Some states enact laws that
extend beyond the federal guidelines to prohibit discrimination
based on sexual orientation, marital status, AIDS/HIV status,
weight, and height. State laws may apply to businesses with few
employees. Other state laws may extend the scope of protection
(e.g., redefining the term disability to include a broader scope of
conditions or extending the protected categories). Still, other laws
extend the nature of available remedies.
Enforcement of Laws Prohibiting

Discrimination
The Equal Employment Opportunity Commission (EEOC)
enforces federal laws against discrimination in the employment
setting. The EEOC is organized into 15 districts and has several field
offices to assist individuals who believe they are the subjects of a
violation of federal law. Individuals who believe they have
experienced a violation of their employment rights may file a charge
of discrimination with the EEOC. The process is not complicated;
however, specific guidelines and time frames must be followed (see
the box on this page). It is unlawful for an employer to retaliate or
take adverse action (e.g., by refusing to hire, denying job benefits, or
making threats) against an employee who opposes any violations of
the employment discrimination laws (e.g., refuses to answer
impermissible interview questions, suggests treatment is unequal
based on disability, or complains to a coworker about sexually
harassing behavior) or files a complaint with the EEOC (42 U.S.C.
§2000e-30). More details about the federal laws prohibiting
employment discrimination can be obtained at the EEOC website
(https://www.eeoc.gov).
Individuals also may file complaints with their state commission
(e.g., human rights commission or civil rights office) when concern
exists that state laws are being violated.
Other Laws Providing Employee Protections

Family Medical Leave Act of 1993
The Family Medical Leave Act of 1993 (FMLA), 29 U.S.C. §§2601–
2654, is a federal law that makes available medically necessary leave
to qualified employees. This act was created to balance the demands
of the workplace with the needs of families, to promote the stability
and economic security of families, and to promote national interests
in preserving family integrity.
Filing an EEOC Claim for Discrimination
• Any individual who believes that their employment rights

have been violated may file a charge of discrimination with
the EEOC.
A charge may be filed personally or by mail to the nearest EEOC
office. An individual can identify the closest EEOC office by
contacting the EEOC at 800-669-4000 or 800-669-6820 (TTY), or ASL
Video Phone 844-224-5122, or by using the EEOC Field Office List
at https://www.eeoc.gov/field-office.
• The following information should be available when filing a

complaint: (1) the name, address, and telephone number of
the person being treated unfairly, (2) the name, address, and
telephone number of the employer or agency alleged to have
discriminated and the number of employees at the
workplace, (3) a brief description of the event or events that
are unfair or harassing, and (4) the dates of the event(s).
• Strict time limits exist within which charges must be filed. A
charge must be filed with the EEOC within 180 days from
the date of the alleged violation. Exceptions exist, but
contacting the EEOC promptly when discrimination is
suspected is best.
• Once a charge has been filed, the employer is notified.
Resolution of the charges is determined based on a review of
the facts by the EEOC.
• Resolution of the charge may involve various courses of
action. An attempt may be made to remedy the
discrimination. Remedies may include, but are not limited
to, back pay, promotion, reinstatement, hiring, front pay,
reasonable accommodation, or other actions that would
make the complainant “whole.” If the EEOC’s attempt to
conciliate a remedy is unsuccessful, legal action may be
available.
• EEOC services are free.
• Additional information may be obtained from the US Equal
Employment Opportunity Commission at 131 M Street NE,
Washington, DC 20507; 202-663-4900 or 202-633-4494 (TTY)
or eeoc.gov
Publications are available that advise employees of their equal
opportunity employment rights. To obtain this information,
contact the EEOC at eeoc.gov/eeoc-publications.
The FMLA applies to public and private employers with 50 or

more employees. To be eligible, an employee must have worked for
the employer for 12 months and worked at least 1250 hours over the
previous 12 months. Under the FMLA an employer must grant an
eligible employee up to 12 weeks of unpaid leave during a 12-month
period for the following reasons:
• Birth and care of a newborn child within 1 year of birth

• Placement of a child for adoption or foster care
• Provision of care for an immediate family member (spouse,
child, or parent) with a serious health condition (includes in
loco parentis)
• Serious health condition that makes an employee unable to
perform the function of their position
• Any qualifying exigency arising out of the fact that a family
member (spouse, son or daughter, or parent) is a covered
military member on “covered active duty”
• 26 workweeks of leave during a single 12-month period to
care for a covered service member with a serious injury or
illness if the eligible employee is the service member’s spouse,
son, daughter, parent, or next of kin (military caregiver leave)
In some circumstances, the FMLA permits leave to be taken

intermittently, such as taking leave in blocks of time or reducing a
regular daily or weekly schedule. When possible, employees should
give their employer 30 days of notice before beginning an FMLA
leave. During an approved FMLA leave, an employer must maintain
the insurance benefits provided as a part of the employment
relationship. Upon return to employment, an employee is required
to be restored to their original position or to an equivalent position
with equivalent pay, benefits, and other terms and conditions of
employment. More details on the FMLA can be obtained at the US
Department of Labor website.
States have passed bills related to paid and unpaid family and
medical leave. The bills fall into three main categories: Family
Medical Leave; states that only have pregnancy leave statutes; and
since 2020, specific pandemic and COVID-19 statutes
(https://www.ncsl.org/research/labor-and-employment/state-family-
and-medical-leave-laws.aspx). States may enact laws that extend the
provisions of the FMLA—for example, domestic violence leave is
available in the state of Washington for victims of domestic violence,
sexual assault, and stalking to seek legal or law enforcement
assistance; to seek treatment by a healthcare provider for physical or
mental injuries; to obtain services from a domestic violence shelter,
rape crisis center, or other social services; or to participate in safety
planning activities (Domestic Violence Leave, ch. 49.76 Wash. Rev.
Code).
Occupational Safety and Health Act of 1970

The Occupational Safety and Health Act (OSHA) of 1970, 29 U.S.C.
§§651-678, is a federal law intended to ensure working conditions
free from recognized hazards to the safety and health of employees.
The law places responsibility on employers and employees to
comply with established standards and training requirements
intended to minimize the number of personal injuries and illnesses
that arise out of employment. In general, employers are obligated to
provide employment free from recognized hazards that may cause
serious physical harm to their employees. For example, OSHA
standards require that the employer provide personal protective
equipment (PPE) in the dental office to minimize the hazards
associated with contact with bloodborne and airborne pathogens.
The US Department of Labor updates the OSHA guidelines. During
2020 and the COVID-19 pandemic, OSHA provided information
specific to Dentistry Workers and Employers. It included
information about recommended PPE ensembles for dentistry
related to specific procedures and cleaning and disinfection
(https://www.osha.gov/coronavirus/control-prevention/dentistry).
Unlike the Centers for Disease Control and Prevention (CDC)
recommendations which are advisory, OSHA guidance includes
references to mandatory requirements under the OSHA guidelines.
Employees, in turn, are obligated to comply with OSHA standards
applicable to their scope of employment. State laws also may be
enacted that equal or exceed the requirements imposed by OSHA.
More details on OSHA can be obtained at the OSHA website
(http://www.osha.gov).
State workers’ compensation provisions provide relief for injured
employees while acting in the course of their employment. Dental
hygienists who are injured at work should notify their employer of
the injury and seek assistance in complying with the workers’
compensation program’s requirements. The home pages of all of the
state government websites can be found at
https://www.usa.gov/agencies.
Sexual Harassment
Like many employment settings, the dental office environment
provides opportunities for frequent interaction among colleagues.
Multiple levels of interactions occur, including employer–employee,
employee–employee, and employer/employee–patient/client. Each
of these levels of interaction provides an opportunity for
inappropriate behavior.
Oral healthcare providers work in close contact with their
colleagues and patients. Dental hygienists must be aware of
behaviors that could be interpreted as sexual harassment. Sexual
harassment is an illegal activity.1 Dental hygienists may be targeted
for inappropriate discussions, behaviors, pictures, texts, emails, or
other electronic communication from employers, colleagues,
patients, or vendors. A harasser may be male or female, and the
victim may be of the same or different gender.
Sexual harassment is a form of discrimination that violates Title
VII of the Civil Rights Act of 1964. Federal regulations define sexual
harassment as unwelcome sexual advances, requests for sexual
favors, and other verbal or physical conduct of a sexual nature when
submission to such conduct is made a term or condition of an
individual’s employment, either explicitly or implicitly; submission
to or rejection of such conduct by an individual is used as the basis
for employment decisions affecting such individual; or such conduct
has the purpose or effect of unreasonably interfering with an
individual’s work performance or creating an intimidating, hostile,
or offensive working environment.
Categories of Harassing Behavior

Sexually harassing behavior falls into two categories: (1) quid pro
quo and (2) hostile environment. Quid pro quo means “something
for something.” This harassment occurs when an employee is forced
to comply with an employer’s sexual demands to get some
economic benefit, such as a pay increase or to remain employed. To
be actionable, an individual must be subjected to unwelcome
harassment.
A hostile environment occurs when any type of unwelcome sexual
behavior creates an offensive or hostile environment. This occurs
when there is unwelcome, serious, or pervasive conduct of a sexual
nature and the impact of the harassment unreasonably interferes
with an individual’s work performance or creates an offensive work
environment. The harassment does not need to result in tangible or
economic job consequences, such as the loss of pay or promotion
opportunities. Examples include offensive jokes or conversation,
comments about appearance, accidental touching or repeated
invitations. An important criterion is that the employer had actual
knowledge or constructive knowledge of the hostile environment
but took no remedial or prompt action. Constructive knowledge is a
legal term that means that the employer, under the circumstances,
should have known about the hostile work environment. An
environment is hostile if a reasonable person would find the
environment hostile or abusive and the victim subjectively perceives
the environment to be abusive. Examples of behaviors that may
create a hostile work environment if sufficiently severe or pervasive
include the following:
• Spoken, written, or email communication that is sexually

explicit in nature
• Unsolicited or unwelcome flirtations or propositions
• Conversation with a sexual content or innuendo
• Suggestive comments about the person’s physical appearance
• Unwanted touching
• Display of sexually suggestive visual materials, such as
magazines, posters, cartoons, photos, or screen shots
• Intrusive questions about the person’s personal life
• Descriptions of the harasser’s sexual experiences
• Use of terms, such as honey
Protection for the Dental Hygienist

Sexual harassment often is discussed in terms of a “power”
relationship, meaning one individual has authority over another. An
individual, such as an employer or professor, has the power to
determine a promotion or a grade. Hostile environments may be
created when a person of authority takes advantage of that
authority and requests activity of a sexual nature. Because the
individual is the person of authority, the target may be fearful of not
complying. Power or authority does not allow an individual to
violate another person’s rights. An employer, colleague, or patient
may be unaware that his or her behavior is offensive. A dental office
may develop an office manual that outlines appropriate and
inappropriate behavior and consequences for failure to fulfill
specific guidelines. However, whether or not an office policy exists,
if dental hygienists are subjected to behaviors that create a hostile
environment, steps can be taken legally and personally to protect
them.
If a dental hygienist is sexually harassed on the job, they should
do the following:
• Say no clearly. Make it clear to the harasser that attentions are

unwanted and that their behavior is offensive. Name the
specific behavior. Write a memo to the harasser asking that
the behavior stop; always keep a copy.
• Hold the harasser accountable for their actions. Do not make
excuses and do not pretend the incident never occurred. Let
employers or colleagues know what happened. Privacy
protects harassers; visibility undermines them.
• Document the harassment. Write down each incident,
including date, time, and place. Describe in detail what
happened, including any responses. Keep a copy at home.
• Document your work. Keep a copy of performance
evaluations and memos that indicate the quality of your
performance. The harasser, if an employer or supervisor, may
question your job performance to justify their behavior.
• Identify other individuals in the work environment who also
may have been targeted by the harasser or who witnessed the
offensive behavior.
• Explore office policy and protocol. Review the office manual
or grievance procedures outlined in the employee handbook.
• File a complaint. If a legal remedy is necessary, contact a state
discriminatory agency or the federal EEOC. The federal
agency covers workplaces of 15 or more employees; however,
individual state law may protect dental hygienists who are
employed in a workplace with fewer staff members.
• Contact an attorney. If a discussion of the situation is
warranted, an attorney specializing in employment
discrimination is advised.
Employment Environment
The majority of employment settings are characterized as respectful
workplaces that strive to follow legal and regulatory rules and
regulations. There are, however, issues and concerns that a dental
hygienist must be aware of and sensitive to in the employment
setting.
Cultural Competence
Employers and employees recognize the diversity of the dental
workforce and the patients who seek treatment from the dental
team. Dental teams must develop awareness and acknowledge each
individual’s unique characteristics, including cultural beliefs and
practices. Culture influences communication style, understanding of
health and disease, and attitudes toward health care. Members of
the dental team should strive to correct cultural misinformation or
bias that impacts the work setting.
Bullying and Cyberbullying

Increased reports of bullying and cyberbullying have been reported
in dental employment settings. Bullying is defined as repeated
actions or threats directed toward a person by one or more
individuals who have or are perceived to have more power. It can
include physical, verbal, or psychological behaviors in any
combination. Behaviors include name calling, obscene gesturing,
malicious teasing, rumors, and social exclusion. Examples in the
dental employment settings can consist of purposefully not
including someone in a lunch outing or spreading cruel rumors in
the office.
Disruptive behavior is a term that may be used to describe
bullying and other behaviors exhibited by employers or employees.
Examples of disruptive behavior may be poor anger management,
obscene language, negative comments about employees or patients,
or physical actions such as throwing an item at another. The
behaviors must be addressed, and employees must be informed of
the consequences if they continue.
Cyberbullying is the intentional and repeated mistreatment of
others through the use of technology such as computers, cell
phones, and other electronic devices. Employers and employees can
be bullies. Bullying behavior should be reported to an employer and
addressed by that employer.
Summary
Because of the importance of commerce in society, employment is
highly regulated by federal and state laws and statutes. Such
regulation is intended to protect the welfare of society by
safeguarding the individual interests of employees. Dental
hygienists are likely to work as employees during the course of their
career. They must be informed of federal and state employment
laws and act to ensure that their rights are upheld.
Reference
1. Zarkowski P. Sexual harassment: it’s unacceptable, J
Mass Dent Society 67(3), 20–23, 2018.
SECTION
III
Simulations and Applications

Case Studies, Activities, and
Testlets
Cases for Study and Discussion

The cases are presented to allow the student of dental hygiene the
opportunity to understand the types of ethical and legal dilemmas
that may be encountered in the study and practice of dental
hygiene.
An expert in dental and dental hygiene ethics has authored each
case, and a wide variety of possible scenarios are presented for
discussion and analysis. Some questions to stimulate thought and
discussion are provided by each author. The ethical decision-
making model presented in Chapter 6 can be applied in each of the
cases.
Case-based ethics discussion is a common method used in ethics
courses for dental and dental hygiene students. All of the cases were
designed to make the reader consider the various aspects of the
situation and, if desired, to apply and follow the ethical decision-
making model.
The worksheet provided in Chapter 6 may be used to help
structure the response to each case. This can be done as a solo
assignment in a classroom setting, with small discussion groups,
with an expert faculty panel, or in a continuing education
environment with experienced dental hygienists.
CASE 1
Mario and the School-Based

Sealant Program
Matt Crespin
Mario Gonzales is a dental hygienist practicing in the state of

Wisconsin. He has a successful school-based dental sealant program
based in Walworth County and partners with the local public health
department to provide care in 12 area elementary schools. Mario
offers his services to all children in the identified schools who return
a signed consent form from parents/guardians who want to
participate. Children with existing dental homes are encouraged to
continue receiving routine care from their current provider since his
program is geared toward reaching children who do not have a
dental home. There is no cost to families for this program as Mario’s
program is part of a larger statewide effort that is supported
through grant dollars for those children who they cannot bill
Medicaid for.
Mario receives a call from Dr. Vanessa Brooks, a local dentist who
is noticeably upset with a situation surrounding a patient. Dr.
Williams shares with Mario that “one of her patients was seen by
your program, and you sealed a tooth that has a noncavitated
carious lesion, and furthermore I’m not happy that you are treating
my patients in your program.” Dr. Williams raised other concerns
regarding the ability of a dental hygienist in Wisconsin to be able to
provide this type of care, which includes diagnosis without the
supervision of a dentist.
Mario explained to Dr. Williams that his program operates
according to the standards of care, particularly the Centers for
Disease Control and Prevention (CDC) recommendations for school-
based sealant programs to reduce dental caries, as well as the
Healthy People 2030 oral health objectives, and he further offered to
have her come and visit sometime to learn more about the type of
care he is providing. He also explained the legality of his ability to
provide care within the dental hygiene scope of care in schools and
other locations due to the practice act in Wisconsin. Mario also used
this interaction as an opportunity to ask Dr. Brooks if he could refer
patients with Medicaid insurance to her office since he struggles
with finding them restorative dental care when he identifies
possible areas of concern. Dr. Brooks also noted that she has
concerns with taxpayer dollars being used to help children who do
not take the responsibility to maintain good oral health. Lastly,
Mario tried to share the current evidence-based practices regarding
when and when not to seal a tooth. Dr. Brooks abruptly ended the
conversation, and Mario put his phone down and walked down the
hall of the school to get his next patient from their classroom.
Questions
1. Does Mario have a right to include this child in his school-
based sealant program if he is a patient of record in Dr.
Brooks’ office?
2. Following his assessment, is Mario able to diagnose the need
for dental sealants?
3. According to the CDC recommendations for school-based
sealant programs, should Mario have placed a sealant on a
tooth that has a noncavitated carious lesion? Discuss your
answer using the CDC guidelines.
4. List and discuss the Healthy People 2030 oral health objectives
that school-based sealant programs address.
5. List and describe which core values from the ADHA Code of
Ethics for Dental Hygienists relate to this school-based sealant
program.
6. What do you think about Dr. Brooks’ comment about personal
responsibility and taxpayer dollars being used to provide care
to this population?
7. How would you have handled this situation if you were
Mario?
CASE 2
To Sell or Not to Sell
Carla Loiacono
Concorde College, Texas
Dr. Chris Hunt has been in private practice for 10 years in a suburb
of a large metroplex. Dr. Hunt graduated from an Advanced
Education in General Dentistry (AEGD) program and associated
with a large general practice for 3 years before buying a building
and opening a solo practice. Although all phases of general
dentistry are performed, the focus of the practice is moving toward
adult esthetic dentistry. Ms. Lisa Meyer is a dental hygienist who
has been in Dr. Hunt’s practice full-time for 3 years and enjoys a
great relationship with her patients and an active schedule. Ms.
Meyer has been a full-time practitioner for 6 years, and this is the
second office in which she has worked. Her greatest professional
rewards are the trust that has developed between her and her
patients and the improvement she has seen in their oral health.
Dr. Hunt recently completed a continuing education series on
esthetic dentistry and hired a practice management company to
review the office. The course director and the management team
both stressed the importance of using the hygienist to “sell
dentistry” to patients. The course and the management team both
identified certain phrases and inferences hygienists should use to
help the patient make the “right” choice.
Dr. Hunt approaches Ms. Meyer and explains her new role to her.
Ms. Meyer is uncomfortable with this change in her job duties
because she feels that she would be using her professional position
to possibly unduly influence patients toward making certain
treatment choices. “Am I taking advantage of the trust that I worked
hard to establish with our patients?” she asks. “No,” Dr. Hunt
replies. “Actually, you are educating our patients about the benefits
of the highest-quality care. In fact, to make this arrangement more
attractive I am including an incentive plan with cash bonuses for
every case that you sell.” This statement concerns Ms. Meyer
because she feels that these incentives may eventually place her own
economic self-interest in conflict with the patient’s best interest.
Questions
1. What aspects of informed consent are important to this case?
2. What are the dental hygienist’s obligations to the patient in
this situation?
3. List and discuss the core values expressed in the ADHA Code
of Ethics for Dental Hygienists that are related to this case.
4. What are the possible legal issues related to this case?
5. Using the ethical decision-making model, analyze this case.
CASE 3
Trevor and the Technology
Trisha Nunn
Texas Women’s University
Trevor Wilson, RDH, BSDH. How great that sounded especially as

Trevor began his brand-new job—a job that at least two of his
classmates wanted as badly as he did. Dr. Reeves not only seemed
to have the same philosophy as Trevor, but she paid exceptionally
well, and the office is state of the art.
On his first day of employment, Trevor was thrilled to have made
it through the first two patients without going over the allotted
appointment times—and he did everything just as he had learned to
do according to the standards of care. The third patient of the day
was 21-year-old Kaleigh Ballantine. Dr. Reeves requested that
Trevor use the laser caries detector because Ms. Ballantine was new
to the practice and had not had a thorough hard-tissue assessment.
Kaleigh had no previous caries experience. Trevor even gloated a
little because he was very familiar with the device. Using the
manufacturer’s guide to the interpretation of findings, Trevor
charted only one reading that strongly indicated a carious lesion,
but he also noted several very borderline readings on the chart
because he knew Dr. Reeves was a perfectionist and would want to
know all possible trouble areas as she was evaluating potential
lesions visually and tactilely during the examination.
Dr. Reeves sat down for the examination, chatted with Ms.
Ballantine, and visually examined the dentition with a mouth
mirror. She looked at the charting of the potentially carious lesions
and said, “Kaleigh, you have a significant number of problems. It
looks like you’re going to need eleven fillings. We’ll want to do
white ones, of course, because of all the bad news about our trusty
silver fillings. The ballpark cost will be around $2,100.” She added,
“Trevor, make sure Kaleigh gets on my schedule so that we can get
all these carious lesions taken care of before she gets into trouble.
Have the girls up front schedule quadrant by quadrant.” Trevor sat
dumbfounded.
Questions
1. What action, if any, should Trevor take immediately?
2. List and discuss the core values from the ADHA Code of
Ethics for Dental Hygienists related to this case.
3. Using the ADHA Standards of Professional Responsibility,
discuss the responsibilities of the dental hygienist that are
applicable to this case.
6. Looking at the events through Dr. Reeves’s eyes, how might
she view the situation?
7. Trevor was really excited about this new job for a number of
reasons. Is there some way he could have avoided being
placed in this situation?
8. How can Trevor avoid putting his job in jeopardy as he
resolves this dilemma?
CASE 4
A Great Boss
Pamela Zarkowski
University of Detroit Mercy
Lesa Lawrence thoroughly enjoyed practicing as a dental hygienist.

