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RGO.Revista Gaúcha de Odontologia (Online)

versão On-line ISSN 1981-8637

RGO, Rev. gaúch. odontol. (Online) vol.60 no.2 Porto Alegre Abr./Jun. 2012

 

ORIGINAL / ORIGINAL

 

Influence of patient age on dentists' decision-making to extract or preserve a tooth

 

Influência da idade do paciente no processo de tomada de decisão de extrair ou manter um dente por cirurgiões-dentistas

 

 

Sérgio D'AVILA I; Pierre Andrade Pereira de OLIVEIRA II; Gigliana Maria Sobral CAVALCANTE I; Eliane Helena Alvim de SOUZA II; Arnaldo de França CALDAS JÚNOR II

I Universidade Estadual da Paraíba, Departamento de Odontologia. Rua Baraúnas, 351, Universitário, 58429-500, Campina Grande, PB, Brasil
II Universidade de Pernambuco, Faculdade de Odontologia. Recife, PE, Brasil

Correspondence:

 

 


ABSTRACT

Objective
The study examined the influence of patient age on the process of decision-making by dentists in keeping or extracting an extensively decayed tooth.

Methods
This is a cross-sectional study that used "case scenarios". The sample consisted of 81 general dental practitioners Campina Grande (Paraíba). They answered a two-part questionnaire, one containing their identification data and another to determine the treatment decision. The case scenario 1 presented a face photograph of a young patient and a photograph of an extensively decayed tooth. After presenting the case, the question was put: "In your opinion, what is the prognosis for this tooth? Would you extract or maintain the tooth? "After a minimum interval of one month, a second meeting was arranged and the case scenario 2 was presented: the photograph of the face of an elderly patient and the photograph of the same tooth, and the same question was asked. Data were entered on a SPSS software spreadsheet and the statistical analysis of association was carried out using the Chi-square test.

Results
The majority opted for greater preservation of the tooth of a young patient (95.1%) than in elderly patients (75.3%). However, the frequency of decisions to extract the tooth in a young patient was compared with the decision for the elderly patient and revealed a greater preservation of the tooth of the young one.

Conclusion
Patient's age influences the decision-making process for treatment by the dentist.

Indexing terms: Community dentistry. Decision making. Prejudice.


RESUMO

Objetivo
Verificar a influência da idade do paciente no processo de tomada de decisão por cirurgiões-dentistas em manter ou extrair um elemento dentário extensamente cariado.

Métodos
Trata-se de um estudo do tipo transversal com a utilização de "cenário de casos". A amostra foi constituída de 81 cirurgiões-dentistas que desenvolviam a atividade clínica em Campina Grande, Paraíba, e que responderam a um questionário com duas partes, uma contendo os dados de identificação e outro para determinar a decisão de tratamento. O cenário de caso 1 apresentava a fotografia da fisionomia do paciente jovem e outra fotografia do dente extensamente cariado. Após a apresentação do caso era feita a pergunta: "Em sua opinião, qual a conduta para esse elemento dentário? Extrairia ou conservaria o dente em questão?" Após o intervalo de um mês, era realizado um segundo encontro, sendo apresentado o cenário de caso 2: a fotografia da fisionomia do paciente idoso e a fotografia do mesmo dente sendo feita a mesma pergunta. Os dados foram lançados na planilha eletrônica do software SPSS e a análise estatística de associação foi feita através do Qui-quadrado.

Resultados
A maioria optou por maior preservação do elemento dentário do paciente jovem (95,1%) do que no paciente idoso (75,3%). Porém, ao compararmos as frequências da decisão de extrair o elemento dentário no paciente jovem com a decisão no paciente idoso podemos notar uma maior preservação do elemento dentário do jovem.

Conclusão
A idade do paciente influencia na tomada de decisão de tratamento do cirurgião-dentista.

Termos de indexação: Odontologia comunitária. Tomada de decisões. Preconceito.


