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So wisdom teeth are also known as third molars but did you know that there are also fourth molars in a small subset of patients?

A recent study was performed by the United States at an Air Base in Japan which is currently in press to appear in the Journal of Oral and Maxillofacial Surgery titeld Prevalence and Management of Fourth Molars: A Retrospective Study and Literature Review by Khurram M. Shahzad and Lawrence E. Roth, 2011.

In the study conducted 409 patients were referred for a third molar (wisdom teeth) consultation. Two of 227 white patients (0.9%) had a fourth molar and 6 of 94 black patients (6.4%) had a fourth molar. One of the other 84 patients (1.2%) also had a fourth molar.

Of these patients with a fourth molar 5 out of 9 (55%) had only 1 fourth molar and 4 out of 9 (45%) had 2 fourth molars. In 7 of the 9 (78%) of the patients the fourth molars were in the maxilla (upper) and in 2 of the 9 patients (22%) the fourth molars were in the mandible (lower). No patients had fourth molars in both the maxilla and mandible.

All of the mandibular (lower)  fourth molars were found to be smaller than the mandible (lower) wisdom teeth but similar in their shape. While the maxillary (upper) fourth molars were smaller than the maxillary (upper) wisdom teeth but appeared with a peg shape which did not represent the shape of the wisdom teeth.

The prevalence in this study of fourth molars was 2.2% and this is similar to the prevalence found from a few other studies were it was between 1% and 2%.

The authors recommend:

“The presence of fourth molars as well as the risks and benefits of extraction versus observation should be discussed with the patients and an individualized treatment plan should be fabricated.”

The authors comment that fhe fourth molars have a possibility of being displaced in the infratemporal fossa or the maxillary sinus during surgery and note that this is more likely to occur if the bone distal to the fourth molars is thin. (Note these are known complications of wisdom teeth removal as discussed on the complications page http://www.teethremoval.com/complications.html)

The authors of course recommend that each patient should have a panoramic x-ray and/or computerized tomography performed.

The authors also say it is even possible to remove a third molar (wisdom tooth) and leave the fourth molar in place which may allow the fourth molar to migrate down and after some time (a few years) a safer extraction can be performed.

Of course the risks of leaving a fourth molar are similar as leaving a third molar (wisdom tooth) for observation http://www.teethremoval.com/risks_of_keeping_wisdom_teeth.html

Below I have added the 2 panoramic radiographs that are in the journal article and I have added some labels for the fourth molars.

Looking at these x-rays removing a fourth molar appears to be even more risky than removing a third molar (wisdom tooth), so hopefully you are fortunate enough to not have a fourth molar.

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Earlier this year over the summer an article appeared in the Journal of Oral and Maxillofacial Surgery discussing the attitudes of program directors and residents toward performing research during residency. I commented on this article here http://blog.teethremoval.com/the-lack-of-importance-of-research-in-oral-and-maxillofacial-surgery-residency-programs/

A new article has appeared in the Journal of Oral and Maxillofacial Surgery written by Dr. James R. Hupp titled Research During Residency – Should it be Mandated? (vol. 69, pages 2685-2687, 2011). In the article is a discussion of research and whether or not it should be performed by oral surgeons in residency.

Dr. Hupp discuses his own experience with research work and then questions if the current accreditation standards require all Oral and Maxillofacial Surgery residents to do research. He says:

“Now the question becomes, should our standards require all residents to have the opportunity to conduct research and, in my mind, also to learn how to communicate the findings of their research. This is indisputably important for residents planning an academic career. However, how does conducting research during training benefit a resident planning to enter private or institutional clinical practice? Perhaps many more residents should be exposed to research which, ultimately, might lead them to pursue an academic career.”

Dr. Hupp raises some interesting points of some other ways a resident can acquire critical thinking skills without necessarily conducting research. These include

1. Hospital and clinic teaching rounds
2. Grand rounds
3. Quality improvement conferences
4. Tumor boards
5. Interdisciplinary conferences
6. Mock boards

Dr. Hupp further states that another important strategy to improve one’s ability to evaluate scientific evidence and review the published data is to hold journal clubs. In these meetings residents will review assigned articles and then discuss the findings with other residents and faculty.