It was important to her to work in a practice that put the patient first
and provided quality care. She also enjoyed being part of a
dedicated “team” and enjoyed the camaraderie of the dental office.
Employees sometimes ate lunch in the office and on other occasions
went out to lunch as a group.
Dr. Frank Harris, Lesa’s boss, usually went out to lunch by himself
or to meet a dentist colleague or a friend. Lesa noticed that after
lunch Dr. Harris frequently smelled like alcohol. She picked up on
the same smell in the morning but also noticed he frequently used
mouthrinse before examining a patient. She wanted to believe that it
was the mouthrinse she smelled, but she was suspicious that it was
the smell of alcohol. Lesa mentioned her concern to her fellow
employees. They acknowledged that Dr. Harris had a history of
alcoholism, and seemed to be managing it through Alcoholics
Anonymous, but recently had started drinking again. His dental
assistant, Corey, assured Lesa that when Dr. Harris appeared
unsteady or tentative, she helped out to ensure that patient care
went smoothly.
Lesa suggested to the office manager that she wanted to help Dr.
Harris by reporting him to the state dental society, which had a
program to assist dentists with a substance abuse problem. The
office manager, Debbie, became very protective of Dr. Harris. She
indicated that all the staff members were receiving generous
salaries, and if Dr. Harris had to stop practicing to participate in a
recovery program, the staff could lose their jobs, income, and
benefits. She reminded Lesa that this had been an ongoing problem
and emphasized that all of the staff worked together to “help” Dr.
Harris when he was in a compromised state. Debbie reminded Lesa
that they were a “team” and needed to work together!
Questions
3. What are the potential legal risks?
4. Does your state practice act address impaired practitioners or
practitioners with substance abuse problems? Does your state
dental society have a program for impaired professionals?
5. Does the ADHA or ADA Code of Ethics specifically address
the issues in this case?
CASE 5
Patients with Special Needs
Michele P. Carr
The Ohio State University
Nancy has been working for the past year as a dental hygienist in a
very busy ambulatory healthcare facility that treats persons who
have intellectual and developmental disabilities. The majority of
patients treated at this facility are covered under government
assistance plans, and when procedures are not covered by the
insurance plan, the facility writes off the charge for the services.
After working in this setting, Nancy found that generally the
patient’s oral hygiene was poor regardless of their ability to perform
oral hygiene procedures on their own or if the patient was
dependent upon a caregiver. In spite of having dedicated numerous
hours training caregivers and providing oral hygiene instruction to
the patients, Nancy has met with little success regarding the
improvement of oral hygiene and periodontal health in patients.
Recently Nancy implemented a program in which patients who
are periodontally involved or continuously have poor oral hygiene
return for 3-month re-care visits instead of the typical 6-month
visits. This approach worked in her previous private practice office
and had positive results. However, in this new facility, she is not
seeing any improvement in oral health and questions the value,
time, and cost to treat these patients when the facility is not being
compensated and she sees no benefit to the patient. Many patients
are waiting months to get a dental hygiene appointment and
eliminating nonresponsive patients on 3-month re-care visits would
allow for more appointments, to be available for those who are
waiting. Nancy is frustrated and wonders how to balance dental
needs and economics with this patient population.
Questions
2. What are the possible legal principles related to this case?
CASE 6
Standard Precautions
Donna Wittmayer
Clark College, Washington
A dental hygiene student was assigned to a community outreach

site where dental care was provided to underserved populations.
One morning, as she was reviewing the charts of the patients she
would be treating that day, she noted that one of the patients was
HIV-positive and had a history of hepatitis C. The student
understood the principles of, and always practiced, standard
precaution procedures; thus, she was not concerned about treating
the patient. Before this patient’s appointment time, the dental
assistant at the site approached the dental hygiene student and
directed her to their supply of disposable laboratory coats. The
assistant stated, “You should wear one of these when treating this
patient, so your cloth laboratory coat will not become
contaminated.” She also instructed the student to place
contaminated instruments in a special container of disinfecting
solution after she had completed treatment on the patient. After the
contaminated instruments had soaked for 30 minutes, they would
be processed through the ultrasonic bath and then would be run
through the autoclave twice to guarantee the instruments were
completely sterilized.
Questions
1. Should the student follow the recommended procedures at the
extramural site, or should she follow the accepted standard
procedures? What are the alternatives for the student?
CASE 7
Warming Up
Gary Chiodo
University of Washington School of Dentistry
A recently graduated dental hygienist has taken a position in a

group practice periodontal office. The professional staff in this office
includes four periodontists and six dental hygienists. Although she
has been on the job only 3 months, the dental hygienist is truly
enjoying the advanced level of practice involved in caring for the
patients. Patients referred into this specialty practice are in need of
various types of periodontal therapy, and the periodontists
maximize the dental hygienists’ talents in performing nonsurgical
interventions. This dental hygienist has observed the degree of care
and thoroughness demonstrated by the periodontists and other
hygienists, and she respects their abilities and level of
professionalism.
For the past few weeks, however, she has been bothered by one of
the periodontists who seems to frequently make inappropriate
comments about her appearance, tease her about private body parts,
tell her sexually oriented jokes, and constantly ask her to go out on a
date with him. Lately, this doctor has begun giving her neck and
shoulder massages in the employee breakroom if he finds her there
alone. She has asked him to stop because these actions make her
uncomfortable and has politely explained that she is not interested
in dating him. These protests have not deterred the amorous
advances of this dentist who is recently divorced and very vocal
about being “in the marketplace.”
Today, while the dental hygienist is in her operatory sharpening
instruments, the dentist comes in and begins rubbing her neck and
shoulders. She rises from her chair and asks him to please stop and
to confine his future interactions with her to professional issues. The
dentist becomes upset at this rejection and says, “You know, I
control a significant part of your salary. I don’t see why you are
always brushing me aside. You’d be lucky to have someone like me.
Maybe you should think more about your future here and warm up
a little.”
Questions
Specifically, what does Title VII of the Civil Rights Act state
related to sexual harassment?
5. How might the dental hygienist deal with this situation so as
not to create animosity between her and others in the office?
Should she be concerned about creating animosity?
CASE 8
Patient Confession
Debi Gerger
West Coast University, California
A 35-year-old female comes to your office as a regular 6-month

recall patient. She has been a patient in the practice since it opened 7
years ago and is always faithful in coming to her appointments. In
general, she is in good health. The dentist completed one bridge a
couple of years ago, and her probing depths are usually generalized
3 mm to 4 mm with light supragingival and subgingival calculus
localized to the lower anterior teeth. Some marginal gingival
inflammation is present from poor brushing technique.
This patient has been seen by the same dentist for years. The
practice is building, and with four dental hygienists now employed,
patients are often scheduled with the first available dental hygienist.
This patient has been seen by a different dental hygienist and then
returns to the dental hygienist who normally sees her each recall.
After the medical history review, the dental hygienist proceeds to
do a full mouth probing and discovers that today’s readings are
significantly lower than the last visit and compliments the patient
on her great improvements.
The patient then reveals that the last dental hygienist told her that
her pockets were so bad that if she did not brush and floss better she
would lose all her teeth. She was also told that her cleaning needed
to be done every 4 months to help control the “mess she was in.”
The patient said she was taking this information in, even though it
was delivered in a demeaning manner by this other dental hygienist
while she was being “tortured by the scaling procedure.” She was in
pain not only during the visit but for 3 days afterward. The patient
also said her 16-year-old daughter had a cleaning by the same
person and was in tears from the pain when she came home. The
daughter’s chart was pulled, and “good oral hygiene and light
plaque” was noted. This is not the first time you have heard this
kind of information about this dental hygienist.
Questions
5. How would you handle this situation?
6. Would you recommend to the patient that she call the state
dental board?
7. Would you tell the patient that you have heard these kinds of
comments before?
8. Would you say something to the dentist?
9. Would you talk with the other dental hygienist?
CASE 9
Guidelines or Mandates?
Shavonne R. Healy
The World Health Organization (WHO) officially declared an

outbreak of severe acute respiratory syndrome (SARS-CoV-2) a
global pandemic in 2019. To help reduce the spread of a highly
infectious respiratory disease and to preserve personal protective
equipment (PPE) for first responders, the Occupational Safety and
Health Administration (OSHA) and the Centers for Disease Control
and Prevention (CDC) recommended that all elective medical and
dental procedures be postponed. State governors across the United
States began issuing stay-at-home orders that corresponded with
WHO, OSHA, and CDC recommendations to temporarily suspend
elective and nonemergency dental procedures until further notice.
OSHA and the CDC released interim guidelines for dental
professionals to refrain from aerosol-generating procedures to
prevent the risk of healthcare-associated SARS-CoV-2 transmission.
The American Dental Hygienists’ Association (ADHA) publishes
interim guidance on returning to work that was aligned with OSHA
and the CDC. The media reported that the virus was and remains a
highly contagious, aerosol-transmissible disease with high
morbidity and mortality rates.
Claire is a 36-year-old mother of two young children. She works as
a solo dental hygiene practitioner for a busy periodontal office. Her
employer, a dentist, has informed her that the office will resume
business effective immediately, including nonemergency
procedures, without the use of aerosol-generating devices in hygiene
operatories. The number of deaths has increased, and little is known
yet about the safety and efficacy of working during a pandemic.
Claire has been monitoring the ongoing guidance from regulatory
and public health agencies and discusses with the dentist the
recommendations from the WHO, OSHA, CDC, and ADHA to
postpone nonemergency procedures until further notice. Claire also
asks the dentist if the practice has secured the recommended PPE,
physical barriers, air-handling system, and supplies for patient
triage protocols. The dentist reacts angrily and tells Claire that those
are “guidelines,” not mandates, and that the office will be
proceeding as it had prior to the start of the pandemic. The dentist
lets Claire know she is expected to return to work along with the
rest of the staff.
Questions
4. What are the possible implications for the practice and
licensed providers if contact tracing from a patient who
contracted the virus identifies the practice as the source and
the evidence-based CDC Infection Prevention and Control in
Dental Settings recommendations, which include the interim
guidelines related to this virus, were not followed?
5. If Claire has further questions related to the return to work for
nonemergency treatment procedures, who can she contact?
CASE 10
Misdiagnosis
Laura Fassacesia
Plaza College Dental Hygiene Program
Andrew Dean is a 58-year-old male, who is an accountant in New

York City. Andrew’s dentist is Dr. Howard Daviss. Dr. Daviss has
treated Andrew for the past 25 years, they are golf buddies, and
Andrew trusts Dr. Daviss. Dr. Daviss’s office is in the building
where Andrew works, and it is very convenient for him.
Andrew’s wife, Razia, sees different dentist who referred her to a
specialist, Dr. Fornix, a periodontist. Razia thinks it is a good idea
for Andrew to see the periodontist for a evaluation. Andrew asked
Dr. Daviss and the dental hygienist at his office for a referral to a
periodontist, but Andrew was told “You do not need to see a
periodontitis—you have gingivitis only, which does not warrant a
referral.”
A few months later, on a Saturday, Andrew began to have a
toothache. When he was brushing his teeth he felt pain. When he
looked in the mirror, he noticed the gingiva around his lower right
molar was swollen and bleeding. He called Dr. Daviss, who put him
on an antibiotic. Dr. Daviss was away for the weekend, but he
explained to Andrew that he may have an infection and need root
canal therapy. Dr. Daviss expected the pain to improve after 24
hours of the antibiotic. The pain did not improve, so Andrew made
an emergency appointment to see his wife’s periodontist, Dr. Fornix.
The periodontist took a periapical x-ray of #30 and a cone beam CT
scan. Tooth #30 had an infection and a class II furcation visible on
the x-rays. Dr. Fornix did emergency surgery, but he could not save
the tooth. The x-rays and subsequent surgery showed
approximately 75% bone loss at the site. Less than the apical third of
the root was embedded in bone. Dr. Fornix asked Andrew to get his
last set of x-rays and his last perio chart from his dentist for review
at his post-op visit. Andrew went home and was very upset.
On Monday, Andrew called Dr. Daviss’s office to request his
records. The last x-rays, a set of four horizontal bitewings, had been
taken 2 years ago. The only full periodontal charting had been
completed 25 years ago, at his initial appointment. The last updates
had been recorded 3 years ago. The updates included recession on
teeth #24 and #25, a 5-mm pocket on #3-MB, and a 4-mm pocket on
#14-DL with bleeding. There was no mention of pocketing, bone
loss, or furcation involvement on #30. When Dr. Fornix called Dr.
Daviss, Dr. Daviss said his dental hygienist had written, “Patient
had gingivitis and need to improve his homecare, 6-month recalls”
in the chart. They never graded or staged his periodontal disease
with the 2017 American Academy of Periodontology (AAP)
Classifications.
Dr. Fornix invited Andrew to come to his office for a periodontal
evaluation as a new patient. The dental hygienist at Dr. Fornix’s
office took a full mouth series of x-rays (FMX) and recorded a
comprehensive periodontal chart including:
• Probing depths
• Gingival margin
• Mucogingival junction
• Clinical attachment level (CAL)
• Mobility
• Furcations recorded with a Nabers probe
• Bleeding upon probing
• Suppuration
The hygienist also recorded: radiography bone loss (RBL), plaque,

and calculus levels.
When all of the recordings were completed, the patient was staged
and graded according to the AAP 2017 Classifications.
The comprehensive exam is part 0 of the five phases of dental
treatment. Andrew was misdiagnosed by Dr. Daviss office, he does
not have gingivitis; he has active periodontitis with no records
indicating when periodontitis began.
Andrew’s periodontal diagnosis was generalized Stage III, Grade
B: mucogingival deformities. Andrew’s treatment plan is as follows:
• phase 0 was accomplished at the first visit of assessment;

• phase I, 6 sextants of scaling and root planing with a 4- to 6-
week reevaluation;
• phase II, 4 quads osseous surgery, 1 dental implant, 2 bone
grafts in areas with vertical defects;
• phase III, a restorative crown on the dental implant;
• phase IV, 3-month recalls.
Andrew feels betrayed by his former dentist and dental hygienist

and will not be returning to Dr. Daviss’s practice.
Questions
2. What are the possible legal issues related to this case? List and
discuss all that may apply.
3. When not choosing to follow the correct AAP protocol for
determining periodontal disease, what should happen to the
dental hygienists and Dr. Daviss for their years of improper
treatment and supervised neglect?
4. Who is responsible for this misdiagnosis?
5. Using the ADA/FDA Dental Radiographic Examinations:
Recommendations for Patient Selection and Limiting
Radiation Exposure, what type of radiographs and frequency
of exposure should have been used for this patient?
Nicole is 35 years old and has been a patient of Dr. Devi for the
past 10 years. Dr. Devi’s dental hygienist is named Tina. Tina has
been treating Nicole’s advancing periodontal disease for 5 years
with a prophy every 6 months. Every time Nicole has an
appointment with Dr. Devi and Tina, she receives locally applied
antibiotics in approximately 6-8 periodontal cites, those with greater
than 5 mm. Office staff told her this was going to prevent her from
going to the periodontist. This is a great product when it is used
correctly. Her dental insurance does not cover the procedure and it
costs $75 per site. The recall appointments often cost Nicole between
$450 and $600 per visit.
At a standard recall visit, Nicole noticed someone else’s name on
the product packet. Nicole asked Tina about the name on the packet,
and Tina responded, “These are the cartridges we did not use on a
different patient. They were sent to us from their medical/pharmacy
insurance, and they are going to expire, so we are using them on
you.” Nicole asked if she was still going to be charged $75 per
cartridge since these seemed to be expiring product for another
individual. Tina responded, “Yes.’’
Nicole then asked Tina why the office never submitted this
treatment to her medical/pharmacy insurance to see if would be
covered. Tina changed the subject. Nicole paid for the visit and left
with a great deal of concern.
When Nicole reached home, she calculated what she had spent
over the past 5 years on these treatments. She estimated that she had
spent between $8,000 and $9,000. In addition, the dental hygienist
had indicated that she still has periodontal pockets present. Tina
then researched the product on the website. The company was very
clear about how to use this product, it was to be placed after scaling
and root planing (SRP). Nicole assumed she was having SRP at each
appointment until she researched “SRP” and discovered that the
treatment she had been receiving was not that. The dental hygienist
had mostly used an ultrasonic scaler, and the appointment only
took a 30 minutes.
Nicole finds evidence that this product is highly effective when
used properly, in conjunction with SRP and 3-month periodontal
maintenance appointments.
Nicole’s research motivated her to make an appointment with a
periodontist. The specialist recommended periodontal rehabilitation
to get her periodontitis under control. After her first periodontal
visit, Nicole is diagnosed with a 2017 AAP Classification: She has
generalized Stage III, Grade C with molar/incisor pattern.
Questions
1. What is the proper appointment and recare interval required
for a patient with periodontitis?
2. Why did Nicole’s dentist decide to place locally delivered
antibiotics subgingivally over the past 5 years and not refer her
to a periodontist?
3. Why would Nicole treatment planned for a prophy only and
not for SRP that is recommended before placing locally
delivered antibiotics subgingivally?
4. Please list the core values from the ADHA Code of Ethics that
were violated.
5. Please list the proper phases of therapy for this patient.
C A S E 11
Medical Clearance and the

Student Dental Hygienist
Karen Sue Williams

Jenna and Lisa are dental hygiene students getting ready to

graduate in a few weeks. Jenna’s grandmother, Evelyn Jackson, has
agreed to be a patient for Lisa so that she can fulfill her final clinical
competency. Ms. Jackson has a history of hypothyroidism for which
she takes 75 mcg of Synthroid daily and breast cancer 6 years ago
that required radiation treatment. She has been in remission for 5
years. Ms. Jackson was recently hospitalized for chest pain with
shortness of breath and referred for follow-up testing with a
cardiologist but has delayed calling for an appointment due to
financial reasons. Ms. Jackson still experiences regular chest pain
and shortness of breath, especially when nervous. Jenna shared her
grandmother’s recent cardiac episode with Lisa so she could plan
for the appointment. Clinic protocol requires a medical consult
and/or clearance for patients with cardiac issues, particularly when
etiology is unknown and there are comorbidities. Lisa is grateful for
the experience but is concerned that she will not have enough time
to complete Ms. Jackson’s treatment with the available appointment
times she has left, especially if she needs to seek medical clearance.
Jenna suggested to her grandmother that since there has not been a
diagnosis by a cardiologist yet, that she does not disclose her recent
hospitalization so Lisa would not need to seek clearance. This
would allow her to complete the grandmother’s treatment and fulfill
her clinical competency just in time for graduation.
Questions
1. List and discuss the core values of the ADHA Code of Ethics
for Dental Hygienists related to this case.
4. What implications of ignoring protocol could there be to the
patient or treating hygienist?
CASE 12
The Dental Therapist
Anne High
Rochester Community and Technical College, Minnesota
Molly is a dental hygienist employed as a dental therapist (DT) in a

state that requires this provider to have dual licensure as a DT and a
dental hygienist in order to provide care to underserved
populations in public health settings. A DT practices under the
general supervision of a licensed dentist in the state and is able to
perform simple extractions, restore teeth, perform some pulp
therapies, and write prescriptions for a limited range of drugs in
addition to the full dental hygiene scope of practice. A formal
collaborative agreement between the dentist and DT has to be on
record with the state board of dentistry. The dentist has to be
involved in the dental diagnosis and treatment planning for all
patients.
Under normal circumstances, Molly uses the rural dental clinic’s
telehealth capabilities and communicated with the dentist via live
video conference. This arrangement allows the dentist to assist in
diagnosis and treatment planning for patients with restorative or
surgical needs. Most of the patients Molly treats are young children
with dental decay, and often a variety of procedures are required
while treating the teeth. The treatment plans often include antibiotic
regimens, pulp therapy, stainless-steel crowns, restorations, and
extraction of primary teeth.
On one particular Thursday, Molly was practicing in the rural
clinic and received an emergency phone call from the mother of a
patient of record. The patient had not completed his treatment plan
last summer and was now in acute pain. Although the dentist had
helped plan the treatment for the patient 9 months ago, the tooth
indicated for a restoration now presented with an infected pulp.
Molly had often treated cases similar to this one and knew what the
dentist would probably recommend, but he was out of town and
unable to be reached for consultation. Because Molly did not want
the child to lose the tooth, she went ahead and treated the patient
without consulting the dentist.
Questions
CASE 13
Summer Employment
Stephanie Bossenberger
Weber State University, Utah
Mary Ann Fisher has been a dental assistant at Dr. Martan’s office
for the past 5 years. She functions as a chairside dental assistant,
exposing radiographs as directed, and acting as the infection control
officer for the dental office. During this time, Mary Ann has been
pursuing her education to become a dental hygienist and recently
completed her first year of the program. She has been an above-
average student both academically and clinically. However, she has
stated that she does not understand why becoming a dental
hygienist takes so long. Several times during clinic, Mary Ann has
been cited by faculty for taking shortcuts and avoiding evaluations.
Since being counseled on this behavior, she has been more careful to
follow protocol. Her clinical performance is at an acceptable level
for a student completing the first year of instruction.
School ended in mid-May, and Mary Ann was able to resume her
employment full-time in Dr. Martan’s office. Dr. Martan is very
proud of Mary Ann and often boasts to patients of her
accomplishments and that she will be a dental hygienist very soon.
Mary Ann continued with the work she had done in the office for a
year, polishing each patient’s teeth before the dentist’s examination.
Now that she has become more adept at instrumentation, she has
probed and scaled the teeth of several patients when she has
considered it necessary.
Mia, the part-time dental hygienist in the office, knew that Mary
Ann was stretching her dental assisting duties and, after careful
consideration, decided it was time to have a meeting to talk about
what was going on in the office. At the meeting, Mia gave out copies
of the state Dental Practice Act, and everyone understood the reason
for the clarification of duties. The dentist thanked Mia and said he
thought it was “very informative and interesting.” For the next 6
weeks, Mary Ann was careful to only provide services that were
listed in the Dental Practice Act, but after that she was scaling and
probing teeth again.
Mia was disappointed in the dentist and the dental assistant as she
thought they would adhere to the legal scope of practice after their
meeting. Although Mia was a bit anxious about being fired, she was
quite sure that Dr. Martan would understand her concern for the
patients in his practice and not wish them to receive substandard
care. The more she thought about the situation, the angrier she
became. She realized that she is required to report to the Board of
Dental Practice any infraction of the state Dental Practice Act.
Questions
1. Should Mia call the dental hygiene program faculty?
2. Is Mia required to tell Dr. Martan that she is going to report
this infraction to the state dental board before she does?
CASE 14
Questionable Case Selection
Shavonne R. Healy
Sean is a dental hygienist working in a new practice that specializes

