ISPITIVANJE STAVOVA STOMATOLOGA O ETIČKIM PRINCIPIMA U SVAKODNEVNOJ PRAKSI EXAMINING DENTISTS’ ATTITUDES ABOUT ETHICAL PRINCIPLES IN EVERYDAY PRACTICE

Uvod: Briga o pacijentima, poznavanje medicinskog prava i usklađenost sa zakonom doprinose efikasnijem rešavanju etičkih dilema, sa kojima se stomatolozi danas često susreću. Pored toga, u određivanju "najboljeg" stomatološkog tretmana, izvesnu ulogu imaju i pacijenti. Cilj istraživanja bilo je ispitivanje stavova stomatologa u Srbiji u vezi etičkih dilema u svakodnevnoj praksi, kako bi se utvrdili faktori koji utiču na njihovo rešavanje. Materijali i metode: Rad je realizovan kao studija preseka. Istraživanje je obuhvatilo 88 ispitanika, 42 apsolventa stomatologije Medicinskog fakulteta u Nišu i Stomatološkog fakulteta u Beogradu i 46 stomatologa iz privatne i državne prakse. Prvi deo upitnika obuhvatio je socio-demografske karakteristike ispitanika, a drugi deo, sačinjen od 7 pitanja zatvorenog tipa, bio je posvećen određenim etičkim dilemama. Statistička analiza urađena je korišćenjem Excel programa iz Microsoft Office programskog paketa i SPSS programa u verziji 18.0. Rezultati: Odgovori studenata i stomatologa na pitanja o pojedinačnim etičkim aspektima nisu se znatno razlikovali, osim u domenu 2. pitanja pod b – da li je oralni hirurg trebalo da izvadi oba zuba na zahtev pacijenta, koji je srčani bolesnik. Pronađena je statistički značajna razlika (χ= 18,834; p < 0,0001) u odgovorima stomatologa u odnosu na odgovore studenata. Zaključak: Znanje većine ispitanika o etičkim principima bilo je zadovoljavajuće. Manji deo ispitanika nije bio dovoljno svestan važnosti primene etičkih principa u stomatološkoj praksi, tako da je potrebno promovisati programe edukacije o lekarskoj etici za stomatologe i studente stomatologije.


Introduction
Medical ethics, as a form of applied ethics, is a science that explores the meaning and aims of moral values in medicine, as well as the basic criteria for evaluating moral aspects. The roots of medical ethics are found in ancient civilizations, so even today the Hippocratic Oath is taken by doctors all over the world 1 , and in recent decades the significance of ethics in medicine has grown 2 .
Patient care, as the strongest ethical obligation of medical workers, lies in all the well-known codes of medical ethics all over the world [3][4][5] , provided that it is very important to know medical regulations in accordance with the law, where patients' safety and respect for the dignity of the patient are particularly emphasized. This brings to raising the awareness of all medical workers, including dentists, about human rights and ethical questions which are getting more complex and which they are more and more often faced with 6,7 . Dentists in Serbia usually have a double role -as medical workers and as employees in dental clinics which do business according to market principlesand they are often faced with conflicts and specific ethical requirements 8 . Furthermore, competition affects the relationship between colleagues and ethical procedures among them.
Likewise, as well as with other medical workers, the development of a good relationship between a patient and a dentist is a significant professional skill [9][10][11][12][13][14] . Dental practice causes more fear and anxiety than other forms of health protection, which contributes to poor oral health of the patient 15 . Consequently, appropriate psychosocial and ethical behavior and efficient communication with individuals from different population groups, with cultural differences, are very important in dentistry 10,16 .
Ethical dilemmas, where the choice among the undesirable and confusing alternatives has to be made 17 , are very common in dentistry 18 , and within the framework of classical education they are not covered enough. Furthermore, in recent decades the direction of making decisions about determining the 'best' dental treatment has been changed from entirely professional to autonomous decision -making of patients, where the competent doctor is obliged to let the patient participate in the decision -making process as much as their mental abilities and maturity allow them [19][20][21] .
