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Second Opinion Advertisements for Dentists

Posted on 07. Jan, 2012 by wisdom.

An article in The Journal of the American Dental Association titled “Are Advertisements That Offer ‘Free Second Opinions’ Ethical by Rod B. Wentworth (October 1, 2011, vol. 142, no. 10, pages 1199-1200) talks about the ethics involved with dentists advertising “free second opinions.”

In the article it says

“So simply offering free second opinions is not in and of itself unethical. It is perfectly acceptable for a patient to seek a second opinion. In fact, dentists should consider suggesting that their patients obtain second opinions, especially when they have questions or concerns about the appropriateness of the recommended treatment.”

One issue raised in the article is that in a second opinion, if a patient has any x-rays they should be sent along with the patient for the second opinion to avoid unnecessary radiation.

The other issue raised is giving second opinions without making disparaging remarks about the patient’s dentist from the first opinion also known as jousting. Doing so can result in possible disciplinary action against the dentist and may have potential legal implications but as a patient if it was warranted I would like to hear the truth.

The purpose of a free second opinion would of course be to help dentists take patients away from each other.

I think second opinions from different dentists is a good idea in some cases but as addressed in this post http://blog.teethremoval.com/are-dentists-ethical-or-scam-artists/ knowing whether a dentist is being too conservative, too aggressive, or somewhere in the middle is difficult often for patients to know. I tend to think more dentists at least in the U.S. lean towards the aggressive side but certainly some are more conservative in their treatment approaches.

The author ends by saying

“Second opinions are not cut-and-dried in an ethical sense. Advertising them certainly is not unethical, and patients are free to select the dentist of their choice, which they may do on the basis of the information received in a second opinion. However, certain actions, such as criticizing a dentist unjustly, administering unnecessary tests or treatment, or misrepresenting fees, skills or experience may be unethical. Only the dentists involved know their motivation and whether it leads to unethical conduct. One hopes that dentists will take the high road to ensure that the oral health of the public and the welfare of patients are of primary importance”

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Why People Hate the Dentist

Posted on 14. Oct, 2011 by wisdom.

Numerous posts on the internet have attempted to shed light on the why people hate the dentist.

Tom over at OralAnswers.com has a two part series on why people hate the dentists located at http://www.oralanswers.com/2011/09/why-people-hate-the-dentist/ and http://www.oralanswers.com/2011/09/why-people-hate-the-dentist-my-theory-part-ii/

Dr. Joe Bulger DDS in Canada changed the name of his blog to hatedentists.com and his written several posts on the topic of people who hate dentists located at http://www.hatedentists.com/1319/hate-dentist/ , http://www.hatedentists.com/1326/dentist-haters/ , and http://www.hatedentists.com/1363/top-10-reasons-people-hate-dentists/

SaneDentist.com has a post by Dr. Mujtaba Ali regarding 5 reasons why people hate the dentist located at http://www.sanedentist.com/here-are-5-reasons-why-we-hate-the-dentist-and-what-a-dentist-thinks-about-them.html

Reading, over these posts and potential explanations for hate towards the dentist just doesn’t seem to do the hate justice and doesn’t touch on all the issues.

So here are some reasons why I think people really hate dentists (subjective opinion):

1) Being motivated by money to the point of detrimental care to their patients

Let’s face it, people go to work to make money so they can survive and look after their loved ones. However, dentistry is not a business and should be about making people motivated to practice healthy habits and not pushing unnecessary surgeries and care. This is touched on on the controversy page of this site and in this post on if dentists are ethical or scam artists. People want to know the facts regarding their care and if it will be helpful or harmful.

Now yes doctors and dentists do have increasing outrageous tuition costs at the undergraduate and professional levels http://blog.teethremoval.com/lets-give-our-kids-a-chance-to-succeed/. What should be happening is strong leadership and organization in dental professional societies to help insure tuition costs do not continue to spiral out of control. Of course dentists should be fairly compensated for their efforts and skills but the current fee schedules often times do not promote health to the fullest.

2) Not factoring liability into the patient side of the equation and ensuring patients who are injured receive fair compensation.