 

 

INTRODUCTION

The definition of the word decision may be considered to be the resolution of a voluntary act which, after a period of evaluation, occasions the execution of an alternative found in a macrocosm of others. Meanwhile, the decision theory is the set of analysis methods and procedures which seeks to guarantee the coherence and effectiveness of the choices made, based on the information available1.

The process of clinical problem resolution is characterized by two big elements of decision-taking, which need to be analyzed separately, although in practice they cannot be separated. The first of these is the content, a knowledge base that resides in the memory banks of the professional in search of the solution to the problem, while the other is the method of applying the knowledge used in this attempt to resolve the problem in question2.

One of the key principles associated with the taking of good clinical decisions is the requirement to be scientifically accurate, since the application of an evidencebased approach has the potential to improve significantly the quality and efficiency of care3.

With the intention of assisting the professional to take decisions in specific clinical circumstances, parameters or guidelines have been developed. The use of these "clinical practice parameters", however, also has its limitations. Many of them are primarily based on the consensus of a select group of professionals, with limited scientific foundations. Other barriers to use include complexity, multiplicity, inflexibility and parameters that conflict with each other4-6.

Given the difficulties of the evidence-based approach, the majority of clinicians naturally draw on their personal experiences and the results they have achieved in their clinics, in order to formulate their own work philosophy3.

In dentistry, these dilemmas may also exist between the spirit of the principle and the descriptive spirit in the decision-taking process. According to the spirit of the principle, the job of the dentist to choose the ideal treatment for each patient requires a rational evaluation of the risks involved in a positive or negative decision, bearing in mind also that it may be important to take into account the values of the patient7-9.

Studies on the variation in dental treatment, although they may not focus on the factors associated with these variations, are important in showing that decisions made by dental surgeons about treatment are also not totally objective. Accordingly, these professionals are open to all the subjectivity and bias common to the decisionmaking process, including the social aspects10.

The aim of this study, therefore, was to ascertain the influence of patient age on the treatment decision process of the dental surgeon, whether to keep or extract an extensively decayed tooth.

 

METHODS

This study was carried out on dental surgeons in the municipality of Campina Grande, in the Brazilian state of Paraíba. The studied population comprised professionals carrying out general clinical duties in the city of Campina Grande. According to data obtained from the Paraíba Regional Dental Council, this comprises 543 duly enrolled professionals. Based on this figure, the sample size was calculated using the finite population formula. The minimum required sample size was 81 dentists.

This was a descriptive and quantitative study using a cross-sectional type design insofar as the "cause" and "effect" were analyzed concurrently. Nevertheless, this classical investigation typology had one specific characteristic: the study used a "case diagram", i.e. a clinical case presentation standardized by the investigator.

A draw was made using the listing supplied by the Paraiba Regional Dental Council, by way of simple sampling, with substitution in instances where the selected professional could not be located.

The classical cross-sectional study typology had one specific characteristic, since a "case diagram" was employed. These are already well-known in epidemiological research and have been used in the majority of specific decision-taking studies11. Used with the method employed by Cabral et al.10 it is regarded as a invaluable method, having the distinct advantage of controlling variables, it being permitted to analyze the extent to which they are responsible for differences in decision-taking12.

The study was submitted to and approved by the Research Ethics Committee at the Paraíba State University (CAAE 0091.0.133.000-05), together with a copy of the Free and Informed Consent form and the Image Donation Form of the actors taking part in the case scenarios, both of which conform to the standards of Resolution 196/96 issued by the National Health Council and the 2002 Helsinki Declaration.

Case scenario no. 1 contained the photograph of the face of a young patient and the photograph of an extensively decayed tooth. Then in case scenario no. 2, the photograph of an elderly patient was shown as well as the presentation of the same tooth shown in case scenario no. 1, although some of the intraoral characteristics of the photograph were digitally manipulated to depict the age of the elderly patient. The two case scenarios were presented to the dental surgeons at different times, with a time interval of at least one month so that the similarities could not be observed.