in implant dentistry. The practice is owned by a surgeon who is well
known for his cutting-edge technologies and customer service and is
considered a talented doctor among his colleagues. When Sean is
not busy with patients, he enjoys helping the team by triaging
emergencies for the surgeon or completing diagnostics for patients
preparing for implant surgery. One morning, Sean was asked to
prepare a patient for consultation with the doctor. The patient is a
65-year-old female referred for possible extraction of abscessed
tooth #30 and immediate implant placement.
Sean brings the patient to the treatment room and begins
reviewing her medical history. He first notes that it has been over 10
years since the patient has seen her primary care physician for a
physical but manages to maintain her “6-month cleanings” with her
regular dentist’s office. The patient stated that she had been told by
her primary care physician 10 years ago she had “prediabetes,” she
is not taking any prescription medications, and she smokes one pack
of cigarettes a day. While taking a periapical film of the site, Sean
noticed localized areas of periodontal inflammation and
supragingival calculus. The radiograph showed evidence of
moderate subgingival calculus on adjacent teeth #29 and #31. Sean
also suspected carious lesions into the dentin on the distal of #29
and mesial of #31.
According to the literature related to case selection criteria, this
patient is not a candidate for dental implants at this time. She has
active periodontal inflammation, untreated caries, smokes, and a
medical history and health status that are unknown. Sean reports
his findings to the surgeon with concerns about the patient’s current
oral and overall health status and risk factors. Sean recommended
that the patient obtain medical clearance from a physician in
addition to periodontal and caries therapy before implant
placement. After the surgeon completed his examination, he
diagnosed tooth #30 as nonrestorable and recommended extraction
with immediate implant placement. The procedure was completed
that day.
Questions
2. Using the ADHA Standards of Professional Responsibility in
the Code of Ethics, discuss the responsibilities of the dental
hygienist that are applicable to this case.
4. What are the medical and dental contraindications to implant
therapy? Which contraindications apply to this patient, and
how might they impact the newly placed dental implant?
CASE 15
The Code
Brad is in his first year of dental school at a well-respected

university on the East Coast. He is the first person in his family to go
to a professional school, and he is the pride and joy of his large
community, all of whom are recent immigrants to the United States.
His church and his extended family are supporting him while he is
getting his education.
The dental school curriculum is very demanding, and as the first
round of examinations approaches, Brad is getting more and more
concerned that he will not perform well. Other students in his class
are talking about “review packets”—old tests from previous years
passed down from upper-level students. Several of the old tests in
the review packet are the exact examinations one professor gives
year after year; he never changes even one question. Using these
tests to prepare for the final examinations would save a great deal of
time and allow Brad to concentrate on his laboratory courses.
The honor code that Brad signed when he started at the university
did not say anything about not using old tests.
Questions
1. If Brad uses the review packets, is it academic honesty or
dishonesty and why?
2. Do the dental school and its professors have a responsibility in
this situation?
3. Are certain types of courses in dental hygiene school more
important than others?
4. If you were Brad, what would you do?
CASE 16
Systemic Racism
Alexandra D.E. Sheppard

University of Alberta, Canada
Ashley is a registered dental hygienist in a midsize city. Ashley just

started working in a general dental practice 3 weeks ago and was
especially happy to obtain the position, as the office is located close
to home. Ashley shadowed the dentist and the previous dental
hygienist during the final year of dental hygiene studies and has
dreamed of working in this office. For the past 2 years, a pandemic
has affected all aspects of life from attending school and small
business closures to restrictions on gatherings, to a concern about
the attainment of appropriate personal protective equipment (PPE)
for dental practices.
Ashley reviews the schedule for the day. The sterilization
technician looks at the schedule as well and says loudly, “Why are
they coming in? I do not like these people at all, as they are the
cause of the virus and the death of my grandmother. Personally, I
think you need to do an extra-thorough disinfection of the operatory
after they leave. I will double-sterilize the instruments so the next
patient does not get ill from their germs. Make sure you wear an
N95 mask. I really dislike these people.” The dental assistant nods in
agreement and both walk out of the sterilization area. Ashley looks
down and becomes quiet.
Ashley is of Asian ancestry. Throughout the day, the comments
from the sterilization tech and the affirmation from the dental
assistant have been bothering Ashley. That evening Ashley decides
to use the six-step decision-making model to help address this
ethical situation.
Questions
5. Discuss the pros and cons of each option that Ashley could
consider as part of coming to a decision.
6. What are the professional responsibilities and considerations
that Ashley should consider?
CASE 17
The Maxillary Bridge
Mary Turner
Sacramento City College, California
Dr. Agar, my dentist employer, has the Timothy family—father,

mother, and two daughters—as patients. The family is a struggling,
lower-middle-class family trying to pay for their daughters’ college
educations. The family had recently received from Mr. Timothy’s
employer a family health policy with dental coverage. Before
receiving this coverage, paying for dental care was always a
substantial problem for the Timothy family. Unfortunately, Mr.
Timothy lost his job 2 weeks ago and is now looking for other
employment.
At this time, Mr. Timothy is in the middle of several appointments
for periodontal debridement before the placement of a new
maxillary anterior bridge. Mr. Timothy has asked Dr. Agar to
postdate an insurance claim form so that his treatment is covered by
the dental plan. Because Dr. Agar would like to help his patient, he
has asked me to alter the dates of the dental hygiene services that I
will be providing to Mr. Timothy so they can also be included on
the claim form.
Mr. Timothy needs the treatment, especially because he is looking
for new employment. I know the family well as one of the daughters
used to babysit my daughter—they need whatever benefits the
insurance will pay.
Questions
1. Should I comply with Dr. Agar’s wishes? After all, he is my
boss.
CASE 18
The Independent Contractor in

Accelerated Hygiene
Shavonne R. Healy
Shantell is a new graduate and novice clinician in the dental hygiene

profession. She recently attended an event held by her local dental
hygiene association and learned about temping opportunities from
a dental provider placement agency. New to the profession, Shantell
thought this would be a great way to gain some clinical experience
and perhaps find a permanent full-time position in a great practice.
Shortly after joining the placement agency as an independent
contractor, she was scheduled to work a few consecutive days at a
large group practice.
When Shantell arrived for her first day of work, she met Kevin, the
dental assistant who would be working with her throughout the
day. Kevin gave Shantell a tour of the office, showed her to an
operatory, and reviewed the day’s schedule. Shantell noticed that
someone had already reviewed the patient records and indicated
patients who needed radiographs and periodontal charting. When
she noticed that she would be seeing hygiene patients out of three
columns on the schedule, she asked Kevin for clarification. He
explained that he would be assisting her in an “accelerated hygiene
schedule.” Kevin would seat the patients, go over medical health
history, take radiographs if needed, polish either before or after
scaling, and stay for the exam with the doctor to document findings
and notes. Shantell was told that her only responsibilities were hand
and/or ultrasonic instrumentation and periodontal charting in the
limited amount of time with the patient she was provided.
Questions
2. According to the ADHA Standards for Clinical Dental
Hygiene Practice, which standards are not being satisfied?
5. Should Shantell follow the instructions of Kevin and only
focus on hand and ultrasonic instrumentation during her time
with the patients?
CASE 19
The Dropoff
Deirdre Marie Fiorini

Plaza College, New York
Maureen is a dental hygienist working in a new dental private

practice. The principal dentist is away and Maureen is scheduled
with a full book of appointments and is already running a few
minutes late. Finally ready for her next patient, Maureen goes to the
waiting room and finds a young boy sitting alone and
unaccompanied. Maureen asks Paul, the receptionist, where the
boy’s guardian is. Paul responds, “His mother left in a hurry. She
said that his brother will pick him up when he is finished with his
appointment. She said there are no changes in his health history.”
Maureen knew from reading his chart that his last health history
was filled out 3 years ago and that the previous hygienist’s notes
only read “child prophy”. Already running late, Maureen called the
young boy into her operatory.
“Hi, Paolo. My name is Maureen. I will be your dental hygienist
today. Are your parents around?” Paolo explained that his mom
had to go back to work, his dad was away on a work trip, and his
17-year-old brother will be picking him up after the appointment.
Maureen proceeded to ask Paolo about his health history and
discuss his diet. All clear, she moves on to his extraoral and intraoral
examination. Paolo presents with obvious demineralization and acid
erosion. Maureen asks Paolo again about his nutrition, and Paolo
reveals he drinks soda usually with every meal. Maureen is quite
concerned, reviews Paolo’s homecare, and provides patient
education on oral hygiene habits and diet.
Maureen knows that Paolo would definitely benefit from regular
fluoride varnish application with a prescription fluoride toothpaste.
She asks what flavor fluoride Paolo wants, confirms no allergies,
and preps his teeth for application. As she starts to tear the
packaging, Maureen remembers that she does not have parental
consent for Paolo, and is still running behind in her schedule. She
knows Paolo is covered by the family’s dental insurance because of
his age. Paolo needs the fluoride application, and Maureen is
worried about the condition of his teeth if she doesn’t do it. If she
charges the fluoride to the insurance company, it will be
documented and proof that she didn’t have parental permission.
Maureen is challenged with ethical and legal influences, with
minimal time to solve her ethical dilemma.
Questions
3. What are the possible legal issues related to this case? What
legal consequences may Maureen face if she proceeds with the
fluoride application?
4. What are the dental hygienist’s potential options, good and
bad?
CASE 20
Integrity Protocol
Donna Lesser
Community College, California
While teaching the general pathology course, Ms. Sally Samson

thought that she detected a student attempting to cheat on a quiz. It
appeared to her that the student had written information on her leg.
Ms. Samson felt that she could not confirm this and decided to
watch the student more closely before making an allegation that
could not be substantiated. Over the next 2 weeks, Ms. Samson gave
two more quizzes in her pathology course. She was almost certain
that the student in question had terms written on the palms of her
hands and that she manipulated her hands in a way to view the
information during the quizzes.
Ms. Samson took her suspicions to the director of the program.
The program director shared with her that no other faculty member
had presented concerns about this student, but she had found
pathology words written on the table in the classroom in which the
pathology course was held. To complicate matters, the program
director told Ms. Samson that the student’s father was a senior
faculty member at the institution, on the faculty council, and heavily
involved in the teachers’ union. With this information, it was
decided that Ms. Samson would try to eliminate the student’s
questionable behavior by implementing additional protocols to
make cheating “too much work.” One new protocol was to have
each student utilize an alcohol spray on their hands before taking a
quiz/examination.
Approximately 4 weeks later, Ms. Samson was giving a midterm
examination and had the students line up to use the alcohol spray.
When the student in question turned her hands over, Ms. Samson
saw terms written on the palms of her hands. She tapped the
student on the shoulder and told her to report to the director’s
office. On the way out of the room, the student vigorously wiped
her palms on her jeans to remove the writing. By the time the
student arrived in the director’s office, she had very vague outlines
of ink on her hands.
Questions
1. How should the program director handle this situation?
2. Did Ms. Samson deal with this problem well?
3. Should all allegations of cheating be reviewed by an honor
council?
4. What role should students in the class play in this dilemma?
CASE 21
Natural or Negligence?
Sandra Stramoski
University of Bridgeport, Connecticut
For the preceding 2 years, following graduation from dental hygiene

school, Martin Vargo, RDH, had grown tired of working in
temporary positions in various offices, rarely seeing the same
patients more than once. He was very excited to have landed a
position in a well-known dental practice in his town. For the past 3
weeks, he had enjoyed being part of this established practice, with
patients from families who for generations had been very loyal
patrons of the dentist, his father, and recently his daughter.
Martin had observed that the patients in the practice were well
cared for, appropriately scheduled for recare appointments, and
generally amenable to recommended treatment. When reviewing
scheduled patients for the day, Martin noted that Mrs. Anna Lewis,
63 years old, was overdue for her dental hygiene appointment,
having last appeared in the office nearly 3 years prior. He also noted
that she routinely declined supplemental fluoride treatments,
despite a history of caries and extensive restorative procedures,
including the removal of all of her amalgam restorations, which had
been replaced with gold and ceramic crowns and inlays. The
previous hygienist had noted that Mrs. Lewis preferred “natural,”
fluoride-free products, and at the last recare appointment she had
refused radiographs, signing a declination form stored in her
electronic chart. Prior images included a series of four horizontal
bitewings, now 4 years old, and a full-mouth series from 7 years
ago.
When updating her medical history, the patient reported that her
medical doctor had prescribed a “water pill,” hydrochlorothiazide,
for high blood pressure, and that her mouth felt continually dry.
Vitals and intraoral and extraoral exams were within normal limits,
except for notably dry oral tissues. The periodontal exam revealed
an increase in gingival recession, several posterior pocket depths in
the 4- to 6 mm range, and moderate interproximal plaque and
calculus. Martin knew that a full mouth series of radiographs
should be part of his treatment plan but worried about the patient’s
response. As he suspected, when he presented his findings to Mrs.
Lewis, including a rational explanation of the need for updated
images, she stated that she would be happy to sign another refusal
form and would not hold him responsible for any “problems” she
might have in the future. She also stated that the dentist always let
her make her own decisions about x-rays. Martin is now worried
not only about displeasing the patient but also about how his new
employer might respond when he admitted that he was not
comfortable assessing and treating the patient without current
radiographs.
Questions
1. How might Martin approach this issue at the moment?
2. What are the ethical and legal ramifications of continuing care
without current radiographic images?
3. What are the guidelines for prescribing and obtaining
radiographs for a patient, given Mrs. Lewis’ history?
4. Does the patient’s assurance that she will not hold Martin
responsible for any future problems have validity? Why or
why not?
CASE 22
Penny Wise, Pound Foolish
Phyllis L. Beemsterboer, Catherine Salveson and Karen Adams

Melissa is a 19-year-old woman at 27 weeks gestation in her first

pregnancy who presents for her first prenatal visit at County Health
Clinic. She has not seen a healthcare provider thus far because she
has not had health insurance coverage—she works at a local pizza
restaurant and her employer doesn’t provide it. The clinic social
worker enrolled her in the Oregon Health Plan (a safety net
program) and explained that she would have coverage during her
pregnancy. Melissa lives with her sister in an apartment and does
not have a car of her own. Her sister drives her to work or she takes
the bus, so traveling to clinic visits is difficult for her.
The nurse practitioner at the clinic determined that Melissa’s
pregnancy had been uncomplicated thus far. She had some nausea
and vomiting in the first trimester that had resolved, and she had
not had any bleeding or contractions. Her history was significant for
a previous abnormal pap, about which she had not followed up, and
chlamydia which was treated as an outpatient 2 years ago. Melissa
smokes a little over a pack of cigarettes per day and denies using
alcohol or recreational drugs during the pregnancy. She has begun
prenatal vitamins. She is in a monogamous relationship with the
father of the baby, who is currently incarcerated for theft. They have
been together for 2 years and plan to marry when he is released next
year.
Melissa’s examination was consistent with 27 weeks gestation, and
the nurse practitioner performed a pap and cervical cultures. She
drew prenatal labs and set Melissa up with an appointment for an
ultrasound, although Melissa was not sure she would be able to get
time off work for the appointment. She stated that her boss was very
strict about time away from work, and she was afraid she would
lose her job if she missed too much.
The nurse noticed that Melissa’s dentition was very poor and
inquired when her last dental examination had been. Melissa could
not remember exactly but thought that it was at least several years
ago. She admitted to some right-sided jaw pain. The nurse gave her
the names of several dentists in the area and encouraged her to
schedule an appointment. Melissa wanted to know if dental care
would be covered by the Oregon Health Plan, because she was
concerned about incurring a large dental bill that she could not pay.
The next week Melissa presented via ambulance to the emergency
room with premature onset of contractions. The labor and delivery
physician obtained the records from the clinic and found that her
chlamydia culture was positive and that the clinic had been unable
to contact Melissa because her phone had been disconnected. The
obstetrician treated Melissa with medication to stop her
contractions, gave her antibiotics for the chlamydia infection, and
looked for any other infections because the infection is a common
cause of premature labor. He found an abscessed molar on her right
side. The next day Melissa’s drug screen returned positive for
opiates.
After 2 days in the hospital, a reviewer from the Oregon Health
Plan indicated to her attending physician that her preterm labor was
felt to be arrested enough that Melissa should be discharged. The
physician did so, giving her strict instructions to see a dentist within
the week to deal with the abscess, explaining to her that her preterm
labor might return if she did not do so. He also explained to her that
the positive drug screen meant that Child Protective Services would
need to be involved after her baby was born. Six days later Melissa
returned to the hospital, having delivered her 29-week infant in the
ambulance on the way to the hospital. Her infant was immediately
taken to the neonatal intensive care unit (NICU), where it was
placed on mechanical ventilation for respiratory distress syndrome.
Melissa had not seen a dentist and still had the abscessed tooth. The
NICU nurse discussed the baby’s expected hospital course with
Melissa, telling her as gently as she could that the baby would likely
be in the hospital for 5 to 6 weeks and could potentially have
intellectual and developmental disabilities (IDDs), blindness, and
chronic lung disease. Melissa looked around at the monitors and
equipment in the NICU, and her tiny baby, and wondered how she
would ever be able to pay for it all. She told herself that she would
worry about the bills later and told the nurse, “I want everything
possible done for my baby.”
Questions
1. What more could the nurse practitioner have done regarding
Melissa’s need for dental care during her visit to the clinic?
2. Does the Oregon Health Plan provide dental coverage for
someone in Melissa’s situation?
CASE 23
Fitting In
Pamela Overman
University of Missouri-Kansas City
Sarah is happy to have a job as a dental hygienist for Dr. Stanley

Dard. Sarah is a newly divorced mother of two teenagers and has to
stay in this area as a part of the divorce settlement. Dr. Dard is a
member of the state dental board, and he really values the
periodontal aspect of care. He serves as a state clinical examiner,
and he checks patients very meticulously to make sure everyone
receives the best of care. Recently, Sarah has seen a side of Dr. Dard
that has her concerned. She walked by his operatory as he was
presenting a proposed treatment plan to a new patient. The patient
was a devout Muslim woman, wearing a traditional loose-fitting
dress and a scarf covering her hair. When discussing the fees with
the patient, Dr. Dard quoted fees that were considerably higher than
those he typically presented. Sarah assumed she had misheard until
it happened again. This second time it was a Hispanic man, who has
limited English-speaking skills. She waits for an opportune moment
and asked Dr. Dard about how he sets fees for services when
presenting treatment plans. He said he sets fees based on the
difficulty of the treatment and seemed disinclined to go into much
more depth.
Today, Sara sees a treatment plan presentation on Dr. Dard’s
schedule, and the treatment room door is closed when she walks by.
After the final patient of the day, Dr. Dard asks Sarah to stop by his
office for a discussion about her performance in his office. He is not
sure she is fitting in. Sarah is panicked and not sure what to do next.
Questions
1. What action, if any, should Sarah take immediately?
4. How might Dr. Dard view this situation?
5. Is there some way Sarah could have avoided being placed in
this situation?
CASE 24
New Skills
Ann McCann
Texas A&M University
The ability to treat children was the reason that Harper Mallone,
RDH, went to dental hygiene school. She loved working at the office
of Dr. Marvin Stallsworth because it was a family practice and she
had the opportunity to treat many children. She hoped to have her
own children someday—caring for them was her special love, and
she was good at it.
Dr. Stallsworth believed in saving as much tooth structure as
possible and often did sealants on teeth with small occlusal carious
lesions. This procedure (called an enameloplasty) involved
excavating only the carious enamel tissue in the pits and fissures of
the tooth with a small bur and then placing a sealant in the area.
Harper would identify the carious lesions during her oral
examination at patient recall appointments. When Dr. Stallsworth
came into the dental hygiene operatory for his examination of the
patient, he would prepare the tooth and then have Harper place the
sealant.
One morning, Dr. Stallsworth requested that Harper learn how to
do an enameloplasty so that she could perform the entire sealant
procedure herself. He said it was very easy to do, and it would free
him up to spend more time with his restorative patients. This would
be a win-win situation for both the office and the patient by
decreasing the length of the dental hygiene appointment. When the
next patient arrived who needed a sealant, Dr. Stallsworth showed
Harper how to do the enameloplasty and had her use a high-speed
handpiece to remove the carious enamel. Harper found the
procedure fairly easy and was looking forward to performing the
procedure on future patients.
She enthusiastically described her new skill to a fellow dental
hygienist at the monthly dental hygiene society meeting. Her friend
expressed surprise that she was placing sealant restorations and told
her she should not be restoring teeth. Harper did not know what to
do. Her employer wanted her to do the procedure independently,
and she liked having more responsibility at the office.
Questions
1. Would this procedure be legal in some states or regions?
2. Whose responsibility is it to know if this task is within the
dental hygiene scope of practice for Harper’s state?
CASE 25
No Openings Today
Alexandra Sheppard
University of Alberta
After graduating as a dental hygienist 3 months ago, Terry had

