Deciding about patients' requests for extraction

Background and OverviewDentists frequently are faced with patients' requests for an extraction, sometimes of the entire dentition. In this article, the authors offer guidelines to help dentists and oral surgeons make decisions regarding such requests for extraction.ConclusionsIn most cases of patients' requesting extractions, the ethical principle of nonmaleficence 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.Practice ImplicationsDental professionals should keep in mind that they cannot be forced to carry out treatment that is at odds with the ethical principle of nonmaleficence or that is outside of the bounds of accepted treatment. To aid dentists in making treatment decisions in such cases, the authors present a flowchart that integrates possible considerations.     

Diagnosis and treatment of temporomandibular disorders: an ethical analysis of current practices

The defining characteristic of a profession – and especially a health‐care profession – is that the behaviour of its members is proscribed by a formal code of ethics. The main purpose of such codes is to guide practitioners' interactions with patients, assuring that patient interests are protected. In other words, the ethical code requires practitioners to place their patients' needs for proper diagnosis and appropriate treatment ahead of their own needs for income and advancement. The dental profession has a code of ethics that was developed by the American Dental Association many years ago; in most clinical situations, determination of proper behaviour is self‐evident. However, the field of temporoman‐dibular disorders (TMDs) has been the subject of considerable controversy for over half a century, and many people have argued that this makes it impossible to evaluate various approaches to treatment of TMDs within an ethical framework. In this article, the authors argue that the large volume of scientific evidence in the contemporary TMD literature provides an ethical framework for the diagnosis and treatment of patients with TMDs within a biopsychosocial medical model. They present a summary of the research with contemporary scientific integrity, which has produced that information over a period of many years. Based on that research, they conclude that dentists may provide conservative and reversible treatments that will be successful for most TMDs and in doing so will comply with the profession's code of ethics. Conversely, the authors claim that those dentists who continue to follow the older mechanistic models of TMD aetiology and treatment are not only out of step scientifically, but are placing their patients' welfare at risk by providing unnecessary irreversible bite‐changing and jaw‐repositioning interventions. Therefore, debate of these issues should not be solely focused on scientific merit, but also upon the compelling ethical obligations that dentists have as a result of the contemporary scientific literature regarding TMDs.     

A comparison of expectations and impressions of ethical characteristics of dentists: Results of a community primary care survey

BackgroundTo better define potential challenges in dental professional ethics, the authors gathered data regarding patients’ characterizations of an ideal dentist and compared them with their impressions of dentists in general.MethodsThe authors invited 500 consecutively seen primary care patients at an academic medical center to participate in the study. Participants completed a 32-item survey assessing key domains of ethical characteristics of health care professionals: trustworthiness, honesty, beneficence, nonmaleficence, respect for autonomy, empathy, compassion, patience, courage, humility and dedication. The authors used the McNemar paired t test to compare respondents’ ratings of ideal dentists with their ratings of dentists in general.ResultsTwo hundred eight-five patients returned completed surveys, for a response rate of 57 percent. The authors found statistically significant differences between ideal and perceived characteristics in all but one domain. The area of greatest difference related to the domain of trustworthiness (that is, dentists should not “propose unnecessary treatments just so they can make money”). For this survey item, 98 percent of patients reported that it was very or extremely important, but only 57 percent of respondents moderately or strongly agreed that dentists in general were engaging in this practice (P < .0001).Conclusions and Practical ImplicationsThese data reveal gaps between patients’ expectations of the dental profession and their actual impressions of dentists in general. Addressing these discrepancies may be crucial if dentistry is to continue to enjoy the public's trust.     

Concordance between patient satisfaction and the dentist's view: Findings from The National Dental Practice-Based Research Network

ObjectivesIn this study, the authors examined the dentist's view of the patient's experience and concordance with the patient's rating of satisfaction.MethodsPractitioners from 197 practices in The National Dental Practice-Based Research Network recruited consecutively seen patients who had defective restorations that were replaced or repaired. At the end of the dental visit, the treating dentist and 5,315 patients completed and returned a survey that asked about the patient's satisfaction.ResultsMost dentists viewed their patients as having been satisfied with the treatment experience (n = 4,719 [89 percent]) and as having perceived them as friendly (n = 5,136 [97 percent]). Dentists had less strong feelings about whether patients had a preference for the restorative material (n = 2,271 [43 percent]) or an interest in obtaining information about the procedure (n = 1,757 [33 percent]). Overall, patients were satisfied, and most of the time dentists correctly predicted this outcome. Among patients who were less than satisfied, there was a substantial subset of cases in which dentists were not aware of this dissatisfaction.ConclusionFor improved patient-centered care, dentists should assess patients' desires, expectations and perceptions of the dental care experience and then manage or correct the expectations and perceptions as needed.Practical ImplicationsBy taking a patient-centered approach, dentists should seek to understand how patients evaluate and rate the services provided, thereby enabling them to focus on what each patient values most.     

