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The American Dental Association: Is it Patient-Centered, Science-Based and Ethically-driven?

Posted on 13. Feb, 2014 by .

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Some time recently (within the past 6 months) the ADA (American Dental Association) has updated their about me page over at http://www.ada.org/aboutada.aspx. 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 http://blog.teethremoval.com/the-war-on-healthcare-patients-who-hate-doctors 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 http://www.teethremoval.com/controversy.html.

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 http://www.teethremoval.com/dental_malpractice.html

“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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Do Physicians Have a Responsibility to Meet the Health Care Needs of Society?

Posted on 23. Nov, 2013 by .

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An interesting article appears in the Fall 2012 issue of the The Journal of Law, Medicine & Ethics by Allan S. Brett titled “Physicians Have a Responsibility to Meet the Health Care Needs of Society.” Allan opens the article by addressing a question that was posed to Ron Paul in the 2012 presidential election by Wolf Blizter which I mentioned before on this post http://blog.teethremoval.com/dumb-americans-trust-their-doctors-for-no-valid-reason/.

Allan aruged that Ron Paul agreed with the sentiment that “physicians have a responsibility to meet the health care needs of society.”

In the article Allan makes the following case.

“In the rest of this essay, I first demonstrate that society is already organized— at least in part — to rescue sick people regardless of ability to pay, and that society is not prepared to abandon that general guiding principle. It follows that physicians — society’s principal instrument for provision of health care services — are expected to meet society’s health care needs. I then argue that the current configuration of the U.S. health care system undermines the ability of physicians to fulfill this mandate effectively. And finally, I argue that the medical profession’s responsibility to meet society’s health care needs also carries a responsibility to practice cost-effectively.”

Later in the article Allan states

“The system of health care delivery in the United States is a patchwork consisting — among other things — of reasonably universal access for urgent medical care, barriers to non-urgent but necessary care for uninsured or under-insured people, and government sponsored coverage for some (but not other) populations. As a result, the system is clinically illogical and operationally dysfunctional. We try to have it both ways: as a matter of human decency we provide urgent medical care without regard to cost, but along the way we demand individual patient responsibility for costs. We boast about offering the best medical care in the world, yet we knowingly provide substandard care (or deny care) to large numbers of people, and we experience health outcomes inferior to those of comparably developed nations.”

Allan expands on some of these points by discussing how medical debt causes bankruptcies and how charitable groups hold picnics or other fund raising events to raise money for medical care. Further Allan mentions how some doctors and hospitals are expected to write off some medical bills for charitable purposes but this results in cost shifting and causing paying patients to pay higher premiums. Allan later mentions how

“A majority of medical schools in the United States are state institutions that receive taxpayer support. Many medical students receive government-sponsored grants and low-interest loans.”

Later in the article Allan says

“Indeed, public opinion opinion polls have shown consistently that a majority of Americans favor some system of guaranteed universal access. Politicians and analysts who claim that “American individualism” or “American exceptionalism” are antithetical to universal access are simply misrepresenting the values of the majority (while representing narrow interests with economic or political motives to maintain the status quo).

Allan goes on to say

“The point here is to emphasize that a system of guaranteed universal access — in which physicians are compensated fairly for provision of medical care to the rich and poor alike — allows physicians to satisfy professional obligations to meet society’s health care needs, and to meet ethical obligations to treat patients without discrimination.”

Allan later says

“…many physicians have placed their own financial interests above the interests of patients by providing unnecessary medical care that is highly profitable under fee-for-service arrangements. There is strong evidence that provision of useless medical care accounts for a substantial proportion of health care costs — up to 30% by some estimates. Physicians tend to blame the steep rise in health care costs on patients (“patients demand things, and I don’t have time to fight with them”), on lawyers (“I do more things than necessary so I won’t get sued”), and on drug company influence on physician prescribing. Then, having driven up costs, physicians blame payers for interfering with medical practice. Although demanding patients, lawyers, and drug company advertising are an inescapable part of the health care landscape, their existence does not excuse physicians from practicing evidence-based, cost-effective medicine.”

The article by Allan S. Brett is well written and he makes his point effectively about why the medical profession has a responsibility to meet society’s health needs. I encourage you to read the entire article.

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What is the Prevalence of Patients with Asymptomatic, Disease-Free Third Molars (Wisdom Teeth)

Posted on 07. Oct, 2013 by .

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An interesting article titled “How Many Patients Have Third Molars and How Many Have One or More Asymptomatic, Disease-Free Third Molars?” appears in the September 2012, supplement 1. (vol. 70, issue 9) of the Journal of Oral and Maxillofacial Surgery written by Thomas B. Dodson, DMD, MPH (pg. S4-S7). The article seems to attempt to arrive at an answer to the question of how many patients really have a wisdom tooth (third molar) that is not causing problems and that has no disease.

In the article Dr. Dodson recommends that patients are divided into 4 different categories when having their wisdom teeth evaluated.

