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Dental Anxiety Associates with Pain During Dental Procedures

Posted on 07. Jun, 2014 by .


It is well known by dentists that some patients experience dental anxiety, with some patients have worse dental anxiety than others. In a review article titled “Dental Anxiety Is Considerably Associated With Pain Experience During Dental Procedures,” by Mike T. John, appearing in J Evid Base Dent Pract, 2013, issue 13, pp. 29-30, the issue of dental anxiety in dental patients is explored.

The study reviews a study titled “Predictors of pain associated with routine procedures performed in general dental practice,” by Tickle M, Milsom K, Crawford FI, and Aggarwal VR, in Community Dent Oral Epidemiol, 2012 Aug;40(4):343-50. In the original study 508 patients who visit 38 different dentists in England participate. Dental anxiety was measured with the Corah Dental Anxiety Scale which resulted in a score between 4 and 20. This score was grouped into 4 different variables representing anxiety. The dental patients were asked to rate their intensity of pain on a scale of 0 to 10 during the procedure, after the procedure, and later after the procedure (not immediate). The researchers performed logistic regression and found that very anxious patients had a fivefold increased odds of experiencing pain during the dental procedure compared to patients who had no dental anxiety.

The reviewer (John) states that due to effective anesthesia most patients do not experience pain during dental procedures. In addition, the study (Tickle and et. al), found that 3.4% of the patients used in the analysis had very high dental anxiety. This is lower than what has been found in previous studies. Hence this study seems to show that pain and dental anxiety are intertwined. Hence if one has a high dental anxiety they may have reluctance to take proper care of their oral health. This could also lead to more days taken off work and frustration.

Hence the reviewer suggests that dentists are aware that dental anxiety exists on a continuum. He suggests that patients with less dental anxiety can be treated by dentists and given coping strategies and pharmaceutical interventions. Of course more complex cases of dental anxiety can be managed by other healthcare professionals. It is hence important that patients who have dental anxiety and especially more serious dental anxiety explore their options and talk to their dentist about it before any procedures occur. Patients should understand that if they need dental care it is in their best interest to practice coping strategies to minimize their anxiety and ability to experience pain during any procedures.

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Ethical Issues for Consent in Dentistry

Posted on 24. May, 2014 by .


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 .


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 located at

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 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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Is Creative Diagnosis on the Rise in Dentistry?

Posted on 26. Apr, 2014 by .


A very interesting MyView column by the American Dental Association (ADA) is titled “Creative Diagnosis” by Jeffrey Camm, D.M.D. located over at 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 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 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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The American Dental Association: Is it Patient-Centered, Science-Based and Ethically-driven?

Posted on 13. Feb, 2014 by .


Some time recently (within the past 6 months) the ADA (American Dental Association) has updated their about me page over at A new video appears and under it the text reads

“This American Dental Association video tells our story and highlights how the ADA has always been a patient-centered, science-based and ethically-driven association. It captures the ADA’s spirit and what the ADA strives to be.”

Viewing the video the words patient centered, science-based, and ethically-driven are repeated. The video also throws around the terms continuous learning, research and development, patents, and up to date. In one segment a dentist presumably says do no harm, always do good, treat people with fairness and honesty, and respect the doctor patient relationship.

Unfortunately I disagree with the ADA’s assertion that they have always been patient-centered, science-based, and ethically-driven. As stated before on this website, see for example this blog post I was never made clear that wisdom teeth were no longer commonly removed in other countries prior to having my healthy wisdom teeth extracted in June of 2006. Guidelines from SIGN and NICE existed in 1999 and 2000 respectively see

If the ADA was always a patient-centered, science-based and ethically-driven association why wasn’t this information made clear at the time. We are talking six years after the guidelines came to light. I am willing to give some leeway here as being up to date with all the new information coming out can be very challenging, but six years is just too long. This information was not found on the ADA’s website or other U.S. based physician/dental organizations.

Furthermore why at the time was information on complications related to wisdom teeth extraction so lacking. Look if constant pain very much so beyond numbness is a complication of removing wisdom teeth, why was this never disclosed? Isn’t this relevant to the discussion?

Let’s highlight a legal case of a complication from wisdom teeth extraction as displayed at

“An attorney, won a total of $503,923.59 for a woman that had her lingual nerve bilateraly severed and a dental burr (drill bit) left in her mouth ….. She suffered from depression, pain, and anxiety and was unable to eat, sleep or open her mouth for weeks after the surgery and could not speak correctly for months… When she gets tired she has a hard time enunciating words…. The broken burr remains in her mouth.”

For one, it baffles me that a possibility that the dental burr can break off during surgery and be permanently left in the mouth does not have to be disclosed. Furthermore, it baffles me that the possibility that a thermal burn can occur during wisdom teeth extraction is not disclosed. Why is this information not disclosed and really even acknowledged? I only came to be aware of it by pouring over hundreds and hundreds of documents.

In the past the ADA has argued for a $250,000 cap on non-economic damages nationally in the U.S. How is this patient centered and ethically driven? The ADA does not seem to really disclose this information on their website. A $250,000 pain and suffering damage award for young injured patients can be unfair, unjust, and downright ridiculous in some instances.

Look I acknowledge that the ADA is taking steps to become patient-centered, science-based and ethically-driven but stating they have always been is in my opinion on weak footing.

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