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Research During Residency for Oral Surgeons?

Posted on 08. Nov, 2011 by wisdom.

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

Hospital and clinic teaching rounds
Grand rounds
Quality improvement conferences
Tumor boards
Interdisciplinary conferences
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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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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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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Oral Surgeon Websites: Similar Content

Posted on 26. Jun, 2009 by wisdom.

I wanted to alert everyone to a new article I just wrote and updated on my website http://www.teethremoval.com/oral_surgery_websites_similar_content_similar_sites.html.

It talks about how oral surgeons are using PBHS Inc. to design them websites. However, PBHS Inc. uses a template for the websites so the content for all of the websites designed is very similar. This means the information on procedures and even after care procedures for a large number of oral surgeon and oral surgeon group’s websites are nearly exactly the same if not identical. This is quite alarming to me and you should be aware of this if you are considering wisdom teeth removal surgery.

The likely explanation is that oral surgeons are not skilled in website design and are not taking the time to modify the content provided by PBHS Inc. Even so, PBHS Inc. has a very large number of oral surgeons in the U.S. who they have developed websites for and are making quite a nice amount of money.