  1. symptomatic, disease present (based on history and radiological examination)
  2. symptomatic, disease absent (includes teething and vague pain symptoms unrelated to wisdom tooth)
  3. asymptomatic, disease present (disease is evident from radiological findings or clinical exam but not patient complaints)
  4. asymptomatic, disease absent

In the article over 20 journal articles are assessed to determine how many patients have wisdom teeth of which a number ranging between 6.0% to 96% is arrived at. The range is so broad due to differences in assessments and definitions. Several articles are briefly described which attempt to show third molar prevalence. These articles sometimes include if the wisdom tooth is erupted or not and the overall prevalence.

The author includes his definition of what a asymptomatic disease free third molar is on clinical examination

“On clinical examination, a disease-free impacted [third molar] will not be visible, cannot be probed, and probing depths (PDs) will be shallower than 4 mm. If the tooth is erupting, there must be adequate space to accommodate the tooth. A disease-free erupted tooth will have reached the occlusal plane, be functional and hygienic, and have PDs shallower than 4 mm. The tooth will be caries-free, or have restorable caries, or be well restored. All 5 surfaces of the tooth can be examined for caries. The tooth will be surrounded by attached gingiva, including the distal aspect of the tooth.”

With regards to radiological examination, no evidence of disease is present. The author is clear to say that the absence of symptoms does not equal the absence of disease. The author later describes two different studies which an estimate of disease free asymptomatic wisdom teeth can be obtained from.

The first study consisted of 409 asymptomatic volunteers. 119 (29%) of the patients in the study were also free of disease (according to the definition provided above). The second study consisted of 249 patients of which 29 (11.6%) had all asymptomatic disease free third molars with a total of 855 wisdom teeth (37.3%) being asymptomatic and disease free.

The author states in the conclusion:

“The differences between the 2 estimates may be due to differences in the sample composition (patient vs volunteer samples), sites of referral (hospital vs school or clinic), definitions of disease status, and eligibility…”

Based on the literature review and the 2 studies the article concludes that patients with disease free asymptomatic wisdom teeth represent a small proportion of patients. In this study, of course some may take issue with the definition of what an asymptomatic disease free third molar is. Furthermore, some may take issue of the difference between a patient with all asymptomatic disease free third molars and some (1 or more but not all) asymptomatic disease free third molars. Naturally it would be the case that encountering a patient with all asymptomatic disease free third molars would occur less likely than encountering a patient with one or more asymptomatic disease free third molars.

When a patient has some asymptomatic disease free wisdom teeth present but also either asymptomatic or symptomatic with disease present wisdom teeth, the issue of whether to extract them all or retain some can be hazy. For example see the case report described under mouth sinus hole in the wisdom teeth complications page http://www.teethremoval.com/complications.html.

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Lessons from Medical Litigation of Dentists

Posted on 07. Oct, 2013 by .

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Back in June of 2013, I discussed in the post Lessons from Medical litigation in oral surgery practice several lessons that can be learned upon exploring lawsuits occurring in an oral surgery setting.

An interesting post on the same topic but applied to dentists as a whole was just written earlier today in DrBicuspid, titled “When a dentist becomes the defendant,” by Meghan Guthman (October 7, 2013, source: http://www.drbicuspid.com/index.aspx?sec=sup&sub=pmt&pag=dis&ItemID=314397&wf=1660“) Apparently this article was already written in the American Student Dental Association in their summer 2013 issue and was just a reprint.

The article discusses some data gathered by Medical Protective which is a malpractice insurance company. Their data shows that the average payment to a plaintiff in a dental malpractice lawsuit is $65,000. Around 20% of their dental malpractice cases between 2003 and 2012 involved a tooth extraction with the average compensation to the patient reported at $48,600. A case study of an extraction related dental malpractice case is provided where a dentist failed to obtain adequate radiographs showing the entire tooth and it’s bulbous root.

The article provides a figure by Medical Protective which shows that dental implant malpractice cases have the highest payouts with the average compensation being over $70,000. Extractions have the second highest payouts of the categories used (extractions, root canal, implant, crown, others).

The article also includes some informative advice from Mario Catalano, DDS. She encourages dentists to put their patient’s interests first  and recommends new dentists build positive relationships with their patients.

I have previously explored dental malpractice issues with a focus on wisdom teeth extractions, see http://www.teethremoval.com/dental_malpractice.html. In a sample of 48 cases used in that article (at present) there was an average award to the patient of over $800,000. I was forced to do some cherry picking of data in this case as I don’t have access to the same amount of dental malpractice information as an insurer. However, the average award was much higher here than indicated by Medical Protective. Part of the issue could be that Medical Protective insurers primarily dentists and not oral surgeons and dentists don’t take on more risky and complicated extractions.

Nonetheless, the average patient award of over $800,000 from the cases on http://www.teethremoval.com/dental_malpractice.html is well under many of the non-economic damage caps in many U.S. states see http://www.teethremoval.com/legal_standpoint.html.

For more on the damage cap issue see for example, The War on Healthcare: Patients Who Hate Doctors.

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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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