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1 What Is Ethics?

Ethics has long been defined as a branch of philosophy and theology that involves systematizing, defending, and recommending concepts of right and wrong behavior. The American College of Dentists defines ethics as studying systematically what is right and good with respect to character and conduct [1]. In short, ethics is about choices. The choosing to act or to not act. Ethical issues faced by dentists and members of the dental team (dental hygienists, dental therapists, dental assistants, and dental office administrative staff) are ever-evolving, both increasing in number and in the complexity of factors needing to be reviewed, considered, and addressed [2]. Ethics affect every decision made in the dental office and are inextricably linked to the daily decisions of overall dental practice. The pursuit of embodying the best of dental ethics and ethical decision-making is both an individual and collective matter.

What one dentist chooses to do or not do has implications and consequences not only for that individual but also for the profession as a whole. What dentist hasn’t heard the inevitable phrase, “I hate dentists,” upon entering an operatory and greeting a new patient. Often regarded as simple patient anxiety, it is worth noting that a previous dental provider, although not expressly causing the dental anxiety/trauma, certainly could have had a role in shaping or exacerbating such patient anxiety in a prior encounter. A previous dentist’s choosing to act or not to act could have heavily influenced the patient’s view of both that dentist specifically, but also the patient’s view of dentists generally and the profession as a whole. Research has shown that the skills, attitudes, and philosophies of various dentists that persons may have encountered in their life spans can affect their oral health status [3].

2 Providing Care for the Geriatric Patient

The US Census Bureau projects that by 2030, more than 20% of the population will be 65 years or older compared with 13% in 2010 [4]. While the geriatric population is ever-growing, the typical older patient is no longer simply a denture wearer. Particularly, as the geriatric population booms, this generation of seniors is often more educated, is more financially well-off, and has a history of routine dental care utilization [5]. Yet typical socioeconomic barriers to access to care remain. Along with continued advancement in dental treatments and more complex treatment planning options, today’s geriatric patient has increasingly retained their natural teeth; thus, a larger number of older people will be seeking dental care in the upcoming years [6]. The retention of teeth also presents a challenge for both patient self-care and oral professional care to maintain the dentition for a whole lifetime [7]. Oral health status in older adults also reflects the cumulative outcomes of oral health behaviors, diseases, and their treatments during a life span [7].

The dental needs of older adults are also changing and growing. “The management of older patients requires not only an understanding of the medical and dental aspects of aging, but also many other factors such as ambulation, independent living, socialization, and sensory function. Many barriers may interfere with providing older patients with dental care, including heightened dental complexity, multiple medical conditions, diminished functional status, loss of independence, uninformed attitudes about dental care in old age, and limited finances.”7 Dental practice specific to geriatric patient care raises specific ethical issues due to the evolving dental needs of older adults. While ethical dilemmas have been vastly studied, taught, and applied, all dentist-patient interactions do not necessarily give rise to an ethical dilemma. However, every dentist-patient, or even dentist-team member, interaction does have within it an ethical dimension.

3 Informed Consent and the Geriatric Patient

One of the most well-known ethical aspects of dental practice is obtaining informed consent. However, despite its common practice, it is also one of the most leniently applied and understood concepts with significant ethical underpinnings. While widely minimized to a signature of understanding and approval, informed consent is of particular interest and concern among an aging patient population. Obtaining informed consent is in all reality more than a simple conversation. It is a communication between patients and their healthcare providers with a goal to ensure full understanding of the clinical procedures that will be performed [6]. The informed consent process should include a discussion of the expected risks, benefits, and alternatives that are available to them and an opportunity to ask questions, discuss their choices, and have time to reflect and provide a clear indication of their eventual decision [6]. The literature suggests that informed consent should include five basic elements or domains: capacity, information, comprehension, voluntariness, and a final decision or choice [6].