Upon the initial contact with the interview, we explained the reason, nature and relevance of the study to dentistry. The professional was told that the aim of the study was to identify factors connected with the decisions made by dental surgeons regarding treatment, when faced with the decision to extract or preserve a tooth. However, the professional was not informed about the emphasis placed on the characteristics of the patient's age

Thus the participation of the professional was requested and he/she signed the Free and Informed Consent Form. Then the interview began, using a twopart questionnaire: the first part identified the sociodemographic variables while the second was used to obtain the decision on the therapy.

We first presented case scenario no. 1: the photograph of the facial features of the young patient and another photograph of the extensively decayed tooth. Following the presentation of the case, the following question was asked: "In your opinion, what is the prognosis for this tooth? Would you extract or preserve the tooth in question?"

After a minimum period of one month, a second meeting was scheduled where case scenario no. 2 was presented, the same question being asked.

The data were input to an electronic spreadsheet belonging to the Statistical Package for Social Science (SPSS) program in order to ascertain the frequency of the results and significant associations between the dependent variable and the independent variables via the Chi-square test

 

RESULTS

For the most part, the sample was composed of the female sex (72.8%); Caucasian (66.7%); working purely as general practitioner (64.2%); without post-graduation course (61.7%); age below 35 years (59.3%); graduated within last 10 years (59.3%); income of up to 8 minimum salaries (58.0%); marital status, single (50.6%); average time spent per patient of up to 20 minutes (44.4%) as shown in Table 1.

The majority of the dental surgeons in the study chose to keep the tooth in both patients, though the decision to extract was made more in the case of the elderly patient (24.7%) than in the young patient (4.9%) as per Table 2.

From the associations between the dependent variable (treatment decision) and the independent variables (socio-demographic characteristics of the dental surgeon), tested using Pearson's Chi-square test, it can be seen that there was an association between the qualifications of the dental surgeon and the taking of the decision to extract the tooth in the elderly patient (p= 0.002). Of those professionals who had a post-graduate degree (specialization, masters or doctorate), 6.5% chose to extract the tooth in the elderly patient versus 36% for professionals who only had an undergraduate course degree (Table 3).

A significant association was also found between the age of the professional and the decision to extract or preserve the tooth in the young patient (p=0.011), where the majority of professionals opting to extract were in the 36 to 45 age range (Table 4).

 

 

 

 

 

 

 

 

 

DISCUSSION

The Regional Dental Council12 confirms that in Brazil, 45.3% of dental surgeons are male and the majority (54.7%) are female. The Northeast region tracks this tendency for the predominance of the female sex, while the federal state having the largest concentration of female dental surgeons is Paraíba, with a total percentage of 68.32%.

As regards the sex of those investigated, the majority of the sample was composed of females (72.8%), corroborating the work of Cabral et al.10. The opposite situation was found in a study by D'Avila et al.13.

In relation to the color of those interviewed, 66.7% stated they were white, the same results being found in other studies10.

As far as the time since graduation is concerned, 59.3% had graduated within the previous 10 years, contrary to that found in another study14 where the majority of those interviewed had been qualified for over 20 years.

With regard to the place where their clinical activities were performed, the profile found was roughly equal, with 1/3 in each of the options: only private service, only public service or both services. In other studies, however, activities were predominantly carried out in the private sector15-16, unlike the study by Pinheiro et al.16, where the predominance was in the public sector.

Turning to the specific case of the decision on whether to extract or preserve a tooth, there is a consensus that tooth extraction is not recommended until all other possibilities to salvage the teeth have been exhausted17-18.

In all the dental surgeons investigated in this study, a preoccupation with not extracting the tooth was noted, the vast majority opting to preserve the tooth, regardless of the patient's age, though when we compare the frequencies of the decision to extract the tooth in the young patient with that in the elderly patient, we can detect a higher degree of preservation of the young person's tooth.

In this decision on whether to extract or preserve, it was seen that the characteristics of the patient, particularly age, had an influence on the decision taken by the professionais11.

One would normally expect that health professionals, and they would also expect this of themselves, would not be affected by the social or demographic characteristics of the patient whenever the latter is in need of a final decision19.