recently found employment in a modern dental practice. Terry was
happy to obtain the position as the job market has been weak and
this practice pays $5 more per hour than many of her classmates are
making. Terry receives many perks at the practice, including a
uniform allowance, and the dentist will be taking all the staff,
including the dental hygienists, two dental assistants, a receptionist,
and the treatment coordinator, to an international conference this
autumn. The practice is located in an affluent area of the city, and
the client base is mostly business professionals. All clients complete
the medical history before being accompanied into the treatment
room. The health histories are reviewed by the treatment
coordinator, who is a dental assistant, before being seen by the
dental hygienist.
One day, Terry has a 2 hour opening in her schedule and is
helping the receptionists with some filing. Terry overhears the
conversation between the treatment coordinator and a client
regarding the medical history. The client had been diagnosed with
Hepatitis C a few years ago and has recently been treated
successfully for syphilis. Terry overhears that the treatment
coordinator has indicated to the client that there is no availability in
the near future in the dental practice, and it is advisable for client to
seek treatment at another office in order to receive treatment in a
timely manner.
Terry indicates that there are quite a few openings in the schedule
and could provide treatment for the client today. The receptionist
replies that this individual is not suitable for the office due to the
findings in the medical history.
Questions
3. What are the concerns and/or treatment contraindications
related to the Hepatitis C status of the patient?
5. Using the ethical decision-making model, analyze this case
using a step-by-step approach.
CASE 26
Just Clean His Teeth
Linda D. Boyd
MCPHS University, Massachusetts
Mary Fordham, RDH, works in a busy general office and sees a

large number of patients who are in need of initial nonsurgical
periodontal therapy. Upon reviewing the medical history of a new
patient, Mr. Donald, Mary notes the patient reported he has
“borderline diabetes.” Further questioning revealed he is not
receiving treatment for prediabetes or diabetes such as oral
medications (e.g., Metformin), dietary or lifestyle modifications, or
insulin. Mr. Donald is unable to provide information on his
hemoglobin A1c (HbA1c) and does not remember the last time it
was checked. Mary continues the appointment with vital signs, risk
assessments, and an intraoral- and extraoral examination and
determines a full series of radiographs is needed because Mr.
Donald has not been to a dentist in 20 years. Continuing with a
comprehensive periodontal examination, Mary finds the patient has
generalized bleeding on probing with localized areas of
suppuration, generalized 4- to 6-mm pocket depths, radiographic
bone loss, interdental clinical attachment loss of 5 mm or more, and
furcation involvement on tooth #3 and #14. The findings suggest
generalized stage III periodontitis. Information related to diabetes
status would be necessary to identify the grade for the periodontitis.
At this point, Dr. Perry enters the operatory to complete the dental
examination and review the assessment data. Dr. Perry and Mary
discuss the diagnosis and treatment plan for the periodontal
disease, and Mary suggests that a consultation with the primary
care provider is needed before continuing with periodontal care
because Mr. Donald does not know his HbA1c, limiting the ability
to assess the potential for progression (grade) for his periodontitis.
Mr. Donald gets upset and says he just wants his teeth cleaned, and
it has nothing to do with his “borderline diabetes.” Dr. Perry
placates Mr. Donald by saying that it is not necessary to consult
with the primary care provider and that Mary will go ahead and
perform the nonsurgical periodontal therapy.
Questions
1. How do you think Mary might handle this situation?
2. Could ignoring this situation has implications for planning
patient care?
3. What would be the range of HbA1c if the patient had
prediabetes? If the patient had diabetes?
CASE 27
Breach of Contract?
Shavonne R. Healy
Dr. Patty Jones is a well-known and highly respected periodontist in

the area. Her current hygienist of 10 years is leaving the practice,
and Jack, a highly skilled and experienced dental hygienist, was
referred for the position by a trusted colleague. During the
interviewing process, Jack informed the doctor of his terms and
conditions and asked that they be documented in his employment
agreement. He understood that the previous hygienist worked 8- to
9-hour days Tuesday to Thursday with a 30-minute lunch break and
all day on Friday with no lunch break. Jack informed Dr. Jones that
he would need an hour for lunch if considered for the position.
Jack also shared his concern about the 60-minute time frame being
allotted for periodontal therapy and voiced that he would need
additional time with patients involving more than one quadrant of
scaling and root planing. Dr. Jones agreed to Jack’s requests, and
they signed the employment agreement. Jack returned the next
week to begin his new role as a periodontal therapist at Dr. Jones’s
office.
Jack had been working for Dr. Jones for 3 months when he started
to notice changes in his schedule. He saw that his lunch hour had
been reduced to 30 minutes and that patients needing four
quadrants of periodontal therapy were being scheduled for 60-
minute appointments. When Jack approached the office manager
about the unannounced changes to his schedule, she responded,
“Dr. Jones wanted hygiene to go back to the regular schedule. It’s
how we are used to doing it, and the old hygienist never
complained about the way we do things.”
Questions
1. Is the employment agreement between Jack and Dr. Jones a
valid contract?
2. What are the possible legal implications of the employment
agreement being breached?
3. Should Jack provide Dr. Jones with an opportunity to remedy
the situation?
4. What would you do if you were Jack?
CASE 28
The Dentist Dental Assistant
Monica L. Hospenthal
Pierce College Fort Steilacoom, Washington
Shari is a dental hygienist who has worked for the past 3 years at
Dr. Merriweather’s practice. Recently she was faced with a highly
illegal and unethical situation when her dentist was out of the
country on vacation.
Dr. Merriweather is a family-friendly employer, fosters a positive
environment, provides benefits, and most importantly, practices
quality and ethical dentistry. He also allows his staff to work to their
full scope of practice within the law.
Dr. Merriweather sometimes takes 4 week breaks and closes the
practice. He is an avid bicyclist and had been planning for months
to leave on a Saturday morning for a 4-week bike tour in Spain.
Shari often schedules to take temporary assignments for part of
these 4-week breaks.
Shari realized on a Saturday afternoon that she had forgotten her
loupes and face shield in her operatory room. Because she and all
the employees have an office key, she decided to swing by the office
on Sunday to collect her things for her Monday temping position.
As she drove into the parking lot of the building, she noticed
Katrina’s car in the parking lot. Katrina is a newer expanded
functions dental assistant (EFDA) with the practice but has been a
dental assistant (DA) for over 10 years. She recently went back to
school to become an EFDA, and therefore, Dr. Merriweather
recently promoted her to lead DA.
Shari enters through the back door of the office and greets a
cheerful hello to Katrina to let her know who it is. As Shari walks
around the corner, she sees Katrina working on a patient! There is a
full restorative cassette open and a local anesthetic syringe, which
clearly has already been used. The patient has a rubber dam on #6
through #11, and Katrina is holding a high-speed handpiece,
looking as if she is getting ready to use it. Katrina looks at Shari and
says, “Oh, hi! I was just placing a filling for my friend because she
doesn’t have the money to go to the dentist. It was just a small
chip.” Katrina turns back to the patient to continue the treatment.
Katrina is allowed to place and finish restorations in the state.
However, dental assistants are not educated or allowed by law to
perform local anesthetic or prepare teeth.
Questions
4. Looking at the events through Dr. Merriweather’s eyes, how
might he view the situation?
CASE 29
Agnes Day
Center for Ethics in Health Care
Oregon Health and Science University
Background
Agnes Day has lived in her own home, alone with her cat, since her
husband died 6 years ago. She is 83 years old, very independent,
and very private. Her independence and privacy have been
challenged for the past several months, however, after she suffered a
stroke with hemiparesis on the left side. Her left hand is badly
contracted and has little feeling. She drags her left foot when she
walks. She occasionally falls but can walk about her home, though
she refuses to use a cane. She can no longer drive and has recently
started paying a young couple to drive her for errands such as
grocery shopping and going to the doctor. Her son and daughter
both live in the area and help her around the house. She will go out
for meals with them and allow them to bring in meals and have
family gatherings at the house, but she will not let them go to doctor
visits with her “because she does not want them to take over.”
Similarly, she has never mentioned the falls to them (or to anyone
else), fearing that if her children knew about them they would try to
force her to live with them or, worse, in a nursing home options she
loathes. Her other medical problems include diabetes, for which she
takes insulin, and chronic congestive heart failure, for which she
takes furosemide (a diuretic).
A Medical Crisis
A few weeks ago Ms. Day suffered a cut on her left hand. Because
she has little feeling in the hand, the cut did not hurt, and Ms. Day
felt no reason to seek medical care. Over the next few days, the cut
became infected, and the infection spread all the way to her
shoulder. Her entire arm became swollen and red. She had fever
and chills, and she became confused and short of breath. When her
son dropped by for a visit and saw how ill she was, he immediately
called 911. Ms. Day was admitted to the hospital.
In the Hospital
Over During the 10 days in the hospital, Ms. Day received IV
antibiotics, drainage of her wound, and management of her diabetes
and congestive heart failure. As she returned to eating solid food,
she bit a nut and cracked a tooth, but the tooth does not hurt, and
Ms. Day is now eager to be discharged. However, Ms. Day’s son
and daughter insist that it is not safe to send their mother home.
Their mother’s recent bouts of confusion have made them very
doubtful about her capacity to manage on her own at home,
especially given her physical limitations. Ms. Day, on the other
hand, is very clear with everyone that she is going back home. She
has agreed to have a visiting nurse come to the house to pack her
wounds but will not allow anyone to stay at the house. She has also
agreed, with some evident impatience and irritation, to make an
appointment to see her dentist. Her children insist on a psychiatric
consult to evaluate Ms. Day’s decision-making capacity. When the
psychiatrists report that they believe Ms. Day has the capacity to
make the decision to go home, the children ask that several
members of the team caring for their mother (Ms. Day’s primary
nurse, attending physician, social worker, and physical therapist)
meet with them for a care conference. Ms. Day’s daughter speaks
first: “Mother might have fooled that psychiatrist, but we have seen
how confused she gets sometimes, and now that she’s so weak after
being in the hospital—how can we just send her back to that house
by herself?”
Back Home
Ms. Day goes home. The plan is for a visiting home health nurse to
see her daily to pack the wound. She will continue with oral
antibiotics. The young couple will continue to run errands, and her
son and daughter plan to bring meals more often. The RN care
manager in the office of Ms. Day’s primary care physician (PCP)
will provide daily telephone support, and a follow-up visit with the
PCP is scheduled in 2 days. Within 24 hours, however, Ms. Day is
severely short of breath. A pharmacist reviews her medications and
discovers that she was discharged without her oral furosemide. She
had been switched from her usual oral medication to IV furosemide
in the hospital, and when this was stopped at discharge, she was not
restarted on her usual oral dose. This omission has made her heart
failure worse.
The Fall
Once Ms. Day was restarted on her furosemide, and her breathing
started to improve, but the follow-up visit to her PCP’s office still
seemed too strenuous, so the visit to the office was canceled. The
physician assistant on the team in the PCP’s office offered to make a
home visit and scheduled it at the same time as the home health
nurse’s next visit to pack the wound. At the end of this home visit,
as the nurse and PA were preparing to leave, Ms. Day got up to go
into the kitchen and fell awkwardly to the floor. The nurse and PA
helped her up, checked her over carefully, and settled her back onto
a chair. They asked Ms. Day if she had fallen often since her stroke.
Ms. Day hesitated, and said, “Maybe once or twice … I don’t know
… maybe a few times.” Then Ms. Day looked directly at the PA and
the nurse and said, “I want you to promise not to tell anyone about
this, especially my children. It will only worry them for nothing.
Promise me?”
The Tooth
Three days after completing her oral antibiotics Ms. Day awakens
with a painful and swollen lower-left jaw. She has a dental abscess
as a result of the broken tooth. It is no surprise that the broken tooth
is a problem now. The antibiotics that were treating her wound
were also keeping the tooth problem in check. A dental abscess in a
person with insulin-dependent diabetes makes diabetes much
harder to control. It can result in very high blood sugars. Ms. Day is
likely to end up in the hospital again if the tooth is not treated right
away, but close coordination will be needed between the dentist and
PCP about insulin dosage at the time of dental care/extraction. Ms.
Day will also need the daily support of her RN care manager to
assist with her diabetes management based on how much she is able
to eat after the dental procedure and the results of her home glucose
monitoring, as well as continued management of her congestive
heart failure.
When the dentist and the PCP initially discuss Ms. Day’s case over
the phone, they agree that close coordination will be required for the
dental extraction in light of Ms. Day’s fragile overall health, but the
dentist is also very concerned about Ms. Day’s living arrangements.
She is particularly concerned about Ms. Day’s ability to manage the
aftercare of what could be a complicated procedure and worries that
it would not be professionally responsible to go ahead with the
dental procedure unless a better homecare plan is in place. The
dentist suggests a further conversation about Ms. Day’s home
situation, this time including the PA and the nurse, who have
firsthand knowledge of it.
A conference call is arranged. The PCP agrees that Ms. Day’s
condition makes it worrisome that she is so insistent on remaining
home alone. The home health nurse reports that Ms. Day is now
willing to allow the couple that she pays to come over every day to
check on her and do more household tasks “to help her stay out of
the hospital.” The PCP is also considering authorizing home health
on a regular basis. The problem is that the PCP would have to sign
home health forms that certify that Ms. Day is “housebound,” and
this is not strictly true. She goes to the grocery store and does other
errands with the couple who care for her and does not quite meet
the requirements.
The Bigger Picture

Agnes Day’s case calls our attention to an increasingly challenging
problem for our society and healthcare system: providing safe, high-
quality, patient-centered long-term care to a rapidly growing elderly
population with multiple chronic illnesses and disabilities. The
federal government estimates that 6 million of the 40 million
Americans over age 65 need some form of daily assistance to live
outside of a nursing home—a figure projected to double by 2030.
For family caregivers, these tasks are often on top of running the
household in the usual way: cleaning, shopping, preparing meals,
and holding down a job.
This case was written by Susan Tolle, with contributions by
members of the Center for Ethics Teaching Interprofessional Ethics
(TIE) Team, Phyllis Beemsterboer and Lynn Jansen Co-Chairs.
Questions
1. What ethical conflicts does the healthcare team face in
deciding about Ms. Day’s discharge from the hospital?
2. What ethical, professional, and interprofessional
considerations come into play in analyzing what happened
when Mrs. Day returned home? Was this an error? If so, how
might such an error be prevented from happening?
3. What ethical conflicts do the physician assistant and nurse
face in deciding how to respond to Ms. Day’s request not to
reveal her history of falls to anyone?
4. What ethical conflicts does the care team (PCP, home health
nurse, RN care manager, physician assistant, and dentist) face
in trying to obtain additional home health services for Ms.
Day?
5. Should the dentist be more involved with Ms. Day’s dental
aftercare?
6. Does society have an obligation to provide high-quality, long-
term care for the growing elderly population? If so, what is the
ethical basis of this obligation?
7. Do health professionals have any obligation to participate in
policy debates about the provision of long-term care? If so,
what contributions are they qualified to make to these debates
based on their professional expertise?
Case 30
Cyberbullying
Toni M. Roucka
Marquette University School of Dentistry
Julia, a bright 13-year-old, had been a patient of Dr. Bill

Moyer for most of her life. She always had very good oral
hygiene and was fortunate to never have needed a dental
restoration. As a result, when Julia came for dental visits it
was Joy, Dr. Moyer’s hygienist, with whom Julia spent the
most time.
The last two times Julia had come in for her routine dental
care, Joy had noticed a stark change in Julia’s behavior. She
seemed quieter, and her oral hygiene was lacking. In fact, her
overall personal hygiene seemed to be suffering. Previously
very talkative and animated, Julia barely answered Joy’s
questions regarding her teeth.
At first, Joy attributed Julia’s behavior to “teenage growing

pains.” Most adolescents seem to go through a phase like
this at some point. Because Joy had developed a rapport with
Julia over the years, she felt comfortable and compelled to
ask her how things were going in her life. What was new?
What was the “teenage buzz” around town? What was the
latest “technology” taking the teen world by storm? Maybe
she could get to the root of what seemed to be bothering her.
That got a rise out of Julia. She snapped back stating, “There
is no buzz or great new technology as far as I am concerned. I
am sick of people on social media spreading lies and rumors
about me. I might as well never go on the Internet again!”
Further questioning revealed that Julia was a victim of
cyberbullying and her parents did not know about it. Joy did
not know exactly what to do next. Dr. Moyer was in surgery,
and she could not interrupt him to ask. Joy decided to speak
with Julia’s mother right after the appointment to alert her to
the problem. Though annoyed at first, Julia seemed to be
grateful that the truth was finally revealed. She was tired of
pretending everything was okay in her life.
Questions
1. Did Joy do the right thing by talking to Julia’s mother
about their conversation?
2. Should Joy have gotten Dr. Moyer’s opinion about the
situation first?
3. List and discuss the core values from the ADHA Code
of Ethics for Dental Hygienists related to this case.
4. Using the ADHA Standards of Professional
Responsibility, discuss the responsibilities of the dental
hygienist that are applicable to this case.
5. Should cyberbullying be considered a form of “child
abuse” and thus rise to the level of mandatory reporting
to child protective services?
6. Could Julia have handled the situation differently? If so,
how?
Suggested Activities
The following activities can be used to enhance the study of ethics

and law in dental hygiene. These activities can be accomplished
individually or in small working groups.
1. Review the ADHA Standards of Clinical Dental Hygiene

Practice and review the six standards to formulate risk
management strategies for clinical practice.
2. Explore the medical and nursing literature on bioethics to see
the range of references available.
3. Look at a medical textbook on ethics. Compare the types of
issues that are presented and discussed to those presented and
discussed in this textbook.
4. What types of ethical dilemmas are on the news or being
discussed in social media?
5. List how many articles in the media, over a period of time,
relate to ethical issues. What principle is most often cited?
6. Search the web and list the number of sites that refer to dental
health care and ethics.
7. Pick one of the following topics and research the issue as it
affects health care and healthcare delivery:
• Abortion
• Access to care
• Assisted suicide/Death with dignity
• Blood transfusion
• Clinical and translational research
• Emergency care
• Health maintenance organizations
• Informed consent
• Law and life support
• Paternalism
• Transplantation
• End-of-life care
• Integrative medicine
• Harvesting reproductive cells
8. Locate the code of ethics from a healthcare professional group,
such as physical therapists, chiropractors, or medical
technologists. Compare with the ADHA Code.
9. Locate the code of ethics for another medical organization,
such as the American Medical Association (AMA) or American
Nurses Association (ANA). Compare it with the ADHA Code
and/or the ADA Code.
10. Access the website for the American Society for Dental
Ethics, and explore what the group does.
11. Access the websites for the following centers for ethical study
and research the materials available:
• Hastings Center, Garrison, NY
• Center for Health Care Ethics, St. Louis, MO
• Center for Ethics in Health Care, Portland, OR
• Midwest Bioethics Center, Kansas City, MO
• Ethics Institute of Dartmouth College, Hanover, NH
• Kennedy Institute of Ethics, Washington, DC
• Mayo Clinic Biomedical Ethics Program, Rochester, MN
12. Research and list the ethical issues that can arise in relation to
dental research.
13. Establish small study groups to explore different cultures
and then compare and contrast common beliefs and practices.
14. Discuss ethnocentrism and how it can affect the practice of
dental hygiene and dentistry.
15. Look up the following ethics and legal words and use them
in a sentence:
• Louche
• Probity
• Turpitude
p
• Peccant
• Malversation
• Malfeasance
• Canard
• Perfidy
• Phronesis
• Iniquitous
16. Establish small groups, and research the state dental practice
acts from several different regions in the United States, then
compare results.
17. Research a recent dental malpractice case in your state or
region, then identify the risk management errors that may
have led to the legal action and suggest risk management
solutions.
18. Analyze the risk management practices in the clinical setting
in which you are working or plan to work.
19. Research the issues surrounding the professional with drug
or alcohol impairment, and determine how those issues are
handled in your state or region, both ethically and legally.
20. Access your state government website, and find out the
rights and responsibilities of employers and employees.
Testlets
Testlet 1
Charlee is a dental hygienist in a busy practice with three dentists,
one other hygienist, and six dental assistants. The office also
supports an administrative staff of four. Oak Grove Dentistry is a
high-volume practice, with 250 to 300 patient visits per week among
clinical practitioners. New patients to the practice are seen first by
the dental hygienists, who take the medical history and perform the
initial examination, including the current periodontal status and
restorative needs.
Although Charlee is impressed by the quality of services that the
patients receive, she is distressed by what she believes is a wide
disparity between her clinical assessment of restorative need and
that of one of the dentists who finds many more carious lesions than
she notes. Her observations were confirmed when she discussed the
issue with the other hygienist and one of the dentists, both of whom
expressed similar concerns.
When Charlee approached Dr. Kane, the owner of the practice,
with her concern, she was told clearly that a definitive diagnosis of
caries and oral disease is within the scope of practice for the dentist,
not the dental hygienist. When Charlee added that the other dental
hygienist also was concerned, Dr. Kane intimated that she was a
“troublemaker” and any further allegations that he was not acting in
the best interests of his patients would not be tolerated.
1. This case presents issues that may be

a. unethical
b. illegal
c. grounds for malpractice
d. all of the above
e. none of the above
2. The main principle involved in this case is
a. autonomy
b. beneficence
c. nonmaleficence
d. justice
e. veracity
3. Does Charlee have any responsibility to the patients in this
practice?
a. No; she is an employee, not the owner, of the practice.
b. Yes; she must adhere to the ADHA Code of Ethics.
4. What section of the ADHA Code of Ethics “Standards” applies
to this situation?
a. “To ourselves as professionals”
b. “To clients”
c. “To employees and employers”
d. “To the dental hygiene profession”
e. “To the community and society”
Testlet 2
A patient assigned to Callie Rose in the periodontal practice at
which she works has a severe case of periodontal disease, Stage IV,
Grade C. The dentist’s employer initially examined the patient and,
because of the amount of calculus present, sent her for scaling and
debridement. The patient is elderly, somewhat shy, and keeps
saying that she wants Callie to do “whatever is necessary” so she
can keep her teeth. Callie is concerned that the patient does not fully
understand her disease, the scope and expense of treatment, and
treatment options.
1. What healthcare obligation is most important in this case?

