Ethical issues related to dental bleaching - Romanian Journal ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Rom J Leg Med [27] 78-82 [2019]
DOI: 10.4323/rjlm.2019.78
MEDICAL ETHICS, SOCIAL SCIENCES AND HUMANITIES
© 2019 Romanian Society of Legal Medicine
Ethical issues related to dental bleaching
Irina Maria Gheorghiu1, Paula Perlea2,*, Anca Nicoleta Temelcea3
_________________________________________________________________________________________
Abstract: In contemporary society, an attractive smile is associated with bright, light colored teeth and is almost a
prerequisite in terms of social and professional integration.
Dental bleaching is currently the most requested cosmetic procedure in the dental office, and can be a standalone
procedure or included in a comprehensive plan for oral cavity rehabilitation. The substance of choice for tooth bleaching is
hydrogen peroxide in different concentrations, depending on the bleaching technique used. However, the ethical issues that
accompany dentist’s decision on this aesthetic procedure are complex and include establishing the real "need" for dental bleaching
and the objective presentation to the patient of the bleaching techniques, boundaries and predictable results. Also, for a successful
outcome of the dental bleaching for both the patient and the physician, it is important that the latter informs the patient about
the side effects, risks, costs, and short- or long-term effects. The professional decision must respect the fundamental principles of
bioethics and ethics within the profession and ethical values must be those which prevails to the dentist, regardless of the financial
temptations that any cosmetic dental technique may represent.
Key Words: Dental bleaching, aesthetic procedure, ethical considerations.
INTRODUCTION associated with dental cosmetic are centered around the
principle of autonomy of the patients, and how/if they
A smiling person is one of the most beautiful enter in conflict with other fundamental principles, such
images. Beyond the light in sight that accompanies it, as non-maleficence, justice, beneficence, and, especially
a pleasant appearance of the dentition is essential. The in the field of cosmetics, veracity [1-4].
color, shape, proportionality, symmetry, position and Cosmetic dentistry procedures are defined as
alignment of the teeth arcade, especially in the frontal those medical maneuvers applied to healthy dental tissues
region, determine the esthetic agreeable and desirable in order to improve their appearance. Improvement in
aspect. Therefore, one of the most important challenges a dental color currently represents the most requested
professional faces in modern dentistry is this new focus cosmetic procedure.
on aesthetic and cosmetic dental procedures.
Ethical issues associated with dental practice Dental bleaching
have became, in recent years, more and more debated, Dental bleaching or tooth whitening (the
especially in cosmetic dentistry; bioethical issues discoloration of hard dental structures) is a method of
1) “Carol Davila” University of Medicine and Pharmacy, Faculty of Dental Medicine, Department of Restorative Dentistry,
Bucharest, Romania
2) “Carol Davila” University of Medicine and Pharmacy, Faculty of Dental Medicine, Department of Endodontics,
Bucharest, Romania
* Corresponding author: “Carol Davila” University of Medicine and Pharmacy, Faculty of Dental Medicine, Department
of Endodontics, Plevnei Avenue 19, 010221, Bucharest, Romania, E-mail: paula.perlea@gmail.com
3) “Carol Davila” University of Medicine and Pharmacy, Faculty of Dental Medicine, Department of Dental Technique,
Bucharest, Romania
78Romanian Journal of Legal Medicine Vol. XXVII, No 1(2019)
treatment characterized by applying a chemical agent from the media, which often focuses on beauty and
that oxidizes the organic pigment in tissues. Following youth. However, it should be noted that social standards
this action, the optical parameters of dental structures of beauty can be confusing or modified in the modern
change, facilitating the release of the chromophore society and therefore, the physician must carefully guide
substances responsible for tooth pigmentation [5, 6]. The their actions within medical ethics and the code of
methods of teeth whitening generally apply to frontal conduct [11-13].
dental arches and can be performed with or without a The natural and normal almost have little place
device achieved by an impression of the arcades called in today's society, and patients want teeth "whiter and
tray [7]. brighter", which make them look younger, healthier and
Teeth whitening is the most common cosmetic more attractive. Unfortunately, sometimes these aesthetic
procedure for adults, being used as either a unique requirements prevail even against real treatment needs of
method, or integrated into a complex oral rehabilitation oral cavity structures [14].
