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Dental Malpractice and Inflation Adjusted Updates

Posted on 09. Nov, 2013 by .

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I wanted to alert readers that several pages on this site have been updated lately regarding dental malpractice as it relates to wisdom teeth removal. I updated the inflation adjusted calculations and figures on the dental malpractice page http://www.teethremoval.com/dental_malpractice.html.The calculations using up to the latest CPI-U from September 2013 have been updated. Interestingly I have calculated an annual return of around 4.25% needed to keep up with inflation since 1970. This is higher than any risk-free investment vehicle (bond, CD, savings) currently being offered.

In addition, to this page I have added a few comments (reworded) recently provided by Lewis N. Estabrooks who is chairman of the board of OMSNIC. He has recently said the following (OMSNIC. Lewis N. Estabrooks, DMD, MS. Board Message. Monitor, vol. 24, no. 5, October 2013.)

“Our statistics show approximately 78% of the claims are denied because there is no negligence. About 12% are settled with the doctor’s consent, usually after the cases are reviewed by a claims committee of six OMS peers. The remaining 10% represent liability cases taken to trial, where OMSNIC and the doctor have a favorable outcome 94% of the time.”

A few weeks ago I updated the figures and the statistics on the wisdom teeth death page. In addition, due to new information provided by OMSNIC (see  http://blog.teethremoval.com/updates-on-anesthesia-provided-by-oral-and-maxillofacial-surgeons/) I have updated the mortality rates in dentistry page.

As eluded to by Dr. Estabrooks in his recent speech, since OMSNIC has a monopoly on insuring oral and maxillofacial surgeons, they have access to a wealth of information on the success (or failure) of their practices. Since they are running a business, they keep a lot of this information closed but do share it with AAOMS. Thankfully, they have released anesthesia data from over a decade in the 2000s. This release seems to have been done though to help oral and maxillofacial surgeons’ state societies fight off challenges about the safety of office anesthesia. Hence, why the white paper titled  “Office-Based Anesthesia Provided by the Oral and Maxillofacial Surgeon,” in 2013, located over at http://www.aaoms.org/docs/papers/advocacy_office_based_anesthesia.pdf was likely made.

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When Abstinence is Evidence-Based

Posted on 17. Oct, 2013 by .

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I came across a 2012 talk Jay W. Friedman gave titled “When Abstinence is Evidence-Based: The Case Against Prophylactic Third Molar Extractions,” at the 2012 National Oral Health Conference. The PowerPoint for the talk is located over at http://www.nationaloralhealthconference.com/docs/presentations/2012/05-02/Jay%20Friedman.pdf (I have mirrored it over at http://www.teethremoval.com/When_abstinence_is_evidenced_based.pdf). For those not aware of Jay W. Friedman you can start by reading the post American Journal of Public Health Author Jay W. Friedman is 2009 Author of the Year and Looking at the Concept of Prevention in Dentistry.
Some interesting graphics appear in the talk, a few which I have included in this post.

jay w friedman third molar dds When Abstinence is Evidence Based
The talk is very concise and to the point and very informative for anyone considering whether or not to extract wisdom teeth (third molars). I will now provide a brief overview of the talk, but encourage you to look at the full talk yourself.

Like usual (see http://www.teethremoval.com/controversy.html) several jabs are taken at AAOMS (the American Association of Oral and Maxillofacial Surgeons). For instance, he mentions how AAOMS placed a 4 page ad in USA Today in 2007 and didn’t mention any potential complications from extraction. He says that even though AAOMS has changed the language on their website on wisdom teeth in 2012, it still essentially says if wisdom teeth are less than perfect than they should be extracted.

Jay W. Friedman argues that normally developing wisdom teeth (third molars) are over-classified as being full bony impactions. He shows several pictures of wisdom teeth that may appear to be impacted at a younger age but then that erupt normally at an older age. For example see the progression of what appears to be an impacted wisdom tooth at age 13 to one that is erupted at age 18.

jay w friedman impaction to eruption When Abstinence is Evidence Based

Like usual he then argues that wisdom teeth have minimal pathology (around 12%) and prophylactic appendectomies and cholecystectomies are not advised due to their risks of surgical complications. Jay W. Friedman estimates that around 70 to 80% of third molars are extracted prophylactically in what he calls FUN surgery (or FUN dentistry). FUN meaning functionally unnecessary. He mentions that AAOMS sponsors most of the research of third molars and only found 9 journal articles mentioning third molars in periodontal journals.

He mentions in his talk about permanent nerve damage and argues that tens of thousands of patients each year are afflicted with permanent nerve damage from removing wisdom teeth for no good reason. He also discusses a study where prolonged mouth opening from wisdom teeth surgery may contribute to tmj symptoms. Dr. Friedman then alludes to the point that economic based surgery instead of evidence based surgery may be the case and presents some numbers to show that wisdom teeth removal is a $4 to $5 billion dollar industry. He implicates other dentists and dental educators and questions their ethics and morals.