a. Confidentiality
b. Informed consent
c. Paternalism
d. Veracity
2. Making sure the patient understands the course of treatment
is honoring the ethical principle of
a. autonomy
b. beneficence
c. justice
d. nonmaleficence
e. veracity
3. Callie should be concerned about this situation because the
patient is
a. elderly and shy
b. too trusting
c. yet to be diagnosed by the dentist
d. not well informed about her oral health
4. What section of the ADHA Code of Ethics “Standards” applies
to this situation?
a. “To ourselves as professionals.”
b. “To clients.”
c. “To employees and employers.”
d. “To the dental hygiene profession.”
e. “To the community and society.”
Testlet 3
A new patient, Marissa, is a 15-year-old who is seeing a dental
hygienist for dental care for the first time. In this practice,
radiographs are taken of every new patient as part of the diagnostic
data gathering. As a safety precaution before taking radiographs,
females potentially of childbearing age are asked whether they
could be pregnant. Marissa, aware that her mother is in the waiting
room, very quietly tells the hygienist that she is pregnant. She also
says that her parents are unaware of her condition and begs the
hygienist not to tell her mother or the dentist.
1. Which main ethical principles are involved for the dental

hygienist in this case?
a. Autonomy and nonmaleficence.
b. Beneficence and justice.
c. Nonmaleficence and veracity.
d. Justice and autonomy.
e. All of the above.
2. At what age would this person become an adult?
a. When she turns 16 years of age.
b. When she turns 18 years of age.
c. When she pays for her own dental care.
d. When the state law says she is an adult.
3. Taking radiographs of pregnant women is not recommended
because
a. radiation is dangerous for a fetus
b. radiation may be dangerous for a fetus
c. pregnancy gingivitis is a risk
d. of concerns for the health of the mother
4. The dental hygienist should first
a. try to convince Marissa to discuss her pregnancy with her
mother
b. inform the dentist of this dilemma
c. contact Marissa’s mother and inform her of the pregnancy
d. delay dental hygiene treatment
Testlet 4
Julie is a part-time dental assistant and a graduate of an accredited
dental assisting program. She was credentialed by the state to
expose radiographs and place pit and fissure sealants as expanded
functions dental auxiliary (EFDA). She works in a practice the 2
days of the week that the dental hygienist is not scheduled and
generally sees a full client load. Many of her clients were children
when she began her employment, but lately, she has noticed that
many of them are now adults on Medicaid.
The dentist explained to her that he would scale the client’s teeth
and directed Julie to polish them because that is “as good as the
hygienist would be able to do.” When Julie checked the Medicaid
claim form for these clients, she found that her services were being
billed as “adult prophylaxis.” This is not in her scope of practice as
an EFDA.
The dentist’s employer told Julie that the Medicaid reimbursement
rates were so poor that he believed these clients were getting more
than adequate treatment. He pointed out that he was one of the few
dentists in the area who provided any treatment to Medicaid
patients and that Julie should be happy to assist in this valuable
service.
1. This case presents issues that are
a. unethical
b. illegal
d. all of the above
2. Which ethical principle is most important in this case?
a. Autonomy.
b. Beneficence.
c. Nonmaleficence.
d. Justice.
e. Veracity.
3. The clinical function of polishing teeth
a. is a traditional dental assisting duty
b. is an expanded dental assisting duty
c. is a function of the dental hygienist
d. can be delegated by the dentist
e. depends on state law
Testlet 5
Renee is happily employed in a large suburban practice that sees
mostly families and children. A number of hygienists work full-
time, and a few come in for only a day or two. Getting to know all of
them has been fun, and they cover for each other when they have to
attend a child’s school play or sporting event. Jessie is a hygienist
with whom Renee has developed a growing friendship, and they
often have lunch together.
One very busy day, Renee is scheduled to complete treatment on a
rather complicated periodontal case when Jessie asks her to switch
patients. The office follows a policy of continuity of care, and each
hygienist completes his or her own patients. Renee asks why, and
her friend indicates that she does not want to provide dental
hygiene treatment to the patient as she is part of a “same-sex
couple” and that this is not what her church believes in.

a. unfriendly
b. illegal
d. all of the above
2. The main ethical principle raised in this case is
a. autonomy
b. paternalism
c. nonmaleficence
d. justice
e. veracity
3. Which of the following would be appropriate for Renee to do
in this situation?
a. Refer Jessie to the office manager with her request.
b. Refer Jessie to the practice’s policies and procedures
manual.
c. Tell Jessie no and discuss with her the legal implications of
her request.
d. All of the above.
e. None of the above.
Testlet 6
Karen is a dental hygienist in the practice of Joe Alvins, DDS. Stacy
is treating Ms. Holloway, a patient with acute gingivitis, who is also
seeing a naturopathic physician to help her with her allergies.
Ms. Holloway has three large posterior amalgam alloys that she
insisted needed to be replaced with the composite because her
naturopath told her “mercury fillings” were unhealthy. Dr. Alvins
has told her that in most cases alloy has proven to be a better choice
in posterior teeth, but Ms. Holloway has made it pretty clear that
she was going to do what her naturopath told her to do. Dr. Alvins
has tried to help her understand the procedure, risks associated, and
material science of both restorations. After a long-informed consent
discussion and process, Dr. Alvins was treatment planning the
composites but not very happy about it. He knew it was not the best
option for the patient.
Dr. Alvins was frustrated that his professional skills and judgment
had been undermined by another clinician. He asked Karen to tell
the patient that the naturopath was making a diagnosis out of his
field of expertise and to talk the patient into adhering to his
treatment plan.
1. Which of the following principles and values are most

involved in this case?
a. Autonomy and informed consent.
b. Confidentiality and justice.
c. Trust and veracity.
d. Paternalism and beneficence.
a. unethical
b. illegal
d. all of the above
3. The dental hygienist should follow the dentist’s request
because
a. the dentist is the ultimately responsible individual
b. evidence-based dentistry does not support this treatment
option
c. she is an employee of the practice
d. all of the above
Testlet 7
Each dental hygiene and dental student in the Greenfield University
Dental School is assigned to an off-campus rotation at a rural clinical
site for a 4-week period, living in housing provided by the local
community. Although the clinical experience is fantastic, the
students are finding the quieter lifestyle boring.
On social media, several students have commented about the lack
of things to do while on this rotation and made fun of what the
locals do for fun, calling local dances and events “white trash
diversions.” One hygiene student, Laurel, is upset about this and
talks to several of her colleagues about this lack of professionalism.
She is met with a resounding response that they can say anything
they want as long as they are not mentioning any patient names and
violating confidentiality.
1. Is there an ethical dilemma present in this case?

a. Yes.
b. No.
2. Do most institutes of higher learning have social media
policies related to student conduct (on campus and off
campus) that these postings may violate?
a. No.
b. Yes.
3. What section(s) of the ADHA Code of Ethics “Standards” may
be involved in this situation?
a. “To ourselves as professionals.”
b. “To the dental hygiene profession.”
c. “To the community and society.”
e. None of the above.
4. A good rule of thumb when using social media is to
a. remember that all digital communications leave a footprint
b. never discuss nondental situations
c. only include people who share your values
d. attend to all of the above
e. attend to none of the above
Testlet 8
Robert, a longstanding patient of dental hygienist Deirdre, asks to
speak with her privately in her operatory. Robert closes the door
and tells Deirdre that he is positive for HIV/AIDS and trusts that
this information will be kept completely confidential. He is afraid
that if other office members are informed, they will treat him
differently and be uncomfortable with him. He was recently referred
for the removal of his third molars to a local oral surgeon, and he
specifically asked not to tell the surgeon about this condition. He
states that he will decide if and when to tell anyone else.
1. What is the prima facie principle that Deirdre must honor?

a. Autonomy.
b. Beneficence.
c. Nonmaleficence.
d. Justice.
e. Veracity.
2. What is the principle that the patient is basing his request on?
a. Autonomy.
b. Beneficence.
c. Confidentiality.
d. Justice.
e. Veracity.
3. What might the dental hygienist need to treat a patient with
HIV/AIDS?
a. T-cell levels.
b. A and C.
c. Enhanced infection control.
e. Consultation with the medical provider.
4. Is there an ethical mandate to accurately record the patient’s
status in the patient record?
a. Yes.
b. No.
Testlet 9
Susan is a 24-year-old woman with a slight developmental delay
who presents for her annual checkup with Gretchen, a dental
hygienist in the office of SmileNice. Susan complains of pain in
tooth number #9 during her appointment, and Gretchen asks her
colleague Dr. Jefferies to look at the tooth. Dr. Jefferies takes a
detailed history and during the process notices that Susan
frequently looks away, fidgets with items in the examination room,
and displays other behaviors that suggest significant anxiety and
possibly incomplete or inaccurate disclosure of facts.
Dr. Jefferies gently queries Susan about the perceived behavior,
and she eventually responds, “My mother told me not to tell you
what happened, or the insurance won’t pay.”
After further exploration, Susan reveals that her injury occurred 3
months ago while riding her bicycle when she was hit by a car that
ran a stop sign. Susan’s mother has indicated they have only limited
dental insurance through her work, which would cover examining
and care for the tooth had it not been the result of an auto accident.
Dr. Jefferies believes that Susan suffered a significant traumatic
blow to the tooth and now has an acute problem from the
devitalized pulp.
Barbara asks both Gretchen and Dr. Jefferies not to say “how the
tooth got hurt because my Mom will be mad at me.”
1. What is the main ethical issue raised in this case?

a. Negligence.
b. Informed refusal.
c. Paternalism.
d. Veracity.
a. unethical
b. illegal
d. all of the above
3. Susan’s anxiety and demeanor may cause the dental health
professionals to consider
a. referral to another care provider
b. referral to a free clinic
c. discussion with Susan’s mother
d. clarification with insurance carriers
Testlet 10
As Laura, a dental hygienist, was seating her long-time patient Mrs.
Johnson, she noticed that the 80-year-old seemed slower and unsure
of herself. During the routine recall appointment, Mrs. Johnson
talked about how proud she was of her four grandchildren,
especially Sammy, who was the apple of her eye. Mrs. Johnson’s
oral health is excellent, and when asked what type of toothbrush she
is using, she smiles and cannot remember which brand. Laura and
her patient laugh over this, saying how easily details slip away.
After the appointment, Laura asks the patient for the name of the
favorite grandchild she had mentioned. The patient appears a bit
confused by the question and looks at Laura in a distracted manner.
This upsets Laura as she and Mrs. Johnson have known each other
for years and their families are close friends.
1. The issue that Laura may be facing here is:

a. paternalism
b. lack of capacity
c. lack of veracity
d. informed refusal
2. The dental hygienist may discuss Mrs. Johnson’s oral health
care with:
a. a family member
b. the primary care physician
c. a surrogate decision maker
d. all of the above
3. It is legally necessary to complete a mental and physical
evaluation before proceeding with dental treatment on an
elderly patient.
a. True.
b. False.
4. What communication strategy could the dental hygienist use
in dealing with elderly patients like Mrs. Johnson?
a. Ignore inaccurate statements.
b. Focus on verbal and nonverbal comprehension cues.
c. Challenge the patient’s vague ideas for clarity.
d. Speak in loud, simple sentences.
Answers to Testlet Questions

Testlet 1
1. d
2. c
3. b
4. b
Testlet 2
1. b
2. a
3. d
4. b
Testlet 3
1. a
2. d
3. b
4. a
Testlet 4
1. d
2. e
3. e
Testlet 5
1. b
2. d
3. d
Testlet 6
1. a
2. e
3. d
Testlet 7
1. a
2. b
3. a
4. a
Testlet 8
1. a
2. c
3. e
4. a
Testlet 9
1. d
2. d
3. c
Testlet 10
1. b
2. d
3. b
4. b
APPENDI
X A
American Dental Association

Principles of Ethics and Code of
Professional Conduct With
Official Advisory Opinions
Revised to November 2020
ADA American Dental Association®

© 2023 American Dental Association. All rights reserved. Reprinted
with permission.
Contents
I. Introduction 153
II. Preamble 153
III. Principles, Code of Professional Conduct and Advisory
Opinions 154
The Code of Professional Conduct is organized into five sections. Each

section falls under the Principle of Ethics that predominately applies to it.
Advisory Opinions follow the section of the Code that they interpret.
Section 1 – PRINCIPLE: PATIENT AUTONOMY (“self-
governance”) 154
Code of Professional Conduct 154
1.A. Patient Involvement 154
1.B. Patient Records 154
Advisory Opinions
1.B.1. Furnishing Copies of Records 154
1.B.2. Confidentiality of Patient Records 154
Section 2 – PRINCIPLE: NONMALEFICENCE (“do no harm”)
154
2.A. Education 155
2.B. Consultation and Referral 155
Advisory Opinion
2.B.1. Second Opinions 155
2.C. Use of Auxiliary Personnel 155
2.D. Personal Impairment 155
Advisory Opinion
2.D.1. Ability to Practice 155
2.E. Postexposure, Bloodborne Pathogens 155
2.F. Patient Abandonment 155
2.G. Personal Relationships with Patients 156
Section 3 – PRINCIPLE: BENEFICENCE (“do good”) 156
3.A. Community Service 156
Advisory Opinion
3.A.1. Elective and Non-Emergent Procedures During
a Public Health Emergency 156
3.B. Government of a Profession 156
3.C. Research and Development 156
3.D. Patents and Copyrights 156
3.E. Abuse and Neglect 157
Advisory Opinion
3.E.1. Reporting Abuse and Neglect 157
3.F. Professional Demeanor in the Workplace 157
Advisory Opinion
y p
3.F.1. Disruptive Behavior in the Workplace 157
Section 4 – PRINCIPLE: JUSTICE (“fairness”) 157
4.A. Patient Selection 157
Advisory Opinion
4.A.1. Patients With Disabilities or Bloodborne
Pathogens 157
4.B. Emergency Service 158
4.C. Justifiable Criticism 158
Advisory Opinion
4.C.1. Meaning of “Justifiable” 158
4.D. Expert Testimony 158
Advisory Opinion
4.D.1. Contingent Fees 158
4.E. Rebates And Split Fees 158
Advisory Opinion
4.E.1. Split Fees in Advertising and Marketing
Services 158
Section 5 – PRINCIPLE: VERACITY (“truthfulness”) 159
5.A. Representation of Care 159
Advisory Opinions
5.A.1. Dental Amalgam and Other Restorative
Materials 159
5.A.2. Unsubstantiated Representations 159
5.B. Representation of Fees 159
Advisory Opinions
5.B.1. Waiver of Copayment 159
5.B.2. Overbilling 159
5.B.3. Fee Differential 159
5.B.4. Treatment Dates 159
5.B.5. Dental Procedures 160
5.B.6. Unnecessary Services 160
5.C. Disclosure of Conflict of Interest 160
5.D. Devices and Therapeutic Methods 160
Advisory Opinions
y p
5.D.1. Reporting Adverse Reactions 160
5.D.2. Marketing or Sale of Products or Procedures
160
5.E. Professional Announcement 160
5.F. Advertising 160
Advisory Opinions
5.F.1. Published Communications 160
5.F.2. Examples of “False or Misleading” 161
5.F.3. Unearned, Nonhealth Degrees 161
5.F.4. Referral Services 161
5.F.5. Infectious Disease Test Results 162
5.F.6. Websites and Search Engine Optimization 162
5.G. Name of Practice 162
Advisory Opinion
5.G.1. Dentist Leaving Practice 162
5.H. Announcement of Specialization and Limitation of
Practice 162
Advisory Opinions
5.H.1. Dual Degreed Dentists 163
5.H.2. Specialist Announcement of Credentials in
Non-Specialty Interest Areas 163
5.I. General Practitioner Announcement of Services 163
Advisory Opinions
5.I.1. General Practitioner Announcement of
Credentials in Interest Areas in General Dentistry
163
5.I.2. Credentials in General Dentistry 164
Notes 164
IV. Interpretation and Application of Principles of Ethics and
V. CEBJA Statements and White Papers 165
VI. Index 165
I. INTRODUCTION
The dental profession holds a special position of trust within
society. As a consequence, society affords the profession certain
privileges that are not available to members of the public-at-large. In
return, the profession makes a commitment to society that its
members will adhere to high ethical standards of conduct. These
standards are embodied in the ADA Principles of Ethics and Code of
Professional Conduct (ADA Code). The ADA Code is, in effect, a written
expression of the obligations arising from the implied contract
between the dental profession and society.
Members of the ADA voluntarily agree to abide by the ADA Code
as a condition of membership in the Association. They recognize
that continued public trust in the dental profession is based on the
commitment of individual dentists to high ethical standards of
conduct.
The ADA Code has three main components: The Principles of
Ethics, the Code of Professional Conduct and the Advisory
Opinions.
The Principles of Ethics are the aspirational goals of the
profession. They provide guidance and offer justification for the
Code of Professional Conduct and the Advisory Opinions. There are five
fundamental principles that form the foundation of the ADA Code:
patient autonomy, nonmaleficence, beneficence, justice and veracity.
Principles can overlap each other as well as compete with each other
for priority.
More than one principle can justify a given element of the Code of
Professional Conduct. Principles may at times need to be balanced
against each other, but, otherwise, they are the profession’s firm
guideposts.
The Code of Professional Conduct is an expression of specific
types of conduct that are either required or prohibited. The Code of
Professional Conduct is a product of the ADA’s legislative system. All
elements of the Code of Professional Conduct result from resolutions
that are adopted by the ADA’s House of Delegates. The Code of
Professional Conduct is binding on members of the ADA, and
violations may result in disciplinary action.
The Advisory Opinions are interpretations that apply the Code of
Professional Conduct to specific fact situations. They are adopted by
the ADA’s Council on Ethics, Bylaws and Judicial Affairs to provide
guidance to the membership on how the Council might interpret the
Code of Professional Conduct in a disciplinary proceeding.
The ADA Code is an evolving document and by its very nature
cannot be a complete articulation of all ethical obligations. The ADA
Code is the result of an on-going dialogue between the dental
profession and society, and as such, is subject to continuous review.
Although ethics and the law are closely related, they are not the
same. Ethical obligations may – and often do – exceed legal duties.
In resolving any ethical problem not explicitly covered by the ADA
Code, dentists should consider the ethical principles, the patient’s
needs and interests, and any applicable laws.
II. PREAMBLE
The American Dental Association calls upon dentists to follow high
ethical standards which have the benefit of the patient as their
primary goal. In recognition of this goal, the education and training
of a dentist has resulted in society affording to the profession the
privilege and obligation of self-government. To fulfill this privilege,
these high ethical standards should be adopted and practiced
throughout the dental school educational process and subsequent
professional career.
The Association believes that dentists should possess not only
knowledge, skill and technical competence but also those traits of
character that foster adherence to ethical principles. Qualities of
honesty, compassion, kindness, integrity, fairness and charity are
part of the ethical education of a dentist and practice of dentistry
and help to define the true professional. As such, each dentist
should share in providing advocacy to and care of the underserved.
It is urged that the dentist meet this goal, subject to individual
circumstances.
The ethical dentist strives to do that which is right and good. The
ADA Code is an instrument to help the dentist in this quest.
III. PRINCIPLES, CODE OF

PROFESSIONAL CONDUCT AND
ADVISORY OPINIONS
Section 1 Principle: Patient Autonomy (“self-
governance”)
The dentist has a duty to respect the patient’s rights to self-
determination and confidentiality.
This principle expresses the concept that professionals have a duty to
treat the patient according to the patient’s desires, within the bounds of
accepted treatment, and to protect the patient’s confidentiality. Under this
principle, the dentist’s primary obligations include involving patients in
treatment decisions in a meaningful way, with due consideration being
given to the patient’s needs, desires and abilities, and safeguarding the
patient’s privacy.
CODE OF PROFESSIONAL CONDUCT
1.A. Patient Involvement

The dentist should inform the patient of the proposed treatment,
and any reasonable alternatives, in a manner that allows the patient
to become involved in treatment decisions.
1.B. Patient Records

Dentists are obliged to safeguard the confidentiality of patient
records. Dentists shall maintain patient records in a manner
consistent with the protection of the welfare of the patient. Upon
request of a patient or another dental practitioner, dentists shall
provide any information in accordance with applicable law that will
be beneficial for the future treatment of that patient.
Advisory Opinions
1.B.1. Furnishing Copies of Records
A dentist has the ethical obligation on request of either the patient
or the patient’s new dentist to furnish in accordance with applicable
law, either gratuitously or for nominal cost, such dental records or
copies or summaries of them, including dental X-rays or copies of
them, as will be beneficial for the future treatment of that patient.
This obligation exists whether or not the patient’s account is paid in
full.
1.B.2. Confidentiality of Patient Records

The dominant theme in Code Section l.B is the protection of the
confidentiality of a patient’s records. The statement in this section
that relevant information in the records should be released to
another dental practitioner assumes that the dentist requesting the
information is the patient’s present dentist. There may be
circumstances where the former dentist has an ethical obligation to
inform the present dentist of certain facts. Code Section 1.B assumes
that the dentist releasing relevant information is acting in
accordance with applicable law. Dentists should be aware that the
laws of the various jurisdictions in the United States are not uniform
and some confidentiality laws appear to prohibit the transfer of
pertinent information, such as HIV seropositivity. Absent certain
knowledge that the laws of the dentist’s jurisdiction permit the
forwarding of this information, a dentist should obtain the patient’s
written permission before forwarding health records which contain
information of a sensitive nature, such as HIV seropositivity,
chemical dependency or sexual preference. If it is necessary for a
treating dentist to consult with another dentist or physician with
respect to the patient, and the circumstances do not permit the
patient to remain anonymous, the treating dentist should seek the
permission of the patient prior to the release of data from the
patient’s records to the consulting practitioner. If the patient refuses,
the treating dentist should then contemplate obtaining legal advice
regarding the termination of the dentist-patient relationship.
Section 2 Principle: Nonmaleficence
(“Do No Harm”)
The dentist has a duty to refrain from harming the patient.
This principle expresses the concept that professionals have a duty to
protect the patient from harm. Under this principle, the dentist’s primary
obligations include keeping knowledge and skills current, knowing one’s
own limitations and when to refer to a specialist or other professional, and
knowing when and under what circumstances delegation of patient care to
auxiliaries is appropriate.
2.A. Education
The privilege of dentists to be accorded professional status rests
primarily in the knowledge, skill and experience with which they
serve their patients and society. All dentists, therefore, have the
obligation of keeping their knowledge and skill current.
2.B. Consultation and Referral

