Informed Consent in Dentistry.

A review of literature regarding informed consent in dentistry reveals a paucity of information and minimal scholarship devoted to this subject. But this begs the question about informed consent somehow being different for dentistry than for medicine or other healthcare delivery. My account draws distinctions where appropriate but is rooted in the premise that informed consent is an ethical construct applicable to vulnerable people as patients independent of what type of treatment or body part being considered. This paper highlights the crucial importance of the process of informed consent and refusal in dentistry, underscoring its important place in oral healthcare. This paper will not address the unique circumstances involving consent in those without capacity or focus on informed consent in the research setting; our focus will be on those patients with full decisionmaking capacity in the clinical setting. I will emphasize the importance of disclosure of treatment options and highlight the benefits of shared-decision-making in the informed consent process.

Combining practice with ethics.

As a dentist at the Mayo Clinic in Rochester, Minnesota, the author has found it easy and rewarding to combine specialty care in orofacial pain with ethics training for complex case management.

Readability of state-sponsored advance directive forms in the United States: a cross sectional study.

BACKGROUND: State governments provide preprinted advance directive forms to the general public. However, many adults in the United States (US) lack the skills necessary to read and comprehend health care-related materials. In this study, we sought to determine the readability of state government-sponsored advance directive forms. METHODS: A cross sectional study design was used. The readability of advance directive forms available online from all 50 US states and the District of Columbia was determined using 6 validated readability scales. RESULTS: Overall, 62 advance directive forms were obtained. For 47 states, forms were available by way of government-sponsored Web sites. The average (SD) readability (with the Flesch-Kincaid score) of all forms was grade level 11.9 (2.6). Similar results were obtained with the other readability scales. No form had a readability score at the 5th grade level or lower, the level recommended by the National Work Group on Literacy and Health. The readability of the forms exceeded this level by an average of 6.9 grade levels (95% confidence interval, 6.3-7.6; P < .001). Only 5 of the forms had a readability score at 8th grade level or lower, the average reading skill level of US adults. The readability of the forms exceeded this level by an average of 3.9 grade levels (95% confidence interval, 3.3-4.6; P < .001). CONCLUSIONS: The readability of US state government-sponsored advance directive forms exceeds the readability level recommended by the National Work Group on Literacy and Health and the average reading skill level of most US adults. Such forms may inhibit advance care planning and therefore patient autonomy.

Impact of tobacco use on the symptoms of painful temporomandibular joint disorders.

This study examines the relationship between the severity of painful temporomandibular joint disorders (TMD) symptoms and current tobacco use in patients evaluated at a specialized orofacial pain clinic. Medical records, including responses to the Chronic Pain Grading Scale (CPGS), from 606 consecutive patients evaluated at the Mayo Clinic orofacial pain clinic with TMD by RDC-TMD criteria were retrospectively reviewed. Univariate analyses were performed comparing tobacco users and non-users. Analysis of covariance and multiple logistic regression models were used to adjust for demographic variables. A p value

Respect for patients' autonomy.

BACKGROUND: Respect for patients' autonomy is an ethical principle in health care highlighted in the ADA Principles of Ethics and Code of Professional Conduct. The author presents a case example to illustrate its importance in dentistry. METHODS: Using a clinical example of disrespect for patients' autonomy, the author underscores the importance of incorporating normative ethical principles in patient-dentist relationships. CONCLUSIONS: Respect for patients' autonomy sustains healthy boundaries between patients and the clinician. It underscores the importance of providing patient education and counsel without attempting to persuade or manipulate patients for dentists' benefit. Practice Implications. Respect for patients' autonomy is a fundamental principle of health care ethics that patients expect dentists to follow. The author encourages dentists to incorporate this principle into every patient encounter.

Attitudes of general dentists regarding the acceptance of gifts and unconventional payments from patients.