The aim of the research was to examine the attitudes of dentists in Serbia related to particular ethical dilemmas which they face in everyday practice, in order to determine the factors that affect their solving.

Materials and methods
The study was designed as a crosssectional study by using an originally constructed epidemiological questionnaire which was developed after a detailed review of the literature and after the selection of the shortlisted papers for further discussion of the research team and the preparation of the questionnaire.
A total of 100 questionnaires were distributed, 12 of which were inadequately completed. The research finally included 88 respondents, that is, 42 final-year dentistry students at the Faculty of Medicine in Niš and at the Faculty of Dentistry in Belgrade and 46 dentists from both private and state practice. The criterion for the dentists' participation in the survey was their willingness and their regular employment, and for the students to be enrolled in the 5th year of dentistry. The questionnaire was anonymous and it consisted of two parts. The first part of the questionnaire covered sociodemographic characteristics of the respondents such as gender, age, institution where they came from and place of residence. The second part consisted of 7 closed-ended questions which referred to different situations from everyday dental practice, related to ethics. The first question presented a situation in which a dentist extracted a boy's tooth without any previous notice since he considered there was no point in treating the tooth. The second question referred to an elderly man with cardiovascular disorders who had only one of his molars extracted by a surgeon, instead of having them both extracted as the patient had previously requested. The third question referred to a patient suffering from hemophilia, who had a very loose tooth extracted by a dentist without any previous consultation with a hematologist. The fourth question described a situation in which a dentist, in his or her private clinic, gave priority to a friend. In the fifth question, the dentist found out that the patient was HIV positive and denied him further treatment because of that. In the sixth question, a patient suffering from hypertension and diabetes had a few of his teeth extracted by a dentist without being prescribed adequate therapy and given a notice about possible complications.
The last question described a situation in which a patient, feeling a toothache in the tooth which had been treated a month before, due to the absence of her own dentist, addressed another one who diagnosed her with chronic inflammation of the periodontium.
The respondents had to choose one of the given answers, after estimating which ethical principle the dentist violated by making their decisions and how, in their opinion, the dentist was supposed to act. They had 15 minutes to complete the questionnaire. The research was done in the period from October 2019 to February 2020.
Using descriptive statistical analysis, the following statistical parameters were shown: arithmetic mean, standard deviation, range of variation, absolute frequency (N) and structure index (%). The comparison of occurrence frequency of some attributive feature modalities between the groups was done by using the Pearson Chi-square test and Fisher's exact test. The comparison of mean values of numerical features between two independent groups of respondents was done using the Student's t-test. Statistical analysis was done using Excel from Microsoft Office and SPSS, version 18.0. An estimation error level less than 5% (p<0,05) was used as the threshold of statistical significance. The results of the statistical analysis are shown in tables and graphs.

Results
The examined sample (n=88) comprised 42 (47,73%) dentistry students, which was slightly less than half of the sample. The other respondents were dentists. The average age of the surveyed students was 24,38±1,65 (in range 22 -30), whereas the average age of the surveyed dentists was 35,63±10,75 (in range 26 -62) and these two groups significantly differed according to age (t=7,007, p<0,0001). More than half of the students were men -23 (54,8%), and two thirds of the surveyed dentists were women -31 (67,4%). There was a significant statistical difference in gender distribution according to the groups (χ 2 =4,391, p<0,05), and there was no statistical significance in regard to the distribution of the place of residence according to the groups (χ 2 =1,664, p>0,05) (Table1). to inform the patient about the improper treatment of the previous dentist 2. to repair the tooth again, but not to inform the patient 3. to discuss the problem with both the patient and his dentist Na drugi deo pitanja, 85,70% studenata odgovorilo je to da doktor nije ispravno postupio, sa čime se složila i grupa stomatologa u 89,10%.
