ETHICS

 

Patients request for extractions

 

 

P Govan

SADA Headoffice

 

 

INTRODUCTION

Think about patient A, a 25-year-old who visits the oral surgeon requesting that all of her teeth be extracted due to a "passion gap" or dental anxiety, among other reasons. The patient has a perfectly sound, but little neglected, dentition. The oral surgeon chooses how to react to the patient's request and opposes the extraction.

Patients frequently ask for their dentist or oral surgeon to remove a few teeth, or even their entire dentition, as in the case of patient A or the popular dental modification known as the "Cape Flats smile" or "passion gap", which originated in Cape Flats, Cape Town, where people purposefully remove their upper front teeth for cosmetic and other reasons.

Even in cases where teeth are in good health, there is an increase in requests for tooth extractions due to patients' increased assertiveness and autonomy. The majority of dentists do not always comply with such requests. Rather, the dentist's own diagnostic assessment, conclusions and expert judgment should be taken into consideration when deciding whether to fulfil the patient's request.

Dental professionals recommend extractions for a wide range of diagnostic findings, including caries, periodontal disease, tooth damage, orthodontic issues and many more.

After receiving sufficient information and the dentist's diagnosis of the need for an extraction, the patient will agree to the suggested course of action. When the dentist determines that the patient's teeth have a good or healthy prognosis and may be saved with alternative treatment options, there is a higher likelihood of conflict with the patient.

Legal and ethical issues to consider

The health and welfare of their patients should always come first for dentists as it is their primary professional duty.

Dentists should evaluate a patient's request for extraction in accordance with ethical standards, some of which are legally mandated. They have an obligation to uphold a quality of care that corresponds with what dentists with like training and experience would do in a like circumstance. Additionally, it is necessary to get the patient's informed consent.

Dentists are not required by law or ethics to provide every therapy a patient requests. Patients are not entitled to all therapies they desire, even though they have the right to autonomy and informed decision-making. Dentists are required to treat patients only within the parameters of recognised procedures.

Due to their ethical obligations to uphold the principles of beneficence (behaving in the patient's best interests) and nonmaleficence (avoiding harm to the patient), dentists are not obliged to perform treatments that do not benefit the patient. One cannot force dentists to deviate from the accepted standard of care.

When a patient continues to insist on an extraction even after the dentist has fully explained why it might not be a good idea, it raises questions about the patient's capacity to make decisions about their treatment. Even if this does not prove that the patient is incapable, the dentist should be aware of this.

 

REQUESTS FOR EXTRACTION

Sometimes a patient will make a fair request to have a whole or partial extraction, such as when the patient's oral health is seriously impaired and extraction is the only treatment choice left, or when the patient needs orthodontic work done.

In one such instance, the patient's teeth are in such terrible shape that, from a dental standpoint, extraction is the only practical solution. It is unlikely that circumstances like this one would lead to significant arguments between dentists and their patients.

In more challenging scenarios, a patient may decline restorative dental treatment offered by the dentist, preferring to have their teeth extracted due to financial constraints or other valid reasons. Even when the patient is fully informed about the consequences, the dentist faces a dilemma whether to respect the patient's decision as part of informed consent, which prohibits treatment against the patient's will. Sometimes, to persuade a patient to undergo necessary restorative treatment, a practitioner might offer to perform the procedure for free or at a reduced cost. However, despite this commendable gesture, economic constraints often impede the dentist's ability to provide such services consistently.

If a patient decides against the recommended restorative treatment from the dentist, the decision to extract teeth must be based on thorough scientific and clinical evaluations, considering factors like the condition of the affected teeth, the patient's symptoms and overall oral health functionality.

The dentist's approach should be to refrain from extracting additional teeth unless necessary. In such situations, the patient is then faced with the choice of either restoring the teeth at a later date when financial circumstances allow or managing with the deteriorating teeth until their condition warrants extraction.

When faced with requests for extraction that lack dental necessity but are influenced by the "passion gap" prevalent in the Cape Flats, practitioners should be aware that refusing treatment could lead them to seek assistance from unlicensed and unqualified providers.

Dentists must follow established care standards and are not compelled to provide treatments outside accepted practices. They are not obliged to offer treatments that may not benefit or could harm patients.

 

IRRATIONAL REQUESTS FOR EXTRACTION

In situations where a patient requests an irrational extraction, dentists should explain why the requested treatment may be detrimental and does not align with their care standards. Ideally, this clarification can discourage patients from seeking the extraction from unqualified individuals.