Capacity to consent refers to the patient’s ability to understand the purpose, implication, and consequences of treatment [2]. Capacity is an issue of the patient’s physical and cognitive ability to fully participate in the informed consent process [6]. Within the geriatric patient population, there are those who suffer limited capacity to make decisions for themselves, including cognitive impairments as a result of mental illness, stroke, dementia, delirium, or other related issues [8]. It has long been established that Alzheimer’s patients present “unique caregiving problems because of troublesome symptoms including impaired memory, disorientation, poor judgment, inappropriate, unpredictable, or dangerous behaviors, incontinence, and the need for constant surveillance” [8]. For a more in-depth discussion on the topic of cognitive impairment, please refer to Chapter “The 3 Ds: Dementia, Delirium and Depression in Oral Health”.

One of the most significant ethical challenges within the issue of informed consent and geriatric dentistry is the fact that capacity to participate in the informed consent process may fluctuate over time. There is also very little standardization of how capacity is accessed and if it is appropriate in the dental clinical setting for that to be a chairside assessment and/or decision. It is also possible that ageism, the holding of negative stereotypes and beliefs regarding older adults, may influence dentist, patient, or even caregiver understandings and actions [8]. “The decision not to treat a condition or illness made on age considerations alone, or the seeking of advice from adult children without first talking with the older patient are, in many instances, examples of ageist behaviors” [8]. Dentists, dental team members, and even caregivers must be careful as many decisions may relate to providing or withholding treatment, especially when a patient may verbally or behaviorally refuse care. An ultimate decision must be made whether or not to override refusal. The role of the caregiver or family member is sometimes a burden of care, and professional altruism and empathy are necessary. For example, if a patient resists riding in the car to make an office visit, planning longer treatment sessions, which limit the need for multiple visits, will reduce caregiver burden substantially. Some cognitively impaired patients have better mental function and less disruptive behaviors at one time of day as opposed to others. For these patients, flexibility in scheduling visits during their “good” time (e.g., only morning visits) will reduce stress for the family caregiver, to say nothing of the dentist [8].

The specific question of declining capacity necessitates both a means for assessing capacity and methodologies for ensuring a patient with declining capacity is able to have autonomy in their treatment care decisions before capacity has indeed declined. While not particularly common in dental care settings, in medical care the advance directive is a customary means of predetermining a patient’s wishes in the event they can no longer consent for themselves. Medicine also has options such as DNR or do not resuscitate orders. On the surface, DNRs may seem to have little relevance to clinical dental care not seemingly surrounding a matter of life or death. However, at their simplest understanding , a DNR order is a decision to not render treatment. Likely occurring much more frequently than clinicians care to admit, the decision to treat or not to treat health problems, including those related to the oral cavity, is made based largely upon the goal of maintaining function and comfort of older patients [8].

Although capacity assessment tools exist, most are not used in everyday healthcare practice, and many are considered time-consuming and insufficient at determining if patients really have the capacity to consent [6]. Some suggest the practicality, efficiency, acceptability, affordability, and sustainability of capacity assessment tools in dentistry makes their useage highly unlikely [6]. In the past, researchers have suggested that dental professionals ask the patient, “who would you like me to consult regarding your treatment if something should happen to you and you are no longer able to express your wishes” [8]. The patient’s response is subsequently documented in the dental record. While this seems simple and satisfying on its surface, like most decisions with ethical implications, simplicity and experiences within ethical dimensions often present with more than what meets the eye. Thus, assessing a patient’s ability to provide consent can be challenging for dentists under a variety of circumstances, including when capacity is affected by mental health status or is transient. With decisions of capacity and informed consent having legal and regulatory implications, the research is inconclusive as to the extent to which dental practitioners should become involved in legally declaring a patient capable or incapable [6].

Best practices within a dental care setting have yet to be clearly established; however, the literature recommends a medical referral for capacity evaluation if the dentist is unsure of the patient’s ability to consent for treatment [9]. Accounting for older patients, in dental care settings, often declining additional information about treatment procedures, some scholars suggest geriatric patients should have 24 hours before any routine dental procedure to process the information provided in the consent forms [10]. Dentist and dental team members must be attuned to nonverbal cues from patients such as visible confusion and inconsistencies in the patient’s behavior, and if the patient’s decision-making capacity appears questionable, immediately involve family members or caregivers in the decision-making process [6].

