Journal of Endodontics, 41:12, 1985-1990, 2015 A. Azarpazhooh, C. Quinonez
Patient autonomy has received more emphasis in the last 20 years as we, in Dentistry, have moved from an authoritative to collaborative model of clinical decision making. The Canadian Dental Association’s Patient Charter of Rights, not to mention the legal profession, has clearly described the process and information that the dental community must create and communicate to the patient for informed consent to occur.
One such decision-making dilemma occurs when a patient is diagnosed with apical periodontitis (AP). Treatment plans usually would include retaining the tooth with conventional or surgical endodontics, extraction of the tooth with replacement with fixed or removable partial dentures, an implant retained crown, or simply leaving the space edentulous.
Recent patient surveys in Ontario clearly show that the majority of patients prefer to save a tooth with AP with conventional root canal treatment or retreatment. Not surprisingly, the desire to retain a tooth is highly correlated with family income. Other corroborating research shows that available disposable income and dental insurance plans increase dental care use by reducing financial barriers to treatment. While 69% of Canadians have some form of dental insurance, a significant and growing proportion remain uninsured (31%).
While the economic health of the “middle class” has received a lot of attention recently from both Federal and Provincial politicians of all stripes, the group of Canadians described as the working poor (WP) often slide under the radar. WP are defined as non-student individuals, age 18-64, who work a minimum of 910 hours (part-time) and have a family income below $34,300 – the Market Basket Measure for low income.
In 2011, Employments and Social Development Canada estimated that 6.4% (1,289,000) of Canadians with an average income of $18,324 fell within the WP category. This population not surprisingly experiences significant barriers in accessing dental care as job place dental insurance is usually lacking and they earn too much to be covered for dental care under public funding.
Some might assume that WP Canadians would prefer extraction rather than tooth preservation and restoration when they have a toothache because of either lack of enabling resources or a relatively low motivation to retain such teeth.
Azarpazhooh and Quinonez, JOE 41:12, 2015, designed a study to determine the actual preference of WP Canadians when confronted with a tooth with AP. The authors conducted a telephone interview of 1049 people who fell into the WP category. 47% of respondents had some dental insurance coverage through their employer while 50% paid for dental care out of pocket. 90% had never received dental care through social assistance.
40% of study participants had a full dentition, and 58% were partially dentate. The majority of partially dentate individuals did not have removable dentures. 25-30% of the group reported that dental issues affected their quality of life.
The authors found that 85% of WP Canadians would rather retain and treat their aching tooth rather than have it extracted. The 15% who preferred extraction were usually >55, paid for their dental care out of pocket, only saw a dentist when in pain, previously had teeth extracted, and perceived their oral health not better than satisfactory.
The take home message for the dental profession is that we must take the time to inform and explain the diagnosis, treatment that is recommended, the alternative treatments possible, as well as attendant costs and risks associated with each treatment to all patients without prejudgment based on how people look, talk or act. Often the patient throws the choice back to us with “I understand but what should I do?” An appropriate response is what we as a dental professional would recommend for ourself or our own family member in the same situation. Sometimes we need to be creative in our treatment planning to accommodate our patient’s desire to save their tooth. For instance, on posterior teeth needing RCT, it is standard to recommend a full coverage crown to protect the tooth. A number of studies show that a cusp protected restoration, either amalgam or composite, can achieve this goal almost as effectively as a crown while reducing costs significantly. After 30+ years in Dentistry, I still am often surprised by what patient’s choose on both sides of the tooth retention question.
Dr. Howard Bittner, DMD, CAGS
About the Author, Dr. Howard Bittner, DMD, CAGS
Dr. Bittner was born and raised in the Surrey / Langley area. Following his pre-dental training at Simon Fraser University, he received his Doctor of Dental Medicine from the University of British Columbia in 1982 and his Certificate in Advanced Graduate Studies in Endodontics from Boston University’s Goldman School of Dental Medicine in 1995.
Dr. Bittner was in private practice in general dentistry for 11 years in Langley before his Endodontic specialty training. He has been practicing Endodontics since 1995.
In his free time, Dr. Bittner loves to participate in a variety of sports including most recent, golfing! He also enjoys being a grandfather to 4, which if you ask him is just the best!