plan. Bleaching is the simplest, least invasive and most In terms of ethical medical judgment, the
inexpensive method to improve the appearance of teeth professional decision to implement teeth whitening
whose color has changed or to reduce and eliminate methods must include some known stages: establishing
stains from their surface. It targets both vital teeth as well the diagnosis in accordance with facts based on
as the nonvital ones, whether the discoloration is uni- or scientific truth followed by a second phase of treatment
multi-dental [8]. recommended in line with professional guides, which
The substance of choice for tooth whitening tempers the collective experience and professional
is hydrogen peroxide in different concentrations, updates. The communication between patient and
depending on the bleaching technique used: 35% for physician is equally important in cosmetic dental
techniques performed in the dental office and 10-16% medicine as in any other medical fields in order to obtain
carbamide peroxide for techniques done at a patient's the best therapeutic result [15].
home. Home bleaching can be done at the direction Any discoloration dental procedure must have its
and under the supervision of a dentist, or with products ethical justification both in terms of objective necessity
bought directly from pharmacies and shops, without a (namely the existence of a diagnosis and clear medical
referral and specialist supervision. indications), and the necessity of initiating therapy; these
Hydrogen peroxide is used as such or in the two issues are closely intertwined.
form of an organic derivative - carbamide peroxide or Applying the techniques for teeth whitening is
urea peroxide. During treatment, it breaks down into done after a thorough examination of the patient and
urea and hydrogen peroxide, like products based on an adequate selection of those clinical cases requiring
sodium perborate. Hydrogen peroxide of low molecular a real treatment using this method. Specific measures
weight penetrates the enamel and dentin and release, include, in this situation, a thorough preoperative
by decomposition, several intermediates byproducts; of clinical examination (personal history and clinical
these, the free radicals cleaving molecules cords that fixe examination); performing periodontal assessments;
pigment in tooth structure, form soluble compounds mandatory additional tests (radiography, vitality tests);
that are eliminated, thus restoring the initial shade of the caring out imaging/photography tests, which include
tooth [9]. the assessment and acknowledging in the questionnaire
Dental bleaching for aesthetic purposes is a the color shade of the teeth to be bleached. An essential
medical procedure currently accepted in medical practice element is the aesthetic questionnaires which should
code. However, it raises a variety of ethical issues related include information about the location and intensity of
to the need to implement it, because it is not a procedure the discolorations; the hue and pigmentation’s saturation
for prevention or treatment [10]. determined by a color key or through instrumental
Currently, for dentists, the question is no analysis; computer simulation of the treatment effect and
longer whether or not to include whitening techniques finally, the assessment of the patient's aesthetic desires
for aesthetic purpose in their practice. To meet the and expectations.
needs and wishes of patients and to be competitive Non-invasive techniques for physiognomy
in relation to other dental offices, it is imperative for a restoration of vital teeth color can be an objective
dentist to offer cosmetic dental treatment procedures. A necessity in cases of pathological discolorations with
pleasant appearance aspect is one of the most important known etiologies and with clearly assessed therapeutic
requirements in the modern world, and patients are indications: genetic discoloration, caused by trauma,
under this constant pressure, both as standard, as well as tetracycline, fluorosis or age related [16].
mandatory requirement for social integration. The color The dyschromia in nonvital teeth is approached
of teeth is one of the most common criteria in discussions using cosmetics therapeutic modalities (dental
of desirable facial aspects. bleaching), restorative (dental veneers) or prosthetic
Patients’ requirements are dictated by pressure (dental crown), depending on the clinical situation.
79Gheorghiu I.M. et al. Ethical issues related to dental bleaching
In the case of superficial localized color changes procedure not a therapeutic one [21, 22].
on the surface of the enamel, such as exogenous stain, The harmful side effects may occur at the level
a complete prophylaxis using specific means at regular of hard tissues, tooth pulp and adjacent tissues such
intervals can remove enough extrinsic stains, tartar and as marginal gingival and periodontal tissue. The most
bacterial plaque so as to satisfy the patients’ aesthetic common manifestations associated with bleaching
without the need for a subsequent bleaching procedure. treatments are: the possibility of developing dental
In other cases, any correcting restorative dental problems hypersensitivity or inflammation of the pulp (for vital
that contributed to the color change may eliminate the teeth), demineralization of the enamel surface (with
need for tooth whitening. In such situations, the ethical effects on the subsequent use of adhesive restorative
dilemma is whether to recommend or perform a teeth techniques), irritation and lesions of gingival fibromucosa
bleaching treatment and is based on dentist’s ethical due to improper or non-existent protection; there were
insight [17,18]. also described mechanical damage of gum tissues due
From an ethical point of view, recommending to insufficient adapted bleaching trays, and the ability of
unnecessary procedures is not allowed, as it may certain substances that release peroxide to have cytotoxic
breach the principle of non-maleficence [19]. From this potential, genotoxic or mutagenic action of other
perspective, the first ethical dilemma faced by a dentist bleaching substances [23-25].
