Ethics and Dental Public Health Course Module
Instructor Guide
The four- to six-hour course module is designed to build upon the student’s prior ethics
understanding targeted to members of the health care provider team (Dentist and Dental
Hygienist). Depending on the experience level of the students (first year versus senior
students) the class may be shortened to four hours by removing some class discussions,
or by assigning them to homework assignments.
The goal is to introduce the students to the type of ethical issues encountered by Dental
Public Health (DPH) professionals and how the principles that guide the decision may
vary from that of the dental practitioner treating individual patients, as well as the
ultimate decision. A variety of cases are presented and suggestions for their use in each
class session on how to stimulate discussion to engage in ethical reasoning. It should be
emphasized that every dental practitioner will be a DPH professional at some times, as
s/he considers issues that affect the entire community.
Competency Addressed:
1. Demonstrate the ability to incorporate ethical reasoning and actions that promote
culturally competent oral health care to individuals and populations
Course Objectives
On successful completion of this course, students will be prepared to:
1. Recognize the similarities and differences in the mission of dental practitioners
versus the dental public health practitioner and how to respond to common ethical
issues facing each.
2. Describe the principles and values underlying public health and dental public health
and compare to those for dental practitioners.
3. Demonstrate how the Code of Ethics developed for dental practitioners will differ
from that for dental public health practitioner.
4. Describe and apply a framework for analyzing the decisions and actions to be made
by dental public health professionals.
Lecture 1: Introduction to Ethics
Present the principles of ethics generally recommended for a health provider (Dentist,
Dental Hygienist) and for a public health professional. Demonstrate how the mission of
the DPH profession suggests different values, principles, and expected actions than a
health care provider treating the individual patient. Recognize how federal and state
agencies, and professional organizations work together to govern the profession.
Consider what elements must be present to generate an ethical dilemma.
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Class discussion of Dr. Miguel Garcia and pediatric patient death case
Please allow at least 20 minutes for a discussion of the Dr. Garcia Case.
You may want to start the discussion by asking if the students think this situation
represents an ethical dilemma. You might select 2-3 students who say Yes and 2-3 who
say No to form two teams and begin the case discussion by asking them to explain how
they substantiate their decision that it is an ethical dilemma.
As you lead the discussion of the death of a child, the following points should be brought
out:
1. Ethical Dilemmas: Remember, an ethical dilemma must have positive moral
considerations on either side of the alternative options; neither side is obviously
correct; and if one acts on one side there may be undesirable side effects brought
about. For the Dr. Garcia situation, there is no positive moral stance for the actions
that Dr. Garcia took. Dr. Garcia and the treating dentist conspired to destroy elements
of the dental chart, to prevent the appearance of negligence. This is not only
unethical, it is illegal to destroy or alter a patient record. Did Dr. Pham have an
ethical dilemma? Could Dr. Pham have refused to destroy the chart, given that Dr.
Garcia, her supervisor told her to do so?
2. Definition of a DPH professional: Dr. Garcia’s occupation is as a manager of a
proprietary health clinic, with a dual responsibility to manage the clinic to generate
profit, often by controlling access and utilization to dental services, and to assure that
excellent dental care is provided to patients. He is not a DPH professional. However,
a DPH might be a director of a Federally Qualified Health Clinic because the mission
there would be to provide as much quality health care as possible within the federal
and state support available. The FQHC may also have a variety of outreach activities
to assist in getting prevention to the most number of people, even if direct services are
not available to all.
3. Quality health care: This case demonstrates the overlap, for a health care provider,
between the ethics of a DPH professional and that of a health care provider. As said
above, Dr. Garcia has a dual responsibility as manager to assure quality care within
the clinics he manages. Is Dr. Garcia asserting his responsibility to assure quality care
for clinic patients? According to expert witness, Dr. Richard Mungo, the care
provided in offering the sedation and the use of the papoose board were not within the
standards of care.
