How dentists and oral and maxillofacial surgeons deal with tooth extraction without a valid clinical indication

The study addresses the ethical and legal complexities surrounding tooth extractions performed without a valid clinical indication. While extractions are commonly performed for reasons such as advanced caries or periodontitis, requests for extraction are sometimes made by patients even when no clear clinical justification exists. These requests may stem from financial constraints, cultural traditions, or severe mental health issues like dental phobia, PTSD, or body dysmorphic disorder. Previous research suggests a significant percentage of extractions are conducted without clinical indication, raising concerns about adherence to the ethical principle of non-maleficence and legal standards of care. This study expands on previous work by comparing the responses of oral and maxillofacial surgeons (OMFSs) and dentists to such requests, given their differing educational backgrounds and professional contexts. The research aims to determine the frequency of encountering such requests, the underlying reasons, the likelihood of granting these requests, practitioners' evaluations of their decisions, and the extent to which patient competency is assessed.

The introduction cites several studies on the reasons for tooth extraction, including financial constraints as the most common reason. Studies are referenced concerning the cultural traditions of extraction (e.g., Dinka and Nuer tribes), and mental health conditions leading to extraction requests (e.g., dental phobia, PTSD, BDD, BIID). Previous research by the authors showed that 6% of Dutch dentists encountered requests for extraction without clinical indication in the preceding three years, with financial reasons being the most prevalent. The authors note the irreversible nature of tooth extraction and the ethical and legal implications of performing it without sound clinical justification, highlighting violations of non-maleficence and legal standards of care.

This study employed a survey design. Questionnaires were distributed to a random sample of 800 dentists and all 256 OMFSs (aged 64 or younger) in the Netherlands, using contact information provided by the Royal Dutch Dental Association (KNMT). The questionnaire contained 18 questions, covering topics like frequency of encountering extraction requests without clinical indication, reasons for such requests, responses to these requests, and evaluation of decisions. A fictitious case of a patient with dental phobia requesting full extraction was also included. Participants could respond in writing or online. Two reminders were sent over three to four weeks. Data was collected from November 2019 to January 2020. Descriptive statistics and Chi-Square tests (p<0.05 considered significant) were used to analyze data using SPSS version 25.0. Ethical approval was obtained, and the study complied with the Declaration of Helsinki. The study distinguished between extractions with clear clinical indications and those originating from patient requests without sound dental reasons. The latter were labeled 'extractions without a valid clinical indication'.

The response rate was 28.1% (n=72) for OMFSs and 30.3% (n=242) for dentists. A significant majority of both groups (81.9% of OMFSs and 68% of dentists) received requests for extractions without clinical indication in the three years prior to the survey. The most common reasons were financial issues and severe dental fear, though dentists reported financial reasons more often than OMFSs (77.4% vs 64.9%). Dentists were significantly more likely (75.6%) than OMFSs (60.7%) to comply with such requests. Few practitioners (less than 6% overall) regretted their decision. Female OMFSs were significantly more likely to refuse non-dental extraction requests than male colleagues. There was no significant difference between OMFSs and dentists in assessing patients' mental competency (approximately 80-87% checked competency in both groups), though methods varied. In a presented fictitious case involving a patient with dental phobia, few practitioners (less than 6% overall) indicated they would perform the total extraction. Notably, all OMFSs who would perform the extraction in the fictitious case were male.

The study highlights the significant prevalence of extraction requests without a clinical indication, primarily driven by financial concerns and dental fear. Dentists' higher compliance rate compared to OMFSs might be attributed to differences in the Dutch healthcare system, including the OMFS's role as a referral specialist who often lacks the comprehensive patient history available to dentists. OMFSs might also find it more challenging to assess the repairability of teeth and the necessity for extraction compared to dentists. Liability concerns could also influence OMFSs' decision-making. The lack of significant difference in competency assessment between the two groups despite differences in training is noteworthy and may require further investigation. The lower regret rate among practitioners may reflect cognitive dissonance. The limitations of relying on self-reported data from practitioners regarding patient regrets are acknowledged. The study's focus on the Netherlands limits the generalizability of the results to other healthcare systems.

The study reveals that a substantial proportion of OMFSs and dentists regularly receive extraction requests lacking clinical justification, largely due to financial and psychological factors. Dentists are more likely to comply. While few express regret, the ethical and legal implications necessitate further research into long-term consequences and the factors influencing decision-making in these complex cases. Future research should explore the long-term impacts of these extractions, delve deeper into the decision-making processes of dental professionals, and examine cross-cultural variations in approaches to these requests.

The study's relatively low response rate (around 30%) and potential difficulties in clearly distinguishing reasons for extractions with and without clear clinical indication are acknowledged limitations. The retrospective nature of the data (covering three years) and the brevity of the fictitious case may also influence the results. The study's focus on the Netherlands limits the generalizability of its findings to other contexts. Finally, the reliance on self-reported data from dental professionals for patient regret introduces potential bias.