Why Patients Visit Dentists – A Study in all World Health Organization Regions

ObjectiveThe dimensions of oral health–related quality of life (OHRQoL) Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact are the major areas where patients are impacted by oral diseases and dental interventions. The aim of this study was to evaluate whether dental patients' reasons to visit the dentist fit the 4 OHRQoL dimensions.MethodsDentists (N = 1580) from 32 countries participated in a web-based survey. For their patients with current oral health problems, dentists were asked whether these problems were related to teeth, mouth, and jaws' function, pain, appearance, or psychosocial impact or whether they do not fit the aforementioned 4 categories. Dentists were also asked about their patients who intended to prevent future oral health problems. For both patient groups, the proportions of oral health problems falling into the 4 OHRQoL dimensions were calculated.ResultsFor every 100 dental patients with current oral health problems, 96 had problems related to teeth, mouth, and jaws' function, pain, appearance, or psychosocial impact. For every 100 dental patients who wanted to prevent future oral health problems, 92 wanted to prevent problems related to these 4 OHRQoL dimensions. Both numbers increased to at least 98 of 100 patients when experts analyzed dentists' explanations of why some oral health problems would not fit the four dimension. For the remaining 2 of 100 patients, none of the dentist-provided explanations suggested evidence against the OHRQoL dimensions as the concepts that capture dental patients' suffering.ConclusionOral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact capture dental patients' oral health problems worldwide. These 4 OHRQoL dimensions offer a psychometrically sound and practical framework for patient care and research, identifying what is important to dental patients.     

A marketing campaign to promote screening for oral cancer

BackgroundOrganizers of the Detroit Oral Cancer Prevention Project at the University of Michigan, Ann Arbor, launched a multifaceted media campaign targeted toward a high-risk population to raise awareness about oral cancer, educate the public regarding the importance of early detection and increase screening rates. The authors present data about the effectiveness of the campaign with regard to the screening behaviors of medical and dental providers.MethodsBefore the start of the campaign and during each of the three years of the campaign, the authors mailed surveys to random samples of physicians and dentists practicing in targeted and non-targeted areas.ResultsMore dentists than physicians reported screening patients routinely, and dentists reported that they referred more patients for biopsy or further evaluation compared with physicians. A larger proportion of dentists and physicians in the targeted area than in the nontargeted area reported that their patients had seen or heard the advertisements. A larger proportion of dentists in the targeted area than in the nontargeted area reported an increase in patients' questions and requests for screening, even after the authors accounted for demographic characteristics (adjusted odds ratio = 2.47).ConclusionsThe survey findings show that the media campaign was effective in influencing providers' screening for signs and symptoms of oral cancer.Clinical ImplicationsAn increase in patients' requests for screening as a result of the implementation of mass media campaigns may promote oral cancer screening and improve patients' chances of survival.     

State governance versus dentists’ autonomy – the case of Swedish dental care

Objective: A trend towards the state governance of healthcare through quality indicators and national clinical guidelines has been observed, and it is argued that this trend can be a challenge to the autonomy of healthcare professionals. In Sweden, these regulatory tools have been implemented in combination with subsidies for adult dental care that are based on guideline recommendations which serve to ensure that dental care is evidence-based and cost-effective. This paper aims to analyse the implications of these changes regarding dentists’ autonomy and whether the government’s political intentions can be fulfilled.

Material and methods: The paper is based on documents from government authorities and professional theories.

Results: The financial control over Swedish dental care has been strengthened, and it can be argued that this is a step in the right direction from a societal point of view, as public resources are limited. Dentists’ professional autonomy with their patients is not affected, which is appropriate, as patients should be treated according to their individual needs and expectations.

