May 02, 2023
Case scenario
An agitated 19-year-old presented with acute dental pain and halitosis to a local dental office in Ohio, United States. The patient complained about one’s particularly poor dental appearance. The dentist on duty conducted comprehensive intraoral and radiographic examinations. Referring to the results, the dentist confirmed 17 carious and erosion lesions. The patient admitted using N-methylamphetamine for at least four and a half years. He claimed not to have felt such severe pain in his teeth before using the drugs. This evidence led doctors to suggest a provisional “meth mouth” diagnosis. Medical and dental records, radiographic findings, and clinical examination confirmed it. The dentist offered a detailed treatment plan with medications and pain relievers. These options excluded recreational drug use. Nonetheless, the patient rejected the offer. The stated reason - it would mean his parents’ involvement with whom he is in conflict. He requested the dentist to extract the most acutely painful teeth. The location was the right lower mandibular quadrant. The patient is yet to return for the next phase of alternative treatment.
Commentary
Similarly to other developed countries, drug abuse in the United States is growing. It represents a severe public health problem. The National Survey of Drug Use and Health indicated “the increase of the use frequency from age 12 and onward” (Ignaszewski, 2021). It peaks in young adulthood. The illegal substance list also expands. Apart from partly legalized marijuana, it includes ecstasy, cocaine, heroin, and other drugs. Patients addicted to drugs or in remission tend to appear complex to manage. This is confirmed by the American Dental Hygienists’ Association (ADHA). Its Code of Ethics reflects specifics of treatment planning and clinical attention.
ADHA Code (2023) rests on a few principles:
1. Confidentiality,
2. Societal trust,
3. Non-maleficence,
4. Beneficence,
5. Justice,
6. Fairness
7. Veracity (conformity to facts).
The specialists work to cure and prevent the deterioration of the disease. Simultaneously, they must promote the well-being of individuals and the public. This includes drug use prevention. They also must follow The Dental Practice Act. Each state has a Board of Dentistry that interprets and implements this document (Dental Practice Act Ohio, 2022). This Act specifies the safety-operational measures and respective legal requirements for dentistry. The one is critical in the context of the legal analgesics available with a prescription or under the doctor’s observation.
Dentists’ awareness of legal aspects of ethical treatment of drug-dependent patients is vital. Such patients are considered vulnerable. Their psychiatric and cognitive disorders affect their decision-making capacity (Ceceli et al., 2022). The principle of autonomy implies a patient’s right to decide on their treatment with all relevant info at hand. Yet, this principle becomes challenging for those lacking competence (Clark, 2021). Respect for autonomy also means obligations to obtain informed consent. As Sherman et al. (2021) admit, informed consent is only valid if comprehension and voluntariness are present. Autonomy also suggests preserved confidentiality and adequate communication attitude. The latter reduces the stigma about one’s mental competence to make uncoerced choices (Hachtel, 2019). In other words, one feels comfortable expressing their will.
Beneficence means “doing good.” It refers to dentists’ responsibility to benefit patients by preventing or removing harm. Yet, it is also about defending rights and eliminating potential harm (Varkey, 2021). In this case, the dentist must inspect the N-methylamphetamine abuse level deeper. It will establish whether anyone is in danger, which overrides confidentiality obligations. Yet, sometimes “helping others” borders on harming them (Halsband et al., 2022). In dentistry, it is vital to balance these principles. According to Alper et al. (2019), it will maximize the net benefit for the patient. The latter implies determining whether clinical decision-making brings more good than harm. It is determined via the Grading of Recommendations Assessment, Development, and Evaluation. The latter operates as a GRADE method. The one analyses the certainty of evidence and the strength of recommendations.
Confidentiality is a way of respecting the patient’s autonomy. It is a sensitive matter for the dentist if drug or substance users are adolescents (Barone et al., 2021). Dentists, including the present case (adolescents ages 10 to 19), must get a full scope of data. Only then can they check a patient’s decision-making capacity. The perfect circumstance is when they meet informed assent/consent criteria, as in Rule 4715-23-03 of the Ohio Dental Practice Act (2022). The requirements for obtaining informed consent also depend on the case’s specifics. An alternative is the patient’s guardian’s written informed consent. Considering adolescents’ legal standing as minors, the parents usually are involved.
The dentist also needs efficient communication skills to address patient-parent conflict. In this case, the conflict is a barrier to confidential care (Barone et al., 2021). The aim is to agree to rely on principles of shared decision-making. The one makes up an exclusive way to provide comprehensive and accessible care. It also facilitates open and honest dialogue between the adolescent and his parents. Yet, it is critical to ensure confidentiality is protected. Its breach could result in a criminal prosecution based on the case law. The latter is inconsistent. But, when a patient proves the presence of cognizable harm, the repercussions are respectively hard (Citron et al., 2022). In some circumstances, the difference between harm and benefit is debatable. The primary principle is always to prioritize the best interests of the patient.
From an ethical-legal perspective, justice and fairness imply the patient’s right to privacy from the dentist. Simultaneously, the patient is obliged to follow the prescribed treatments. This is, again, why drug users are recognized as vulnerable patients. They might be denied certain drugs “in the name of justice, public safety, and personal protection.” Paradoxically, this occasionally harms patients. The reason is simple: treatment they have been rejected for might have benefited them. Hence, excluding patients with addiction is unethical in particular cases.
Currently, the legal frameworks for dental care are regularly updated. It includes punitive interventions and rehabilitation. One of the primary lenses here is restorative justice. It is focused on alternatives assuring societal trust and helping patients with drug abuse (Walgrave et al., 2021). Dentists play a critical role in restoring patients’ lives through ethics-based intervention. This will let them become independent and autonomous. In the current case, the dentist has recognized the drug abuse and the danger a patient presents to himself. The specialist is entitled to refer the agitated patient to a rehabilitation center. It directly resonates with the restorative justice principle of “replacing hurt by healing” (Kaur et al., 2019). Restoring the healthy dental appearance after “meth mouth” will upgrade patients’ self-esteem. It is a highly ethical perspective for vulnerable patients. The one upholds non-maleficence or zero harm and other ADHA principles.
Declaration: No conflict of interest.
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References
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