Dentists shall be obliged to seek consultation, if possible, whenever
the welfare of patients will be safeguarded or advanced by utilizing
those who have special skills, knowledge, and experience. When
patients visit or are referred to specialists or consulting dentists for
consultation:
1. The specialists or consulting dentists upon completion of their

care shall return the patient, unless the patient expressly
reveals a different preference, to the referring dentist, or, if
none, to the dentist of record for future care.
2. The specialists shall be obliged when there is no referring
dentist and upon a completion of their treatment to inform
patients when there is a need for further dental care.
Advisory Opinion
2.B.1. Second Opinions
A dentist who has a patient referred by a third party1 for a “second
opinion” regarding a diagnosis or treatment plan recommended by
the patient’s treating dentist should render the requested second
opinion in accordance with this Code of Ethics. In the interest of the
patient being afforded quality care, the dentist rendering the second
opinion should not have a vested interest in the ensuing
recommendation.
2.C. Use of Auxiliary Personnel

Dentists shall be obliged to protect the health of their patients by
only assigning to qualified auxiliaries those duties which can be
legally delegated. Dentists shall be further obliged to prescribe and
supervise the patient care provided by all auxiliary personnel
working under their direction.
2.D. Personal Impairment

It is unethical for a dentist to practice while abusing controlled
substances, alcohol or other chemical agents which impair the
ability to practice. All dentists have an ethical obligation to urge
chemically impaired colleagues to seek treatment. Dentists with
first-hand knowledge that a colleague is practicing dentistry when
so impaired have an ethical responsibility to report such evidence to
the professional assistance committee of a dental society.
Advisory Opinion
2.D.1. Ability to Practice
A dentist who contracts any disease or becomes impaired in any
way that might endanger patients or dental staff shall, with
consultation and advice from a qualified physician or other
authority, limit the activities of practice to those areas that do not
endanger patients or dental staff. A dentist who has been advised to
limit the activities of his or her practice should monitor the
aforementioned disease or impairment and make additional
limitations to the activities of the dentist’s practice, as indicated.
2.E. Postexposure, Bloodborne

Pathogens
All dentists, regardless of their bloodborne pathogen status, have an
ethical obligation to immediately inform any patient who may have
been exposed to blood or other potentially infectious material in the
dental office of the need for postexposure evaluation and follow-up
and to immediately refer the patient to a qualified health care
practitioner who can provide postexposure services. The dentist’s
ethical obligation in the event of an exposure incident extends to
providing information concerning the dentist’s own bloodborne
pathogen status to the evaluating health care practitioner, if the
dentist is the source individual, and to submitting to testing that
will assist in the evaluation of the patient. If a staff member or other
third person is the source individual, the dentist should encourage
that person to cooperate as needed for the patient’s evaluation.
2.F. Patient Abandonment

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.
2.G. Personal Relationships

with Patients
Dentists should avoid interpersonal relationships that could impair
their professional judgment or risk the possibility of exploiting the
confidence placed in them by a patient.
Section 3 Principle: Beneficence (“Do Good”)
The dentist has a duty to promote the patient’s welfare.
This principle expresses the concept that professionals have a duty to act
for the benefit of others. Under this principle, the dentist’s primary
obligation is service to the patient and the public-at-large. The most
important aspect of this obligation is the competent and timely delivery of
dental care within the bounds of clinical circumstances presented by the
patient, with due consideration being given to the needs, desires and values
of the patient. The same ethical considerations apply whether the dentist
engages in fee-for-service, managed care or some other practice
arrangement. Dentists may choose to enter into contracts governing the
provision of care to a group of patients; however, contract obligations do
not excuse dentists from their ethical duty to put the patient’s welfare first.
3.A. Community Service

Since dentists have an obligation to use their skills, knowledge and
experience for the improvement of the dental health of the public
and are encouraged to be leaders in their community, dentists in
such service shall conduct themselves in such a manner as to
maintain or elevate the esteem of the profession.
Advisory Opinion
3.A.1. Elective and Non-Emergent Procedures During a Public
Health Emergency
Dentists have ethical obligations to provide care for patients and
also serve the public at large. Typically, these obligations are
interrelated. Dentists are able to provide oral health care for patients
according to the patient’s desires and wishes, so long as the
treatment is within the scope of what is deemed acceptable care
without causing the patient harm or impacting the public. During
public health crises or emergencies, however, the dentist’s ethical
obligation to the public may supersede the dentist’s ethical
obligations to individual patients. This may occur, for example,
when a communicable disease causes individual patients who
undergo treatment and/or the public to be exposed to elevated
health risks. During the time of a public health emergency,
therefore, dentists should balance the competing ethical obligations
to individual patients and the public. If, for example, a patient
requests an elective or non-emergent procedure during a public
health crisis, the dentist should weigh the risk to the patient and the
public from performing that procedure during the public health
emergency, postponing such treatment if, in the dentist’s judgment,
the risk of harm to the patient and/or the public is elevated and
cannot be suitably mitigated. If, however, the patient presents with
an urgent or emergent condition necessitating treatment to prevent
or eliminate infection or to preserve the structure and function of
teeth or orofacial hard and soft tissues, the weighing of the dentist’s
competing ethical obligations may result in moving forward with
the treatment of the patient.
3.B. Government of a
Profession
Every profession owes society the responsibility to regulate itself.
Such regulation is achieved largely through the influence of the
professional societies. All dentists, therefore, have the dual
obligation of making themselves a part of a professional society and
of observing its rules of ethics.
3.C. Research and

Development
Dentists have the obligation of making the results and benefits of
their investigative efforts available to all when they are useful in
safeguarding or promoting the health of the public.
3.D. Patents and Copyrights

Patents and copyrights may be secured by dentists provided that
such patents and copyrights shall not be used to restrict research or
practice.
3.E. Abuse and Neglect

Dentists shall be obliged to become familiar with the signs of abuse
and neglect and to report suspected cases to the proper authorities,
consistent with state laws.
Advisory Opinion
3.E.1. Reporting Abuse and Neglect
The public and the profession are best served by dentists who are
familiar with identifying the signs of abuse and neglect and
knowledgeable about the appropriate intervention resources for all
populations.
A dentist’s ethical obligation to identify and report the signs of
abuse and neglect is, at a minimum, to be consistent with a dentist’s
legal obligation in the jurisdiction where the dentist practices.
Dentists, therefore, are ethically obliged to identify and report
suspected cases of abuse and neglect to the same extent as they are
legally obliged to do so in the jurisdiction where they practice.
Dentists have a concurrent ethical obligation to respect an adult
patient’s right to self-determination and confidentiality and to
promote the welfare of all patients. Care should be exercised to
respect the wishes of an adult patient who asks that a suspected case
of abuse and/or neglect not be reported, where such a report is not
mandated by law. With the patient’s permission, other possible
solutions may be sought.
Dentists should be aware that jurisdictional laws vary in their
definitions of abuse and neglect, in their reporting requirements and
the extent to which immunity is granted to good faith reporters. The
variances may raise potential legal and other risks that should be
considered, while keeping in mind the duty to put the welfare of the
patient first. Therefore a dentist’s ethical obligation to identify and
report suspected cases of abuse and neglect can vary from one
jurisdiction to another.
Dentists are ethically obligated to keep current their knowledge of
both identifying abuse and neglect and reporting it in the
jurisdiction(s) where they practice.
3.F. Professional Demeanor in
the Workplace
Dentists have the obligation to provide a workplace environment
that supports respectful and collaborative relationships for all those
involved in oral health care.
Advisory Opinion
3.F.1. Disruptive Behavior in the Workplace
Dentists are the leaders of the oral healthcare team. As such, their
behavior in the workplace is instrumental in establishing and
maintaining a practice environment that supports the mutual
respect, good communication, and high levels of collaboration
among team members required to optimize the quality of patient
care provided. Dentists who engage in disruptive behavior in the
workplace risk undermining professional relationships among team
members, decreasing the quality of patient care provided, and
undermining the public’s trust and confidence in the profession.
Section 4 Principle: Justice (“Fairness”)
The dentist has a duty to treat people fairly.
This principle expresses the concept that professionals have a duty to be
fair in their dealings with patients, colleagues and society. Under this
principle, the dentist’s primary obligations include dealing with people
justly and delivering dental care without prejudice. In its broadest sense,
this principle expresses the concept that the dental profession should
actively seek allies throughout society on specific activities that will help
improve access to care for all.
4.A. Patient Selection

While dentists, in serving the public, may exercise reasonable
discretion in selecting patients for their practices, dentists shall not
refuse to accept patients into their practice or deny dental service to
patients because of the patient’s race, creed, color, gender, sexual
orientation, gender identity, national origin or disability.
Advisory Opinion
4.A.1. Patients with Disabilities or Bloodborne Pathogens
As is the case with all patients, when considering the treatment of
patients with a physical, intellectual or developmental disability or
disabilities, including patients infected with Human
Immunodeficiency Virus, Hepatitis B Virus, Hepatitis C Virus or
another bloodborne pathogen, or are otherwise medically
compromised, the individual dentist should determine if he or she
has the need of another’s skills, knowledge, equipment or expertise,
and if so, consultation or referral pursuant to Section 2.B hereof is
indicated. Decisions regarding the type of dental treatment
provided, or referrals made or suggested, should be made on the
same basis as they are made with other patients. The dentist should
also determine, after consultation with the patient’s physician, if
appropriate, if the patient’s health status would be significantly
compromised by the provision of dental treatment.
4.B. Emergency Service

Dentists shall be obliged to make reasonable arrangements for the
emergency care of their patients of record. Dentists shall be obliged
when consulted in an emergency by patients not of record to make
reasonable arrangements for emergency care. If treatment is
provided, the dentist, upon completion of treatment, is obliged to
return the patient to his or her regular dentist unless the patient
expressly reveals a different preference.
4.C. Justifiable Criticism

Dentists shall be obliged to report to the appropriate reviewing
agency as determined by the local component or constituent society
instances of gross or continual faulty treatment by other dentists.
Patients should be informed of their present oral health status
without disparaging comment about prior services. Dentists issuing
a public statement with respect to the profession shall have a
reasonable basis to believe that the comments made are true.
Advisory Opinion
4.C.1. Meaning of “Justifiable”
Patients are dependent on the expertise of dentists to know their
oral health status. Therefore, when informing a patient of the status
of his or her oral health, the dentist should exercise care that the
comments made are truthful, informed and justifiable. This should,
if possible, involve consultation with the previous treating
dentist(s), in accordance with applicable law, to determine under
what circumstances and conditions the treatment was performed. A
difference of opinion as to preferred treatment should not be
communicated to the patient in a manner which would unjustly
imply mistreatment. There will necessarily be cases where it will be
difficult to determine whether the comments made are justifiable.
Therefore, this section is phrased to address the discretion of
dentists and advises against unknowing or unjustifiable disparaging
statements against another dentist. However, it should be noted
that, where comments are made which are not supportable and
therefore unjustified, such comments can be the basis for the
institution of a disciplinary proceeding against the dentist making
such statements.
4.D. Expert Testimony

Dentists may provide expert testimony when that testimony is
essential to a just and fair disposition of a judicial or administrative
action.
Advisory Opinion
4.D.1. Contingent Fees
It is unethical for a dentist to agree to a fee contingent upon the
favorable outcome of the litigation in exchange for testifying as a
dental expert.
4.E. Rebates and Split Fees

Dentists shall not accept or tender “rebates” or “split fees.”
Advisory Opinion
4.E.1. Split Fees in Advertising and Marketing Services
The prohibition against a dentist’s accepting or tendering rebates or
split fees applies to business dealings between dentists and any
third party, not just other dentists. Thus, a dentist who pays for
advertising or marketing services by sharing a specified portion of
the professional fees collected from prospective or actual patients
with the vendor providing the advertising or marketing services is
engaged in fee splitting. The prohibition against fee splitting is also
applicable to the marketing of dental treatments or procedures via
“social coupons” if the business arrangement between the dentist
and the concern providing the marketing services for that treatment
or those procedures allows the issuing company to collect the fee
from the prospective patient, retain a defined percentage or portion
of the revenue collected as payment for the coupon marketing
service provided to the dentist and remit to the dentist the
remainder of the amount collected.
Dentists should also be aware that the laws or regulations in their
jurisdictions may contain provisions that impact the division of
revenue collected from prospective patients between a dentist and a
third party to pay for advertising or marketing services.
Section 5 Principle: Veracity (“Truthfulness”)
The dentist has a duty to communicate truthfully.
This principle expresses the concept that professionals have a duty to be
honest and trustworthy in their dealings with people. Under this principle,
the dentist’s primary obligations include respecting the position of trust
inherent in the dentist-patient relationship, communicating truthfully and
without deception, and maintaining intellectual integrity.
5.A. Representation of Care

Dentists shall not represent the care being rendered to their patients
in a false or misleading manner.
Advisory Opinions
5.A.1. Dental Amalgam and other Restorative Materials
Based on current scientific data, the ADA has determined that the
removal of amalgam restorations from the non-allergic patient for
the alleged purpose of removing toxic substances from the body,
when such treatment is performed solely at the recommendation of
the dentist, is improper and unethical. The same principle of
veracity applies to the dentist’s recommendation concerning the
removal of any dental restorative material.
5.A.2. Unsubstantiated Representations

A dentist who represents that dental treatment or diagnostic
techniques recommended or performed by the dentist has the
capacity to diagnose, cure or alleviate diseases, infections or other
conditions, when such representations are not based upon accepted
scientific knowledge or research, is acting unethically.
5.B. Representation of Fees

Dentists shall not represent the fees being charged for providing
care in a false or misleading manner.
Advisory Opinions
5.B.1. Waiver of Copayment
A dentist who accepts a third party1 payment under a copayment
plan as payment in full without disclosing to the third party1 that
the patient’s payment portion will not be collected, is engaged in
overbilling. The essence of this ethical impropriety is deception and
misrepresentation; an overbilling dentist makes it appear to the
third party1 that the charge to the patient for services rendered is
higher than it actually is.
5.B.2. Overbilling
It is unethical for a dentist to increase a fee to a patient solely
because the patient is covered under a dental benefits plan.
5.B.3. Fee Differential

The fee for a patient without dental benefits shall be considered a
dentist’s full fee.2 This is the fee that should be represented to all
benefit carriers regardless of any negotiated fee discount. Payments
accepted by a dentist under a governmentally funded program, a
component or constituent dental society-sponsored access program,
or a participating agreement entered into under a program with a
third party shall not be considered or construed as evidence of
overbilling in determining whether a charge to a patient, or to
another third party1 in behalf of a patient not covered under any of
the aforecited programs constitutes overbilling under this section of
the Code.
5.B.4. Treatment Dates

A dentist who submits a claim form to a third party1 reporting
incorrect treatment dates for the purpose of assisting a patient in
obtaining benefits under a dental plan, which benefits would
otherwise be disallowed, is engaged in making an unethical, false or
misleading representation to such third party.1
5.B.5. Dental Procedures

A dentist who incorrectly describes on a third party1 claim form a
dental procedure in order to receive a greater payment or
reimbursement or incorrectly makes a non-covered procedure
appear to be a covered procedure on such a claim form is engaged
in making an unethical, false or misleading representation to such
third party.1
5.B.6. Unnecessary Services

A dentist who recommends or performs unnecessary dental services
or procedures is engaged in unethical conduct. The dentist’s ethical
obligation in this matter applies regardless of the type of practice
arrangement or contractual obligations in which he or she provides
patient care.
5.C. Disclosure of Conflict of

Interest
A dentist who presents educational or scientific information in an
article, seminar or other program shall disclose to the readers or
participants any monetary or other special interest the dentist may
have with a company whose products are promoted or endorsed in
the presentation. Disclosure shall be made in any promotional
material and in the presentation itself.
5.D. Devices and Therapeutic

Methods
Except for formal investigative studies, dentists shall be obliged to
prescribe, dispense, or promote only those devices, drugs and other
agents whose complete formulae are available to the dental
profession. Dentists shall have the further obligation of not holding
out as exclusive any device, agent, method or technique if that
representation would be false or misleading in any material respect.
Advisory Opinions
5.D.1. Reporting Adverse Reactions
A dentist who suspects the occurrence of an adverse reaction to a
drug or dental device has an obligation to communicate that
information to the broader medical and dental community,
including, in the case of a serious adverse event, the Food and Drug
Administration (FDA).
5.D.2. Marketing or Sale of Products or Procedures

Dentists who, in the regular conduct of their practices, engage in or
employ auxiliaries in the marketing or sale of products or
procedures to their patients must take care not to exploit the trust
inherent in the dentist-patient relationship for their own financial
gain. Dentists should not induce their patients to purchase products
or undergo procedures by misrepresenting the product’s value, the
necessity of the procedure or the dentist’s professional expertise in
recommending the product or procedure.
In the case of a health-related product, it is not enough for the
dentist to rely on the manufacturer’s or distributor’s representations
about the product’s safety and efficacy. The dentist has an
independent obligation to inquire into the truth and accuracy of
such claims and verify that they are founded on accepted scientific
knowledge or research.
Dentists should disclose to their patients all relevant information
the patient needs to make an informed purchase decision, including
whether the product is available elsewhere and whether there are
any financial incentives for the dentist to recommend the product
that would not be evident to the patient.
5.E. Professional
Announcement
In order to properly serve the public, dentists should represent
themselves in a manner that contributes to the esteem of the
profession. Dentists should not misrepresent their training and
competence in any way that would be false or misleading in any
material respect.3
5.F. Advertising
Although any dentist may advertise, no dentist shall advertise or
solicit patients in any form of communication in a manner that is
false or misleading in any material respect.3
Advisory Opinions
5.F.1. Published Communications
If a dental health article, message or newsletter is published in print
or electronic media under a dentist’s byline to the public without
making truthful disclosure of the source and authorship or is
designed to give rise to questionable expectations for the purpose of
inducing the public to utilize the services of the sponsoring dentist,
the dentist is engaged in making a false or misleading
representation to the public in a material respect.3
5.F.2. Examples of “False or Misleading”

The following examples are set forth to provide insight into the
meaning of the term “false or misleading in a material respect.”3
These examples are not meant to be all-inclusive. Rather, by
restating the concept in alternative language and giving general
examples, it is hoped that the membership will gain a better
understanding of the term. With this in mind, statements shall be
avoided which would: a) contain a material misrepresentation of
fact, b) omit a fact necessary to make the statement considered as a
whole not materially misleading, c) be intended or be likely to create
an unjustified expectation about results the dentist can achieve, and
d) contain a material, objective representation, whether express or
implied, that the advertised services are superior in quality to those
of other dentists, if that representation is not subject to reasonable
substantiation.
Subjective statements about the quality of dental services can also
raise ethical concerns. In particular, statements of opinion may be
misleading if they are not honestly held, if they misrepresent the
qualifications of the holder, or the basis of the opinion, or if the
patient reasonably interprets them as implied statements of fact.
Such statements will be evaluated on a case by case basis,
considering how patients are likely to respond to the impression
made by the advertisement as a whole. The fundamental issue is
whether the advertisement, taken as a whole, is false or misleading
in a material respect.3
5.F.3. Unearned, Nonhealth Degrees

A dentist may use the title Doctor or Dentist, D.D.S., D.M.D. or any
additional earned, advanced academic degrees in health service
areas in an announcement to the public. The announcement of an
unearned academic degree may be misleading because of the
likelihood that it will indicate to the public the attainment of
specialty or diplomate status.
For purposes of this advisory opinion, an unearned academic
degree is one which is awarded by an educational institution not
accredited by a generally recognized accrediting body or is an
honorary degree.
The use of a nonhealth degree in an announcement to the public
may be a representation which is misleading because the public is
likely to assume that any degree announced is related to the
qualifications of the dentist as a practitioner.
Some organizations grant dentists fellowship status as a token of
membership in the organization or some other form of voluntary
association. The use of such fellowships in advertising to the general
public may be misleading because of the likelihood that it will
indicate to the public attainment of education or skill in the field of
dentistry.
Generally, unearned or nonhealth degrees and fellowships that
designate association, rather than attainment, should be limited to
scientific papers and curriculum vitae. In all instances, state law
should be consulted. In any review by the council of the use of
designations in advertising to the public, the council will apply the
standard of whether the use of such is false or misleading in a
material respect.3
5.F.4. Referral Services

There are two basic types of referral services for dental care: not-for-
profit and the commercial. The not-for-profit is commonly
organized by dental societies or community services. It is open to all
qualified practitioners in the area served. A fee is sometimes
charged the practitioner to be listed with the service. A fee for such
referral services is for the purpose of covering the expenses of the
service and has no relation to the number of patients referred. In
contrast, some commercial referral services restrict access to the
referral service to a limited number of dentists in a particular
geographic area. Prospective patients calling the service may be
referred to a single subscribing dentist in the geographic area and
the respective dentist billed for each patient referred. Commercial
referral services often advertise to the public stressing that there is
no charge for use of the service and the patient may not be informed
of the referral fee paid by the dentist. There is a connotation to such
advertisements that the referral that is being made is in the nature of
a public service. A dentist is allowed to pay for any advertising
permitted by the Code, but is generally not permitted to make
payments to another person or entity for the referral of a patient for
professional services. While the particular facts and circumstances
relating to an individual commercial referral service will vary, the
council believes that the aspects outlined above for commercial
referral services violate the Code in that it constitutes advertising
which is false or misleading in a material respect and violates the
prohibitions in the Code against fee splitting.3
5.F.5. Infectious Disease Test Results