Conclusions: This article shows that the state’s governance does not directly detail dentists’ work, which indicates a balance between state governance and dentists’ autonomy. However, further research is required to get knowledge on Swedish dentists’ view of the governance.     

Provision of Oral Health Care by Dentists to Community-Dwelling Older Patients

BackgroundResearch into oral health care for older people has shown that dental care in general decreases with increasing age and frailty and, therefore, oral health care provision may be complex. The aim of this study is to identify the oral health care dentists provide to community-dwelling older people and which barriers they experience in doing this.MethodsIn this cross-sectional study, a representative sample of dentists in the Netherlands was asked to prospectively select one older patient and describe this patient using a specially developed registration form; the patient was requested to fill out a questionnaire. The relationship between experienced barriers in providing oral health care to older patients and characteristics of the dentists and the patients was studied by means univariate and multivariate logistic regression analysis.ResultsIn total, 923 dentists were asked to participate in the study. Data were available for 39.4% dentist–patient pairs. In most cases (87.4%), oral health care was focussed on conservation of the dentition. In all, 14.0% of the dentists experienced barriers in providing oral health care for older people. Some patient factors increase the risk of experiencing barriers, eg, the more difficult behaviour of older patients and the greater disease burden.ConclusionsOral health care was mostly focussed on conservation of the dentition, and dentists especially experience barriers in oral health provision to older patients if they are already frail.     

The effect of training on the use of tobacco-use cessation guidelines in dental settings

BackgroundAn increase in the number of dentists conducting tobacco-use cessation treatment is needed. The authors assessed the effects of high-intensity training (HIT) or low-intensity training (LIT) and reimbursement on general dentists' tobacco-use–related attitudes and treatment behaviors.MethodsThe authors randomly selected 265 dentists in three states and assigned them to one of five groups: HIT workshop groups with and without tobacco-use cessation counseling reimbursement, LIT mailed self-study groups with and without reimbursement or a control group. Outcomes at follow-up were dentists' self-reported tobacco-use–related attitudes and behaviors and patients' reports of dentists' behaviors.ResultsSignificantly more dentists in the intervention groups reported having positive attitudes and behaviors at follow-up than did dentists in the control group. Dentists in the HIT groups, however, reported assessing patients' willingness to quit and assisting them with the quitting process significantly more often than did dentists in the LIT groups. Significantly more patients of dentists in the intervention groups who used tobacco reported receiving advice and assistance from their dentists than did patients of dentists in the control group. Adding reimbursement to HIT or LIT conditions did not provide additional intervention effect.ConclusionDentists trained by means of a workshop or self-study program used components of a recommended guideline more frequently and felt more positive toward tobacco-use cessation counseling than did dentists in the control group.Clinical ImplicationsAlthough the workshop training was more successful than the self-study training, the latter's reach among dentists could have a more significant public health impact. The effect of reimbursement needs further study.     

Differences in Characteristics of California Dentists Who Employ Dental Hygienists and Those Who Do Not

BackgroundDental hygienists can increase dentists’ productivity, yet nationwide, one-third of dentists do not employ a hygienist. The profession needs more information on the characteristics of these dentists and their reasons for not employing hygienists.MethodsThe author used a 2003 survey of California dentists and a logistic regression analysis to assess factors independently associated with dentists’ employment of hygienists. These factors included dentists’ personal, practice, population, productivity and patient care characteristics. She also assessed characteristics of dentists who did not employ hygienists and their reasons for not doing so.ResultsDentists who worked full time, employed more administrative personnel, had more operatories, had longer appointments, had more income from private payers and had more elderly patients were more likely to employ hygienists than were dentists with alternative characteristics. Graduates of dental schools outside the United States and those with fewer white patients were less likely to employ hygienists. Reasons for not employing hygienists included personal choice, high costs and not having a sufficient volume of work.ConclusionsThe author's findings suggested that in employing hygienists, dentists consider preferences, practice income and patient demand, among other factors. Further examination of reasons for employing hygienists is warranted.Practice ImplicationsHiring a hygienist increases a dental practice's patient capacity, yet not all dentists can or choose to do so. Policies aimed at increasing dental workforce capacity must take into account dentists’ characteristics and preferences.     

