How we should make a decision for teeth extraction

1. ETHICAL AND LEGAL GUIDELINES
DECIDING ABOUT PATIENTS’
REQUESTS FOR EXTRACTIONKhairallah Moutaz

2. 1. Agerholm D. Reasons for extraction by dental practitioners in England and Wales: a comparison with 1986 and
variations between regions. J Dent 2001;29(4):237-241.
2. Jovino-Silveira RC, Caldas Ade F Jr, de Souza EH, Gusmão ES. Primary reason for tooth extraction in a Brazilian
adult population. Oral Health Prev Dent 2005;3(3):151-157.
3. Mordohai N, Reshad M, Jivraj SA. To extract or not to extract? Factors that affect individual tooth prognosis. J
Calif Dent Assoc 2005;33(4):319-328.
4. Richards W, Ameen J, Coll AM, Higgs G. Reasons for tooth extraction in four general dental practices in South
Wales. Br Dent J 2005; 198(5):275-278.
5. McCaul LK, Jenkins WM, Kay EJ. The reason for the extraction of various tooth types in Scotland: a 15-year
follow up. J Dent 2001;29(6): 401-407.
6. Johnson TE. Factors contributing to dentists’ extraction decision in older adults. Spec Care Dentist
1993;13(5):195-199.
7. McCaul LK, Jenkins WM, Kay EJ. The reasons for extraction of permanent teeth in Scotland: a 15-year follow-up
study. Br Dent J 2001;190(12):658-662.

3. OBJECTIVES
1. Legal and ethical principles
relevant to the assessment of a
request for extraction.
2. Describe cases in which
psychological or emotional
considerations appear to influence
irrational request for extraction.
3. Discuss how to resolve these
issues (cases).

4. DOCTOR
QUACK (WITCHDOCTOR)
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5. WHAT IS BIOETHICS?
• Bioethics is about the study of ethical
issues arising along health care or
research, and the associated decision-
making process to resolve them.
• When does an issue in practice be an
ethical issue ?

6. 1- WHEN THERE IS CONFLICT OF MORAL
VALUES, AND BELIEFS BETWEEN THE
HEALTH CARE PROVIDERS AND THE
PATIENTS.
 Blood transfusion to a severely bleeding patient
refuses to take blood, even this refusal can lead to
severe life threat and eventually death.

7. 2- When the issue in focus is related
to justice in allocating the available
resources.
A classical example is which of the
cancer drugs should be funded
publicly. Should we choose a drug
which efficiently improves the
quality of life of few patients? Or a
drug that makes little improvement
for a larger number of patients.

8. 3- When there is conflict of commitments and responsibilities
At one hand, there is the
commitment of the health care
provider to preserve patients' lives,
however there is the responsibility to
"rationally" use the resources
available to him/her on the other
hand. The classical example of which
is "one ICU bed, and Two patients:
whom to choose?"

9. THREE QUESTIONS
• How to take an (and not the) ethically
acceptable decision to the issue in
focus?
• Why did we take this decision? (i.e.
why we chose this ethical option and
not another?)
• How to implement the decision we
have taken?

10. • Clinical ethics: which is concerned with the
ethical issues related to clinical practice in
health care settings.
• Research Ethics is concerned with the
protection of humans participating in research.
• Organizational ethics, which is concerned
more with fair allocation of health care
resources.

11. ETHICAL PRINCIPLES IN CLINICAL
PRACTICE (BEAUCHAMP & CHILDRESS 2009):
• Autonomy "self-rule" (Respect for
persons): this refers to the person's
right to make free decisions about his
or her health care.
• Beneficence (Do Good)
• Non-maleficence (Do No Harm)
• Justice

12. A. FREE INFORMED CONSENT:
• "Without a consent, either written or
oral, no surgery may be performed.
• It is the patient, not the doctor, who
decides whether surgery will be
performed, where it will be done,
when it will be done and by whom it
will be done."
-- Allan v. New Mount Sinai Hospital (1980) 28 O.R. 356

13. B. DISCLOSURE
• This refers to the process
during which physicians
provide information about a
proposed medical
investigation or treatment to
the patient.

