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Ethical Issues for Consent in Dentistry

Posted on 24. May, 2014 by .

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An article appears in the Journal of Medical Ethics, vol. 39, pp. 59-61, January 2013, titled “Consent in dentistry: ethical and deontological issues,” written by Adelaide Conti, Paola Delbon, Laura Laffranchi, and Corrado Paganelli. The authors are from Italy and so the focus of the article is a discussion of some of the ethical issues in dentistry. I have previously discussed some ethical issues in medicine and dentistry. See for example, Attending to the Patient in the Informed Consent Process and Are Dentists Ethical or Scam Artists?.

In the article the authors say

“The right of patients to make decisions about their healthcare has been enshrined in legal statements: in Italy the National Constitution establishes that personal liberty is inviolable and that no one may be obliged to undergo any given health treatment except under the provisions of the law…In addition, the Charter of fundamental rights of the European Union and the Council of Europe’s ‘Convention on human rights and biomedicine’ establish the general rule of free and informed consent in the health field.”

The authors touch on how it is possible that some treatment options provided by dentists may be considered a disfigurement in some cultures but a sign of beauty in another culture. Hence, it is possible that some scientifically sound treatment approaches could potentially harm personal values.

The authors further touch on informing a child or incompetent adult and essentially argue that a child should be consulted and the degree of information exchanged should be based on their cognitive abilities.

The authors end the article by saying

“In summary, ‘it is not the written word but the interaction between dentist and patient … the foundation of informed consent’ that ‘should not be looked on as a legal necessity and a duty, but rather as a virtue of good dental practice’ and, according to us, a knowing synthesis of kindness of practitioners to take ‘care’ of understanding of the patient without prejudice, tailoring to adequately inform every unique person.”

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Patient Safety and the Culture of Cover-Up

Posted on 17. May, 2014 by .

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An interesting article was written by George Lundberg titled “A culture of cover-up has slowed the patient safety movement” on December 1, 2012, on KevinMd.com located at http://www.kevinmd.com/blog/2012/12/culture-coverup-slowed-patient-safety-movement.html.

In the article Dr. Lundberg says

“Promoting patient safety, preventing medical error, preventing physician error, preventing errors in diagnosis, preventing nurse error, preventing surgical error, preventing communication error, preventing health illiteracy error, preventing errors from language barriers, preventing laboratory error, preventing computer error, preventing patient mix-ups, preventing right and left side of body mix-ups, preventing mistakes, since mistakes are the stepping stones to failure.

Recognizing human frailty, recognizing physician humanity, recognizing system fallibility, owning up to problems, eliminating cover-up, acting out professionalism, recognizing that professionalism means self governance, individually and as groups.

Self criticism, peer criticism, a culture of peer review, honesty, truth, disclosure, fairness, and negotiated settlements.

Objective evaluation and commitment to quality. Quality improvement by preventing error. Systematic error, systematic prevention of error. An error caught before an action is taken based upon that error is, in effect, not an error.

These are the fundamental truths that the patient safety movement is all about.”

Dr. Lundberg later says

“However, sad to say, improvement in documented actual patient safety has lagged grotesquely. Part of that retardation can be blamed upon a continuing culture of cover-up.”

Dr. Lundberg mentions a program recently explored by the Agency for Healthcare Research and Quality (AHRQ). I have discussed AHRQ before see for example Tips to Prevent Medical Errors – AHRQ.

As outlined in the article “AHRQ Seeks To Help Patients Report Adverse Medical Events” from September 24, 2012, located over at http://www.ihealthbeat.org/articles/2012/9/24/ahrq-seeks-to-help-patients-report-adverse-medical-events.aspx. The AHRQ is currently looking into a system that would allow patients to report such things as medical errors and harms to the federal government. This is an interesting development, however, the issue of malpractice liability needs to be addressed. Certainly physicians have concerns about being sued if a patient suffers a potential error.

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Blood Levels in Fat Cells May Help Predict Migraine

Posted on 10. May, 2014 by .

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A new study appearing in the journal Headache: The Journal of Head and Face Pain, looks at people experiencing two to twelve migraine headaches a month. In this study researchers found that measuring a fat-derived protein called adiponectin before and after migraine treatment is useful in revealing if headache patients felt pain relief or not. The researchers of the study are hopeful that finding this potential biomarker for migraine of adiponectin may be used for developing new and better migraine treatment options.

Finding better treatment options for migraine sufferers is lucrative because roughly 36 million Americans suffer from migraine headaches which can last longer than 4 hours at a time. Women are three times to get migraines when compared to men.

In the study the researchers collected blood from 20 women who visited 3 different headache clinics for an acute migraine attack during a period of a few years. The women had their blood taken before treatment with sumatriptan or naproxen sodium or a placebo. The researchers drew blood at 30, 60, and 120 minutes after the drug was given. The researchers then looked at blood levels of adiponectin along with two subtypes or fragments of total adiponectin in circulation: 1)  low molecular weight (LMW)-adiponectin and high molecular weight (HMW)-adiponectin.

The researchers found that when all 20 women in the study had levels of LMW that increased, the severity of their pain decreased.  Further, when the ratio of HMW to LWM increase, the pain severity increased. The researchers believe that reducing levels of adiponectin or targeting the 2 subtypes of adiponectin may be a useful strategy for a new medication that can be helpful for those who suffer from migraine.

Of course also looking at potential other causes for LMW to increase can also be useful for migraine suffers.

Source: B. Lee Peterlin, Gretchen E. Tietjen, Barbara A. Gower, Thomas N. Ward, Stewart J. Tepper, Linda W. White, Paul D. Dash, Edward R. Hammond, Jennifer A. Haythornthwaite. Ictal Adiponectin Levels in Episodic Migraineurs: A Randomized Pilot Trial. Headache: The Journal of Head and Face Pain, 2013; 53

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Ingestion of Foreign Body During Dental Procedures

Posted on 03. May, 2014 by .