An advertisement or other communication intended to solicit
patients which omits a material fact or facts necessary to put the
information conveyed in the advertisement in a proper context can
be misleading in a material respect. A dental practice should not
seek to attract patients on the basis of partial truths which create a
false impression.3
For example, an advertisement to the public of HIV negative test
results, without conveying additional information that will clarify
the scientific significance of this fact contains a misleading omission.
A dentist could satisfy his or her obligation under this advisory
opinion to convey additional information by clearly stating in the
advertisement or other communication: “This negative HIV test
cannot guarantee that I am currently free of HIV.”
5.F.6. Websites and Search Engine Optimization

Many dentists employ an Internet web site to announce their
practices, introduce viewers to the professionals and staff in the
office, describe practice philosophies and impart oral health care
information to the public. Dentists may use services to increase the
visibility of their web sites when consumers perform searches for
dentally-related content. This technique is generally known as
“search engine optimization” or “SEO.” Dentists have an ethical
obligation to ensure that their web sites, like their other professional
announcements, are truthful and do not present information in a
manner that is false and misleading in a material respect.3 Also, any
SEO techniques used in connection with a dentist’s web site should
comport with the ADA Principles of Ethics and Code of Professional
Conduct.
5.G. Name of Practice
Since the name under which a dentist conducts his or her practice
may be a factor in the selection process of the patient, the use of a
trade name or an assumed name that is false or misleading in any
material respect is unethical. Use of the name of a dentist no longer
actively associated with the practice may be continued for a period
not to exceed one year.3
Advisory Opinion
5.G.1. Dentist Leaving Practice
Dentists leaving a practice who authorize continued use of their
names should receive competent advice on the legal implications of
this action. With permission of a departing dentist, his or her name
may be used for more than one year, if, after the one year grace
period has expired, prominent notice is provided to the public
through such mediums as a sign at the office and a short statement
on stationery and business cards that the departing dentist has
retired from the practice.
5.H. Announcement of
Specialization and Limitation of
Practice
A dentist may ethically announce as a specialist to the public in any
of the dental specialties recognized by the National Commission on
Recognition of Dental Specialties and Certifying Boards including
dental public health, endodontics, oral and maxillofacial pathology,
oral and maxillofacial radiology, oral and maxillofacial surgery,
orthodontics and dentofacial orthopedics, pediatric dentistry,
periodontics, and prosthodontics, and in any other areas of dentistry
for which specialty recognition has been granted under the
standards required or recognized in the practitioner’s jurisdiction,
provided the dentist meets the educational requirements required
for recognition as a specialist adopted by the American Dental
Association or accepted in the jurisdiction in which they practice.*
Dentists who choose to announce specialization should use
“specialist in” and shall devote a sufficient portion of their practice
to the announced specialty or specialties to maintain expertise in
that specialty or those specialties, Dentists whose practice is devoted
exclusively to an announced specialty or specialties may announce
that their practice “is limited to” that specialty or those specialties.
Dentists who use their eligibility to announce as specialists to make
the public believe that specialty services rendered in the dental
office are being rendered by qualified specialists when such is not
the case are engaged in unethical conduct. The burden of
responsibility is on specialists to avoid any inference that general
practitioners who are associated with specialists are qualified to
announce themselves as specialists.
Advisory Opinions
5.H.1. Dual Degreed Dentists
Nothing in Section 5.H shall be interpreted to prohibit a dual
degreed dentist who practices medicine or osteopathy under a valid
state license from announcing to the public as a dental specialist
provided the dentist meets the educational, experience and other
standards set forth in the Code for specialty announcement and
further providing that the announcement is truthful and not
materially misleading.
5.H.2. Specialist Announcement of Credentials In Non-Specialty

Interest Areas
A dentist who is qualified to announce specialization under this
section may not announce to the public that he or she is certified or
a diplomate or otherwise similarly credentialed in an area of
dentistry not recognized as a specialty area by the National
Commission on Recognition of Dental Specialties and Certifying
Boards or by the jurisdiction in which the dentist practices unless:
1. The organization granting the credential grants certification or

diplomate status based on the following: a) the dentist’s
successful completion of a formal, full-time advanced
education program (graduate or postgraduate level) of at least
12 months’ duration; and b) the dentist’s training and
experience; and c) successful completion of an oral and written
examination based on psychometric principles; and
2. The announcement includes the following language: [Name of
announced area of dental practice] is not recognized as a
specialty area by the National Commission on Recognition of
Dental Specialties and Certifying Boards or [the name of the
jurisdiction in which the dentist practices].
Nothing in this advisory opinion affects the right of a properly

qualified dentist to announce specialization in a recognized
specialty area(s) or the responsibility of such dentist to maintain
exclusivity in the special area(s) of dental practice announced as
provided for under Section 5.H of this Code. Specialists shall not
announce their credentials in a manner that implies specialization in
a non-specialty interest area.
5.I. General Practitioner
Announcement of Services
General dentists who wish to announce the services available in
their practices are permitted to announce the availability of those
services so long as they avoid any communications that express or
imply specialization. General dentists shall also state that the
services are being provided by general dentists. No dentist shall
announce available services in any way that would be false or
misleading in any material respect.3
Advisory Opinions
5.I.1. General Practitioner Announcement of Credentials in
Interest Areas in General Dentistry
A general dentist may not announce to the public that he or she is
certified or a diplomate or otherwise similarly credentialed in an
area of dentistry not recognized as a specialty area by the National
Commission on Recognition of Dental Specialties and Certifying
Boards or by the jurisdiction in which the dentist practices unless:
1. The organization granting the credential grants certification or

diplomate status based on the following: a) the dentist’s
successful completion of a formal, full-time advanced
education program (graduate or postgraduate level) of at least
12 months duration; and b) the dentist’s training and
experience; and c) successful completion of an oral and written
examination based on psychometric principles;
2. The dentist discloses that he or she is a general dentist; and
3. The announcement includes the following language: [Name of
announced area of dental practice] is not recognized as a
specialty area by the National Commission on Recognition of
Dental Specialties and Certifying Boards or [the name of the
jurisdiction in which the dentist practices].
5.I.2. Credentials in General Dentistry

General dentists may announce fellowships or other credentials
earned in the area of general dentistry so long as they avoid any
communications that express or imply specialization and the
announcement includes the disclaimer that the dentist is a general
dentist. The use of abbreviations to designate credentials shall be
avoided when such use would lead the reasonable person to believe
that the designation represents an academic degree, when such is
not the case.
NOTES
1. A third party is any party to a dental prepayment contract that
may collect premiums, assume financial risks, pay claims,
and/or provide administrative services.
2. A full fee is the fee for a service that is set by the dentist,
which reflects the costs of providing the procedure and the
value of the dentist’s professional judgment.
3. Advertising, solicitation of patients or business or other
promotional activities by dentists or dental care delivery
organizations shall not be considered unethical or improper,
except for those promotional activities which are false or
misleading in any material respect. Notwithstanding any ADA
Principles of Ethics and Code of Professional Conduct or other
standards of dentist conduct which may be differently
worded, this shall be the sole standard for determining the
ethical propriety of such promotional activities. Any provision
of an ADA constituent or component society’s code of ethics
or other standard of dentist conduct relating to dentists’ or
dental care delivery organizations’ advertising, solicitation, or
other promotional activities which is worded differently from
the above standard shall be deemed to be in conflict with the
ADA Principles of Ethics and Code of Professional Conduct.
4. Completion of three years of advanced training in oral and
maxillofacial surgery or two years of advanced training in one
of the other recognized dental specialties prior to 1967.
IV. INTERPRETATION AND

APPLICATION OF PRINCIPLES OF
ETHICS AND CODE OF
PROFESSIONAL CONDUCT
The foregoing ADA Principles of Ethics and Code of Professional
Conduct set forth the ethical duties that are binding on members of
the American Dental Association. The component and constituent
societies may adopt additional requirements or interpretations not
in conflict with the ADA Code.
Anyone who believes that a member-dentist has acted unethically
should bring the matter to the attention of the appropriate
constituent (state) or component (local) dental society. Whenever
possible, problems involving questions of ethics should be resolved
at the state or local level. If a satisfactory resolution cannot be
reached, the dental society may decide, after proper investigation,
that the matter warrants issuing formal charges and conducting a
disciplinary hearing pursuant to the procedures set forth in Chapter
XI of the ADA Bylaws and Governance and Organizational Manual of
the American Dental Association (“Governance Manual”).
PRINCIPLES OF ETHICS AND CODE OF PROFESSIONAL
CONDUCT, MEMBER CONDUCT POLICY AND JUDICIAL
PROCEDURES. The Council on Ethics, Bylaws and Judicial Affairs
reminds constituent and component societies that before a dentist
can be found to have breached any ethical obligation the dentist is
entitled to a fair hearing.
A member who is found guilty of unethical conduct proscribed by
the ADA Code or code of ethics of the constituent or component
society, may be placed under a sentence of censure or suspension or
may be expelled from membership in the Association. A member
under a sentence of censure, suspension or expulsion has the right
to appeal the decision to his or her constituent society and the ADA
Council on Ethics, Bylaws and Judicial Affairs, as provided in
Chapter XI of the ADA Bylaws and Governance Manual.
V. CEBJA STATEMENTS AND WHITE

PAPERS
THE STATEMENTS AND WHITE PAPERS BELOW HAVE BEEN
PREPARED BY CEBJA AND ARE AVAILABLE FOR VIEWING OR
DOWNLOAD IN PDF FORMAT AT www.ada.org/cebjastatements:
Announcement of Credentials in General Dentistry—Last
reviewed 2021
Dental Tourism—Last reviewed 2020
Ethical Aspects of Dental Practice Arrangements—Last reviewed
2020
Ethical Considerations When Using Patients in the Examination
Process—Last reviewed 2020
The Ethics of Temporary Charitable Events—Last reviewed 2020
General Practitioner Announcement of Credentials in Non-
Specialty Interest Areas—Last reviewed 2019
Gift Giving to Dentists from Patients, Colleagues and Industry—
Last reviewed 2020
Marketing or Sale of Products or Procedures—Last reviewed 2022
Patient Rights and Responsibilities—Last reviewed 2019
Reporting Abuse and Neglect—Last reviewed 2020
Specialist Announcement of Credentials in Non-Specialty Interest
Areas—Last reviewed 2019
Statement on the Ethics of the Measles Crisis—Created 2019
Statement Regarding the Employment of a Dentist—Last reviewed
2018
Treating Patients with Infectious Diseases Having Unknown
Transmission Parameters—Initial adoption 2022
Unearned Nonhealth Degrees—Last reviewed 2021
VI. INDEX
ADVISORY OPINIONS ARE DESIGNATED BY THEIR
RELEVANT SECTION IN PARENTHESES, e.g. (2.D.1.).
A
Abandonment, 155
Ability to practice (2.D.1.), 155
Abuse and neglect, 157
Abuse and neglect (reporting) (3.E.1.), 157
Adverse reactions (reporting) (5.D.1.), 160
Advertising, 160
Credentials
general dentistry (5.I.2.), 164
interest areas, general dentistry (5.I.1.), 163
non-specialty interest areas, specialist (5.H.2.), 163
nonhealth (5.F.3.), 161
unearned (5.F.3.), 161
honorary (5.F.3.), 161
membership and other affiliations (5.F.3.), 161
specialty, 163
Dual degrees (5.H.1.), 163
False and misleading (examples) (5.F.2.), 161
General dentists, 164
HIV test results (5.F.5.), 162
Honorary degrees (5.F.3.), 161
Infectious disease test results (5.F.5.), 162
Name of practice, 162
Non-specialty interest areas (5.H.2. and 5.I.1.), 163
Published communications (5.F.1.), 160
Referral services (5.F.4.), 161
Services, 163
Specialties, 163
Unearned, nonhealth degrees (5.F.3.), 161
Advisory opinions (definition), 153
Amalgam and other restorative materials (5.A.1.), 159
Announcement of specialization and limitation of practice, 162
Autonomy (patient), 154
Auxiliary personnel, 155
B
Beneficence, 156
Billing, 159
Bloodborne pathogens, exposure incident, 155
Bloodborne pathogens, patients with disabilities or (4.A.1.), 157
C
CEBJA statements and white papers, 165
Code of professional conduct (definition), 154
Community service, 156
Confidentiality of patient records (1.B.2.), 154
Conflict of interest, disclosure, 160
Consultation and referral, 155
Copayment, waiver of (5.B.1.), 159
Copyrights and patents, 156
Credentials (see advertising)
D
Degrees (advertising) (5.F.3. and 5.H.1.), 161, 163
Dental amalgam and other restorative materials (5.A.1.), 159
Dental procedures, incorrectly reporting (5.B.5.), 160
Dentist leaving practice (5.G.1.), 162
Devices and therapeutic methods, 160
Disabilities, patients with bloodborne pathogens or (4.A.1.), 157
Disclosure, conflict of interest, 159
Disruptive behavior (3.F.1.), 157
Dual degreed dentists (5.H.1.), 163
E
Education, 155
Emergency service, 158
Expert testimony, 158
F
False and misleading advertising, examples (5.F.2.), 161
Fees
contingent (4.D.1.), 158
differential (5.B.3.), 159
rebates, 158
representation of, 159
split, 158
Furnishing copies of records (1.B.1.), 154
G
General practitioner announcement of credentials (5.I.1.), 163
General practitioner announcement of services, 163
General standards (for announcement of specialization and
limitation of practice), 162
Government of a profession, 156
Gross or continual faulty treatment (reporting), 158
H
HIV positive patients (4.A.1.), 157
HIV post-exposure obligations, 155
HIV test results (advertising) (5.F.5.), 162
I
Impaired dentist, 155
Infectious disease test results (5.F.5.), 162
Interpretation and application of Principles of Ethics and Code of
Professional Conduct, 164
J
Justifiable criticism, 158
Justifiable criticism (meaning of “justifiable”) (4.C.1.), 158
Justice, 157
L
Law (and ethics), 153
Limitation of practice, 162
M
Marketing or sale of products or procedures (5.D.2.), 160
N
Name of practice, 162
Nonhealth degrees, advertising (5.F.3.), 161
Nonmaleficence, 154
O
Overbilling (5.B.2.), 159
P
Patents and copyrights, 156
Patient abandonment, 155
Patient autonomy, 154
Patient involvement, 154
Patient records, 154
confidentiality (1.B.2.), 154
furnishing copies (1.B.1.), 154
Patient selection, 157
Personal impairment, 155
Personal relationships with patients, 156
Practice
ability to (2.D.1.), 155
dentist leaving (5.G.1.), 162
name of, 162
Preamble, 153
Principles of ethics (definition), 153
Principles
beneficence, 156
justice, 157
nonmaleficence, 154
patient autonomy, 154
veracity, 159
Procedures (marketing or sale) (5.D.2.), 160
Products (marketing or sale) (5.D.2.), 160
Professional announcement, 160
Professional demeanor, 157
Published communications (5.F.1.), 160
R
Rebates and split fees, 158
Records (patient), 154
confidentiality (1.B.2.), 154
furnishing copies (1.B.1.), 154
Referral, 155
Referral services (5.F.4.), 161
Reporting
abuse and neglect (3.E.1.), 157
adverse reactions (5.D.1.), 160
gross and continual faulty treatment, 158
personal impairment, 155
Representation of care, 159
Representation of fees, 159
Research and development, 156
S
Sale of products or procedures (5.D.2.), 156
Search Engine Optimization (5.F.6.), 162
Second opinions (2.B.1.), 155
Specialist (announcement and limitation of practice), 162
Specialist (announcement of credentials in non-specialty interest
areas) (5.H.2.), 163
Split fees, 158
T
Treatment dates (5.B.4.), 159
Therapeutic methods, 160
U
Unearned, nonhealth degrees (5.F.3.), 161
Unnecessary services (5.B.6.), 160
Unsubstantiated representations (5.A.2.), 159
Use of auxiliary personnel, 155
V
Veracity, 159
W
Waiver of copayment (5.B.1.), 159
Websites and search engine optimization (5.F.6.), 162
*
In the case of the ADA, the educational requirements include
successful completion of an advanced educational program
accredited by the Commission on Dental Accreditation, two or more
years in length, as specified by the Council on Dental Education and
Licensure, or being a diplomate of an American Dental Association
recognized certifying board for each specialty announced.
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Glossary
abandonment discontinuation of a patient–provider relationship