14. C. CAPACITY:
• Refers to the presence of a group/set of
functional abilities, a person needs to
possess in order to make a specific
decisions (Griso and Applebaum, 1998).
These include:
• To UNDERSTAND the relevant information
• To APPRECIATE the relatively foreseeable
consequences of the various options
available.

15. D. VOLUNTARINESS:
• Refers to a patient's right to make treatment
decisions free of any undue influence.
Influences include:
• Physical restraint or sedation.
• The use of explicit or implicit threat to ensure
that the treatment is accepted.
• Manipulation involves the deliberate distortion
or omission of information in an attempt to
induce the patient to accept a treatment.

16. EXTRACTIONS
Caries
Periodontal disease
Severe trauma to the
teeth.
Third molars.
Orthodontic reasons.
Dentist:
- Diagnosis
- Inform adequately
Patient:
Giving consent to the
proposed treatment.

17. 2.4% TO 17%
Autonomy,
What should the dentist do if
the teeth in question actually
are still sound?
It seems unethical simply to
grant that request.

18. LEGAL VIEWPOINT SURROUNDING
REQUESTS FOR EXTRACTION
1. Standard of care
2. Informed consent from the
patient
A dentist never can be obligated
to breach the standard of care.
This also is known as the
“principle of professional
autonomy.”

19. The interventions must conform to “the
degree of care and skill that a dentist of the
same medical specialty would use under
similar circumstances.”
The way in which this standard of care is
interpreted differs from country to country.
If recourse a dentist decision in a state that
uses locality rule, the dentist’s interventions
are evaluated in reference to the standards
of the state or of the community.
It is important to keep in mind that these
standards focus on dentists and their
geographically determined habits.

20. RATIONAL
IRRATIONAL
25-year-old man, who comes to the
oral surgeon with the request to
remove all his teeth because he has
dental care phobia. His dentition is
completely sound.
The oral surgeon does not support
the extraction.

21. Continues to insist an extraction
The dentist has provided extensive
information explaining that such an
extraction would be harmful to him.
The dentist should be mindful if his patient
has the capacity to make a decision about
his own health care.
If the patient does not have the capacity to
provide informed consent, his or her
decision is not valid
Without a valid consent, the dentist can
provide no treatment of any kind.

22. FIRST SCENARIO: A PATIENT
WHOSE TEETH ARE IN SUCH
BAD CONDITION THAT
EXTRACTION IS THE ONLY
REALISTIC OPTION.
Unlikely to result in major
disagreements between dentists and
their patients.

23. SECOND SCENARIO: THE DENTIST PROPOSES TO
RESTORE THE PATIENT’S TEETH, BUT THE PATIENT
REFUSES AND REQUESTS EXTRACTION INSTEAD
PROVIDING REASONS UNDERSTANDABLE (FINANCIAL
HARDSHIP).
Informed the patient properly, the requirement
of informed consent prohibits from treating the
patient against his well.
Bide by the principle of beneficence: some
dentists might offer the restorative treatment
at a lower price or perhaps even free of charge.
The dentist should refuse to extract. The
patient then has the option to have those teeth
restored at a later date when personal finances
so allow.

24. THIRD SCENARIO: A PATIENT WHOSE DENTITION DOES
NOT DEMONSTRATE ANY MEDICAL NEED FOR
EXTRACTION, BUT WHO REQUESTS AN EXTRACTION FOR
CULTURAL REASONS.
 Peoples of Sudan, it is tradition to have the follicles or teeth
removed.
 South African studies demonstrate that 41 % of teeth
extraction were performed for cultural reasons, of which
93.7 percent were removals of the four maxillary incisors.
 What should a dentist practicing do if a patient from such
an ethnic or cultural group asks him or her to carry out this
intervention.
 The dentist is legally bound by the standard of care and not
obliged to treat beyond the bounds of accepted treatment.

25. IRRATIONAL REQUESTS FOR EXTRACTION
The request is based not on rational
considerations, but instead on fear or some
other psychological condition.
The patient has the capacity to provide
informed consent. Criteria for the capacity to
consent include a determination that the
patient understands basic information about
the diagnosis, prognosis and the consequences
of the proposed treatment.
Generally, when a patient lacks the capacity to
provide informed consent for treatment, the
consent must be provided by a surrogate who
shall represent the interests of the patient.

