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

Oral and maxillofacial surgeons (OMFSs) and dentists regularly face patient requests for tooth extraction. While extractions are clinically indicated for conditions such as advanced caries or periodontitis, patients sometimes request extraction without a sound clinical reason. Such requests may be linked to financial constraints, cultural practices, or psychological factors including dental phobia, PTSD, somatoform disorders, body dysmorphic disorder (BDD), or body integrity identity disorder (BIID). Prior estimates suggest that 3.6–5.9% of extractions lack a valid clinical indication. A previous Dutch survey found that 6% of dentists encountered such requests in the past three years, with financial reasons most common, and 76% of requests granted. These practices raise ethical (non-maleficence) and legal concerns when irreversible procedures are performed without valid indications. Given differences in training and practice context, this study investigates whether OMFSs and dentists differ in how often they encounter, assess, and respond to extraction requests without a clear clinical indication, including the reasons for requests, granting rates, post-decision evaluations, and the extent to which patient decision-making competence is checked.

The paper references studies documenting standard clinical reasons for extractions (caries and periodontitis) and highlights estimates that 3.6–5.9% of extractions occur without valid clinical indication. A prior Dutch study of 800 dentists reported that 6% encountered such requests over three years; financial reasons were most common (~50%), followed by combined psychological/financial reasons (28%), psychological reasons only (18%), and others (4%), with 76% of requests granted. Ethical frameworks (e.g., non-maleficence in dental ethics codes) and legal standards of care caution against irreversible procedures without sound clinical justification. Cultural practices (e.g., among Dinka and Nuer) and psychological conditions (dental phobia, PTSD, somatoform pain, BDD, BIID) are noted in literature as drivers of requests. The study situates its analysis within these findings, noting a lack of prior comparative work between OMFSs and dentists on non-dental reasons for extraction and assessments of patient competency.

Design and participants: A cross-sectional survey was administered to all 256 OMFSs and a random sample of 800 dentists in the Netherlands (aged ≤64 years) via mail with an option to respond on paper or online. Contact details were provided by the Royal Dutch Dental Association (KNMT). The questionnaire (18 items plus demographics) asked about frequency of requests for extraction without clear clinical indication, management of such requests, patient reasons, and included a fictitious case (a 35-year-old with dental phobia requesting full clearance) with response options: comply, not comply, or uncertain. The survey instrument was piloted among five dentists. Data collection: Initial mail-out occurred in November 2019 with two reminders 3–4 weeks apart; data collection ended January 2020. An independent research bureau anonymized the data before analysis. Statistical analyses: Descriptive statistics summarized distributions. Group differences (OMFSs vs dentists; gender; age) were tested using Chi-square tests with p<0.05 considered significant. Analyses used SPSS v25.0. Ethics: Participation implied consent for anonymized data use, explained in the cover letter. No patient records were used. The study followed the Declaration of Helsinki and was deemed exempt from the Dutch Medical Research Involving Human Subjects Act by the ACTA Ethics Committee (nWMO, protocol 201935).