4. Justifiable Criticism: Is Dr. Richard Mungo violating the ADA Code of Professional
Conduct Section 4: Justice, item 4C Justifiable Criticism, in accusing Drs. Garcia and
Pham of negligence in a court of law? According to the ADA Advisory Opinion,
“Expert Testimony. Dentists may provide expert testimony when that testimony is
essential to a just and fair disposition of a judicial or administrative action.” Thus, the
action that Dr. Mungo took is not only allowed, it is required, if, in his honest
professional opinion, the care that Dr. Pham and Dr. Garcia took was not consistent
with the US standard of care. Again, this case emphasizes the dual oversight on
ethical guidelines that DPHers will have, from their professional organization (ADA,
ADHA, AGD, etc) and that of the Public Health Leadership Society.
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Lecture 2: Application of Ethical Issues on Dental Public Health decision-making.
Present some common ethical issues that arise for DPH professionals. Discuss any local
examples that may have come up in the news. Present the Principles for the PH
Leadership Society that are based on the values learned last session. Discuss how each
relates to the DPH responsibilities. Highlight differences between the DPH responsibility
and that of a health care provider treating the individual patient. Discuss the proposal to
remove high sugar drinks from the middle school vending machine. Close by offering a
framework for ethical reasoning that may aid in the selection between various alternatives
and implementation DPH programs.
Class discussion: Vending Machines Found in Most Middle Schools
Please allow at least 20 minutes for a discussion of the Vending Machine Case. This case
may be used in a number of modules, Principles of Dental Public Health, Prevention,
Advocacy, and Oral Health Literacy in addition to the course on Ethical Reasoning.
You may want to start the discussion by asking for student volunteers to participate in a
panel discussion about how, as the local Dental Director for the city they would advise
the School Board, taking into consideration their health provider and DPH roles. You
could also invite community leaders to participate in a discussion in class, for example,
someone from the Parent Teacher Association, the School Board, a school nurse, and/ or
a dentist or dental hygienist.
As you lead the discussion, the following points should be brought out:
1. Program goals and alternatives: You, a DPH leader have been asked to advise the
school board on what would be the best action to take, whether to remove all drinks
that are high in sugar, or to leave them in place and educate the middle school
students about the risks of obesity and diabetes from consuming high sugar products.
Are both of these program alternatives that a DPH provider might recommend? If not,
why?
2. Program effectiveness: How effective would each of these programs be in achieving
the stated aim, to reduce the risk for middle schoolers for obesity and type 2 diabetes?
Is there sufficient evidence that high sugar drinks cause obesity or diabetes to endorse
this program? Do you need to know information on effectiveness of the program in
order to make an ethical decision? How would you find such information?
3. Autonomy vs. Beneficence: This is a true ethical dilemma because the principles of
autonomy (right to choose) and beneficence (doing good for the community patient)
are in conflict. What principles relates to your DPH decision to remove the drinks?
What principle relates to the option to educate the students to make their own
decision? The decision to remove the drinks effectively makes the student’s decision
for him or her. You, as the DPH professional are promoting population health and
exercising the principle of beneficence, in that you are trying to do ‘good’ for the
children. However, you are putting the principle of paternalism (‘father or DPHer
knows best’) ahead of the PH Leadership Society principle of “achieving the
community’s health while respecting the rights of individuals (autonomy), in that you
feel you must make the decision and that the middle school students are incapable of
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understanding an education message and making such a decision. Which principle do
you think is more appropriate in this situation, and why? If this were an elementary
school would you have made the same decision? Why?
4. Understanding of DPH, School Board roles in the ethical reasoning: What is the
role of the School Board in this decision? What is the DPH professional’s role? Is the
board asking you, the DPH professional to make the decision, or to advise what the
objective information on program effectiveness and ethical considerations are? Do
you have a responsibility to advocate for a community perspective as a DPH leader?
Why, or why not?