26. PATIENT SEEMS TO HAVE THE CAPACITY TO
PROVIDE INFORMED CONSENT, BUT THE
EXTRACTION REQUEST ITSELF APPEARS
IRRATIONAL?
This scenario may arise if the patient
has an extreme Fear of dental
treatment, a Post Traumatic Stress
Disorder (PTSD), a somatoform pain
disorder or a condition in which a
disturbed perception of one’s own body
is the focal point, such as Body
Dysmorphic Disorder (BDD) or Body
Integrity Identity Disorder (BIID).

27. FEAR OF DENTAL TREATMENT
 A 37-year-old man with a phobia of dental treatment that arose
after a traumatic experience during the extraction of a third molar.
He has a number of carious teeth, and gingivitis. The restored
teeth are in good condition.
 After the third-molar extraction he began refusing any dental
treatment and asked for a total extraction to be performed under
general anesthesia.
 The dentist did not consider total extraction to be indicated and,
together with a psychologist, had many discussions with the
patient about the subject.
 The patient had no evidence of psychopathology.
 After considering these options for three months, the patient
persisted in his request.
 The dentist required him to sign a letter in which he stated that he
knew of no dental reason for the total extraction and that this was
to take place at the specific request of the patient.
 The dentist then performed the total extraction.

28. If a patient is found to have a specific phobia
about dental treatment, he may lack the
capacity to make decisions.
Some mental illnesses lead to a patient’s
decreased capacity to consent requiring
specialized psychiatric treatment.
A dentist should discuss with the patient the
option of a referral to a mental clinician to
treat the underlying phobic condition.
Dental-care phobia is a treatable condition
with an excellent prognosis.
Most patients with this condition respond
well to therapy

29. Forms of psychopathology in which fear is
driven by traumatic experiences, not related
to dental care.
PTSD, which can be caused by incest, abuse,
rape (including oral rape) or torture.
PTSD manifests itself as a serious form of
fear that frequently exceeds the patient’s
emotional strength. Dental restorative
treatment is impossible, the patient
frequently views extraction under general
anesthesia as the only solution.
Treatment of PTSD certainly requires the
involvement of a mental health professional.

30. SOMATOFORM PAIN DISORDER
 47-year-old woman, has undergone extensive dental
treatment during the course of several years because of
pain that she experienced.
 Most of her teeth have been restored and treated
endodontically. In addition, she has undergone various
apical resections and even, at her request, a few extractions
by various dentists .
 None of this, however, made any difference with regard to
the pain that she continues to experience.
 Now she is requesting urgently that her dentist remove her
entire dentition, because she is certain that this will bring
her pain to an end. The dentist cannot find any oral
pathology that could explain the lingering pain.

31.  Dentist should not carry out any dental intervention
before investigating the possibility of a psychological
component that might explain the pain.
 The terms “somatic,” “somatoform” or “somatization”
frequently are used by mental health professionals to
describe a situation in which psychological stress is
translated into physical complaints without there being
any demonstrable physical disease process. If the resulting
complaint is pain, this is called a “somatoform pain
disorder.”
Extraction is unnecessary and ineffective
intervention and could be viewed as
malpractice.

32. DISORDERS OF SELF-PERCEPTION
Who are extremely ashamed of their looks.
This condition is known as
“dysmorphophobia” or BDD,
Aspect of their appearance that their
concern is considered pathological.
Patients with BDD frequently consult
plastic surgeons, dermatologists,
orthodontists or dentists with the request
that they remove or change the imagined
defect.

33.  Patients with one of these disorders have the feeling that
their limbs do not belong to them.
 Surgeon was reported to have treated patients with
probable BIID by amputating the lower parts.
 This case is analogous to the removal of healthy teeth.
 In this case even the patient had received adequate
information , one has to wonder, whether the patients had
the capacity to consent to such leg amputations.
 Dentist should consider referring the patient to a mental
health professional before undertaking any dental
intervention.
 For patients with BIID, no effective therapy is known.

35. CONCLUSION
In most cases of patients’ requesting
extractions, the Ethical principle of non
maleficence will play a decisive role in
the dentist’s decision making.
In cases in which the request appears
influenced by a specific mental condition
such as a phobia of dental treatment,
extraction rarely is justifiable.