Research into social categorization and stereotyping suggests, however, that these expectations are not realistic. People make judgments about categories or groups of people and extrapolate these judgments to all individuals mentally assigned to that category or group20. In the study by D'Avila et al.13, it was found that 70.7% of those interviewed demonstrated interference through first impressions, which is quite common behavior amongst human beings.

There is evidence that the characteristics of the patient, the professional and the work also specifically influence the treatment decision by the dental surgeons21.

When a study was carried out analyzing the influence of the ethnicity of the patient on the decisions by the dental surgeons to extract or preserve an extensively decayed tooth, it was found that there is a significant shift in the decisions taken by the professionals between white patients and those of African origin, such that they decided to extract more frequently when the patient was of African origin than when the patient was white (25.6% vs. 16.2%)10.

When Dolan et al.22 submitted to the clinical dental surgeons case diagrams identical to those of a partially toothed patient, with just a difference in the patient's age, the dentists' plan of treatment for the case (limited treatment vs. extensive treatment) was associated significantly with the patient's age.

As the studies suggest, attitudes and expectations associated with the social identity of the patient can shape the evaluation and response of the professional towards the patient's clinical problems. Doctors prefer to treat younger people, while they harbor negative images of elderly patients23-24.

Another important point to stress is the professional qualification as a bigger influence on the decision to preserve the tooth. There is evidence that, with professionals who have taken a post-graduation course (specialization, masters or doctorate), the tendency to opt for conservative treatment is increased.

D'Avila et al.13 believe that under any hypothesis, choices should be guided by respect for human dignity and there should be no discrimination of people in the healthcare services by virtue of race, sex, age or socioeconomic condition and, if selection criteria do exist, they should be transparent and acceptable to professionals and society alike.

Based on the findings above, it is extremely important that, in the relationship between patient and the professional who is treating him/her, there should be a relationship of humanization, this being an essential part of the process of professional qualification of the dental surgeon, as well as in the professional's daily practices25.

 

CONCLUSION

Despite the fact that the overriding philosophy is to preserve teeth, the age of the patient is a factor which influences the dental surgeon in the process of taking decisions on treatment.

Collaborators

S D'AVILA took part in the project conception, data analysis and composition of the article. PAP OLIVEIRA gathered the pilot project data, made adjustments between the pilot and the study, took part in the gathering of data and the composition of the article. GMS CAVALCANTE took part in the gathering of data, analysis of results and the composition of the article. EHA SOUZA took part in the project conception, analysis and discussion of the data, and the composition of the article. AF CALDAS JÚNIOR took part in the revision and composition of the article.

 

REFERENCES

1. Campolina AG, Ciconelli RM. Qualidade de vida e medidas de utilidade: parâmetros clínicos para as tomadas de decisão em saúde. Rev Panam Salud Pública. 2006;19(2):128-36. doi: 10.1590/S1020-49892006000200013.         [ Links ]

2. Area-Neto AR. Raciocínio clínico: o processo de decisão diagnóstica e terapêutica. Rev Assoc Med Bras. 1998;44(4):301- 11. doi: 10.1590/S0104-42301998000400009.

3. Mathews SC, Pronovost PJ. Physician autonomy and informed decision making: finding the balance for patient safety and quality. JAMA. 2008;300(24):2913-5. doi: 10.1001/ jama.2008.846.

4. Gordan VV, Garvan CW, Richman JS, Fellow JL, Rindal DB, Qvist V, et al. How dentists diagnose and treat defective restorations: evidence from the dental practice-based research network. Oper Dent. 2009;34(6):664-73. doi: 10.2341/08-131-C.

5. Shugars DA, Bader JD. Practice parameters in dentistry: where do we stand? J Am Dent Assoc. 1995;126(8):1134-43.

6. Savoie I, Kazanjian A, Basset K. Do clinical practice guidelines reflect research evidence? J Health Serv Res Policy. 2000;5(2):76- 82.

7. Kay EJ, Nuttall NM. Clinical decision making - an art or a science? Part II: making sense of treatment decisions. Br Dent J. 1995;178(3):113-6.