Dr. Hupp goes on to say:

“In the end, I am having trouble throwing my full support behind requiring all residents to perform research. I am more comfortable requiring that all participate in some scholarly activity and being provided the time and faculty support for the activity.”

At the end of the article is a comment about how OMS departments in the U.S. have a low number of residents participating in research and how steps are being put in place to address this.

I tend to think all residents should have at least a little experience with performing research work but that is because I like to do a lot of different things myself. There is only so much time in each day so somehow having certain residents being more skilled at different areas within the specialty may be in the best interest of the public.

There are also some wise words that appear in the article by Dr. Hupp

“ The stewardship side of me says people having had the advantage of being highly educated need to find ways to use that education for the greater good of society. Furthering human kind’s understanding of our world, particularly as it relates to health, is a valuable endeavor in and of itself”

I have previously commented on this post http://blog.teethremoval.com/lets-give-our-kids-a-chance-to-succeed/ about how lately there is a trend towards more students to pursue careers in the financial industry which quite frankly doesn’t create any real value for society. I challenge any smart, motivated, and talented individuals who may be reading this post or know of someone who meets this criteria to consider a career in healthcare and particularly in dentistry and/or oral surgery (although of course for the right reasons).

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There is an interesting series over at QuantiaMD on Managing the Difficult Patient. Presentations are available for viewing as long as you sign up for with your email. One such presentation was originally called The Patient Who Knows too much but has been changed to The Cyberchondriac. http://quantiamd.com/player/wywzswwh?courseid=31844

Mary Modahl  who is QuantiaMD Chief Communications Officer said after the original title was added

 ”‘The Patient Who Knows Too Much’ is a very poor title. Certainly a patient can never know too much. In every way, we’re supportive of doctors meeting their patients’ need for care.”

Dr. Joseph Scherger, vice president for primary care at Eisenhower Medical Center in Rancho Mirage, California, defines a Cyberchondriac in the presentation:

“This is a patient who is on the internet…indiscriminate with the material they are reading…they consider themselves an expert yet often their true medical knowledge is limited…they are pushing you to do things based on their information.”

Dr. Scherger takes a jab at Cyberchondriacs and says

“…sometimes these patients are very overweight, they are on the internet all the time…”

He also says that if a patient is going to bring in a stack of materials from the internet they should send it in advance and not just expect the doctor to have the time to go over everything and check the sources at the visit.

One of the problems in the presentation discussed by Dr. Gerald Hickson, director of the center for patient professional advocacy at Vanderbilt University School of Medicine, is how a patient may see a medical doctor and then go see a subsequent provider. This subsequent provider may engage in jousting and being critical of the other doctor and possibly even suggest they take legal action. He urges physicians to not be so critical of other providers as they may not know all the information.

I often question the quality of information found on the internet and know that it can be extremely difficult to learn what the truth is even if the source is reputable as I have discussed in some detail here http://blog.teethremoval.com/why-people-who-google-and-search-online-for-health-information-just-dont-get-it/

Source: http://www.fiercehealthcare.com/story/can-difficult-patient-know-too-much/2011-07-08

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A few days ago an article titled “Do I Really Need to Remove My Wisdom Teeth? appeared in Community Magazine by Jacques Doueck located at http://www.communitym.com/article.asp?article_id=101936 

The article opens with

“I was prompted to write this article because of two adult patients who suffered severe damage, infection, and swelling because they delayed taking out wisdom teeth. One of them actually broke his jaw because of a wisdom tooth that should have been removed long ago. The patient, 48 years old, lost both teeth and the fractured jaw forced him to eat baby food for six months. The other patient was 65 years old and had to have the wisdom tooth and the adjacent molar removed.”

This opening in this article kind of cracks me up because both of these patients are quite old, especially the 65 year old.

Of course we could go back and forth all day with between cases like the above and cases of young healthy individuals such as myself who had there wisdom teeth removed at a young age and then had lasting pain and problems for life. Numerous reports of complications from wisdom teeth extractions are indicated at the wisdom teeth stories page and complications page.

Even so the article does offer some useful advice, such as this

“If a wisdom tooth is completely horizontal, the chances of bone disease are so high that we can predict with pretty good probability that in 10 or 20 years that person will have gum and bone problems that will pose a risk to other teeth.”