- Response and sample: OMFS response 28.1% (n=72); dentist response 30.3% (n=242). OMFSs were representative in gender and age; dentists were representative in gender but slightly older than the population. - Frequency of requests (Jan 2016–Nov 2019): 81.9% (n=59) of OMFSs vs 68.0% (n=164) of dentists received at least one request for extraction without a clear clinical indication (Chi-square=5.224, df=1, p=0.022). - Reasons for last request: Predominantly financial and severe dental fear. OMFSs: financial only 36.8%; psychological only 29.8%; both 28.1%; other 5.3%. Dentists: financial only 49.7%; psychological only 18.2%; both 27.7%; other 4.4% (differences not statistically significant). Overall, financial reasons reported at 64.9% (OMFSs) vs 77.4% (dentists); severe dental fear at 50.9% (OMFSs) vs 36.5% (dentists). - Granting requests: Dentists more likely than OMFSs to grant the most recent request (76.1% vs 61.4%; Chi-square=4.999, df=1, p=0.034). Female OMFSs refused more often than male OMFSs (66.7% vs 25.6%; Chi-square=8.746, df=1, p=0.003). No significant age effects; among dentists, no significant gender/age effects on granting. - Hesitation prior to extraction: OMFSs hesitated less often than dentists (26.3% vs 39.2%; Chi-square=3.010, df=1, p=0.083; not significant). - Provider regret after extraction: Very low; OMFSs 2.9% vs dentists 5.3% (Chi-square=0.313, p=0.576). - Patient regret (as known to provider): OMFSs reported none; 6.9% of dentists reported patient regrets. OMFSs more often did not know if patients regretted (64.7% vs 17.2%; Chi-square=29.991, df=2, p<0.001). - Competency checks: No significant difference in checking decision-making competence (OMFSs 82.5% vs dentists 87.4%; Chi-square=0.865, p=0.352). Methods (multiple possible): asking test questions (OMFSs 89.4%; dentists 91.9%), asking family/partner (38.3% vs 30.1%), consulting a colleague (25.5% vs 22.1%), consulting a physician (8.5% vs 5.9%), consulting psychologist/psychiatrist (4.3% vs 1.5%). Reasons for not checking differed: OMFSs often had no doubt about competence; dentists often presumed competence when not institutionalized. - Fictitious case (35-year-old with dental phobia requesting full clearance): Very few would comply (OMFSs 5.7% vs dentists 3.0%; Chi-square=3.805, df=2, p=0.149). Among dentists, those who would comply were all male (5.7% vs 0.0%; Chi-square=6.566, p=0.010).

The study addressed whether OMFSs and dentists differ in encountering and managing requests for extractions without clear clinical indications. Both groups commonly face such requests, primarily due to financial constraints and severe dental fear. OMFSs encountered these requests more often but were less likely than dentists to comply. Possible explanations include OMFSs’ limited prior relationship with patients, easier ability to refuse and refer back, greater exposure to complications, and dual training in medicine and dentistry with potentially stricter ethical norms. Female clinicians, especially OMFSs, appeared more reluctant to perform non-indicated extractions, potentially reflecting gender-related differences in patient-centered communication. Despite ethical and legal concerns, providers rarely reported regret after performing such extractions, and dentists reported modest patient regret; this may reflect cognitive dissonance or underdetection. Competency assessments were common but not universal, and typically informal; surprisingly, OMFSs did not assess competency more often than dentists. In the hypothetical scenario, both groups expressed strong reluctance to extract, suggesting awareness of ethical/legal standards, though real-world pressures may lead dentists to grant requests more often. Findings underscore the tension between patient requests and professional duties of non-maleficence and adherence to the standard of care.

More than eight in ten OMFSs and nearly seven in ten dentists reported receiving extraction requests without a clear clinical indication, most often for financial reasons and dental fear. Dentists were more likely than OMFSs to grant such requests. Most providers checked patient decision-making competence, and reports of regret—by clinicians or patients—were uncommon. Given the ethical and legal implications and the invasiveness of tooth extraction, further research is needed on long-term patient outcomes, drivers of clinician decision-making, effective strategies to manage financially or psychologically motivated requests, and the role of formal competency assessments.

- Response rate around 30%, though common for surveys; representativeness was generally adequate, with slight underrepresentation of younger dentists. - Distinguishing between indicated and non-indicated extractions can be difficult; the standard of care is not a sharp boundary and may vary across practitioners and contexts. - Three-year recall period may introduce recall bias. - The fictitious case was brief and may have been interpreted variably; results might differ for requests involving fewer teeth. - Conducted within the Dutch healthcare and legal context; findings may not generalize to countries with different systems or referral pathways (e.g., direct access to OMFSs). - Complex normative aspects were interpreted using ethical/legal principles, but more empirical work is needed to elucidate underlying reasons and processes guiding clinician decisions.