Assessment of treatment provided by dental health aide therapists in Alaska: a pilot study

BackgroundDental health aide therapists (DHATs) in Alaska are authorized under federal law to provide certain dental services, including irreversible dental procedures. The author conducted this pilot study to determine if treatments provided by DHATs differ significantly from those provided by dentists, to determine if DHATs in Alaska are delivering dental care within their scope of training in an acceptable manner and to assess the quality of care and incidence of reportable events during or after dental treatment.MethodsThe author audited the dental records of patients treated by dentists and DHATs who perform similar procedures for selected variables. He reviewed the records of 640 dental procedures performed in 406 patients in three health corporations.ResultsThe author found no significant differences among the provider groups in the consistency of diagnosis and treatment or postoperative complications as a result of primary treatment. The patients treated by DHATs had a mean age 7.1 years younger than that of patients treated by dentists, and the presence or adequacy of radiographs was higher among patients treated by dentists than among those treated by DHATs, with the difference being concentrated in the zero- to 6-year age group.ConclusionsNo significant evidence was found to indicate that irreversible dental treatment provided by DHATs differs from similar treatment provided by dentists. Further studies need to be conducted to determine possible long-term effects of irreversible procedures performed by nondentists.Clinical ImplicationsA need to improve oral health care for American Indian/Alaska Native populations has led to an approach for providing care to these groups in Alaska. The use of adequately trained DHATs as part of the dental team could be a viable long-term solution.     

Financial,psychological, or cultural reasons for extracting healthy or restorable teeth

BackgroundThe purpose of this study was to determine how often dental patients request extraction for nondental reasons and how dentists handle such requests.MethodsThe authors conducted a survey among 800 Dutch dentists from November 17, 2019, through January 5, 2020. The questionnaire contained 17 items, including a hypothetical case vingette.ResultsA total of 242 dentists responded to the survey (response rate was 30.3%, 48.3% of respondents were women, and mean [standard deviation] age was 45.3 [11.8] years). Sixty-eight percent of respondents reported that they had been confronted with a request for extraction on nondental grounds in the past 3 years. One-half of these dentists received such a request 5 times or fewer, 21.3% received such a request 6 through 10 times, 11.3% received such a request 11 through 20 times, and 8.8% received such a request 21 through 30 times. Their most recent request concerned a financial reason (49.7%), a combination of psychological and financial reasons (27.7%), a psychological reason (18.2%), or another reason (4.4%). Most dentists (87.5%) evaluated the patient’s competency to make health care decisions. Of all nondental extraction requests, 75.6% (n = 114) were granted. Only 4.0% (n = 6) of the dentists regretted the extraction. Most dentists (82.0%, n = 191) would have refused the extraction in the hypothetical case vignette.ConclusionsNondental requests for extraction are relatively common. Although dentists are reluctant in theory, they are likely to grant such requests in everyday practice, particularly if the patient cannot afford an indicated conservative treatment.Practical ImplicationsDentists should keep in mind that they cannot ethically or legally be required to perform an intervention deemed harmful, even if an autonomous patient made the request.     

Oral Cancer Knowledge,Attitudes and Practices: A Survey of Dentists and Primary Care Physicians in Massachusetts

BackgroundThe authors conducted a study to assess dentists' and primary care physicians' oral cancer knowledge, attitudes and practices in the Commonwealth of Massachusetts.MethodsThe authors mailed a 38-item, pretested questionnaire to a stratified sample of dentists and primary care physicians in Massachusetts. The sample population included all general medicine, internal medicine and family practice physicians listed with the Massachusetts Board of Registration in Medicine and all Massachusetts Dental Society members. The authors invited a random sample of more than 1,000 clinicians to participate in the survey. They assessed knowledge, attitudes and practices of respondents and performed a bivariate analysis of responses to questions by using statistical software.ResultsForty-nine percent of physicians reported performing an oral cancer examination in patients aged 40 to 55 years, compared with 92 percent of dentists (P < .001). For patients 56 years or older, 54 percent of physicians reported performing oral cancer examinations, compared with 93 percent of dentists (P < .001). More than 96 percent of physicians reported that they asked patients about smoking and alcohol use. However, only 9 percent of physicians and 39 percent of dentists were able to identify the two most common sites on which oral cancer develops (P < .001). Fifty-seven percent of dentists and 24 percent of physicians correctly identified the most common symptom of early oral cancer.ConclusionThis survey identified an existing gap in knowledge and practices among physicians and dentists and underscores the need to enhance oral cancer education among both professional groups.     