Worth noting is the concept of geriatric assent, meaning agreement of someone not able to give legal consent to participate in the activity. Accounting for many of the same aforementioned challenges with informed consent and declining capacity, even garnering assent can be challenging. The geriatric assent process still involves the accumulating burden over time on caregivers who may choose to “shortcut” communication for the sake of decisional efficiency and expediency [11]. Despite office productivity goals and maximized efficiency, dentists and dental team members are ethically bound to promote assent, even when consent is unattainable or inconclusive. Promoting assent is a more proactive procedure than merely arranging for incompetent patients to passively abide by decisions for which they have had little or no input [11].

4 Elder Abuse, Evolving Technologies, and Changing Models of Care Delivery

Elder abuse is a multifaceted and pervasive public health issue, which includes physical, sexual, and emotional abuse, financial exploitation, and neglect (caregiver neglect and self-neglect) [12]. It is estimated that only a fraction of elder abuse cases actually come to the attention of adult protective services [13]. Two-thirds of physical abuse cases result in injuries to the head, neck, and/or mouth—areas visible to oral healthcare providers during examination and treatment [14, 15]. Dentists, dental hygienists, dental therapists, dental assistants, and all dental team members are in a unique position to detect elder abuse and neglect.

As the practice of dentistry advances technologically, there arises an increased need to garner an ethical perspective as it relates to new and evolving treatment modalities. With the overwhelming increases and availability of both implants and digital dentistry, appropriating an ethical lens is necessary. Scholars have formulated an ethical framework for “responsibly practiced implantology” [16]. Among issues noted are supposed prevalence in potential placement of implants as a rationale for tooth extraction. This concept is specifically guarded against in that there is concerted effort in retaining natural dentition. “The mere option of replacing the tooth with an implant should not be the leading factor in the decision of whether or not to extract a tooth” [17].

Dental caries is still clearly a public health problem for many older Americans, such as those of lower socioeconomic status, with dementia, who are homebound, and who are institutionalized [5]. Studies have shown that the perceived need of dental care is reduced as functional dependency increases, and dental care use concurrently decreases, especially in those older adults who are institutionalized [18, 19]. Adequate access to dental care does not exist for many United States nursing home residents [18]. The dental treatment geriatric patients seek and ultimately receive is directly dependent on their self-perceived need, their financial ability to pay for that care, and issues such as transportation and documentation, rather than the normative need detected during an oral examination by a dentist [19]. It has been established that the majority of dental care for older adults takes place in private practices [5]. For functionally independent and older adults with frailty, minor modifications in office design or flow to allow for age-related changes allows private practitioners to treat this population [20].

Providing dental care for institutionalized geriatric patients presents both challenges and opportunities. With much emphasis on interprofessional and collaborative care, geriatric health and specifically oral health present a great opportunity for evolving models of care delivery. Although the geriatric population is increasing, institutionalization and nursing home utilization are declining, and there is a greater desire among seniors and their families to age in place [21]. One of the most significant developments in geriatric care is the shift to a model of care based in community living often termed adult day-care centers. The current generation of older adults wants to age in place, and they do not want to be institutionalized. Models, such as the Programs of All-inclusive Care for the Elders (PACE), have been gaining traction [21, 22]. Ethical duty and obligation implores that dentists and dental team members strive to be part of the interprofessional teams that care for older adults in these new models of care. The PACE is a managed care organization that provides comprehensive medical and social services to a population of frail, community-dwelling older adults, most of whom are dually eligible, having Medicare and Medicaid benefits, US government-based forms of healthcare insurance for the poor and older adults, respectively [23]. The PACE actually has its origins with the work of a public health dentist and social worker in San Francisco in the 1970s who recognized a need for long-term care services that kept individuals in the community while maintaining a good quality of life [24, 25]. Effectiveness of a dental program in long-term care has been found to be contingent on dental care, routine and continual oral hygiene, and assessment [24]. In particular, they found routine oral hygiene and assessment were most important to a program’s success and that simply providing dental services is insufficient to having an effective dental program [21].

PACE programs readily offer dental services, which often include partnering with a community dentist [26]. This can and often includes providing dental services on-site, affording more significant interaction between dental professionals and other members of the patient care team [27]. Physically including dentistry within PACE programs sites could allow community dentists to shadow, network, and refer complex, medically compromised geriatric patients. There are also advanced dental education programs or general practice residency programs who have partnered with hospitals that are connected to PACE facilities and programs [28]. Dental schools may also seek partnerships with local PACE programs to expose students to a model of collaborative team-based care in geriatrics [27].