When faced with a patient who appears capable of providing informed consent but requests an irrational extraction, dentists encounter a challenging scenario. This situation may arise if the patient has extreme fear of dental treatment, PTSD, a somatoform pain disorder or a condition involving distorted body perception.

Requests for tooth extraction can sometimes be influenced by psychological factors rather than rational considerations. It is crucial to approach these requests differently depending on the patient's ability to provide informed consent. This involves assessing their comprehension of the diagnosis, prognosis and treatment outcomes, as well as their judgment of what is in their best interest.

Fear of dental treatment

Fear of dental treatment is a common concern for many people, often resulting in apprehension or anxiety. Typically, this fear does not hinder the patient's ability to discuss treatment options with the dentist and provide informed consent.

However, if a patient's fear of dental treatment becomes intensified due to previous unpleasant experiences, they may avoid seeking dental care altogether, including routine check-ups.

In cases where a patient has a specific phobia related to dental treatment, they may struggle to make decisions about their dental care.

Some mental illnesses can also impact a patient's ability to provide consent, requiring specialised psychiatric treatment rather than dental intervention alone. In such cases, dentists should offer support and assistance to the patient while striving to deliver effective oral healthcare without exacerbating their phobic fear.

Sedation or general anaesthesia can be utilised during dental procedures to manage pain or anxiety, but it is important to note that these interventions aim to facilitate dental care rather than address long-standing dental fear.

If a patient's request for tooth extraction is driven by extreme dental fear, dentists should consider discussing the option of referral to a mental health professional to address the underlying phobia.

It is crucial to recognise that dental-care phobia is a treatable condition with a favourable prognosis, and seeking help from mental health professionals can lead to effective management and improved oral healthcare outcomes.

 

PTSD

Posttraumatic stress disorder (PTSD) can lead to intense fear and anxiety, often stemming from traumatic experiences unrelated to dental care.

This fear can make it challenging for patients to undergo dental restorative treatment, leading them to perceive extraction under general anaesthesia as the only viable solution. While behavioural treatments may help alleviate these fears to some extent, addressing PTSD typically requires the expertise of a mental health professional.

It is important to recognise that dental care can be particularly difficult for individuals with PTSD due to their heightened sensitivity to stressors. Collaborative efforts between dental professionals and mental health professionals can provide comprehensive support and management for patients with PTSD, ensuring they receive the necessary care while addressing their psychological needs.

Somatoform pain disorder

In cases of somatoform pain disorder, a unique challenge arises when a dentist determines that no dental treatment is necessary, yet the patient insists on tooth extraction due to unexplainable pain originating from the teeth.

When the source of pain cannot be attributed to any organic cause, the dentist should refrain from performing dental interventions until investigating the possibility of a psychological component contributing to the pain.

Performing an extraction in such cases would be considered unnecessary and ineffective, potentially constituting malpractice.

Disorders of self-perception

Similarly, in cases involving disorders of self-perception, where patients view extraction as the only solution due to perceived defects in their appearance, dentists should exercise caution.

Patients may seek consultation from various healthcare professionals, including plastic surgeons, dermatologists, orthodontists or dentists, with requests to alter or remove the imagined defect.

In these situations, dentists need to consider referring the patient to a mental health professional before proceeding with any dental intervention. This collaborative approach ensures patients receive comprehensive care that addresses both their physical and psychological needs.

 

CONCLUSION

In conclusion, if a dentist recommends extraction based on a thorough diagnostic and prognostic assessment, and the patient provides informed consent, extraction is both ethically and legally justificable. This holds even if the patient initially suggests extraction, and the dentist subsequently determines it to be clinically justified.

However, more challenging situations arise when a patient's request for extraction is driven by financial constraints or cultural factors. While dentists cannot compel patients to undergo specific treatments, patients also cannot compel dentists to perform treatments that deviate from accepted standards or ethical principles.

When faced with requests for extraction outside of these frameworks, dentists should demonstrate empathy for the patient's needs and explain why extraction may not be feasible. They should then collaborate with the patient to develop an alternative treatment plan that aligns with accepted standards and meets the patient's needs to the best extent possible.

In cases where a mutually agreeable treatment plan cannot be reached, dentists are not obligated to perform extractions and should generally decline to do so. This approach ensures patient care remains within accepted standards while respecting the autonomy and wellbeing of both patients and practitioners.