Information et consentement

Providing information for patients is a pre-requisite to obtain appropriate patient's consent for a research project or for health care. After having been fully informed, the patient can decide whether or not to participate in the suggested procedure. In a dentistry private practice context or for aesthetic surgery, the treatment contract reflects the specificity inherent in the fee-for-service system. Recognizing the place of the patient's consent is recognizing the right of patients to autonomy. Consent is a counter-weight to that medical paternalism which has long shackled patients in the inferior position of dominated/dominator relationships; it marks the end of medical imperialism. The consent, as based on the patient's autonomy, creates a new equilibrium in medical team/patient relationships. Law n^o 2002-303 of March 4, 2002, which deals with patients' rights and the quality of the health system, is a crucial text in terms of patient/care provider relationship.     

Teaching and assessing ethics and law in the dental curriculum.

The General Dental Council's recommendations on dental education places a new emphasis on the importance of ethics and law in the dental curriculum, stating that students should have an awareness of moral and ethical responsibilities involved in the provision of care to individual patients and to populations. The duties of care to protect a patient's life and health at all times, to respect their autonomy to make informed choices about what happens to them, and to do this fairly and without prejudice, are widely accepted as the fundamental ethical principles governing all health care. The specifics of these duties of care are detailed in Maintaining Standards: guidance to dentists on professional and personal conduct, published by the GDC.     

Ethical issues encountered by dentists in the care of institutionalized elders

Increasing numbers of Institutionalized elders have very poor oral health. It has been suggested that ethical problems may influence dentists who attempt to provide oral care for these people, but little attention has been given to research in this area. A qualitative Interview method was used to Investigate the views and experiences of dentists working with institutionalized elders. Particular attention was given to the ethical difficulties encountered and how the dentists resolved them. Ten dentists experienced in long-term care were interviewed individually by means of open-ended questions. Thematic analysis identified ethical problems focused on the difficulty of identifying the wishes of patients or predicting the outcome of treatment. The participants reported few difficulties in making clinical decisions in this setting. However, analysis revealed that the ethical perspectives of the dentists varied substantially. Variation was notable, particularly in their preference for ideal or practical treatment and in their preference for autonomy or beneficence.     

Dental Implants: A Role in Geriatric Dentistry for the General Practice?

BackgroundIn the general population, the use of dental implants has become a management strategy for replacing missing teeth. As part of the treatment plan for the aging population, general dentists should consider this treatment modality in their practices.OverviewThis study reviews specific issues concerning the aging population and tooth replacement therapies. Older people often desire to replace missing teeth, but they have complex medical, social, economic and resource issues that must be accounted for in their treatment plan. Dentists need to give careful attention to the patient-based assessment, diagnostic criteria and diagnostic steps to help the patient and family understand the strengths and challenges of each type of tooth replacement therapy. The author emphasizes the importance of careful evaluation and assessment of fixed versus removable implant–retained prostheses in the aging population.Conclusions and Clinical ImplicationsFor many general dentists, dental implants have become an increasingly common treatment option for missing dentition. With the population becoming increasingly older worldwide, the general dentist will be confronted with patients who have complex medical and social histories who desire tooth replacement therapy. The rational delivery of this oral health care will assist in providing a high quality of life for these patients.     

Treating patients with traumatic life experiences: Providing trauma-informed care

Background and OverviewDentists frequently treat patients who have a history of traumatic events. These traumatic events (including childhood sexual abuse, domestic violence, elder abuse and combat history) may influence how patients experience oral health care and may interfere with patients’ engagement in preventive care. The purpose of this article is to provide a framework for how dentists can interact sensitively with patients who have survived traumatic events.ConclusionsThe authors propose the trauma-informed care pyramid to help engage traumatized patients in oral health care. Evidence indicates that all of the following play an important role in treating traumatized patients: demonstrating strong behavioral and communication skills, understanding the health effects of trauma, engaging in interprofessional collaboration, understanding the provider's own trauma-related experiences and understanding when trauma screening should be used in oral health practice.Practical ImplicationsDental patients with a history of traumatic experiences are more likely to engage in negative health habits and to display fear of routine dental care. Although not all patients disclose a trauma history to their dentists, some patients might. The trauma-informed care pyramid provides a framework to guide dental care providers in interactions with many types of traumatized patients, including those who choose not to disclose their trauma history in the context of oral health care.