Several studies have explored horizontally impacted wisdom teeth to demonstrate that they are the least likely to erupt normally as discussed on the wisdom teeth risks page.

Another important piece of advice from the article is this

“A wisdom tooth that comes only part way through the skin leaves a person open to high risk of decay and infection. “

The article does mention that wisdom teeth should not be removed routinely and that wisdom teeth crowding is not a valid reason to remove wisdom teeth.

Even so, I do disagree with some of the arguments made in the article such as saying that the best age to remove wisdom teeth is between 16 and 18 and saying that by waiting it may be much more difficult to recover. An ideal age to remove wisdom teeth is debatable and further studies should be undertaken as indicated over at http://www.teethremoval.com/wisdomteeth.html

The guidelines for removing wisdom teeth are indicated over at http://www.teethremoval.com/wisdomteeth.html which say that an impacted wisdom tooth should only be removed if it is causing a problem or there is some other indication for the surgery.

In these current guidelines no mention of a horizontally impacted wisdom tooth and partially erupted wisdom tooth is present but certainly this should be considered as a potential reason to remove wisdom teeth. However, due to the potential for serious harm to occur with wisdom teeth removal, such as what happened to me, I think one needs to carefully consider the current facts and evidence before removing any wisdom teeth that are not causing problems.

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I have previously discussed on this blog how students graduating from medical school have an average debt of around $158,000 and the average debt of those graduating from undergraduate college is around $27,000 in the U.S.  In fact, the video called College Conspiracy http://blog.teethremoval.com/college-conspiracy-and-united-states-hyperinflation/ profiles a dentist who is stuck with with high loans from school  (around the 11 minute mark). One quote appearing in this video is “…as soon as you get out of school you are indentured for life.”

This figure below showing the inflation cost of college tuition (in blue), medical care (in red), and general inflation (in black) from http://www.leftbusinessobserver.com/College.html pretty much tells more of the story. In fact I would argue that college tuition costs and medical costs are correlated with each other and you should be able to calculate some sort of correlation coefficient.

An interesting article titled “Our Junior Colleagues and Interstate Medicaid Clinics” written by Michael W. Davis DDS appears in the New Mexico Dental Journal, Fall 2011, vol. 62, no. 4, pages 24-28, helps further show the major problems with increasing college tuition and how this directly impacts and increases medical care costs.

The article is available over at http://dentistthemenace.com/documents/M%20Davis%20NMDA%20Fall%202011.pdf

The article discusses how often dentists are stuck with high loans after graduating from dental school and may end up working as transient laborers in Medicaid clinics. This lends itself readily towards fraud, criminal activities, and abuse.

The end of the article says:

“…many of our junior professionals are facing hard times and hard choices. Some face the prospect of either not paying bills, or working and contributing to the abuse of disadvantaged children. Medicaid fraud and abuse is big business, and played out on a vast interstate corporate stage. State government may collude with these large dental corporations in abusing poor children for profit. We either address these problems, or face wholesale collapse of Medicaid programs, and a sellout of large segments of our junior colleagues.”

In fact the business model of these Medicaid clinics accounts for fines, penalties, and legal settlements within it. Dentists are deemed as expendable as new dentists can just be hired to replace the one who got caught.

The article discusses several scams and how they play out. In brief

1. Billing for services never rendered
2. Restraining children in a papoose board. (I discuss how pediatric patients in a restraint can contribute towards the unfortunate occurance of death at the dentist office http://www.teethremoval.com/dental_deaths.html)
3. Unbundling of charges
4. Upcoding of services
5. Overtreatment and basing care on what pays more Medicaid dollars particularly with pedodontic crowns and pulpotomies

What is even more shocking is a discussion of “Pay-to-Play” politics between state government and Medicaid providers.

The article further states:

“Eventually taxpayers with their limited resources will demand an accounting of the Medicaid money-pit. Their frustrations will certainly be vented at corporate creeps who scammed the system, and government regulators, who gave these crooks a pass.

Ultimately the first step in fixing the medical crisis where profits seem to trump ethics has to be dealt with by substantially lowering the cost of medical education. Having a large amount of debt for a long time is not a comfortable prospect for most and leads to a lot of stress and worrying and seems to lead some young dentists to pursue aggressive and excessive medical treatments that should not be performed.

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