Other interesting points and numbers are mentioned in the talk which I have glossed over. Jay W. Friedman essentially ends his PowerPoint by saying

“When there is sufficient evidence that abstention is evidence-based, we are ethically bound to inform the public so that it may avoid treatment that is potentially injurious.”

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Upcoming Changes to JOMS and AAOMS in 2014

Posted on 07. Oct, 2013 by .

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I wanted to update readers on some of the upcoming changes which will be taking place in the world of oral and maxillofacial surgery in 2014.

The first change has to deal with JOMS (Journal of Oral and Maxillofacial Surgery). These updates are addressed in the editorial in the September 2013, JOMS, by  James Hupp titled, “The Journal’s Performance and Upcoming New Features” (J Oral Maxillofac Surg., vol. 71, pp. 1481-1483, 2013).

In brief, JOMS has managed to decrease the time it takes to get accepted in the journal from 12 to 18 months to just 3 to 6 months. This improves the time for new updates to permeate throughout the field. Furthermore, when articles are accepted they are available rapidly for viewing online (although editing still has to occur).

Several interesting developments are occurring:

A) Soon, AAOMS Press Releases will be developed for selected articles in JOMS. A press release will be written by AAOMS staff and allow for wider dissemination of ideas to the general public.

B) A new perspectives section will be included

“It will offer essays written on topics of interest to our specialty, including health policy, clinical controversies, and education and research matters, as examples.”

Now AAOMS president Miro A. Pavelka has some further information on related to these developments which he mentions in AAOMS Today in the September/October 2013 issue, (vol. 11, issue 5) in the in my view section, titled “Reflections on a year of challenges and achievements.” In this he states

“…we are redesigning and revitalizing our Web presence with the introduction of a separate site dedicated to the public – not only potential patients, but also insurers and legislators and any other non-member visitor – and designed to tell the OMS story.”

Now I am not exactly sure hows these changes will play out. It seems like AAOMS wants to move towards what the ADA and AMA do with regard to press releases/web presence. AAOMS currently has some (but not a whole lot) of patient targeted information pages on various diseases/conditions such as wisdom teeth, dental implants, and anesthesia. They also have a member targeted website with additional information.

These changes seem to be occurring to help increase trust and confidence of the information provided and for the information to be read and remain relevant.

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Improving Patient Safety: Updates on Oral and Maxillofacial Surgery

Posted on 12. Jun, 2013 by .

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In a recent blog post I discussed how a few new videos have appeared in recent months related to oral and maxillofacial surgery Videos Related to Oral and Maxillofacial Surgery. The American Association of Oral and Maxillofacial Surgeons (AAOMS) has also updated several sections of their website in the last year or so. They now have a section titled Orthodontics and Oral Surgery where they have videos related to showcasing various techniques that oral and maxillofacial surgeons and orthodontists perform. In addition they have updated and written a new page titled “Culture of Safety“. The page is a welcome addition and discusses how safety is the number one priority in the oral and maxillofacial surgery office.

Now I wanted to take a moment to respond to this page and some other developments I have seen lately across the blogosphere.

1) The first point to address relates to the issue of safety versus appropriate treatment. Much of the of the motivation for my website was based on the fact that it was never discussed to me back in 2006 that no scientific evidence supported or refuted third molar extraction. In addition, many of the complications that can occur from wisdom teeth extraction were conveniently not mentioned. Furthermore, AAOMS was actively promoting the extraction of healthy wisdom teeth. AAOMS in September, 2007, placed a 4-page advertisement supplement in USA Today urging the extraction of wisdom teeth without mentioning any possible risks and complications that could occur from their removal. In 2010, they held a third molar conference with the intent of the press conference to provide media with a chance to write articles and perhaps discuss on a TV news segment the potential problems with leaving healthy impacted wisdom teeth in hence why they should be removed. (see Third Molar Multidisciplinary Press Conference, Multidisciplinary Conference on Third Molars (Wisdom Teeth) , and  Wisdom Teeth Removal Controversy)  It is only recently in late 2011, that AAOMS reversed course (see Advocacy White Paper on Third Molar Surgery by AAOMS )

Hence, my one of my motivations was to get people to question whether or not removing healthy impacted wisdom teeth is the correct treatment choice or not. AAOMS seemed to be promoting a strategy of having most wisdom teeth extracted and not mentioning any scientific evidence to patients and failing to disclose many of the risks, so I was frustrated. In order to help to get people to think about risks and benefits of third molar surgery I looked a numerous articles and lawsuits to find some data. This is discussed on the complication, death, and lawsuit pages in most detail.

Now in my mind the idea of safety and the idea of appropriateness of treatment are two separate distinct issues.

2) The second point to address is on the culture of safety discussed to occur in AAOMS offices. The webpage states

“While the culture acknowledges that as human beings, we are all capable of making mistakes, it further holds that we are capable of recognizing our errors and identifying ways to prevent them from happening again.”