As discussed on this website and well known, doctors and dentists have concerns with liability when they see a patient. Numerous physician groups in the U.S. such as the American Medical Association and American Association of Oral and Maxillofacial Surgeons are actively pursuing legislation to limit non-economic ‘pain and suffering’ damage caps to $250,000. http://blog.teethremoval.com/the-war-on-healthcare-patients-who-hate-doctors/ and http://www.teethremoval.com/legal_standpoint.html

The American Association of Oral and Maxillofacial Surgeons continues to recommend and say that most healthy wisdom teeth should be removed when a patient is young and healthy such as a teenager but yet also push for damage caps of $250,000 at the national level. Several cases are illustrated on this site at http://www.teethremoval.com/complications.html and http://www.teethremoval.com/dental_malpractice.html in which a damage award of $250,000 for certain cases is just downright unfair, unjust and ridiculous.

In fact I argue that you should avoid having wisdom teeth extracted in any state such as California and Texas which have $250,000 non-economic damage caps. There are other potential approaches instead of the current medical malpractice system such as discussed here http://www.teethremoval.com/legal_system_medical_malpractice that dentists should be advocating for for their patients. This includes such things as a no fault insurance for negative outcomes, a no-fault approach, or health courts.

3) Lack of focus on research

Let’s face it many people simply do not like the dental drill and needles and other instruments used by a dentist. New approaches should be further explored. For example, extract wisdom teeth without the need for all these tools with perhaps some other method to prevent wisdom teeth from even growing.

Further echoing back towards #1 many dentists and doctors are motivated to go into specialties that pay higher instead of going into more academic and research oriented careers. This works to hinder much needed progress and discovery.  In addition many patients who want to know the latest up to date research are left in the dark.

Further it is my belief that patients and their reactions both positive and negative to treatments should be investigated. Often times there will be no record of how a patient responded to a treatment.

4) Engaging in conspiracy, collusion, and trying protect themselves from potential liability to the detriment of their patients

There are numerous complications that can occur from having wisdom teeth extracted as indicated here http://www.teethremoval.com/complications.html.

However, when I had my wisdom teeth extracted I consented to only around 8 such complications and was never made aware that there are numerous other potential serious risks involved. Furthermore the fact that healthy wisdom teeth are not extracted in the U.K. due to the risk of harm was not disclosed.

Still to today I have yet to see any informed consent forms that list permanent headache as a known complication from having wisdom teeth extracted.  As discussed on wisdom teeth removal stories by others other patients have had headaches occurring from having wisdom teeth extracted and were told as was I that it was not related to the surgery. It is my belief that patients have a right to know about serious potential risks before consenting to a potentially life altering surgical procedure.

In addition, other dental websites on the internet fail to disclose many of the potential risks and complications from having wisdom teeth extracted.  Some of this may have to do with dentistry being focused on the oral cavity and so some do not like to readily admit that teeth have implications on other aspects of the body and health. Another reason of course is going back to #1 where their is a push towards selling procedures and care instead of providing information to patients to better help them make health decisions.

Patients get angry when they are lied to and feel like they have been taken advantage of. In some cases patients are told they had to have impacted wisdom teeth extracted even though no scientific evidence currently supports having healthy impacted wisdom teeth extracted. Further patients get angry when they are lied to by their dentist and office staff about complications that have occurred from surgery.

5) Pain

Ultimately going to the dentist can cause a lot of pain. Some of this pain may just be due to their teeth hurting or it could be due to a lasting horribly painful complication from treatment.

6) Anxiety

Since patients know that dentists can cause them a lot of pain they get anxious about seeing a dentist. This may even cause them to have nightmares and be unable to sleep for days prior to seeing their dentist.

7) Giving patients a hard talk

Some patients may need to be told that certain things they are doing to take care of their teeth are not good. Some dentists may discuss this in a way with the patient that they take offense to, although it really shouldn’t be taken that way.

8 ) Taking sexual advantage of patients

As discussed here http://www.teethremoval.com/sexual_assault_under_anesthesia_for_wisdom_teeth_removal.html some dentists have sexually assaulted their particularly young female patients during treatments and procedures. This has absolutely no place in dentistry. Certainly dentists are people and can have urges but this has no place in the workplace with paying customers.

9) Dental boards and organizations not protecting the public

I had no desire whatsoever to create this website. It is very unfortunate that high quality care and protecting and providing information to the public so they can make an informed choice about dental treatments is not the top priority.

