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Students’ Views on Ethics and colleagues (2001) suggested that written information be given in conjunction with verbal information, particularly to children, as their study revealed that children respond poorly to verbal communication alone. As mentioned previously, Kang and others (2009) showed that a combination method— with written and visual information in particular, for their study—increases information processability and subsequently improved retention of information. There may be some benefit to presenting the information in more than one way, and the benefit may extend beyond comprehension and retention of information, as suggested by a study by Wright and colleagues (2010) that showed increased motivation in orthodontic patients who received both verbal and written information in the consent process. Evidence is still lacking and findings are not consistent, particularly when it comes to effective information presentation methods. Existing studies point to the low level of comprehension and recall of treatment information by orthodontic patients and parents, and future studies are needed to assess how this communication gap between patients and orthodontists can be diminished through more effective consultation methods. In particular, studies with a sufficiently large sample size allowing several intervention groups with different combination of methods may be of value. Conclusions Current evidence does not support the claim that orthodontists are meeting their ethical obligation to base treatment on informed consent by patients or their parents. Information recall by orthodontic and orthognathic patients and parents was low, particularly regarding information on risks associated with treatment. In general, children recalled less than parents. Several studies investigated the effectiveness of different modalities in presenting treatment information to patients and parents, but results are inconsistent. Due to inconsistencies in the available studies, no definitive conclusion can be drawn regarding which method is most effective when communicating with patients, and further study is needed. ■ References Ackerman, J. L. & Proffit, W. R. (1995). Communication in orthodontic treatment planning: Bioethical and informed consent issues. Angle Orthodontist, 65 (4), 253-262. Baird, J. F., & Kiyak, H. A. (2003). The uninformed orthodontic patient and parent: Treatment outcomes. American Journal of Orthodontics and Dentofacial Orthopedics, 124, 212-215. Brons, S., Becking, A. G., & Tuinzing, D. B. (2009). Value of informed consent in surgical orthodontics. Journal of Oral and Maxillofacial Surgery, 67, 1021-1025. Cameron, C. A. (1997). Informed consent n orthodontics. Seminars in Orthodontics, 3 (2), 77-93. Ernst. S., Elliot, T., Patel, A., Sigalas, D., Llandro, H., Sandy, J. R., et al (2007). Consent to orthodontic treatment—Is it working? British Dental Journal, 202, E25. Harwood, A., & Harrison, J. E. (2004). How readable are orthodontic patient information leaflets? Journal of Orthodontics, 31, 210-219. Kang, E. Y., Fields, H. W., Kiyak, A., Beck, F. M., Firestone, A. R. (2009). Informed consent recall and comprehension in orthodontics—Traditional vs improved readability and processability methods. American Journal of Orthodontics and Dentofacial Orthopedics, 136, 488.e1- 448. e13. Mortensen, M. G., Kiyak, H. A., & Omnell, L. (2003). Patient and parent understanding of informed consent in orthodontics. American Journal of Orthodontics and Dentofacial Orthopedics. 124, 541-550. Patel, J. H., Moles, D. R., & Cunningham, S. J. (2008). Factors affecting information retention in orthodontic patients. American Journal of Orthodontics and Dentofacial Orthopedics, 133, S61-S67. Salgo (1957). Salgo v Leland Stanford Jr. Board of Trustees, 317 P.2d 170 (Cal Ct App 1957). Thickett, E., & Newton, J. T. (2006). Using written material to support recall of orthodontic information: A comparison of three methods. Angle Orthodontist, 76, 243-250. Thomson, A. M., Cunningham, S. J., & Hunt, N. P. (2001). A comparison of information retention at an initial orthodontic consultation. European Journal of Orthodontics, 23, 169-178. Wright, N. A., Fleming, P. S., Sharma, P. K., & Battagel, J. (2010). Influence of supplemental written information on adolescent anxiety, motivation and compliance in early orthodontic treatment. Angle Orthodontist, 80, 329-335. 34 2011 Volume 78, Number 4
Students’ Views on Ethics The Ethics of Routine Use of Advanced Diagnostic Technology Renata Khelemsky, DMD The advent of new technology often holds the promise of improving on imperfect, previously used devices. Specifically, the dental setting has seen numerous cases of technological advances, such as the high-speed dental drill, adding a distinct and real benefit to practice. Within the last decade, the advent of digital radiography in dentistry has led to increased attention from practitioners for its many apparent benefits such as ease of use, immediate observation of images, and the ability to enhance image quality without retakes (Christensen, 2004). A recent issue in the realm of digital image acquisition relates to the safety of radiation exposure and the practice of using advanced imaging techniques such as the cone beam computer tomography (CBCT) scan in various clinical situations, especially those affecting children and adolescents. According to a recent article in the New York Times entitled “Radiation Worries for Children in Dentists’ Chairs,” (Bogdanich & McGinty, 2010), the dental office has emerged as the site of faulty and unnecessary radiography practice where specialists employ high-radiation CBCT scans for routine use on the susceptible population of younger patients. The facts that underlie the situation are important to the discussion of ethical issues. For example, it is well-known that CBCT scans have allowed dentists to investigate maxillofacial structures in all three dimensions during challenging situations of implant placement, surgery, and orthodontics (Hatcher, 2010). The use of such scans has coupled each imaging session to “specific clinical questions.” To much surprise, Bogdanich and McGinty (2010) showcase plenty of examples of how dentists are generally unaware of the CBCT radiation dose compared to conventional two-dimensional techniques. The scholarly literature is also inconsistent but tends to agree that, regardless of the variables an operator can control, CBCT scans generally expose patients to significantly more radiation than panoramic and cephalometric radiographs (Hatcher, 2010). Still, the risks of morbidity and treatment failure from poor diagnostic imaging also need to be evaluated. The present situation most certainly confronts dentists with an inherent ethical question: should the CBCT be used for clinical decision making given the risk associated with additional radiation exposure? Ethical Principles A primary survey may suggest that dentists are using new digital technology to enhance the accurate diagnosis and This essay was written as a class assignment in the ethics sequence at the Columbia University College of Dental Medicine when Dr. Khelemsky was a third-year student. She is currently a resident in the Oral and Maxillofacial Surgery Program at Beth Israel Hospital. The paper was submitted by Dr. Robert Miner, who teaches in the ethics program at Columbia. 35 Journal of the American College of Dentists
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