In my mind it is great to see openness and transparency about this issue. Unfortunately, in my experience as described in 1) AAOMS seems to have a history of not being transparent and open about many issues. When I was conducting research on wisdom teeth on the internet prior to my surgery in 2006, many of the relevant facts I would have like to know were not at all open and easily available. I have created an extensive complications page in order to determine if I had overlooked anything that could have caused me to have a 24/7 headache since 2 days after having 4 wisdom teeth extracted. The question that always ran through my mind when I was conducting this research was isn’t it important for treating clinicians to know what problems in the past have occurred so they can be better rectified in the future. Unfortunately, I was not seeing any large effort of this underway at the time of the updating the bulk of the complications page a few years ago.

AAOMS discusses creating transparency and establishing accountability. Unfortunately they seem to be ignoring the main reason as to why a culture of safety has been slow to come about in medical practice which is due to the legal system. I have discussed alternatives to the medical legal system before. Kevin from the popular KevinMD.com blog has recently written a post on improving patient safety.

“…[while] openly talking about errors needs to come from inside the medical world, she neglects another important factor: the medical malpractice system.  It’s confrontational, a quality that impedes openness. It’s also why some hospital lawyers encourage opaqueness after adverse events, not only within the medical community, but to patients as well…until our malpractice system encourages that same transparency and ceases to be adversarial, any gains in patient safety will continue to be limited.”

I have also talked about this issue before when I talk about the U.S. Legal and Medical Malpractice where I say

“Understand that the current medical malpractice climate in the U.S. provides very little incentive for health care professionals, physicians, and hospitals to disclose errors, learn from them and improve quality, and apologize to patients that have been injured. Patients and doctors need to be in an environment where they can work together that is mutally beneficial”

In the past AAOMS has focused on trying to get legislation passed that limits non-economic damage caps nationally to $250,000 see
The War on Healthcare: Patients Who Hate Doctors. I wondered to myself why the focal point is not on trying to get legislation passed that will change the medical malpractice system to some other form.

On the culture of safety page AAOMS has the following quote

“The culture of safety concept was first conceived by the aviation industry. In the 1970s, the industry suffered a number of accidents attributable to human error. In response, the industry changed its standards and operations drastically. By implementing cross training, checklists, and better communication channels for now-empowered crewmembers, the safety record of the aviation industry today is an enviable one.”

As I have mentioned before in this post alternatives to the medical legal system the airline industry is very different than the health care industry as the doctor usually does not have his or her health and well being on the line. When a pilot operates a plane if it crashes they might get hurt or killed, so they have a strong incentive to correct any mistakes. In the case of a surgery, if the surgeon makes a mistake only the patient may get hurt or killed, so I suggested a way to have doctors have more skin in the game so to speak.

Nonetheless, it is nice to see some efforts being undertaken to attempt to improve quality and patient care.

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Dental Patients Warned of Possible HIV and Hepatitis Exposure Due to Oral Surgeon’s Practices

Posted on 30. Mar, 2013 by .

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Previously in this post Oral Surgeon Investigated for Reusing Needles and Syringes it was discussed how last summer in 2012 an oral surgeon in Colorado was investigated for re-using syringes and needles while performing various oral and facial surgery procedures. Around 8,000 patients were told to be tested for potential HIV, hepatitis B, and hepatitis C.

Recently, in Oklahoma around 7,000 patients were told to be tested for potential HIV, hepatitis B, and hepatitis C who were treated by an oral surgeon due to his potentially rusty instruments and lax sterilization procedures.

A complaint by the Oklahoma  Board of  Dentistry was filed against the oral surgeon on March 26, 2013. It is located over at http://ftpcontent.worldnow.com/ktul/documents/Harrington_Complaint_OBD.pdf.

The complaint says that an unidentified patient who was treated by the oral surgeon tested positive for HIV and hepatitis C shortly after being treated for dental procedures. The complaint says that during the Dental Board’s investigation there were multiple sterilization issues, multiple cross contamination issues, the drug cabinet was often unlocked, and some of the dental assistants were routinely providing the IV sedation for some procedures. In addition, it was found that no written infection prevention policies and procedures were available or used.

The complaint goes on to say that the oral surgeon was a menace to the public health for practicing dentistry in an unsafe or unsanitary manner and committed gross negligence by deferring decisions and supervision of cleaning and infection control to dental assistants.

The American Dental Association (ADA) posted on March 29, 2013, that they are monitoring the news story of the Oklahoma oral surgeon, see ADA cites infection control resources as media focuses on Oklahoma oral surgeon. The ADA also issued a press release.

The ADA says

“The ADA has long recommended that all practicing dentists, dental team members and dental laboratories use standard precautions as described in the Centers for Disease Control and Prevention’s Infection Control in Dental Health Care Settings guidelines…Infection control procedures are designed to protect patients and health care workers by preventing the spread of diseases like hepatitis and HIV. Examples of infection control in the dental office include the use of masks, gloves, surface disinfectants and sterilizing reusable dental devices. In addition, dental health care providers are expected to follow procedures as required by the Occupational Safety and Health Administration.”

The ADA also recommends that if dental patients have any concerns they discuss with their dentist their infection control procedures. The ADA also issued several talking points to dentists to help them discuss infection control with their patients.

Additional Source: Donna Domino, “7,000 patients warned of possible hepatitis, HIV exposure,” DrBicuspid.com. March 29, 2013

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