Many oral surgeons continue to recommend that healthy impacted wisdom teeth be extracted in young patients http://blog.teethremoval.com/the-truthiness-of-extracting-wisdom-teeth-james-r-carey/ without adequately providing information on the facts, evidence, risks, and harms of surgery.  Again this goes back to #1 .

10) Poor service

Ultimately all of these issues set up for poor service and unsatisfied patients. It can be hard to please every patient and know how different patients will react. However, poor service really encompasses all of the issues already touched upon. Other things that could be a problem is lack of knowledgeable dental staff or a dated dental office.

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Dental Care in Japan

Posted on 19. Jun, 2011 by wisdom.

I found an interesting piece by Kevin Rafferty in The Japan Times Online from June 15, 2011, titled “A dentist need not be a masked demon.” The article is located here http://search.japantimes.co.jp/cgi-bin/eo20110615a1.html

The article gives an inside look into recent developments in dentistry with a particular focus on Japan but the principals and message apply globally.

The main focus on the article centers around a report soon to be published in both English and Japanese titled “Guideline for treating caries following a minimal intervention policy, an evidence and consensus based study.” The report was conducted by Mikako Hayashi of Osaka University Graduate School of Dentistry and her committee in which 18 months was spent conducting research.

Some notabled quotes from the article by Kevin Rafferty include

“Recent advances in dentistry include recognition that teeth, if properly treated, regularly cleaned and cared for with a healthy diet, have self-healing properties, so that drilling and filling of teeth showing signs of decay should be a last, rather than a first, resort.”

Mikako Hayashi adds

“…I tell my students to pretend they are feathers when using drills: Be gentle and avoid deep digging…By the same token, deep drilling of teeth and filling with old fashioned metal inlays and crowns may be the sure way to hasten their loss. Drilling deeply weakens the vital tooth structure and may inflict lasting damage on the prospects of preserving the pulp that is the core of the living tooth. Excavating and filling locks the teeth into a potentially vicious downward spiral when the fillings fail and the dentist drills deeper.”

The article provides insights into dentistry in Japan noting that students graduating from dental school in Japan have limited experience with real patients and practicing minimal intervention.

Yasuko Momoi from Tsurumi University who was the chairperson of the panel for the evidence based report adds

“The dental profession is not a business, but should be based on a conscientious sense of duty. We have a treaty with God, Buddha, Mohammed or Christ to respect people, in accordance with the Hippocratic Oath. In Japan, dentistry is based on the concept of public salvation; in the U.S. of individual salvation.”

I am interested in seeing this report and was very impressed by Kevin’s article. He does have a unique perspective though as he is married to Mikako Hayashi. At the end of the article are many tips laid out to improve Japan’s dental system.

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The American Association of Oral and Maxillofacial Surgeons Fails to Use Basic Statistics in Research on Wisdom Teeth

Posted on 13. Dec, 2010 by wisdom.

I have previously reported how the American Association of Oral and Maxillofacial Surgeons (AAOMS) recently had a press conference on wisdom teeth in Washington, D.C. See http://blog.teethremoval.com/third-molar-multidisciplinary-press-conference/ for more information.

Shortly after the press conference they issued a press release available at http://www.aaoms.org/docs/media/third_molars/press_release.pdf which is titled “Conventional Wisdom about Wisdom teeth Confirmed: Evidence Shows Keeping Wisdom teeth May be More Harmful than Previously Thought.” One of the additional key findings listed in this press release  is

“Most patients (60 percent) with asymptomatic wisdom teeth prefer extraction to retention.”

This finding comes from a recent article in the Journal of Oral and Maxillofacial Surgery, titled “Most Patients With Asymptomatic, Disease-Free Third Molars Elect Extraction Over Retention as Their Their Preferred Treatment.”  The article is by Brian E. Kinard, BS and Thomas B. Dodson, DMD, MPH.  It appears in the December 2010 issue in volume 68, issue 12, on pages 2935-2942.

The article uses a study sample from patients presenting to the Department of Oral and Maxillofacial Surgery at Massachusetts General Hospital between November 2008 and August 2009 for the evaluation and management of their third molars (wisdom teeth) by Thomas B. Dodson.  In the article on Table 8 it is presented that a total of 319 patients were seen during this time who had asymptomatic disease free wisdom teeth. 129 of these patients chose to keep their wisdom teeth and 190 of these patients chose to extract their wisdom teeth. A simple calculation was performed by the authors of 190/319 * 100 = 60%. (it actually equals 59.5611 % but they rounded up). This is how they arrived at their statement quoted above that most patients with asymptomatic wisdom teeth prefer extraction and how they arrived at the titled of the article most patients prefer extraction.

