**Ethical Scenario 1**

Mrs. Emmerich lives in a rural area and drives 2 hours for dental care. Several years ago, at Dental Office A, she was diagnosed with generalized periodontitis. Her general dentist recommended that she see a periodontist. Mrs. Emmerich, who did not want to make the long drive for a consultation with a periodontist, told her general dentist that she would just continue to keep her regular 6-month appointments with the hygienist. Neither the general dentist nor the hygienist pursued the discussion any further with Mrs. Emmerich.

Several years later, Mrs. Emmerich moved to the city to be nearer her adult daughter. She is a new patient in your general dentistry practice, Dental Office B, and a comprehensive periodontal examination reveals attachment loss and mobility of the molar teeth. You carefully explain the findings to Mrs. Emmerich using clear, easily understood words. Once Mrs. Emmerich fully understands the periodontal diagnosis, you begin the process of shared decision-making with her.

Mrs. Emmerich expresses her regret that no one at the previous dental office explained her periodontal condition or her treatment options. She believes that if she had understood the diagnosis, she would have sought a consultation with a periodontist. She feels that her condition is much worse now than it might have been.

1. How do the approaches to care planning in the two dental offices differ?
2. How do you think that shared decision-making at the time of the initial diagnosis (Dental Office A) might have affected the patient's choices?
3. How do you think that shared decision-making at the time of the initial diagnosis (Dental Office A) might have affected the long-term prognosis of Mrs. Emmerich's dentition?
4. Why do you think Mrs. Emmerich was willing to accept a referral to a periodontist from Dental Office B? Was it just that she now lives in a city?

**Ethical Scenario 2**

Mrs. Nguyen is the first patient of the afternoon in your periodontal office. She is new to the practice. She is a 50-year-old lady who has only lived in the United States for the last 3 years. Her English skills are minimal, but she works as a medical researcher, so you assume that she understands medical terminology.

Mrs. Nguyen has Stage II, Grade B periodontitis with generalized horizontal bone loss on her posterior teeth. You determine that periodontal instrumentation using local anesthesia is indicated. The next phase of treatment will be based on the findings at the time of the reevaluation and will be determined by Dr. Evans, one of the periodontists in the office.

You review the proposed periodontal treatment plan with her. She asks no questions and signs at the bottom of the consent for treatment form, on the signature line. You tell her that you will begin the recommended treatment at today's appointment. You prepare the anesthesia syringe and as you approach Mrs. Nguyen, she becomes very agitated, screaming and covering her mouth with her hands. She refuses to allow any further treatment today. She gets up abruptly and leaves the office.

1. What could the hygienist have done differently to avoid the above situation?
2. What ethical principles are in conflict in this dilemma?
3. Now that Mrs. Nguyen's experience has been a negative one for her, what is the best way to handle this ethical dilemma?
4. What changes might the hygienist make when explaining the proposed treatment to future patients?