Researchers have suggested that similar programs that care for the growing population of older adults who prefer to remain in the community should place an emphasis on routine oral hygiene care and should not make providing on-site dental care a sole focus of their programs. In addition, programs should have a coordinated system of referral to dentists. The proposed model suggests the important role that nurses and an interprofessional team can play as communicators and facilitators in this process. Lastly, a communal gathering location, such as the PACE center, is necessary to ensure a common location where members regularly congregate and health providers and nurses have access to individuals. This is where older adults can receive routine medical and dental assessments and obtain preventive home care products, such as fluoridated toothpaste and toothbrushes [21]. Opportunities abound for ethical practice among dentists and dental team members to forge creative partnerships for delivering collaborative care.

5 Barriers to Care: An Ethical Lens on Medical Mistrust and the History of Racism in Healthcare

Geriatric patients of certain demographic backgrounds and cultural identities may invoke yet another ethical dimension of care, namely, medical mistrust and the history of racism within healthcare delivery systems. Particularly in the United States, where denial of healthcare and even basic human rights were once fully legal, remnants of those historic atrocities still unfortunately remain. Particularly at a time when a patient’s zip code (US postal codes) is the best predictor of health outcomes [29], dentists and dental team members must wrestle with the long-lasting effects of structural racism within healthcare. This remains true particularly in geriatric populations who are of the age to have been born prior to, lived in, or were raised during legal American segregation. Many studies have shown that there are substantial racial differences in trust in healthcare providers and healthcare systems. African Americans were significantly more likely than Whites to report low trust in healthcare providers in this study [30, 31]. Even after controlling for sociodemographic, prior healthcare experiences, and structural characteristics of care, African American race had a significant effect on low trust in healthcare . However, different factors were associated with low trust among African Americans and Whites. Among African Americans, the source of medical care had a significant independent association with low trust, whereas among Whites, the number of annual healthcare visits was associated significantly with low trust. It is possible that different factors were associated with low trust among African Americans and Whites because of differences in healthcare experiences and sources of medical care between these populations” [30]. It has been suggested that among African Americans, previous experiences with healthcare providers and sources of medical care may be more important sources of distrust in healthcare providers than sociodemographic characteristics.

With the ever-evolving discoveries and medical mistrust that continued to be revealed, what once was merely folklore in nature has come to modern light as ethical lapses of monumental proportions. The research and subsequent book and movie detailing the origin of the commonly used HeLa cells underpins much of the practice of modern medicine in the United States. These “HeLa cells” originated from the flesh and blood of an African American woman named Henrietta Lacks. Her cells were taken for scientific purposes without any consent or foreknowledge from her, nor her family and loved ones. These cells were used for decades, even to this day. They have been involved in key discoveries in many fields including cancer, immunology, and infectious disease [32]. Even most recently, they have been used in research to develop vaccines aimed at combating the COVID-19 pandemic [33]. Yet another ethical abuse destined for the big screen involves the story of the first heart transplant in the segregated southern United States in 1968. This also involved the lack of informed consent to obtain the heart and kidneys of a black patient, Bruce Tucker, for the purposes of performing organ transplants for other recipients [34]. Actions such as these, and their subsequent lack of ethical and moral behavior, have direct linkages to communal mistrust, and some may argue an earned distrust, in healthcare, healthcare professionals, and healthcare delivery systems [35]. These historic ethical lapses are often in the memories and minds of minority geriatric patients that themselves have been participants, positively or negatively, within old institutions of segregation and overt racism.

While racism may or may not remain as overt within healthcare today, racial biases undoubtedly remain [36]. In fact, perceived racism particularly with older minority patients has been found to be a possible contributor to health disparities [37]. Within dentistry, healthcare providers’ racial bias is also evident. Dentists’ decision-making has been impacted by the race of the patient, resulting in a greater likelihood of extractions (less root canal therapy recommendations) for Black patients presenting with a broken-down tooth and symptoms of irreversible pulpitis [38]. Showing that treatment planning decisions may indeed be subject to and/or influenced by racial bias. It is an ethical duty for dentists and dental team members to be self-aware, hopefully reducing the impact potential biases can have on the treatment and care patients receive. For a more in-depth discussion on the topic of health disparities, please refer to Chapter “Health Disparities in Oral Health”.