offering teeth whitening services, besides the situation One of the most significant ethical dilemmas to
of an identified and diagnosed dental pathology, is to dental bleaching is the result of these methods. Patient
establish the notions of "beauty" and "need" or “medical expectations in terms of the effect of bleaching methods
indication” about the smile and dental color. may be unrealistic, and therefore it is mandatory to present
The color of teeth is characterized by hue, to the patients, prior to initiating any treatment, the
saturation, luminosity, opalescent, fluorescence and aesthetic tooth discoloration range that can be expected
translucency. Beyond these objective criteria, establishing and the limits of the whitening methods [26, 27]. Patients
a dental color shades as "beautiful" is a subjective action, always want certain guarantees of the therapeutic results.
both for the patient and for the doctor. Frequently, Bleaching is a procedure whose results depend on many
patients want "white teeth", which for them means "pure factors, such as a dentist's professional expertise, teeth
white". It may not be possible to achieve in their particular individual variation, long habits of patients, diet and
situation using whitening methods; sometimes, it may dental hygiene. It is difficult to guarantee and promise
even be undesirable in relation to skin color or age. The the patient a specific tooth shade or result. Dealing with
perception of the importance of dental color is different patients’ expectations and "guarantees" offered about
from person to person and is subject to cultural and/or the aesthetic results, may currently represent a topic of
educational criteria. morally and ethically interest, but also represents a legal
In an era in which agreeable requirements of issue increasingly facing by the dentists.
dental aspect, including a light shade of dentition, are Virtually each patient wants and expects a
priorities for the population and quasi- mandatory for forecast of the aesthetic result that he/she will get at the
social integration, it is becoming increasingly difficult end of the bleaching treatment. It is necessary for the
to set the beauty standard about dental color [20]. doctor to give the patient a conservative and objective
The professionalism of the dentist intervenes in this estimate, that is based on science and estimated final
therapeutic decision making based on professional appearance, and, for this purpose, the dentist must
competence, and to the same extent, on character completely answer patient’s following questions: which
and moral principles, which dictate the need, i.e. the will be the result aesthetic, which is the required number
therapeutic indication of color change using dental of treatment sessions, which is the lifetime of dental color
whitening techniques. change and what behavior patterns and dietary habits the
Like any medical procedure, dental bleaching patient needs to change in order to keep the treatment
involves risks, and the patient should be informed about outcome [28].
the benefits, costs, complications and short and long- Therefore, the patient should agree with
term prognosis. It also requires a disclosure of medical a particular result of the bleaching procedure, as
ethics treatment alternatives. Unfortunately, often the represented by an objective standard (image, gradient,
risks of teeth whitening therapy procedures are not fully and so on), and not to a general bleaching procedure,
known or understood by the patient. or simply achieving whiter teeth, as this often puts the
An ethical aspect that is extremely important is dental specialist in jeopardy for civil complains. This is
knowing the side effects of tooth whitening techniques especially important in cosmetic procedures, in which
or chemicals used, even if the whole is considered a safe the result, and not the diligence to act, is essential in
procedure. This is the case especially when chemicals establishing malpractice liability.
that induce discoloration are at low concentration and is All these aspects must be well documented
even more important since we refer to a cosmetic dental through aesthetic questionnaires, which include
80Romanian Journal of Legal Medicine Vol. XXVII, No 1(2019)
localization and intensity of color changes, hue and the other hand, their effectiveness can be questioned.
saturation pigmentation (determined by a key color Currently, these commercial products are verified by
or other instrumental methods of analysis), and a appropriate professional bodies [32], but for home
computer simulation of the effect of teeth whitening. bleaching products patients should always use reputable
Communication is a necessary component of all aesthetic known firms and only under the supervision of a dentist.
efforts and is greatly facilitated by viewing the provided One of the most discussed and controversial ethical issues
image on the computer. The performance in digital in cosmetic dentistry is the financial aspect, namely the
imaging technology is helpful in viewing, evaluating and fees charged by doctors.