once it has been established.
access to care relates to the timely utilization of necessary health
services to ensure optimal health outcomes.
accreditation a nongovernmental process for ensuring that a
predetermined set of standards has been met; used to assure the
public that the graduates of a particular program are prepared to
practice.
allegation an assertion, claim, or statement of an individual in a
legal proceeding.
amoral to be without morals; that which is indifferent to morality.
at-will employment implies an agreement between employer and
employee that employment is for an indefinite time frame and can
be terminated by either the employer or employee at any time.
autonomous independent and self-determining.
autonomy the principle of self-determination in a person; the right
to participate in and decide on a course of action without undue
influence; provides the foundation for a right to privacy and the
ability to choose.
battery the commission of bodily harm against another person.
beneficence the principle of promoting good or well-being.
breach of contract the act of breaking a contract, agreement,
promise, or legal duty by failing to perform a promised or
required act.
bullying involves aggressive behavior with the intention of hurting,
causing fear, or threatening another person; is an intentional act
that may involve nonverbal or verbal threats, harassment, and
verbal or physical assault.
capacity a clinical term used to describe a person’s ability to
understand his or her healthcare conditions and treatment options
and ability to make decisions independently.
character collectively, the qualities that define a person or group of
persons; a person’s moral nature.
civil action legal action taken to protect the private rights of
individuals.
civil law legal matters other than criminal ones; includes torts and
contractual agreements.
civil rights the rights granted to residents of the United States by
the US Constitution and legislative acts passed after the Civil War;
freedom of speech, the right to vote, and freedom from
discrimination.
code of ethics a set of rules or guidelines that address the ethical
standards of a professional group.
competency having the knowledge, skill, and ability to perform a
prescribed set of tasks or duties independently and with
confidence.
confidentiality that which is entrusted or held in secret; the precept
by which information shared by a patient during the course of
receiving health care is kept in confidence by the healthcare
provider.
consequentialism the theory that the rightness or wrongness of
actions is determined by consequences; also called teleology.
contributory negligence an action or lack of action that contributes
to the harm or injury of an individual and negatively affects his or
her health status.
criminal action a legal action taken in a court of law to protect
society.
criminal law a body of laws established for the purpose of
preventing harm to society; describes what conduct is criminal
and prescribes the punishment for criminal conduct; may be
codified into criminal or penal codes.
cyberbullying involves intimidating, threatening, or bullying an
individual through the use of electronic communication.
defamation the act of maliciously making a false statement that
injures another’s reputation; termed libel if a written statement,
slander if an oral statement.
defendant a person being sued in a civil case or charged with a
crime.
Dental Health Professional Shortage Areas (DHPSA) defined as a
geographic area, population, or facility experiencing a shortage of
dental health providers and services; designation used to identify
areas and/or populations experiencing a shortage of vital services.
dental record a written comprehensive, ongoing file of assessment
findings, treatments rendered, notations, and contacts with the
dental patient.
deposition an out-of-court discovery method in which information
is given under oath of testimony of a party or witness and
recorded by a court reporter; can be subject to cross-examination.
direct supervision requires all dental hygiene services to be
provided in the presence of a supervising dentist; the dentist must
be on the premises and approve all services.
discovery the process by which or period during which each party
involved in a lawsuit obtains information concerning the facts of
the lawsuit; includes depositions, interrogations, and record
copying.
discrimination the act of treating persons differently based on
factors they cannot control, such as age, handicapping condition,
race, or gender.
disruptive behavior similar to bullying and harassment in that it
involves physical and/or verbal aggression and intimidation that
obstruct the normal flow of daily activities.
distributive justice the just allocation and distribution of resources
for the good of society.
due process the right of fair application of laws or regulations for
each person; a process established to ensure fairness and equity.
duty action or conduct based on a moral or legal obligation.
emancipated minor an individual younger than 18 years who is
independent of a parent; laws can vary from state to state.
employment a situation in which an individual works for payment.
employment categories terms that define the terms of employment.
Equal Employment Opportunity Commission federal agency that
investigates claims of employment discrimination and sexual
harassment.
ethical analysis the process by which ethical decisions are made
using a structured format.
ethical dilemma a situation in which two or more ethical principles
are in conflict.
ethical theory a systematic examination of morals involving critical
reflection and analysis about what is right and wrong.
ethics the inquiry into the nature of morality or moral acts; values
by which human beings live in relation to other human beings,
nature, a higher power, and/or themselves.
faculty license a credential provided by some states to dental
hygienists licensed in another jurisdiction whose practice of
dental hygiene is limited to dental hygiene education.
federal laws laws enacted and upheld by the US government.
fidelity an ethical principle compelling one to be faithful in keeping
one’s professional promises and responsibilities.
fiduciary relationship a relationship based on responsibility
between the patient and the healthcare provider.
general supervision allows the dental hygienist to provide patients
with services within the scope of practice with the prior
authorization, but not the presence, of a dentist.
good cause means there is a legally sufficient grounds for an action
taken.
harassment the act of annoying or threatening a person by word or
deed.
health disparities differences experienced by socially
disadvantaged populations to achieve optimal health; closely
related to social, economic, and/or environmental disadvantages.
Hippocratic Oath written by a physician in the fourth century, an
oath that is the foundation for most ethical codes in health care.
impaired professional an individual who has undergone
professional training but who is no longer able to function in a
professional capacity because of illness or substance abuse.
implied not specifically stated or written but capable of being
inferred by action(s).
incident reporting a written report that details the aspects of an
accident or unusual situation.
independent practice of dental hygiene can mean a dental
hygienist may practice within the scope of practice without the
supervision of a dentist; in some states, it allows the licensee to be
the proprietor of one’s own dental hygiene practice.
informed consent the act of providing information to and ensuring
the understanding of a patient regarding treatment risks,
treatment options, and the nature of the disease or problem.
injury any wrong or damage done to another person or his or her
rights, reputation, or property.
injury causation the required link between a patient’s injury and a
dental hygienist’s breach of duty (i.e., the patient’s injury must be
caused by the dental hygienist’s breach of duty).
intentional tort a civil wrong that occurs when an individual
intends the results of an action.
interprofessional education occasions when students from two or
more health professions learn together during all or part of their
professional training with the objective of cultivating collaborative
practice to improve the quality of patient care at the individual
and population level.
just cause similar to good cause, it is a standard that must be met to
justify disciplinary action taken or dismissal of an employee.
justice the principle that deals with fairness and the allocation of
what people earn or deserve.
licensure a process regulated by a governmental agency in which
individuals are authorized to perform certain functions.
malpractice professional services, such as those performed by a
dentist or dental hygienist, done without reasonable care or skill
or in violation of ethics.
moral dilemma situation in which obligations and responsibilities
are in conflict.
moral distress frustration from perceived powerlessness when what
is happening appears to be wrong and the person is unable to act
ethically.
moral principle a guideline that defines and directs people to do
what is right.
moral reasoning the formulation of a morally ideal course of action;
the process of judging what one ought to do in a specific situation.
moral sensitivity the process of interpreting a situation from a
moral perspective; involves making inferences about thoughts,
feelings, and perceptions of others; understanding.
moral uncertainty a state of questioning whether a moral obligation
exists, and/or if so what is the scope of that obligation.
moral weakness a state in which moral responsibilities and
personal inclinations are in conflict.
morality that which is right and good; the quality of an action with
regard to right and wrong.
negligence a lack of reasonable and prudent care resulting in harm.
nonconsequentialism (also called deontological ethics or Kantian
ethics) theory which asserts that an action is right when it
conforms to a duty or rule.
nonmaleficence the principle that states the duty to avoid harming
the patient, summarized in the phrase “Do no harm.”
oath a solemn promise to do something or to follow some
guideline(s).
obligation a duty to conform to a rule or custom.
paternalism an act or action based on doing good for a patient, in
the manner that a father would, but which is done without the
patient’s full knowledge; an approach that limits a patient’s
autonomy.
patient record a legal document compiled by a healthcare
professional through interaction with a patient; a recording of all
patient contacts and communications, it can be maintained in
written form, but most often it is maintained in an electronic
format.
peer review the process of allowing professional colleagues to
critically examine treatment provided in a dental or dental
hygiene case and to render an opinion on the appropriateness of
that treatment.
prima facie duty considering only one single moral principle; the
first principle to act on over another equally compelling principle;
the duty that may be primary.
primum non nocere a Latin term meaning “First, do no harm.”
principle a general normative standard of conduct, holding that a
particular decision or action is true or right or good for all people
in all times and all places.
professional autonomy the concept that a professional who
provides care for a patient, thereby establishing a patient–
provider relationship, is not obligated to provide that care if it
would involve performing unethical services.
professional code the written standards that detail the
responsibilities of a particular group.
professional traits characteristics desirable in a healthcare
professional.
professionalism the quality of performing with the skill,
knowledge, and abilities of a professional person; the possession
of specialized knowledge and skill in a field of human endeavor.
quality assessment a process used systematically and continuously
to assess the quality of the patient care delivery system for the
purpose of improvement.
quality assurance program system used to evaluate outcomes to
provide methods to improve both undesirable outcomes and
patient care.
quality improvement system used to collect information that will
lead to the improvement of procedures, processes, and outcomes.
quid pro quo a Latin term meaning “something for something.”
regulation a rule or restriction.
relativism the theory that truth is not absolute but is relative to
circumstances, individual beliefs, cultural background, or other
factors.
risk factors structures, procedures, or processes that could lead to
undesirable outcomes.
risk identification identification of potential risks in order to create
a program to minimize or eliminate said risk.
risk management a process of identifying potential risks, measuring
the seriousness of potential outcomes and the likelihood of
occurrence, and creating strategies and/or programs to manage or
eliminate those risks.
sanction a penalty attached to a law to gain compliance.
scope of practice the broad range of duties legally defined for a
particular healthcare provider.
sexual harassment a form of discrimination; that involves
unwelcome talk or touching or other actions regarding sexual
activity.
social contract an understanding, spoken or unspoken, between
healthcare workers and the populations they serve; ensures that
the moral and legal obligations dictating the conduct of healthcare
workers will be followed when interacting with the public.
social justice a belief that there should be equity among all people,
and that all have the right to economic, social, and political
opportunities.
social media digital communication such as blogs, microblogs,
social networking, and media sharing.
societal trust the core ethical value related to the public’s trust in a
profession based upon the actions and behaviors of members of
that profession.
standard a quality or specific level of performance.
standard of care the level and quality of care expected of a
reasonable and prudent practitioner.
statute of limitations the state law or part of a specific statute that
specifies the period during which legal action must be taken.
statutory law a body of law created by acts of the legislature.
supervision the act of directing or observing the activities of
another person.
temporary licensure (sometimes called provisional licensure) a type
of licensure granted by a state to a dental hygienist, already
licensed in another state, for a prescribed time period or purpose
until the next scheduled licensing examination is conducted.
term employment has a definite duration, usually one to four years.
tort a civil wrong in which another’s person or property is harmed
as a result of negligent or intentional acts.
trait a characteristic.
unintentional tort a civil wrong that occurs when an individual
does not intend the results of an action.
utilitarianism (also termed deontology) the theory that an action is
right when it conforms to a rule of conduct or judgment
providing the greatest balance of good or evil.
value a principle or concept considered worthwhile.
veracity truth telling; honesty.
virtue ethics a theory that focuses on the character traits of an
individual rather than on the individual’s specific behavior.
volunteer license a credential that may be provided to a dental
hygienist who is licensed in another jurisdiction and meets
defined eligibility criteria and allows the seeking and provision of
volunteer services in another state.
Index
Page numbers followed by “f” indicate figures, “b” indicate boxes,
and “t” indicate tables.
A
Abandonment, 88–89
Abuse
ethical dilemma, 61b
reporting, 82
Access to care, 65, 69
Accreditation of dental hygiene program, 20
standards for dental hygiene education programs, 21b
Accredit programs, 20
Acquisition of dental hygiene skills, 20
Advanced Education in General Dentistry Program (AEGD), 109
Age Discrimination in Employment Act of 1967, 98–99
Allegations, 86
American Academy of Periodontology (AAP), 9, 88
American Association of Colleges of Nursing, 19
American Association of Colleges of Osteopathic Medicine, 19
American Association of Colleges of Pharmacy, 19
American Association of Public Health Dentistry, 11
American Dental Education Association (ADEA), 19, 56, 68
recommendations for improving oral health status of Americans,
68b
social justice, definition, 68
American Dental Hygienists’ Association (ADHA), 9b, 11, 15–16, 43,
45, 51, 89, 116
guidance on returning to work, 116
House of Delegates, 52
oath for dental hygienist, 15–16
American Psychological Association (APA), 10
Americans with Disabilities Act of 1990, 99
disability, understanding of, 99
protection of disabled individuals, 99
reasonable accommodation, 99
Amoral stage of moral development, 29t
Assessment, dental hygiene diagnosis, planning, implementation
and evaluation (ADPIE), 8–9
Association of American Medical Colleges, 19
Association of Schools of Public Health, 19
Autonomous stage of moral development, 29t
Autonomy, 17, 37, 40, 44
application of, 40
conflict with paternalism, 42
definition, 40
principle, 40
B
Basic Life Support (BLS) certification, 83
Beneficence, 37, 39
application of, 40
Board of Dental Examiners, 76–77
Board of Dental Health Care, 76–77
Board of Dentistry, 76–77
Breach of contract, 87, 89, 93, 135
case study, 137
Bullying, 103
C
Capacity, 45
Cardiopulmonary resuscitation (CPR) certification, 83
Case studies
breach of contract, 137
cyberbullying, 141
dental school curriculum, 123
dental therapists, 120
dentist dental assistant, 137
diagnosis and treatment plan, 135
discrimination in treatment practice, 100
employment environment, 103
ethical decision-making, 58
ethical dilemmas, 37
legal requirements for dental hygienist, 24
misdiagnosis, 117, 118
negligence, 130
patient confession, 115
periodontal debridement, 125
professional responsibilities, 124
school-based sealant program, 107, 108
standard precautions, 113
summer employment, 121
Categorical imperative, 33
Character, 30, 31
development, 30
education programs for, 30
virtuous traits of, 34
Child maltreatment, 46
Civil action, 86
Civil offense, 86
Code of dental practice, 24
Code of ethics, 49
Cognitive development theory, 30
Commission on Dental Accreditation, 20, 81
Communication, 19
cultural competence skill, 103
definition, 9–10
effective, 10
electronic, 11
nonverbal, 9, 10
social media, 12
visual, 9–10
written, 9–10
Compassion, 23
Competencies in dental hygiene, 20, 45
competency continuum, 21f
patient care, 20, 21b
Confidentiality, 4, 7–8, 33, 45, 46
application of, 46
legal implications, 12
of patient records, 82
Consequentialism, 31–32
Consequentialist ethics, 31
Contributory negligence, 92
Criminal action, 86
Critical error, 5–6
Cultural sensitivity, 10
Cyberbullying, 103
case study, 141
D
Defendant, 86
Dental abscesses, deaths from, 67
Dental health care personnel (DHCP) safety, 4
Dental Health Professional Shortage Areas (DHPSA), 67
Dental hygiene license
continuing education requirements, 80
display of, 79
faculty license, 79, 79t
fees, 81
full license, 79t
renewal of, 79, 80
scope of practice, 81
temporary/provisional licensure, 78, 79t
volunteer license, 78–79, 79t
Dental hygiene practice, 16, 75–76
CODA-accredited dental hygiene program, 78
education programs, 20
kickbacks, prohibition on, 83
licensure provisions. See Dental hygiene license
periodontal debridement, 125
rules and regulations, 77–78
self-referral statutes, 83
statutory law for, 86
supervision requirements, 81, 82
treatment plans, 132
Dental hygienist, 17, 95–96
cautions using social media, 12
communication skill, 6
duty of self-regulation, 16
duty to disclose information, 90–91
legal requirements for, 24, 25
oath, 15, 16
preventive role, 19–20
prima facie duties, 46
primary goal, 3
professional liability insurance, 12, 82
professional obligation, 77, 96
professional traits or attributes. See professional traits
scope of practice of, 24
seeking and obtaining employment, 96
violation of standard of care, 92
virtues, 22–23
Dental hygienist–patient relationship, legal principles of, 85, 86 See
also Informed consent; Informed refusal
reporting requirements, 93
rights and responsibilities, 88b, 88–89
shared responsibility, 92
Dental Quality Assurance Commission, 76–77
Dental school curriculum, 123
Dental Service Organization (DSO), 95
Dental therapists, 69
Dentist dental assistant, 137
Dentist’s pledge, 18
Deontological ethics, 32
Deontology, 32, 33
Depositions, 86
Direct supervision, 81
Discovery of evidence, 86
Discrimination, 99 See also Employment laws
Disruptive behavior, 103
Distributive justice, 41, 67–68
Documentation, 6, 8, 9, 89 See also Patient record
assessment, dental hygiene diagnosis, planning, implementation
and evaluation, 8–9
continuing education requirements, 80
of informed consent, 91, 92
Domestic violence leave, 101
Double effect, principle of, 39
Due process provisions, 83
Duty to disclose information, 90, 91
E
Egocentric stage of moral development, 29t
Electronic communication, 11
Employment contract, 97–98
Employment environment, 103
cultural competence, 103
Employment laws
accommodation of disabled individuals, 99
against bullying and cyberbullying, 103
employee protections, 100, 101
program for dentists with substance abuse problem, 111
prohibiting discrimination, 98, 100
for protection of dental hygienist, 102, 103
for sexual harassment, 101, 102
state workers’ compensation, 101
Employment of dental hygienist, 96, 126
application and interview process, 97
employment categories, 97, 98
permissible inquiries during interview, 96, 97
preparation for working interview, 96
selection process, 96
Equal Employment Opportunity Commission (EEOC), 99–100
Equal Pay Act of 1963, 98
Errors, 5–6
Ethical analysis, 56
Ethical awareness, 56–57
Ethical codes, 50–51
for dental hygiene, 51
physician’s duties, 50–51
Ethical decision-making, 59f
application of ethical principles, 59
case study, 110, 112, 114, 127
critical checkpoints, 57
implant therapy, 122
implementing decision, 60
information collection, 58
learning, 55, 56
making decision, 60
models, 58
solving dilemma using, 61, 62
Ethical dilemmas, 37, 38, 55, 56 See also Ethical decision-making
for dental hygienists, 60, 61b
example, 37–38
Ethical principles
capacity, 45
confidentiality, 45, 46
informed consent, 43b, 43, 44
paternalism, 42, 43
veracity, 43
Ethical theories, 31
Ethic of care, 29
Ethics education, 28
Expanded Functions Dental Auxiliary, Dental Assistant (EFDA), 137
Expanded- or extended-duty dental hygienist, 24–25
Expert learning continuum, 20
F
Faculty license for dental hygienist, 79, 79t
Family Medical Leave Act of 1993 (FMLA), 100, 101
domestic violence leave, 101
notice period for, 100–101
pregnancy leave statues, 101
unpaid, 100–101
Fidelity, 46
G
Gender, association with oral diseases, 66
Gilligan’s theory of moral development, 29–30, 30t
H
Harm, 39
Health belief mode, 11
Healthcare providers
characteristics of, 16b
ethical principles in care, 17
rights and responsibilities, 16
services provided, 16
Health care records, 82
Health disparities, 65, 66
Health Information Privacy, 4
Health Insurance Portability and Accountability Act (HIPAA), 89
Heteronomous stage of moral development, 29t
Hippocratic Oath, 18, 38–39, 45–46, 50–51, 51b
Honesty, 23
Hostile environment, 102
I
Impaired professional, 61
Imperfect duties, 33
Implant therapy, 122
Implied promises, 46
Incident reporting, 4–5
Indirect supervision, 81
Informed consent, 43, 44
application of, 44
in case of minors, 91, 127
components of, 43b
criteria, 44
documentation of, 91, 92
elements of, 90, 91
to health care, 90
history, 90
implied, 44
verbal, 44
written, 44
Informed refusal, 44, 92
Interprofessional competency domains
interprofessional communication, 19
roles and responsibilities, 19
teams and teamwork, 19
values and ethics, 19
Interprofessional education (IPE), 19
Interprofessional Education Collaborative (IPEC), 19
J
Justice, 40–41
application of, 41
distributive, 41
Justifiable paternalism, 42
K
Kickbacks, prohibition on, 83
Kohlberg’s theory of moral development, 28–29, 29t
L
Legal requirements for dental hygienist, 24, 25
case study, 112, 113
code of dental practice, 24
implant therapy, 122
legislative changes, 24
scope of practice, 24
shared responsibility, 91–92
state dental practice act, 24
Legal system
beyond a reasonable doubt, 86
contract law, 86–87
dealing with civil and criminal offenses, 86
dental hygienist–patient relationship, 86
depositions, 86
discovery of evidence, 86
intentional tort of battery, 87
legal actions for health care injuries, 89–90
preponderance of evidence, 86
statute of limitations, 92–93
tort law, 87
trial, 86
unintentional tort of negligence, 88
Licensure, 24
M
Malpractice, dental, 92
Misdiagnosis, case study, 117
Moral
dilemmas, 56–57, 57t
distress, 57, 57t
educational programs and interventions for, 28
Kant’s test for, 33
principles, 56
sensitivity, 56–57
uncertainty, 56–57, 57t
weakness, 56–57, 57t
N
National Institutes of Health (NIH), 10
National Practitioner Data Bank, 4–5, 93
Negligence
contributory, 92
unintentional tort of, 88
Noncritical error, 5–6
Nonmaleficence, 37–38
application of, 39
Nonverbal communication, 10
Normative ethics, 37
Normative principles, 37
O
Occupational exposure, 4–5
Occupational Safety and Health Administration (OSHA), 4, 7, 101,
116
Oral health care, 65
disparities and inequalities, 65, 66
ethical goals in, 67–68
for patients with special needs, 112
risk indicators for poor, 66–67
social justice in, 68
Oral Health in America: Advances and Challenges, 66
Oral health literacy, 5, 10
Other potentially infectious material (OPIM), 5
P
Pain management, 3
Paternalism, 42, 43
application of, 42
conflict with autonomy, 42
for gender neutrality, 42
justifiable, 42
responsibility of dental hygienist, 42–43
Patient records, 7–8, 8b, 82
components of, 8b
electronic form, 8
records management system, 8
Patient satisfaction surveys, 10
Periodontal debridement, 3, 125
Periodontal therapy, 3
case selection criteria, 122
misdiagnosis, 117, 118
diagnosis and treatment plan for, 135
for patients with special needs, 112
time frame for, 135
treatment plans, 132
Piaget’s theory of moral development, 28, 29t
Policies and procedures (P&P), 7
attestation by employee, 7
contents, 7
employee grievances and termination, 7
employee professional conduct, 7
employment information, 7
mission statement, 7
product and equipment use and maintenance, 7
protocol, 7
workplace legislation and regulation, 7
Pregnancy Discrimination Act (PDA), 98
Preponderance of evidence, 86
Professional code of ethics, 49
in health care, 49, 51
obligation of professionals, 50
Professionalism, 18
commercial model, 18
guild model, 18
interactive model, 18, 19
Professional traits, 22, 23, 23b
honesty and integrity, 23
interpersonal communication, 23–24
liability insurance, 12, 82
loyalty, 23
malpractice, 92
maturity and self-analysis, 23
reliability and responsibility, 23
self-respect, 24
Q
Quality assessment, 5, 9
Quality assurance audit, 8, 9
Quality assurance program, 4, 5
assessment of quality, 5–6
outcomes dimension, 5
process dimension, 5
structure dimension, 5
R
Regulations, definition, 4
Reliability, 23
Responsibility, 23
Risk assessment and reduction template, 6b
Risk identification, 4–5
incident reporting in, 4–5
Risk management, 3, 4
individual, 11, 12
operational safety and compliance programs, 4
Rule making, 78
S
School-based sealant program, 107, 108
Self-effacement, 22–23
Self-referral statutes, 83
Sexual harassment, 101, 102
Social contract, 67
Social justice, 68
Social media communication, 12
Societal trust, 38
Socioeconomic status (SES), association with oral diseases, 66–67
Standards
of care and regulations, 4, 40, 92
for clinical dental hygiene practice, 21–22, 22b, 80
for dental hygiene education programs, 21b
precautions, 113
State Dental Boards, 76–77
State Dental Commission, 76–77
State governments, divisions of, 75–76
executive branch of, 77–78
legislative branch of, 76
Statutory law, 76–77
Summer employment, 121
Supervision, 81
direct, 81
general, 81
independent practice, 82
indirect, 81
unsupervised practice, 82
T
Theories of cognitive moral development, 28–29
Gilligan’s model, 29–30, 30t
Kohlberg’s three-level model, 28–29, 29t
Piaget’s four-stage model, 28, 29t
Therapeutic privilege, 43
Treatment plans, 120, 132
Trial, 86
U
Uniformed Services Employment and Reemployment Rights Act of
1994, 99
Universal law, 33
Unsupervised practice of dental hygiene, 82
Utilitarianism, 32–33
V
Values, 46
Veracity, 43
Verbal consent, 44
Virtue ethics, 33, 34
Volunteer license of dental hygienist, 78–79, 79t
W
Washington State Denturist Act, 76
Written
consent, 44
instructions, 10

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Ethics and Law in Dental

Kristin Minihan-Anderson, RDH,

ETHICS AND LAW IN DENTAL HYGIENE FOURTH EDITION

Copyright © 2024 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any

This book and the individual contributions contained in it are

Previous editions copyrighted 2017, 2010, and 2002.

International Standard Book Number: 978-0-323-76119-2

Senior Content Strategist: Kelly Skelton

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Phyllis L. Beemsterboer, RDH, EdD

Lezlie M. Cantrell, RDH, BSDH, MSDH, PhD

This book is dedicated to my sons, Cody John and Colton Robert

To Peter L. Bonagura, for his undying support, encouragement,

To my mentor and dear friend, Olga A.C. Ibsen, who inspires me

When Alfred Civilion Fones graduated from dental school in 1890,

Background and Importance to the

Future and current dental hygiene professionals will find Ethics

Many of us in dental hygiene education have used this textbook as

Chapter 1 Risk Management

Individual Risk Management

Chapter 2 Ethics and Professionalism

The Healthcare Provider

The Dental Hygienist

Competency in Dental Hygiene

Standards for Clinical Dental Hygiene Practice

Professional Traits for the Dental Hygienist

Chapter 3 Ethical Theory and Philosophy

Theories of Cognitive Moral Development

Overview of Ethical Theories

Chapter 4 Ethical Principles and Values

Values and Concepts

Applying Principles and Values

Chapter 5 Codes of Ethics

Professional Codes in Health Care

Ethical Code for Dental Hygiene

Chapter 6 Ethical Decision Making in Dental Hygiene and Dentistry

Learning Ethical Decision Making

Ethical Dilemmas for the Dental Hygienist

Solving a Dilemma Using the Ethical Decision-Making Model

Chapter 7 Social Responsibility

Disparities in Oral Health Care

Health Disparities and Professionalism

Dental Therapists as Part of the Oral Healthcare Workforce

Chapter 8 Society and the State Dental Practice Act

The Practice of Dental Hygiene

Rules and Regulations

Continuing Education Requirements

Other Selected Statutory Provisions

Chapter 9 Dental Hygienist–Patient Relationship

Legal Framework of the Relationship

Overview of the Legal System

Rights and Responsibilities of the Dental Hygienist and Patient

Legal Actions for Healthcare Injuries

Chapter 10 Dental Hygienist–Dentist-Employer Relationship

Seeking and Obtaining Employment

Bullying and Cyberbullying

Section III Simulations and Applications

Case Studies, Activities, and Testlets

Cases for Study and Discussion