All decisions that healthcare providers make are affected by their own cultural background as well as the background of the persons for whom the decisions are made [39]. Different ethnic groups have varied attitudes toward seeking help, proposing ideal solutions to problems, and even considering who is part of the family [40]. Often the most vulnerable and susceptible populations to disease have the most historic impediments to healthcare access [41]. Overall, while untreated dental caries in older Americans significantly has decreased, health disparities and inequities remain with higher prevalence of untreated dental caries in older African Americans and Hispanics Americans, those with lower incomes and less education and current or former smokers [5, 42]. Greater retention of teeth predisposes many older adults to a continual risk of both new and recurrent coronal and root caries and extends the risk for developing gingivitis and periodontal diseases [43]. This is particularly true of vulnerable populations most directly affected by a lack of access to oral healthcare. A barrier to care, in need of ethical exploration is also the issue of language. While not often seen as an ethical dilemma in its purest sense, the issue of language and potential language barriers that may exist between dental providers and patients is an ever-present ethical dimension. Though the number of Spanish-speaking providers in the United States is on the rise, studies have shown an increased presence of periodontal disease in Spanish-speaking older adults of Mexican ancestry despite having regular dental care at home [44]. While access to care issues are multivariate in nature, the ethical lens must also remain a consideration.

6 The COVID-19 Global Pandemic and the Geriatric Patient: An Ethical Lens

Patients with pneumonia of unknown cause were reported in Wuhan, China, in December, 2019 [45]. Later named, COVID-19, the virus quickly spread across the global landscape, in short order being declared a pandemic by the World Health Organization [46]. “Due to the rapid spread of COVID-19, the risk of it causing significant fatality and the stress it poses for health care workers and its potential to overwhelm the capacity of health care systems resulted in many countries adopting measures to restrict human mobility, in an attempt to limit the spread of the disease” [47]. Dental care providers were required to halt all nonemergency treatment procedures due to the concern that many dental procedures may produce aerosols and facilitate COVID-19 spread [48]. Older patients were thought to be highly susceptible, and one of the hardest hit populations were residents of long-term care facilities or geriatric patients who are institutionalized [49]. The earliest outbreak of COVID-19 in the United States was in a long-term care facility in the state of Washington, USA, which had a high fatality rate [50].

In addition to affecting long-term care facilities in unknown proportions, it has been established that PACE programs within the United States are on trend with the aging population’s desire to age in place and even chose home-based care. This trend and choice, along with forced social distancing restrictions, has only increased with the effects of COVID-19 on long-term care and home care industries catering to older adults [23]. The COVID-19 pandemic has further exacerbated problems accessing oral healthcare for those populations already most at risk for oral disease. The pausing of care, while appropriate for some populations, may have seen a worsening of dental caries, periodontal disease, or even pathology for older populations. The soaring positivity rates of the virus has resulted in disruptions in the delivery of maintenance dental treatments for many geriatric patients who were forced to take indefinite hiatus in their oral care.

The COVID-19 pandemic has laid bare many of the healthcare inequities and disparities that have long gone unnoticed by the masses leading to a full mainstream understanding and public conversation [51]. Connecting to the history of medical mistrust by minority US populations, barriers to greater participation of Black people in COVID-19 trials still exist as well as the hesitancy in taking advantage of vaccine administration that are now widely available in most high-income countries [52,53,54]. Although the COVID-19 pandemic presents an additional ethical hurdle for geriatric patients and their dental providers, like other disruptions before, innovation is birthed. Greater acceptance for teledentistry, a move away from live patient board exams, and even an expansion of dental and dental hygiene scopes of practice to include vaccine administration are just a few of the many positive disrupters by which the COVID-19 pandemic has challenged the status quo [55,56,57].