approving by the patient of the treatment options. Private dental practice is a lucrative activity
By properly informing and communicating providing complex and highly specialized medical
with the patient, he/she can properly and objectively services so it should be always done only by professionals
understand the procedure, its limitations and the who know and apply the basic principles of medical
possibility that the actual result might be different than ethics.
expected [29]. The principle of patient’s autonomy Efficiency, productivity and profits are
requires informed consent thereof, demonstrating that indispensable elements of a market economy, but ethical
adequate information on the therapeutic approach was medical procedures must always be the focus of the
presented, understood and agreed upon [30]. service that will benefit the patient. The profession of
Acting in accordance with the principles of dental practitioners should not be practiced as a mere
bioethics, the dentist must always have priority in business, according to the code of conduct [33]. The
regard to the "best interest of the patient". Therefore, physician should always present the estimated costs of
the physician should take into account the medical and the procedure before starting it, and clearly specify if
non-medical benefits generated by the procedure to a these costs are expected to grow, and also specify the
particular patient, and make sure that non-maleficence potential costs associated with the treatment of potential
is respected [31]. In a cosmetic procedure, the benefit- complications.
to-risk ratio needs to be much higher compared to It is well known that much of current dentistry
therapeutic procedures, and any risks that might appear is mainly focused on cosmetic procedures, among which
should be minimized and brought to the attention of the bleaching has an increased weight and its material benefits
patient. In clinical ethics it is often argued that the final are tempting to dentists. As such, only the intrinsic moral
professional decision regarding the therapeutic conduct qualities of the dentist, as well as a rigorous application of
belongs to the doctor through the perseverance to the notions of bioethics, may guide the dentist to practice
professional independence. In cosmetic procedures, even with honor and competence [34].
though this is still the case, the importance of the patient’s In conclusion, bleaching teeth has become lately
views is extremely important, and physicians should a lucrative area for dental practitioners. The increase in
never impose a specific cosmetic procedure; if they do patient’s demand for aesthetic whitening procedures is an
not agree with the patient about the optimal course of the effect of the modern world, in which the pleasant esthetic
cosmetic treatment, they should refrain from performing appearance and color of the teeth are a requirement and
the procedure. a necessity of social integration. Along with professional
One moral and ethical responsibility of dentists expertise, there are multiple ethical issues associated with
is to educate patients on non-professional bleaching professional teeth whitening, that should always be taken
products which can be bought from the market and used into account by practitioners.
at home without any control or a doctor’s referral. Often,
these commercial products contain various substances Conflict of interest. The authors declare that
(such as weak acids) which can cause damage to tooth there is no conflict of interest.
structure if they are used for extended periods, and, on
References
1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 7th edition, Oxford University Press 2012, 12-13.
2. Ojovanu A, Ojovanu V. Bioethics and dentistry: the establishment of essentials subjects. Studia UBB Bioethica, 2012, LVII (1): 59-64.
3. Rogozea L, Purcaru D, Leasu F, Nemet C. Biomedical research – opportunities and ethical challenges. Rom J MorpholEmbryol, 2014, 55(2
Suppl):719–722.
4. Faith KE. The Ethics of Cosmetic Dentistry: Beneficence, beauty or "bucks"? 2010, http://www.oralhealthgroup.com/features/the-ethics-of-
cosmetic-dentistry-beneficence-beauty-or-bucks/
5. Féliz-Matos L, Hernández LM, Abreu N. Dental Bleaching Techniques; Hydrogen-carbamide Peroxides and Light Sources for Activation,
an Update. Mini Review Article.Open Dent J, 2014; 8: 264–268.
6. Dudea D, Florea A, Mihu C, Câmpeanu R, Nicola C, Benga G. The use of scanning electron microscopy in evaluating the effect of a
bleaching agent on the enamel surface. Rom J MorpholEmbryol, 2009, 50(3):435–440.
81Gheorghiu I.M. et al. Ethical issues related to dental bleaching
7. Lazarescu F. Incursiune în estetica dentară. SSER, 2013, 200-210.
8. Heyman HO, Swift jr EJ, Ritter AV. Sturdevant’s Art and Science of Operative Dentistry. 6thed, Mosby Elsevier INC., St Louis, 2013, 89-112.