The results of the paper which refer to the respondents' answers and the distribution difference among them are given in graphs ( Figure 1) and tables (Table 2). Regarding the first question, more than half of the students (57,10%) said that the dentist violated the principle of truthfulness, and almost an identical answer was given by the dentists (52,20%). In the second part of the question, 85,70% of the students said that the dentist did not do the right thing, and the group of the dentists also agreed with that in 89,10%.
In the second question, the majority of the students (69,00%), as well as the majority of the dentists (73,90%) said that the oral surgeon violated the principle of autonomy, respecting the rules of the profession so as not to harm patient.A statistically significant difference was found in the second part of the question (χ 2 =18,834, p<0,0001), where 54,80% of the students said that the oral surgeon should not have extracted both teeth, while the dentists were more explicit in giving the answer (93,50%).
In the third question, both groups agreed that the dentist should have consulted a hematologist, the students in 97,60%, and the dentists in 95,70%. The greatest number of both groups of the respondents, 85,70% of the students and 67,40% of the dentists, considered that the dentist's act did not meet the principle of non-maleficence.
In the next question, 81,00% of the students and slightly higher percentage of the dentists, 93,50% thought that the dentist had made a mistake, giving priority to his friend. The majority of the respondents, 88,10% of the students and 87,00% of the dentists, said that the principle of justice was violated.
In the 5th question, there was no statistically significant difference either. Half of the students 50,00%, as well as 54,30% of the dentists, chose the answer in which the dentist should not have kept quiet. In the second part of the question, 83,30% of the students claimed that the dentist should not have informed the patient's relatives about their disease, and 84,80% of the dentists agreed with that.
In the 6th question, 95,20% of the students and 97,80% of the dentists said that the dentist did not do the right thing. The same percentage, 95,20% of the students considered that the dentist should have informed the patient about possible complications. 95,70% of the dentists had the same opinion.
In the last question, slightly more than half of the respondents, 52,40% of the students and 52,20% of the dentists answered that the dentist should talk to the patient and their attending physician about the problem.

Discussion
On the basis of the respondents' answers in this research, it can be said that the attitudes of final year dentistry students and dentists about individual ethical aspects mostly agree.
As a rule, a dentist is obliged to provide a patient with relevant information and it has both ethical and potentially legal implications 22,23 . As both groups of the respondents had divided attitudes regarding the first question, it can be said that our dental practice has not adopted a definite attitude related to informing patients about their treatment. In this situation, the principle of beneficence is in conflict with the principle of autonomy and the principle of truthfulness. When it comes to anxious patients and patients who are not willing to cooperate, in order to provide the necessary treatment, the best way for the dentist is to adhere to the principle of beneficence, which means that they have to violate the other two principles. This obviously confuses the dentists in our environment, so an explanation supported by professional organizations and associations is necessary.
The respondents had fewer dilemmas in the second question since most of the respondents agreed that the dentist did the right thing as he prevented the patient from an additional, unnecessary intervention and antibiotic treatment, although he did not adhere to the principle of autonomy. In the second part of the question, a statistically significant difference was found in the answers: guided by greater work experience and the principle of non-maleficence, the dentists were more explicit when saying that the oral surgeon was not supposed to extract both teeth, but to save the tooth whose carious lesion could have been fixed. The use of unnecessary, exaggerated or inefficient medical procedures is harmful to many patients, especially to the elderly or those who have other diseases, and it is often considered an ethical issue 24,25 . A dentist should inform a patient about their medical condition and risks, understandably and clearly, using words that the patient will certainly be able to understand, in accordance with their education and age.
The essence of the information is to help the patient make the right decision by themselves, which they can do only if they have all the necessary information 26,27 .