7 Ethical Decision-Making: Principles and Embracing Narrative Ethics

Ethical decision-making for dentists can be relatively straightforward and simple or can delve into quite a complex process of weighing out options and various stakeholder viewpoints. Due to the ever-evolving complex nature of dentistry and dental practice, several models of ethical decision-making have been developed and utilized over time. Most models involve contemplation of ethical principles and include multiple considerations [1]. Professions, including dentistry, are largely defined as such in part because of self-governed and developed codes of ethics. A code of ethics defines the moral boundaries within which professional services may be ethically provided. Many dental organizations have codes of ethical conduct for guidance of dentists in their practice. The American Dental Association (ADA) has five guiding and fundamental principles which are the following: patient autonomy, non-maleficence, beneficence, justice, and veracity (Fig. 1).

Fig. 1
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Principles of dental ethics

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Many models and frameworks exist to aid healthcare practitioners in managing ethical challenges that arise during clinical care. The most classical understanding of dental ethics and ethical decision-making stems from the classic work of Ozar’s Central Values of Dental Practice. These values are delineated as follows: (a) the patient’s life and general health, (b) the patient’s oral health, (c) the patient’s autonomy, (d) the dentist’s preferred patterns of practice, (e) esthetic values, and (f) efficiency in the use of resources [58]. Also widely used is the Four Box Model derived from Jonsen, Siegler, and Winslade, in which ethical problems are analyzed in the context of four domains: medical indications, patient preferences, quality of life, and contextual features (i.e., social, economic, legal, and administrative) [59]. Each topic can be approached through a set of specific questions with the goal of identifying the various circumstances of a given case and linking them to their underlying ethical principle [60].

One of the most recent developments in dental ethics has been the use of narrative ethics as a model for ethical decision-making. Narrative ethics is a different way of thinking about teaching ethics. While principle-based ethics is useful, it can tend to put ideas into specified boxes and silos. Narrative ethics enables one to deconstruct cases in a broader sense with the ethical choices made more easily subject to reflection and evaluation [61]. It also helps one think about an ethical scenario as a story, helping to better empathize with other persons’ thoughts and feelings and enabling more thoughtful decision-making. Some critique put forth concerning narrative ethics has been the lack of appeal to rules, principles, or other ethical constructs [62].

Roucka and More have developed a specific narrative dental ethics decision-making model rubric and framework relying on both narrative and story as well incorporating consideration of classic healthcare ethical principles (Fig. 2 and Table 1). Their model includes the following: identifying the stakeholders, asking if harm was done to anyone and by whom, rating (4 being excellent 1 being poor) the outcome from the perspective of each stakeholder, inquiry of how the story makes one feel, determining if the circumstances give the perception of an optimal outcome, identifying flaws one may identify (breach of principles, procedural and/or ethical), and lastly, an attempt at rewriting the story to make the scenario such that an optimal outcome is perceived by all stakeholders [63].

Fig. 2
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The process of narrative ethics

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Table 1 Roucka/More Narrative Ethics Rubric
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The narrative dental ethics decision-making model allows for building of empathy, inspires self-reflection, encourages memory through emotional connection, and aids in illustrating various points of view. A narrative dental ethics approach also reminds the user that ethics and ethical decision-making are not conducted in a vacuum. Dentists bring their varying life experiences and perspectives to the proverbial ethical decision-making table. This would include, but not limited to, personal experience and upbringing, religious beliefs or the lack thereof, professional training and experiences, practice locations, patient expectations, social customs, societal norms, and more. These various life experiences and perspectives shape dentists understanding and well-being, ultimately affecting patient outcomes. Most assuredly, open consideration of ethical issues leads to improved quality of decisions [8], ultimately yielding a better life for geriatric patients and increased satisfaction and altruism for dentists and the dental care team.

8 Conclusions

Providing care for the geriatric dental patient highlights numerous ethical issues, some applicable across the patient demographic but some highly specialized for elder care. Understanding and fully applying informed consent, particularly in the age of rising dementia and declining capacity; elder abuse, evolving technologies and changing models of care delivery; medical mistrust and history of racism in healthcare; and the effects of the global COVID 19 pandemic are all issues best seen through an ethical lens. Although a myriad of frameworks exist for ethical decision-making, the use of narrative ethics for dentists and dental team members offers much promise.