5. PHLS Values (Community collaboration, public trust, public discourse) in
action: Is part of your DPH role to recommend that a public education campaign take
place so that parents can be informed and participate in the decision-making? If so,
how might that take place? Could a third set of volunteers (assuming the role of the
School’s Parent Teacher Association) join the student School Board and the DPH
professional volunteers to join the ethical debate on assuring there is appropriate
public discourse? How do you justify the decision using the ethical principles of
Public Health Leadership Society in your response?
Related discussion or activities: As you complete the above case discussion, or for an
individual or team homework assignment you might raise the question of how the ethical
reasoning might vary if the situation was an elementary school or high school, or if a
Medicaid parent is giving an infant a milk bottle when the child goes to bed at night, or if
a parent decides to not allow a child to participate in a school sealant program. The
student would follow the framework for ethical reasoning and how to justify PH
programs that conflict with individual liberty; lay out the issues and a possible solution in
one page. Discussion could also include State of California Assembly Bill 459,
introduced in February 2013 bringing into law the types of food that can be provided in
vending machines.
Lecture 3: Application of Ethical Reasoning on DPH decision making for Disease
Prevention and Community Health Promotion.
Discuss the DPH responsibility to encourage healthy behaviors. Review briefly the
framework for considering how to justify DPH programs that conflict with individual
liberty and how to reduce the ethical risk of a proposed DPH program. Then apply this to
a situation where two counties debated whether or not to have water fluoridation.
Case Discussion: Pinellas County Commission votes to stop putting fluoride in water
supply and Hillsborough’s Plant City voted to implement fluoridation:
Please allow at least 15 minutes for a discussion of the Pinellas Fluoridation Case.
You may want to start the discussion by asking for student volunteers to participate in a
panel discussion about how, as the local Dental Director for the city they would advise
the School Board, taking into consideration their health provider and DPH roles.
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As you lead the discussion, the following points should be brought out:
1. Program goals and alternatives: You are a practicing health care provider (Dentist,
Dental Hygienist) in Pinellas County and read in the Tampa Bay newspaper that the
County Commission plans to vote to remove fluoridation from the water supply after
7 years of use in early October. What action would you take to fulfill your
responsibility? Are there alternatives to water fluoridation that you will suggest to
the County Commissioner? With whom do you communicate this information?
2.
Understanding the roles of the DPH, the practicing health care providers,
and the County Commission in the ethical reasoning and decision-making:
What is the role of the health care provider in this decision? What is the DPH
professional’s role? If the county/ city has no Dental Director might you be charged
to function in that role as a DPH professional? Is the County Commission asking you
and/or the DPH professional to advise them in making the decision, or in providing
programmatic information on effectiveness and ethical considerations? Should the
County Commissioner ask for input and advice? Is advocacy part of the joint ethical
responsibility of health care providers in the community?
3.
Program safety and effectiveness: How safe is water fluoridation? How
effective is a water fluoridation program in reducing caries? What principles of the
ADA Code of Ethics and Professional Conduct and the PH Leadership Society are
applicable to the discussion on safety and effectiveness? How would you frame your
argument to convince the County Commission that they should vote against
defluoridating?
4.
Advocating and empowering community members: Do you need to know
information on disparities in oral health status in order to make an ethical decision as
a practicing health care provider? What about the wishes and values of the
community? How would you find such information? Who would you contact? Is
there evidence that appropriate community interaction took place? Was the health
community actively engaged in the decision-making process? Was this the correct
decision? Did the notice on the Pinnellas website provide adequate information to
the community?
And at the same time, Hillsborough County’s Plant City votes to implement fluoride
in the water supply:
At the same time that Pinellas County defluoridated their community water supply, Plant
City, in Hillsborough County discussed whether to implement a plan to fluoridate, and
voted to implement. In the ADA November 7, 2011 article, Dr. Oldham discusses his role
as a practicing dentist in assuring that the city council members had the information
necessary to make a final decision. Discuss the similarities and differences between these
two situations and how the actions of the health care providers and DPH leaders
functioned in this situation.
