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Advocacy White Paper on Third Molar Surgery by AAOMS

Posted on 19. Dec, 2011 by wisdom.

Recently the American Association of Oral & Maxillofacial Surgeons (AAOMS) issue a Press Release located over at http://www.prnewswire.com/news-releases/aaoms-white-paper-discusses-why-when-and-how-to-treat-third-molar-teeth-135889358.html

In the conclusion of the press release it states

“The AAOMS encourages patients and their families to talk to their general dentist, orthodontist or family physician to determine whether third molar surgery is indicated. If a decision is made to retain these teeth, regular dental check-ups and good dental hygiene to control or prevent periodontal disease are essential.”

The press release discusses a recent Advocacy White Paper released on Third Molar Surgery. This is located at http://www.aaoms.org/docs/evidence_based_third_molar_surgery.pdf

I think the this recent White Paper issued on November 10, 2011, is well worth the read for anyone considering having elective healthy wisdom teeth surgery performed.

The paper mentions some of the recent controversy of the medical necessity of removing erupted and impacted third molars.

Numerous references to the scientific literature are provided.

Of course as an adovacy paper it states

“ AAOMS fully supports the elective, therapeutic removal of impacted  third molar teeth that are not likely to erupt into a disease free position, whether the third molar teeth  exhibit symptoms or not, and preferably prior to the onset of periodontal or pericoronal disease”

Near the end of the white paper it states

“There is no pat answer, cookbook recipe, or  flow chart that is universally accepted regarding the decision making process. The presence of the third  molar teeth, their position within the jaws and or dental arches, the condition of the teeth and  associated teeth and structures, the presence or potential for pathology associated with the third molar  teeth must be considered carefully. The risks of complications involved with early treatment of third  molar teeth that are likely to cause problems versus the morbidity caused by retained third molar teeth  and subsequent treatment in an older patient must be weighed.”

Of course as an advocacy paper it is slightly biased towards surgical intervention.

There is discussion of a case in the literature

“of a patient who is “60 years old, had taken bisphosphonates, had undergone chemotherapy, aortic, and mitral valve  replacements”. She presented with acute cellulitis. Days of hospitalization, surgery, and rehabilitation  were necessary to restore her health”.

Of course as I like to point out a 60 year old who made it that long without problems from wisdom teeth is pretty good when compared to cases like mine of young healthy adults who had drastic and serious complications from wisdom teeth extraction as indicated over on the complications page http://www.teethremoval.com/complications.html

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What is Science Up to?

Posted on 06. Dec, 2011 by wisdom.

A hilarious piece aired on The Daily Show with Jon Stewart back in October 26, 2011 titled “Science: What’s It Up To?”

In the segment Aasif Mandvi sits down with Republican Strategist Noelle Nikpour

She says

“Scientists are scamming the American people right and left for their own financial gain.”

Aasif Mandvi comments

“Why are surgeons the only ones allowed to perform surgeries and other surgeons are the only ones who get to say whether this surgery is necessary or not? Doesn’t make any sense. And the only other people that can check to make sure that they are not manipulating ….are other scientists.”

Dr. Martin Chalfie later comments

“All that we do in science is subjected to peer review.”

Of course the issue as pointed it in the segment is that the peers are other scientists like them.

Watch the segment below.

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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

1. Hospital and clinic teaching rounds
2. Grand rounds
3. Quality improvement conferences
4. Tumor boards
5. Interdisciplinary conferences
6. 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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Tips to Prevent Medical Errors – AHRQ

Posted on 06. Oct, 2011 by wisdom.

The largely ineffective Agency for Healthcare Research and Quality (AHRQ) has a list of 20 Tips to Help Prevent Medical Errors  http://www.ahrq.gov/consumer/20tips.htm

Number 20 on the list is

 ”Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources.”

It then suggests to ask your doctor if the treatment is based on the latest evidence. The way this is presented it seems to say that doctors and nurses often do not always present treatment options based on the latest evidence.

As argued by Shannon Brownlee, http://www.washingtonmonthly.com/features/2007/0710.brownlee.html the U.S. is clearly in need of an

“… independant agency that would fund systematic reviews of the medical literature, as well as clinical trials to test the comparative effectiveness of everything from drugs to treatments”

Unfortunately the current AHRQ is not performing this service as it was rendered somewhat ineffective thanks to Newt Gingrich and Congress in 1996 over the issue of spinal fusion surgery.

The Agency for Health Care Policy and Research (AHCPR) was created in 1989 to produce evidence-based, clinical-practice guidelines. What ended up happening was the AHCPR panel concluded that there was little evidence to support surgery as a first line treatment for low back pain and that nonsurgical interventions should first be used. The medical device industry and several doctors organizations opposed governmental control over the research and evaluation of new technologies including The American Society of Cataract Surgery, the American Board of Ophthalmologists, and the North American Spine Society.

Sensing a threat to their livelihoods, many surgeons bombarded Congress with letters contending that the agency’s panel was biased and found a sympathetic ear with Newt Gingrich and the Republican House majority.  The AHCPR had a budget that became crippled and it’s mission shifted and it became the Agency for Healthcare Research and Quality (AHRQ). As a result, numerous spinal fusion surgeries continue to be performed.

Currently today the American health system is based on scientific evidence as long as the evidence supports commercial interests; but all too often when the science conflicts with commercial interests, science gets nudged aside.

Sources:

1) Overdosed America: The Broken Promise of American Medicine (P.S.)
John Abramson. Harper Collins Publishers. 2004.

2) Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer Shannon Brownlee.Bloomsbury USA. 2007.

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Surgical Treatment of Migraine Headaches

Posted on 04. Jul, 2011 by wisdom.

A study published in Plastic and Reconstructive Surgery shows that trigger site surgery may aid in reducing or even eliminating migraine headaches.

100 patients in a study underwent injection of botulinum toxin A (Botox) into up to 4 potential trigger sites. If a trigger site was identified to be effective than surgery was performed in that trigger area in order to decompress nerves and remove muscles.

71 of 79 patients that were evaluated over a 5 year period were observed to have improvement. This meant they had less mean migraine intensity and or less mean migraine duration.

20 of 69 patients (29.0%) reported elimination of migraines and 41 of 69 patients (59.4%) experience a significant decrease.

Surgery is not without risk and neither is injection of botulinum toxin A.  2 patients had hypersensitivity, 2 patients had hyposensitivity, and 2 patients had numbess at their 5 year follow up. This complications occured in the front region. 1 patient had occasional neck stiffness and 2 patients had occasional neck weakness which occurred in the occipital region.

I know from firsthand experience after having an occipital nerve block in attempt to end my 24/7 headache brought on by removing my wisdom teeth that injections into nerve and muscle areas in an effort to reduce headache can just make things worse as also indicated by this study. ( I discuss this more on http://www.teethremoval.com/occipital_nerve_block.html)

Therefore, anyone suffering from any headache condition should of course proceed with caution before having any injection and/or surgical procedure performed.  There are many different types of headache and jumping into any procedure that can just make pain and suffering worse is not well indicated. Even so an injection and/or surgical procedure can aid in helping those who suffer from migraine.

Due to the design protocol of this study there is no way to tell if the botulinum toxin A injection alone would produce similar results to it and the surgery.

Reference: Bahman Guyuron, Jennifer S. Kriegler, Janine Davis, Saeid B. Amini. Five Year Outcome of Surgical Treatment of Migraine Headaches. Plastic and Reconstructive Surgery. vol. 127. no. 2. 2010.

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