Ethics and Halacha in Dentistry - Synopsis of the Responsa

1. Forcing Dental Treatment on Children

a. According to Jewish law, the father is responsible for provision of the basic necessities of life for his children. In halachic literature these necessities are formally referred to as mezonot - food. Hence the father is obligated to finance his children's medical treatment in exactly the same way that he is obligated to provide them with food.

Sources: Shulchan Aruch Even HaEzer 90 (with reference to the husband's obligations to his wife); Responsa of the Chatam Sofer, Yoreh Deah 91; Minchat Yitzchak 6:150.

According to the regulations of Israeli batei din (religious courts), this obligation exists until the child reaches the age of fifteen. However, according to secular law - which is binding on Israeli courts - the obligation continues until the age of eighteen.

b. According to halacha a father may force a son up to the age of thirteen to undergo medical treatment. A daughter may only be forced until the age of twelve. Thereafter, unless the issue is one of life or death, dental treatment may not be forced without the child's consent.

Sources: Ketubbot, 11a (in the discussion as to whether a minor who has now matured may cancel the conversion process undertaken on his behalf when he was still a minor); Chiddushei HaMeiri ibid. Rambam, Hilchot Melachim, 10:3; Shulchan Aruch Yoreh Deah 268:7.

c. If the child has reached the set age and he refuses treatment, the father - although he may not force the child - is still obligated to try, using educational means, to convince the child to agree to the treatment.

Sources: Kiddushin 30a (discussing general guidelines for education of children of various ages); Chiddushei HaMeiri (commenting on the above mentioned discussion).

d. If the father is capable of convincing his child to agree to necessary medical treatment then he is obligated to do so, both because of the obligation to educate and because of the general, humane obligation which applies regardless of the age of the child or of the kinship.

The source for the latter obligation is in mitzvat hashavat aveidah (the Law of Restoration of Property) which involves not only returning an article which has been lost but also
prevention of harm, including bodily harm.

Sources: Deut. 22, 1-3; Sanhedrin 93a; Rambam, Commentary on the Mishna, Nedarim 4:4.

2. Informed Consent to Small Risks for Dental Implants

The type of treatment referred to here is one where there is no danger to the patient's life if it is not undertaken. Therefore halacha obligates the dentist to inform the patient in advance as to the expected chances of success, even when the risk of failure is small, and all the more so when it is high. Otherwise, if the treatment is unsuccessful the patient is entitled to sue the dentist for damages.

Sources: Ramban, Sefer Torat HaAdam; Beit Yosef, Yoreh Deah 336; Responsa Tashbetz 3:82.

3. Urgent Dental Treatment on Shabbat

The Talmud lays down the principle that any internal damage to the body - including inside the mouth - is life-threatening. Hence it is permissible to perform a procedure otherwise forbidden on Shabbat in order to treat it. Accordingly, the Rambam rules: “If a person has suffered a blow to his body, from his lips inward - whether it be in his mouth or in his intestines or in his liver or in his spleen or anywhere else in his body - then he is considered someone who is dangerously ill, and there is no need to evaluate his condition exactly, since it is assumed to be serious. Hence we perform [necessary] forbidden action on Shabbat for him immediately, without evaluation."

Following in the footsteps of the Rambam, Rav Yosef Karo states: "For any internal damage, i.e. from the teeth inwards and including the teeth, we may perform forbidden activities on Shabbat." The types of activities referred to here include even those activities which would be forbidden by the Torah were it not for saving his life.

Sources: Avodah Zarah 28a; Rambam, Hilchot Shabbat 2:5; Shulchan Aruch Orach Chaim 328:3.

It must be emphasized that whenever the Talmud defines a specific illness as posing danger to life then in every case it must be treated as such even if the doctor or the patient himself claims that there is no danger. For example, scurvy is characterized inter alia by bleeding of the gums and from the intestines. In contrast, when there is no defined illness but rather a general description, such as "internal damage," for example toothache (in the absence of a medical diagnosis), then it is permissible to perform activities otherwise forbidden on Shabbat for the sufferer pending a definitive diagnosis by a doctor. But as soon as the doctor (or patient) is certain that there is no danger, then it is no longer permitted to perform forbidden action on Shabbat.

Sources: Mishna Brura 328:8, Pri Megadim; Mishbatzot Zahav ibid.2; Eshel Avraham no. 1.

Hence someone who is suffering from acute toothache may travel to the dentist to determine whether his situation is dangerous, since toothache is included in the definition of internal damage. And with regard to pain in the internal organs it has already been determined that one may set aside Shabbat laws in order to be examined by a doctor.

Source: Biur Halacha 328:3.

With regard to removing teeth on Shabbat the rulings of the Poskim as to what should be done differentiate between unbearably sharp pain and reasonable pain, and between removing a painful tooth without a dentist's instructions, and pulling the tooth on the instruction of a dentist.

Sources: Beit Yosef Orach Chaim 328; Bayit Chadash and Sefer HaLevush; HaRama; Orach Chaim 328:3; Biur Halacha 10, Eliyahu Rabba, Pri Megadim, Eshel Avraham no. 2, Mor UKetziah; Sefer Issur VeHeter 59:18; Halachot Ketanot 2:10.

We may draw the following conclusion: pulpitis, "which causes severe and unbearable pain," is included in the list of cases which are defined as internal damage. Therefore
it is permissible to travel to a dentist who will administer the necessary treatment on Shabbat in order to heal the tooth, to take painkillers, or to remove the tooth, even if such activities involve actions which are forbidden on Shabbat by the Torah. However, it is preferable - where possible - that such cases are treated by a non-Jewish dentist who is not subject to the laws of Shabbat. If this is not possible, or if the patient relies more on a Jewish dentist, then he is permitted to go to the Jewish dentist even if the treatment will involve activities forbidden by the Torah on Shabbat.

4. Saving a Tooth which is Dislodged on Shabbat

a. If there is no need to perform activities forbidden by the Torah on Shabbat (e.g. traveling or operating electrical equipment) and the final fixture can be performed by the dentist after Shabbat, it is permissible to rinse the tooth and reinsert it immediately, or to soak it in cold milk for a few hours and then reinsert it since this involves only temporary placement which is not forbidden by the Torah.

Sources: Har Tzvi (Responsa) on Orach Chaim Tal Harim; Tzitz Eliezer 15:25.

b. The permanent fixture for the tooth using filling material is forbidden on Shabbat because of the prohibition of building. However there is disagreement among the Poskim as to whether "building" which occurs within the body is prohibited by the Torah, or whether the prohibition originates only in a decree of the Sages.

It must also be remembered that if the filling material is prepared on Shabbat by mixing powder with liquid, there is a further Torah prohibition of kneading. Obviously if an electrical machine must be operated then more prohibitions are added.

I conclude with a quotation from a Shabbat hymn:

Anyone who guards Shabbat properly from transgression,

His reward is very great, according to his efforts,

Each in his camp and each by his flag.