BACKGROUND: Professional boundaries ensure that a dentist's focus remains on the patient's welfare. Such boundaries may be compromised by accepting gifts from patients. METHODS: General dentists attending a continuing dental education conference completed an anonymous questionnaire about professional boundaries and acceptance of gifts from patients. The authors compared subjects' responses to questionnaire items and calculated descriptive statistics. RESULTS: Of the 333 dentists attending the conference, 219 (65.8 percent) submitted a completed or partially completed survey. Of the respondents, 81.2 percent endorsed receiving gifts, 82.5 percent thought accepting inexpensive gifts was acceptable, 79.7 percent would accept a dinner invitation from a patient, 52.1 percent would accept a $1,000 discount from a business owned by a patient and 59.0 percent would fabricate a set of dentures in exchange for house-painting services. More than one-third of respondents stated they would not accept a gift worth $25 to $100, and 51.1 percent would not accept a gift worth more than $100. There were no statistically significant differences in responses stratified by sex, age and years in practice, with the exception that female dentists were significantly less likely to accept a dinner invitation. Logistic regression models revealed that younger dentists and dentists with fewer years in practice were less likely to respond "agree" or "strongly agree" to accepting gifts worth $25 to $100, and female dentists were less likely to respond "agree" or "strongly agree" to accepting a dinner invitation. CONCLUSION: A majority of dentists endorsed accepting gifts from patients, which may put them at risk of violating boundaries with patients. Practice Implications. Our findings suggest that general dentists should establish policies regarding the receipt of gifts from patients and inform them of such policies.

Surgical management of advanced degenerative arthritis of temporomandibular joint with metal fossa-eminence hemijoint replacement prosthesis: an 8-year retrospective pilot study.

PURPOSE: The purpose of this study was 2-fold: to evaluate the surgical outcome and surgical morbidity of the temporomandibular joint (TMJ) metal fossa-eminence hemijoint prosthesis replacement, implanted in patients with degenerative arthritis, and to establish whether future, more rigorous clinical trial assessment of the hemijoint replacement is warranted. MATERIALS AND METHODS: Eighty-four patients (79 females and 5 males) involving 108 joints (60 unilateral, 24 bilateral) were operated on, and 112 joint metal fossa-eminence prostheses were placed. Information was gathered from patient response questionnaires and clinicoradiographic medical chart review. Change in pain intensity (preoperative versus current) was measured by 2 methods: 1) pain experience (1 to 6) and 2) pain intensity (visual analog scale, 1 to 10). Chewing ability, jaw opening, and joint noise were evaluated (visual analog scales, 1 to 10). Surgical morbidity and implant survival were documented. RESULTS: The average period from initial TMJ symptoms to metal fossa-eminence implant surgery was 12.3 years. The average number of previous TMJ surgeries was 1.9. Pain was reduced 56% and 61.2% by 2 methods. Chewing ability, jaw opening, and joint noise were improved by 53.4%, 50.2%, and 64%, respectively. Nine of 112 implants were explanted during the study period. Patient satisfaction for the clinical outcome was 8.3 on a scale of 0 to 10. CONCLUSION: The surgical placement of the Co-Cr-Mo metal fossa-eminence prosthesis (partial joint replacement) provides significant focal preauricular pain relief and reduces TMJ dysfunction secondary to advanced degenerative arthritis. The results of this case series supports further investigation of this form of surgical management in a rigorously controlled prospective fashion.

Psychological and physiological parameters of masticatory muscle pain.

The objective of this research was to identify the psychological and physiological variables that differentiate persons reporting masticatory muscle pain (MMP) from normal controls (NC). This study examined the characteristics of 35 MMP patients in comparison to 35 age-, sex-, and weight-matched NCs. All subjects completed a series of standardized questionnaires prior to undergoing a laboratory evaluation consisting of a psychosocial stressor and pressure pain stimulation at multiple body sites. During the evaluation, subjects' emotional and physiological responses (heart rate, blood pressure, respiration, skin temperature, and muscle activity) were monitored. Results indicated that persons with MMP reported greater fatigue, disturbed sleep, depression, anxiety, menstrual symptoms, and less self-deception (P's < 0.05) than matched controls. At rest, MMPs had lower end tidal carbon dioxide levels (P < 0.04) and lower diastolic blood pressures than the NCs (P < 0.02). During laboratory challenge, both groups responded to the standard stressor with significant physiological activity and emotional responding consistent with an acute stress response (P < 0.01), but there were no differences between the MMPs and NCs. Muscle pain patients reported lower pressure pain thresholds than did NCs at the right/left masseter and right temporalis sites (P's < 0.05); there were no differences in pressure pain thresholds between MMPs and NCs for the left temporalis (P < 0.07) and right/left middle finger sites (P's > 0.93). These results are discussed in terms of the psychological and physiological processes that may account for the development of muscle pain in the masticatory system.