Thomas B. Dodson admits that their bias in this result as “…it is possible for clinicians to present treatment options in a manner, consciously or unconsciously, that directs patients toward the clinician’s preferred treatment.”  This is a valid concern. I also have a problem in that no statistical analysis was done beyond this point with this specific result.

During my undergraduate studies I took several courses on statistics. One popular program to use is MINITAB in addition to knowing how to do hand calculations.

Using this proportion data it is possible to do in MINITAB and by hand a 1 proportion test and determine a confidence interval. A 95% (two sided) confidence interval of this data is (0.539505, 0.649924).  This is calculated by calculating an estimator for the standard error. This estimator is the square root of [(p * (1-p)/n] where p is in this case 190/319 corresponding to the sample proportion which is an estimator of the population proportion and n is the sample size which in this case is 319. We then look up in a t table or use MINITAB to determine the test statistic, which in this case is 1.96745. The 95% confidence interval is then calculated as 190/319 +/- sqrt[(190/319 * (1-190/319)/319] *1.96745  . We then arrive at our 95% confidence interval of 53.9505% to 64.9924% which means we are 95% confident that the true population proportion of those who keep their asymptomatic wisdom teeth falls in this range.

The other important piece of information we need to asses is if we have enough samples in our data. A total of 319 patients were used in this study who had disease free wisdom teeth but it turns out we need more than 319 patients to make an accurate assessment before we can even calculate a 95% confidence interval.

If we look at the Statistics Department at Penn State University we can easily find an educated guess and  conservative method to determine the required sample size.  In this case our educated guess is calculated as [ (1.96)^2 *  0.595611 * (1 - 0.595611) ] / (0.05)^2 which equals 370.113 and our conservative method is calculated as [ (1.96)^2 *  0.5 * (1 - 0.5 ] / (0.05)^2 which equals 384.16. Thus we determine that it is necessary to have at least 371 patients in our study to be able to even come up with a statement as to whether or not we can be 95% confident that patients prefer either to extract or retain healthy impacted wisdom teeth.

The authors only used 319 patients in their study and thus the data does not allow them to make such as statement as they did which AAOMS subsequently reported in a press release.

I encourage Thomas B. Dodson and other oral surgeons to consider using some basic statistics in their research before releasing such information to the the public who should be receiving information that can allow them to make informed decisions about their health.

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Dentalhealth.org

Posted on 22. Oct, 2010 by wisdom.

I wanted to let everyone know about the site dentalheath.org. It is a site by the British Dental Health Foundation. There is a section for the public, a section for the press, and a section for professionals.

Most people will find the Dental Health Information Leaflets section in the for the public part of the website to be useful. There are numerous useful dental related categories such as wisdom teeth, what to do following an extraction, x-rays, and so on.

Since the site is from the British Dental Health Foundation, it’s intended audience is for people who live in Britain so this is important to keep in mind. Even so the information can be helpful for everyone. The site is arranged so that frequently asked questions for each category are asked and then answered.

For example, in the wisdom teeth category, a question is “What are the main reasons for taking wisdom teeth out?” The answer is

Far fewer wisdom teeth are now taken out than in the past. If the tooth is not causing problems, your dentist will not want to remove it. They will only remove wisdom teeth: - when it is clear that they will not be able to come through into a useful position because there is not enough room, and they are also causing some pain or discomfort - if they have only partly come through and are decayed – such teeth will often decay as it will be difficult to clean them as thoroughly as your other teeth - if they are painful.

Another example, in the what to do following an extraction category, a question is “I am still in pain, what could it be?” The answer is

Sometimes an infection can get in the socket, which can be very painful. This is where there is little or no blood clot in the tooth socket and the bony socket walls are exposed and become infected. This is called a dry socket and in some cases is worse than the original toothache! In this case, it is important to see your dentist, who may place a dressing in the socket and prescribe a course of antibiotics to help relieve the infection. You may also feel the sharp edge of the socket with your tongue and sometimes small pieces of bone may work their way to the surface of the socket. This is perfectly normal.

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