Teenager Requesting Elective Extraction of a Sound Premolar
A 15-year-old boy attends with his mother requesting removal of a sound, fully erupted upper left first premolar (UL4) because 'it sticks out' and he is unhappy with his smile. He is in the middle of active orthodontic treatment with fixed appliances and his orthodontist has not been consulted. He is fit and well, takes no medication, and has no allergies. His mother supports the request and says she has read about 'extraction for crowding' online. On examination, UL4 is sound, in occlusion, and the upper arch shows mild crowding. His orthodontist is due to review him in six weeks.
1. Should you extract the tooth today? Justify your answer with reference to consent, orthodontic planning, and the principles of elective extraction.
Read the worked answer
No - do not extract today.
Reasons:
- Orthodontic planning - extraction of a premolar is an irreversible, space-altering decision that must be made by the treating orthodontist as part of an overall plan. Extracting UL4 in isolation could compromise the orthodontic result, create asymmetry, or remove a tooth the orthodontist intended to use for anchorage or alignment.
- Consent - at 15 he is Gillick-competent in principle, but this is an elective, irreversible procedure with aesthetic and functional consequences. Both he and his mother need to understand the alternatives (orthodontic alignment, composite build-up, accept the appearance). A request based on an online article is not informed consent.
- Sound tooth - extracting a healthy tooth for appearance alone is a last resort; conservative options should be explored first.
- Communication - contact the orthodontist before any decision; the six-week review is imminent.
Action: explain the risks and alternatives, decline to extract today, and arrange a joint discussion with the orthodontist. Document the refusal and the reasons.
2. How would you structure the conversation with the boy and his mother, and what would you do if they insisted on extraction?
Read the worked answer
Structure the conversation:
- Explore the concern - what specifically bothers him? Is it the position of the tooth, the crowding, or something else? Use open questions.
- Explain findings - the tooth is healthy; removing it will not necessarily improve the smile and may worsen the orthodontic outcome.
- Explain the process - orthodontic decisions about extractions are made with the full plan in mind; his orthodontist needs to be involved.
- Present alternatives - orthodontic alignment, cosmetic options, or simply waiting to see the orthodontist's view.
- Check understanding - teach-back; confirm both he and his mother understand.
- Document - the discussion, the decision, and the plan to liaise with the orthodontist.
If they insist:
- You are not obliged to carry out a procedure you believe is not in the patient's best interests. Explain that you will not extract a sound tooth without orthodontic input.
- Offer a second opinion or referral to the orthodontist or a colleague.
- Maintain the relationship - do not be dismissive; acknowledge his concerns.
- If he remains unhappy, arrange the orthodontic review sooner rather than later.