In today's practice, dentists often encounter patients who have different kinds of blood coagulation disorders, such as hemophilia 28 . In the third question, the majority of both groups believe that the dentist violated the principle of non-maleficence and that he had to involve a hematologist when making the decision. The ethical principle about avoiding doing harm to a patient originates from the Hippocratic principle 'primum non nocere', which means 'first, do no harm'. If a dentist anticipates possible complications, being aware that they can do harm to the patient, they will refer them to an oral surgeon, who will carry out preoperative preparation and will be able to carry out the indicated intervention safely. This attitude is typical of health care systems which imply the availability of specialists and development, so the answers are considered to be very positive.
The ethical attitude of dentists is based on the individual feeling of responsibility towards the patient and the assessment of what is the correct behavior. The legislation and the professional code of medical ethics do not guarantee the application of ethics in practice. Therefore, dentists have to pay attention to the boundaries in the doctor -patient relationship, they have to respect the patient and care about their well-being, in accordance with scientific knowledge and ethical principles 29 , although in everyday practice, ethical aspects are mostly a matter of habit 30 .
In the fourth question, most of the respondents said that the principle of justice was violated. Justice is an ethical principle which obliges doctors to treat all of their patients in the same way, regardless of their gender, race, nationality, religion, social or political affiliation. Dentists should put an effort to advocate an attitude of empathy, to respect the personality of each patient, their dignity and intimacy. If justice is understood as non-discrimination, than it implies equal rights to dental health care for all patients 31 .
When it comes to the question dealing with an incurable infectious disease, the respondents' answers in both groups were homogeneous and indicate that we have adopted the attitude that the patient has the right to be truly informed about their medical condition.
Respecting the principle of adequately informing the patient and their family members, the principle of autonomy is also applied 26,27 . However, since it is about an incurable, but also transmitted disease, just knowing that the patient is HIV positive, has an intimidating and negative impact on them and it raises an ethical dilemma, should the patient be told the truth immediately or referred to an infectologist?
Contemporary medical ethics confirms that even HIV positive patients have the full right to get dental services, which are, in that case, performed according to a special protocol. In the second part of the question, most of the respondents from both groups had a negative answer. The principle of confidentiality is implied in the professional codes of ethics, and it is especially respected when it comes to HIV. There is a clash between the interests of the physician-patient relationship in terms of confidentiality and the interests of the public to prevent infectious diseases. It is assumed that only patients themselves can decide whether they are going to tell other people about the disease they have, due to the risk and possible consequences on their private, public and professional lives 32 . Furthermore, patients are obliged to behave responsibly and not to endanger the others in their environment.
In the sixth question, the answers are in accordance with the previous attitudes and our respondents accept the principle of autonomy, since the patient should have been informed with the full right about possible complications. Risk diseases in dentistry, which include diabetes and hypertension, mostly require a different treatment procedure, that is, preoperative preparation and the physician's consent before tooth extraction. The students and the dentists agreed with the previous fact in the highest percentage.
Contemporary codes of dental practice direct dentist towards providing their patients with all the necessary information, but they should also avoid criticizing their colleagues in front of the patient or generally in public 33 . In the last question, the highest percentage of both respondent groups did not want to degrade their colleague, which is ethically correct, and they said that the dentist should discuss the problem with the patient and his dentist.
The results obtained in this research can also be found in other papers dealing with similar problems. The questionnaire used in this study primarily pointed out the basic ethical principles in everyday dental practice.
Many researchers have used many other, more detailed questionnaires which examine the application of the other ethical principles and it could be an imperative for further research in our country. The limitation of this study is the fact that the used questionnaire is based on subjective assessment, so the respondents' bias cannot be avoided.

Conclusion
Dentists and final year dentistry students in Serbia have similar attitudes related to ethical dilemmas from everyday practice. The knowledge about respecting ethical principles is mostly satisfying. Only a small number of the respondents were in doubt or they were not sufficiently aware of the importance of applying ethical principles in dental practice. It implies that we should promote educational programs about medical ethics and the significance of the physicianpatient relationship for dentists and their coworkers, which will help them build even better professional communication with the patient, but also communication with each other, and it will help them improve treatment outcomes.