Considerații etice privind tratamentul estetic restaurator şi endodontic al dinților vitali şi devitali

Introduction

Modern restorative dentistry is currently based on new scientific discoveries and developments. Regenerative methods, bioactive materials, as well as new adhesive technologies are already widely used to improve the mechanical and adhesion properties of current dental materials, so as to obtain minimally invasive, durable and successful direct restorations.

At the same time, the spectacular advance of computer technologies, artificial intelligence, digital dentistry (3D printing of prosthetic works, digital impression, intraoral camera, intraoral scanning, digital radiography), the use of laser in dentistry, robotic surgery, all of these leave their mark on the treatment techniques approach⁽¹⁾.

Ethical considerations in esthetic restorative treatment of vital teeth

All these far-reaching scientific developments bring today, more than ever, ethical challenges and dilemmas. Therefore, strong emphasis is placed on the application of the four principles of bioethics described by Beauchamp.

• The principle of respect for autonomy: respecting the person’s capacity to choose (“respect for autonomy”).
• The principle of beneficence: caring for the well-being of the person in question (“beneficence”).
• The principle of non-maleficence: avoiding causing harm (“non-maleficence”).
• The principle of justice: all persons must be treated fairly, respecting the balance between the personal needs of the patient and the resources of society, without differences in access to medical care (“justice”)⁽²⁾.

The ethical challenges associated with restorative treatments of vital and non-vital teeth are related to a variety of aspects, such as the use of adhesive materials as a modern and biological alternative to dental amalgam, but also raise a multitude of issues of esthetic restorations of tooth shape and color⁽³⁾.

The branch of dentistry called cosmetic dentistry has experienced a special development in recent decades, initially using mainly whitening techniques for vital and non-vital teeth, later adding veneering methods, gingival recontouring procedures or enamel microabrasion.

It is precisely through this impressive development of dental cosmetic therapies that new ethical considerations arise in our profession. Thus, the doctor’s activity no longer represents mainly the painful and functional conditions treatment, but rather the achievement of an attractive dentofacial appearance, an essential condition in modern society. In this way, the boundary between the objective necessity of a dental intervention and the subjective one, which the dentist performs at the exclusive request of the patient, without any other clear necessity other than the physiognomic one, can be ambiguous and fine, and the entire decision – especially the responsibility – belongs to the professional⁽⁴⁾.

The most requested cosmetic dental procedure is tooth whitening (dental bleaching), as a result of which the optical parameters of the hard dental structures change, neutralizing and eliminating the molecules and agents that caused the dyschromia. Bleaching techniques, especially when they are addressed to vital teeth, bring into discussion the bioethical aspect of the necessity of this procedure, since it is not intended for prevention or treatment; practically, we refer to the mandatory existence of a diagnosed clinical situation and the necessity of this therapy, other than the patient’s wish, otherwise the principle of non-maleficence may be violated. From an objective medical point of view, a pathological change in tooth color (discoloration) must be present, such as that produced by fluorosis, tetracycline, genetic anomalies and others, or that in the case of a non-vital tooth, in order not to face an ethical dilemma, as it is highlighted in many articles and modern studies⁽⁵⁾.

Another ethical issue raised by the dental bleaching treatment is the need to objectively present to the patient, before initiating any procedure, the techniques, mechanisms, limits and especially the predictable results, as patients often have unrealistic expectations, in addition to the possibility of short-term or long-term side effects (on dental pulp, periodontal tissues, enamel demineralization, tooth sensitivity), and even the cytotoxic or mutagenic potential of peroxide-based substances which has been described⁽⁶⁾.

All cosmetic dental treatments of vital and non-vital teeth require obtaining the patient’s informed consent, in a special manner compared to other types of treatment, starting precisely from the premise that this category of patients has higher expectations regarding esthetic results and especially demands “safe guarantees” regarding them. However, medicine is a profession of diligence, not of result, according to the code of ethics, and one of the fundamental principles of practicing the profession of dentist is: “dedicating all science and skill to the patient’s interest, as well as taking all due care to ensure that the decision made is correct, acting in the best interest of the patient”⁽⁷⁾.

The steps to obtain a complete and documented informed consent for dental bleaching procedures, in accordance with the principles of bioethics and medical liability, are:

• comprehensive examination and appropriate selection of cases requiring the procedure;
• complementary investigations (radiographs, pulp vitality tests, periodontometry);
• esthetic questionnaire, which represents the examination along with written and imaging documentation regarding the particularities of dyschromia (etiology, location, intensity, hue and color saturation);
• using augmented reality by simulating the final result on the computer;
• accurate determination of the patient’s wishes and expectations⁽⁸⁾.

Dental bleaching, like other dental cosmetic techniques for improving the color and esthetic appearance of the dental arches, may represent a financial temptation for the dentist, in the situation of private practice and the general economic status, but the professional decision must be made only based on the ethical and moral values of the dentist himself. In this way, dissatisfaction and especially litigation that may arise as a result of medical malpractice accusations can be avoided.

Ethical considerations in endodontic treatment of non-vital teeth

An extremely frequent aspect encountered in dental practice is the decision – which must be made taking into account the principles of bioethics – regarding an endodontic restorative treatment and coronal restoration of a tooth with chronic apical pathology, after the failure of conservative treatment to preserve pulp vitality, versus alternative implant-prosthetic treatment.

Bioethics also intervenes in the situation where the dentist is faced with the decision of endodontic restorative treatment and coronal restoration to keep a tooth that presents chronic periapical pathology on the dental arch or resorts to implant-prosthetic therapy, by extracting the respective tooth and replacing it with a dental implant and a dental crown.

The decision to extract a tooth with chronic periapical lesion, which is on the borderline between a conservative and a radical treatment, follows several steps, in which, along with the diagnosis, a number of aspects must be investigated and carefully analyzed:

• the status of the dental arches;
• the place and role that the tooth has from a functional point of view;
• the state of the marginal periodontium;
• especially the estimation of the medium and long-term prognosis of the saved tooth;
• the local and regional implications and complications of inserting a dental implant.

Tooth extraction is a radical and irreversible method, and it should be taken into account following a complete evaluation, which also includes the quality and quantity of the bone structures, the patient’s general health status, respectively the need for additional surgical interventions such as bone addition (grafting) or sinus lifting.

It should be noted that, in recent years, the success rate of endodontic treatment is close to that of implant therapy, but we must mention that in the dental implant, the probability of subsequent complications is higher^(9,10). Considering these objective aspects, the ethical challenge in this type of clinical situation is represented by the correct and detailed presentation to the patient of all the limits and particularities of each type of treatment, together with the associated costs. The latter are obviously higher in the case of implant-prosthetic therapy, so the doctor’s decision must be based on the second principle of bioethics, of beneficence, together with loyalty and fairness towards the real interest of the patient. The principle of patient autonomy must also be respected, as the patient is free to choose the therapeutic method he wants, in this regard, the informed consent being essential, as mentioned before⁽¹¹⁾.

The first option in the case of a tooth with chronic periapical periodontitis should always be the conservative endodontic treatment, followed by direct or indirect coronal restoration of hard dental structures, and financial motivation should never take precedence.

Conclusions

In modern esthetic restorative and endodontic treatments, the balance between socioeconomic development, society’s demands, practicing dentistry as a liberal profession and medical bioethics in current practice is not easy to maintain, raising ethical dilemmas and requiring rigorous application of ethical and moral principles by the dentist.

Conflict of interests: none declared.

Financial support: none declared.

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