The third molar controversy: framing the controversy as a public health policy issue.

PURPOSE: This article summarizes the current research available concerning the removal of impacted third molars, and provides a background from which practitioners, public health policy advocates, and third-party payers can more objectively assess the the issues of appropriateness of care and overutilization of third molar surgery. MATERIALS AND METHODS: A literature review was undertaken, with emphasis on noninterventional outcome studies and studies using statistical modeling techniques. RESULTS: The health care resources being devoted to the removal of third molars are in the billions of dollars. There is an attempt at limiting these expenditures by third-party payers. These attempts have focused on the prophylactic removal of asymptomatic third molars. Some sources label the procedure as unnecessary surgery. Analysis of the literature does not answer this question with any degree of confidence. CONCLUSION: There appears to be a need for large population-based studies to provide practitioners with data to help them decide when intervention is indicated and when it is not. There is little agreement on how many third molars are being removed for so-called prophylactic reasons. The studies that are available on the nonintervention course are few and have significant flaws. The studies that argue against prophylactic removal are largely based on statistical models. The application of these models as a basis for clinical decision making is questionable. The effects of provider supply and reimbursement must be considered as an integral part of the controversy.

Illinois Dental Anesthesia and Sedation Survey for 1996.

Dentists in the state of Illinois who possess a permit to administer sedation or general anesthesia were surveyed. A 71% response rate was achieved. Of the respondents, 86% held permits for deep sedation/general anesthesia and 14% held permits for parenteral conscious sedation. By practice specialty, 84% were oral and maxillofacial surgeons, 11% were general dentists, 5% were periodontists, and fewer than 1% were dental anesthesiologists. Advanced Cardiac Life Support training was possessed by 85% of the respondents. The most common anesthesia team configuration (82%) was a single operator-anesthetist and two additional assistants. Only 4% reported use of a nurse anesthetist, and 2% used an additional MD or DDS anesthesiologist. The vast majority (97%) of the practitioners do not intubate in the office on a routine basis. Supplemental oxygen was used by 81% of the respondents whenever intravenous agents were used. A total of 151,335 anesthetics were administered during the year. One mortality occurred in a patient with an undisclosed pre-existing cardiac condition. Four other events were reported that required medical intervention or hospital evaluation; however, no permanent injuries were reported. Other practice characteristics were described.

Who should determine the medical necessity of dental sedation and general anesthesia? A clinical commentary supported by Illinois patient and practitioner surveys.

Many third-party payers try to deny benefits for dental sedation and general anesthesia. The term "not medically necessary" is often applied to these services by third-party payers. The label is poorly defined and varies from payer to payer. This paper uses original practitioner and patient opinion surveys to support the position that the definition of medical necessity is solely the joint responsibility of the patient and his/her physician. These surveys also support the argument that both patients and practitioners view dental sedation and general anesthesia as a medically necessary procedure if it allows a patient to complete a medically necessary surgical procedure that he/she might otherwise avoid.

Oral amyloidosis as initial symptom of multiple myeloma. A case report.

A case of multiple myeloma has been presented where intraoral amyloidosis was the presenting symptom associated with the disease. Definitive diagnosis was based on the findings of hyperglobulinemia, marrow aspiration showing plasma-cell infiltration, proteinuria, amyloidosis, and anemia.