9. Carey CM. Tooth Whitening: What We Now Know. J Evid Based Dent Pract. 2014, 14 Suppl: 70–76.
10. Doughty J, Lala R, Marshman Z. The dental public health implications of cosmetic dentistry: a scoping review of the literature.CommDent
Health, 2016;33(3):218-224.
11. Newbrun E. Professional ethics and professional etiquette in dentistry: are they compatible?, 2007, 55(3):119-25; discussion 171-85.
12. Lawrence DJ. The Four Principles of Biomedical Ethics: A Foundation for Current Bioethical Debate. J ChiroprHumanit, 2007;14:34-40.
13. Stanley M. What is an ethical dentist? 2016, http://www.dentistry.co.uk/2016/04/07/what-is-an-ethical-dentist/
14. Silva FBD, Chisini LA, Demarco FF, Horta BL, Correa MB. Desire for tooth bleaching and treatment performed in Brazilian adults:
findings from a birth cohort. Braz Oral Res. 2018;32: e12.
15. Zorilă MV, Ungureanu BS, Zăvoi ER, Ciurea ME, Gheonea DI. Ethical issues in therapeutic endoscopy – can communication between
patient and physician make a difference? Rom J MorpholEmbryol2015, 56(2 Suppl):885–889.
16. Hegde MN, Krishna S. Overview of in-office bleaching of vital teeth. Int Res J Pharmacy, 2012, 3(11): 12-16.
17. Hancocks S. The ethics of cosmetics. Br Dent J, 2011;211(11): 501.
18. O'Higgins E. Ethics and dentistry., 2014, 60(4):186-188.
19. American Dental Association. Principles of ethics and code of professional conduct, with official advisory opinions revised to November
2016, Chicago, 11. http://www.ada.org/about-the-ada/principles-of-ethics-code-of-professional-conduct.
20. Theobald AH, Wong B, Quick A, Thomson W. The impact of the popular media on cosmetic dentistry. New Zealand Dent J, 2006, 102(3):
58-63.
21. Al-Tarakemah Y, Darvell BW. bleaching. Dent Mater, 2016;32(10):1281-1288.
22. Singh JKM, Sengut M, Halim MS, Ab-Ghani Z, Abd Rahman N. Safety comparison of over the counter bleaching with professionally
prescribed home bleaching agent. Eur J Gen Dent 2018; 7:35-40.
23. Li Y, Greenwall L. Safety issues of tooth whitening using peroxide-based materials. Brit Dent J, 2013, 215:29–34.
24. Machado LS, de Oliveira FG, Rocha EP, dos Santos PH, Briso AL, Sundefeld ML, Sundfeld RH. Clinical trial evaluating color change and
tooth sensitivity throughout and following in-office bleaching. Int J Period Rest Dent, 2013, 33(2):209-215.
25. de Geus JL, Wambier LM, Kossatz S, Loguercio AD, Reis A. At-home vs In-office Bleaching: A Systematic Review and Meta-analysis. Oper
Dent, 2016;41(4):341-356.
26. Kelleher MG, Djemal S, Lewis N. Ethical marketing in 'aesthetic'('esthetic') or 'cosmetic dentistry'. Part 1, 2012, 39(5):313-326.
27. Al-Omiri MK, Al Nazeh AA, Kielbassa AM, Lynch E. Randomized controlled clinical trial on bleaching sensitivity and whitening efficacy
of hydrogen peroxide versus combinations of hydrogen peroxide and ozone. Sci Rep. 2018;8(1):2407.
28. Majeed A, Farooq I, Grobler SR, Rossouw RJ. Tooth-Bleaching: A Review of the Efficacy and Adverse Effects of Various Tooth Whitening
Products. J Coll Physicians Surg Pak, 2015;25(12):891-896.
29. Kelleher M. Ethical issues, dilemmas and controversies in 'cosmetic' or aesthetic dentistry. A personal opinion. Br Dent J, 2012,
27;212(8):365-367.
30. Curcă GC. Concepts of deontological responsibility and medical malpractice. Rev Rom Bioet, 2010, 1: 161-169.
31. Taylor RM. Ethical principles and concepts in medicine. HandbClin Neurol. 2013; 118:1-9.
32. http://www.fda.gov
33. Simonsen R. Commerce versus Care: Troubling Trends in the Ethics of Esthetic Dentistry. The Dentl Clin North Am, 2007, 281-287.
34. NaidooS. Ethical considerations in community oral health. J Dent Educ, 2015;79(5 Suppl): S38-44.
82You can also read