8. Kay EJ, Nuttall NM. Clinical decision making - an art or a science? Part IV: assessing risks and probabilities. Br Dent J. 1995;178(5):190-3.

9. Sutherland SE. The building blocks of evidence-based dentistry. J Can Dent Assoc. 2000;66(5):241-4.

10. Cabral ED, Caldas Jr AF, Cabral HAM. Influence of the patient's race on the dentist's decision to extract or retain a decayed tooth. Community Dent Oral Epidemiol. 2005;33(6):461-6. doi: 10.1111/j.1600-0528.2005.00255.x.

11. McKinlay JB, Potter DA, Feldman HA. Non-medical influences on medical decision-making. Soc Sci Med. 1996;42(5):769-76. doi: 10.1016/0277-9536(95)00342-8.

12. Conselho Federal de Odontologia. Pesquisa revela novo perfil do CD. J Cons Reg Odontol. 2003;10(52):6-7.

13. D'Ávila S, Rago E, Maia AMA, Caldas Junior AF. Escolha de paciente: quais os critérios adotados? Rev Ciênc Méd. 2006;15(5):399-406.

14. D'Ávila S, Oliveira PAP, Lucas RSCC, Souza EA. Assistência odontológica x plano de saúde: um estudo em Campina Grande, Paraíba, Brasil. Pesqui Bras Odontopediatria Clín Integr. 2007;7(3):259-63.

15. Conselho Regional de Odontologia de Santa Catarina. Perfil dos cirurgiões-dentistas de Santa Catarina e expectativas em relação ao CRO. Florianópolis: Conselho Regional de Odontologia de Santa Catarina; 2002.

16. Pinheiro VC, Menezes LMB, Aguiar ASW, Moura WVB, Almeida MEL, Pinheiro FMC. Inserção dos egressos do curso de odontologia no mercado de trabalho. RGO - Rev Gaúcha Odontol. 2011;59(2):277-83.

17. Artigas PID, Oliveira EA, Pereira Júnior FB, Sardinha SC, Andrade MG. Investigação de fatores que limitam a autonomia de pacientes do SUS no processo de decisão de sua integridade bucal. Rev Ciênc Méd Biol. 2007;6(3):316-23.

18. Vargas AMD, Paixão HH. Perda dentária e seu significado na qualidade de vida de adultos usuários de serviço público de saúde bucal do Centro de Saúde Boa Vista, em Belo Horizonte. Ciênc Saúde Coletiva. 2005;10(4):1015-24. doi: 10.1590/ S1413-81232005000400024.

19. van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians' perceptions of patients. Soc Sci Med. 2000;50(6):813-28. doi: 10.1016/S0277-9536(99)00338-X.

20. Andersen SM, Klatzky RL, Murray J. Trains and social stereotypes: efficiency differences in the social information processing. J Pers Soc Psychol. 1990;59:192-201.

21. Kay EJ, Blinkhorn AS. A qualitative investigation of factors governing dentists treatment philosophies. Br Dent J. 1996;180(5):171-6.

22. Dolan TA, Clifford AM, Davidson SN, Mitchell GS. Patient age and general dentists' treatment decisions. Spec Care Dentist. 1992;12(1):15-20.

23. Johnson SM, Kurtz MF, Tomlinson T, Howe KR. Students stereotypes of patients as barriers to clinical decision-making. J Med Educ. 1986;61(9 Pt 1):727-35.

24. Cankurtaran M, Halil M, Ulger Z, Dagli N, Yavuz BB, Karaca B, et al. Influence of medical education on students attitudes towards the elderly. J Natl Med Assoc. 2006;98(9):1518-22.

25. Canalli CSE, Gonçalves SS, Chevitarese L, Silveira RG, Miasato JM. A humanização na Odontologia: uma reflexão sobre a prática educativa. Rev Bras Odontol 2011;68(1):44-8.

 

 

Correspondence to:
S D'AVILA
e-mail:
davila2407@hotmail.com

 

Received on: 9/5/2011
Final version resubmitted on: 2/8/2011
Approved on: 1/9/2011