As another participant who was key in the decision-making, consider the value of the
Fluoridealert issued by Paul Vanderploog, Director from the Hillsborough County Water
Resource Services issued calling out “As a public utility which provides high-quality
drinking water to more than 350,000 people, Water Resource Services receives numerous
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advisories, statements, position papers, opinions and articles from a wide variety of
sources. Our staff carefully evaluates each new development in the industry. Medical
issues in particular can be extremely complex and confusing, and difficult to put into
context by anyone other than medical professionals. That is why, in such matters, we rely
on medical experts - in particular, the Hillsborough County Health Department - to
evaluate the validity of the material and determine what message should be relayed to the
public. Utilities are not allowed to make such judgment calls themselves. To do so would
violate procedures, protocol and laws established to safeguard our customers.”
If time permits, a Youtube clip from the Rachel Maddow show presents news reporting
on how a Republican candidate backed anti-fluoridation. This could be used for a class
discussion on how the topic of fluoridation often flows far from the science to people’s
beliefs on individual control, politics, and trust in health care providers.
Moving on with a discussion of two other public health tools, collection and use of
epidemiologic data & population surveillance. The case for such screening and collection
of data for oral cancer is presented, and the question is raised as to how to apportion the
DPH professional’s time and resources for collection of data and screening versus
programs designed to reduce alcohol and tobacco use.
As you lead the discussion, the following points should be brought out:
1. Program Effectiveness and selecting from program alternatives: Should studies
of the effectiveness of community based interventions be deferred until clinical
effectiveness in reducing morbidity and mortality has been established? Is the
community empowered or benefited when a DPH implements collection of cancer
data if such data does not improve program outcomes? Is there value to data
collection that serves some or all members of the community? Should the
community approve the implementation of cancer registries?
2. Ensure the professional competence of professionals: What roles should various
health professionals and DPH professionals play in early detection of oral and
pharyngeal cancers?
3. How should effort and other resources be allocated among strategies designed
primarily to prevent these cancers (e.g., tobacco use prevention) versus strategies
aimed at early detection? To what extent do early detection efforts reinforce
messages about reducing tobacco and alcohol use?
Lecture 4: Application of Ethical Reasoning on DPH decision making for considerations
in human subject research and the DPH and health care professional’s responsibility to
report cases of elder abuse.
Information is presented on the value of Informed Consent and the ethical considerations
regarding the use of human subjects in the research, using the Vipeholm study on caries
as a model.
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Vipeholm study on caries
Considerations on Human Subject Use in Research
Class Discussion considering the PHLS principles:
• Are there ethical concerns about the fact that this study was conducted on subjects
who were mentally handicapped?
• What factors might explain the decision of the Medical Board to approve this
study?
• Would such a study be conducted today? Why or Why not?
Instructor Guide to Elder Abuse and Neglect Case Vignette:
This rich case offers students an opportunity to link oral clinical, legal and ethical issues.
The case describes an older person who displays angular cheilitis, possible dementia or
physically-related dementia as well as signs of possible neglect. The tutor should try to
highlight all of the issues, weaving in the health practitioner’s and the dental public
health professional’s responsibility to evaluate and report elder abuse and neglect.
Angular cheilitis (also called perlèche, cheilosis, or stomatitis) is a condition displaying
deep cracks and splits at the corners of the mouth. In a severe case splits or cracks may
begin to bleed when the mouth is opened and a shallow ulcer or a crust may form.
Possible causes of angular cheilitis include:



Infection. Fungal infections are the most common, but viral or bacterial infections
can also occur.
Nutritional deficiency of B vitamins, iron or folic acid.
Over-closure of the mouth in someone who has been without teeth or dentures for
some time.
Definition of Senile Dementia: General loss of cognitive abilities, including impairment
of one’s memory, organizational skills, abstract thinking abilities in a previously
unimpaired individual.