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In the complications of wisdom teeth page on this site http://www.teethremoval.com/complications.html I have discussed cases of teeth being displaced into various places of the body. A tooth can also either be aspirated and end up in the respiratory tract or ingested and likely pass several days after being swallowed. Dental instruments can also break off during surgery and end up in various places of the body.

Some recent studies and cases have emerged for other dental procedures where foreign bodies were ingested. An article titled ” Precautions for accidental ingestion of a foreign body,” appears in J Can Dent Assoc 2013;79:d5, located over at http://www.jcda.ca/article/d5. This article describes a case where a 58 year old man underwent treatment for a dental crown and accidentally ingested a 20 mm stainless steel post intended to support the prosthesis. An imaging study revealed the post in the mid-abdomen and the patient, since he was not in distrust, was told to monitor for it to be passed. The patient never saw the post pass in his GI tract but subsequent imaging studies did not reveal it so it is presumed to have passed. This of course, opens up the possibility that maybe there is a better way to monitor a foreign body if it has been ingested to make sure it passes in the GI tract. This article cites another study conducted in 2011, Obinata K, Satoh T, Towfik AM, Nakamura M. An investigation of accidental ingestion during dental procedures. J Oral Sci. 2011;53(4):495-500.

This article presents 23 cases of accidental ingestion of foreign bodies occurring during dental procedures at the Center for Dental Clinics of Hokkaido University Hospital between 2006 and 2010. The authors found that most cases occurred when practitioners had less than 5 years of experience. Some of the cases of accidental ingestion presented include a scaler tip, a metal core, a metal crown, a metal onlay, and a bur. Three (3) of the 23 cases had to be retrieved by endoscopic procedures whereas the remaining 20 cases of passed through the GI tract within 10 days with no adverse events. It appears one case involved a wisdom tooth but it is not clear if it was being extracted or some other type of treatment was performed.

The authors mention that the incidence of accidental ingestion during dental procedures was found to be 0.0041% and 0.0044% at 2 prior dental colleges in Japan. In this study the number was found to be 0.0037% (case/patients) per year of accidental ingestion.  The authors state

“Moreover, the occurrence (cases/dentists) per year was 0.018, being very close to the figure of 0.021 reported from 2 French insurance companies representing 24,651 French general dental practitioners over an 11-year period (1994-2004).”

Near the end of the study the author state

“In the treatment of molars, the present authors suggest inclining the head of the patient to one side to help catch objects in the buccal pouch. However, the best countermeasure is still meticulous care to fix burs tightly and to use dental instruments in the properly prescribed way. Additionally, practitioners can make patients aware of the possibility of dental objects dropping in such cases, and instruct them to spit out any dropped objects.”

It appears that more foreign bodies are accidental ingested than aspirated. Further, most foreign bodies that are accidentally ingested are safely passed through the GI tract with 7 to 10 days.

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Is Creative Diagnosis on the Rise in Dentistry?

Posted on 26. Apr, 2014 by .

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A very interesting MyView column by the American Dental Association (ADA) is titled “Creative Diagnosis” by Jeffrey Camm, D.M.D. located over at http://www.ada.org/9151.aspx and published October 21, 2013. In the column the author touches on an issue he faces as a dentist where he has patients who have seen other dentists who were likely unethical in their treatment (and treating when it is not warranted) – a term he calls creative diagnosis. Of course one can ask, what is the motivation for creative diagnosis and one would answer money and staying afloat.

Essentially the author describes several cases he has dealt with at his practice:

  1. A 16 year old patient who graduates from his pediatric practice and sees a new dentist who then says she has 16 cavities. The patient and her mother of course are upset and he reviews her teeth. He then asks 5 other dentists to review the radiographs and finds a diagnosis of between 0 and 4 cavities. (suggesting the new dentist was practicing creative diagnosis)
  2. In another case he sees a 2 year old who comes in with a full mouth series of radiographs. He says a child that young has no business having a full mouth series. (suggesting the other dentist was practicing creative diagnosis)
  3. He also describes how his practice gets a lot of referrals for general anesthesia and second opinions on anesthesia. However, in many of these cases he doesn’t agree with the treatment plan as the patients have minimal or no decay. (suggesting possible creative diagnosis and difference of opinion in treatment)

The author further states

“The difficult task for me with all this creative diagnosing is trying to explain to the parent why my treatment plan is hundreds (thousands?) of dollars different than someone else’s treatment plan. I can only cover up so much with my explanation of different treatment criteria, sharper explorers, conservative vs. more aggressive therapy, blah, blah, blah.”

In another post I have touched on whether or not dentists are ethical, see http://blog.teethremoval.com/are-dentists-ethical-or-scam-artists/. It seems to be the case that some dentists are not being ethical and this can’t be explained by either a more conservative or more aggressive treatment, it simply is a matter of economics. However, in other cases some dentists do disagree on certain aspects of care particularly with regards to how many cavities are present. The take home message for patients seems to be, it is beneficial to get several opinions on any treatment plans you are suspicious or have hesitations about. It is also useful to do some research online or elsewhere if able. Of course, seeing several dentists to decide on a treatment plan is not covered under usual aspects of normal care. It seems like it should be…

Further, many dentists are facing financial pressures due to increasing student loans. For example see the post http://blog.teethremoval.com/lets-give-our-kids-a-chance-to-succeed/. It is important that these loans do not continue to increase substantially in the future so that dentists in the future are not further pressured into even more creative diagnosis. This does not benefit patients.

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