Possible causes of senile dementia include:

Excessive use of alcohol

Neurodegenerative disease

Various types of brain injury, such as a single event through trauma or loss of
blood or oxygen to the brain through stroke
Definition of elder abuse: An all-inclusive term, representing all types of mistreatment
or abusive behavior toward older adults. Mistreatment can be an act of commission
(abuse) or omission (neglect), intentional or unintentional. Victims have one
characteristic in common: They are all vulnerable! (See California Department of
Justice’s and AARP’s joint comprehensive consumer information booklet, A
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Citizen’s Guide for Preventing and
ag.ca.gov/bmfea/pdfs/citizens_guide.pdf)
Reporting
Elder
Abuse,
at:
Types of elder abuse and neglect:
 Physical/Sexual (malnutrition, injuries such as bruises, welts, sprains, dislocations,
abrasions, lacerations, forced sexual contact)
 Emotional (verbal assault, threat, fear, or isolation)
 Material/Financial exploitation (theft or misuse of money or property for another
person’s profit or advantage)
 Medical abuse (withholding or improper administration of needed medications, or
withholding of aids such as dentures, glasses, or hearing)
 Passive or active neglect (conduct by the abuser resulting in the deprivation of care
necessary to maintain physical and mental health
 Violation of rights (forcing an older person from home or into an institutional setting
without his or her consent)
 Self neglect (often associated with dementia, other mental impairment, isolation,
depression, and alcohol abuse)
Warning signs of abuse and/or neglect include:
 Depression
 Fear
 Anxiety
 Social isolation
 Illness that does not appear to be responding to treatment
 Frequent trips to the emergency room
Reporting Elder Abuse and Neglect
 Health care professionals are required by law to report abuse to Adult Protective
Services (APS), the State Attorney General. Local law enforcement, or the licensing
and certification program of the State’s Department of Health Services (DHS) that
oversees health facilities such as nursing homes.
 Under-reporting: only about 16% of cases are reported (Wold, 2000).
 Elder abuse is not readily discernible and typically concealed by either the caregiver or
the care recipient.
 The abused may not report the problem because of shame, fear of retaliation, or
loyalty to the abuser
 70% of abused are female
Principles that shape adult protective services practice:
 client’s right to self-determination
 use of the least restrictive alternative
 maintenance of the family unit whenever possible
 use of community-based services rather than institutions
 avoidance of ascription of blame
 presumption that inadequate or inappropriate services are worse than none
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Interventions to support caregivers:
 Adult day care
 Respite care
 Home Health care
 Counseling in person or by phone
 Training programs/skill development
 Self-care techniques
 Support groups
 Internet resources
Elder Abuse: What Should Dental Health Professionals Know?
Two recent articles published by the Academy of General Dentistry offer helpful
suggestions for screening of older patients and keeping a careful eye.
ORAL/FACIAL INJURIES
o Fractured or loose teeth
o Lip trauma
o Bruising of edentulous ridges or facial tissue (area of the mouth covered by a
denture)
o Avulsed teeth (tooth and root structure forcibly knocked from the jaw bone)
o Upper jaw broken or dislocated (fractures of maxilla)
ORAL SIGNS OF NEGLECT
o Poor personal or oral hygiene
o Bad breath (halitosis)
o Gross dental disease
POSSIBLE FEARS OF ABUSED SURVIVORS
o Lying down for treatment
o Having objects put into their mouths
o Having a dentist’s hand covering their nose or mouth
o Fear of not being able to breathe or swallow
o Fear of gagging or being sick
o Fear that the dentist may become annoyed or angered
Sources: Michael C. Herren, DMD and Raymond J. Bryon, Jr., DMD, “Elder Abuse
Update,”
General
Dentistry,
May/June
2005,
www.agd.org/library/2005/june/dart_157.pdf;
Garwin, Jennifer, “Elder Abuse How to Spot It.” AGD Impact, Vol. 33 (6), April 2005,
www.agd.org/library/2005/june/garvin.ssp
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