Oral and Maxillofacial Surgery, Pain Control, Physical Diagnosis

Course Director and Clinic Director

• Ruben Figueroa, MS, DMD, Room 407, 617-638-4350, -4360, -4863

Chairperson

• David Cottrell, DMD, Room 407, 638-4350

Faculty

• Donald F. Booth, DMD
• Thomas B. Kilgore, DMD
• David Cottrell, DMD
• Philip L. Maloney, DMD
• Hirshom William, DMD
• Puskar Mehra, DMD
• Bhatia Iswar, DMD
• Herbert F. Bernstein, DMD
• Lawrence T. Herman, DMD
• and resident staff

Location

Oral/Maxillofacial Surgery Clinic
Suite G-425, 4th Floor, 617/638-4360
Boston University
Goldman School of Dental Medicine
Boston Medical Center (BMC), Newton Street. Campus
BMC, Harrison Avenue Campus

Clinic Hours

Monday-Friiday 8:30 a.m.-12:00 p.m., 1 p.m.-4:30 p.m.

Introduction

The clinical program in oral and maxillofacial surgery is designed to give students a standard clinical experience in office surgical procedures and problems associated therewith. The hospital aspect of the rotation allows them to participate in the management of severe odontogenic infections, minor and major maxillofacial injuries as well as repair of soft tissue wounds in the ER at Boston Medical Center, Harrison Ave. Campus. Additional hospital experience will be gained by student participation with the resident in the evaluation for hospitalization and admission process, physical exam and writing of orders. Students will be asked to observe or assist with the more complicated procedures. With this exposure the student will recognize the clinical and surgical indication for appropriate patient referral.

Departmental and Student Seminars

Departmental guest lectures, seminars, CPC's and case reviews are regularly scheduled in which students on rotation are required to participate at BUGSDM and Boston Medical Center (BMC).

Each student will present two or three seminars, 30 minutes long, on an assigned topic at 7:30 a.m. each morning.

Entry-Level Skills and Prerequisites

Students on clinical rotation should have mastered the material presented in the first portion of the didactic course. The notes and text assignments for the Hospital Dentistry and Advanced Oral Surgery Sections should also be reviewed.

During the Oral Surgery rotation, many of the in-patient and out-patient clinical problems will call on the student's ability to draw from material presented in the Basic Sciences. There is a strong positive correlation that students with a grasp of the Basic Sciences will perform at higher levels, gain more from the course and have more fun during the clinical rotation. A review of the material presented in Head and Neck Anatomy, Endocrinology, Oral Pathology, Pharmacology, Physical Diagnosis, Pain Control and Biology of Disease is prudent prior to the rotation.

Attendance

On the weeks assigned to the Oral Surgery Clinical Rotation, students will report at 7:30 a.m. to the Oral Surgery Conference Room. Repeated unexcused tardiness and absences will usually result in dismissal from the rotation with a failing grade.

Students will not be allowed, except for emergency reasons, to schedule their clinic patients during this rotation.

Oral Surgery Clinic Protocol

Responsibilities While in the Oral Surgery Clinic:

1. Students are directly responsible to the resident, the clinic supervisor and her assistants. Patients will be assigned by the resident or clinic supervisor. Before addressing the patient, be sure that a completed medical history questionnaire is in the record. The student will be asked to review the patient's dental problem and medical history and perform an oral and head neck exam, including recording the BP, P, and Respiratory Rate at this time. At this point diagnostic radiographs, if necessary, should be taken.
2. Once the diagnosis and plan for treatment are determined and before any procedure is initiated, the student must discuss the case with an instructor. Prior to surgery, all patients must sign consent forms for surgery and anesthesia. Those under 18 years of age must obtain a signed permission from a parent or guardian, unless the child is considered an emancipated minor. All surgery is to be done under supervision. The instructor and student should double check that the treatment plan indicates clearly the extraction of those teeth considered at this time for extraction. The Oral Surgery consultation form must be completed and signed by the faculty.
3. Once a patient's treatment is completed, he/she should be given appropriate verbal instructions for post-operative and follow-up care. An envelope, containing exodontia sponges, with printed instructions as well as the telephone contact for emergency services is provided for the patient. The student is responsible for writing appropriate prescriptions (for pain relief, etc). The patient should be told how, in case of post operative problems, he/she can contact the Oral Surgery Resident after clinic hours or on the weekends. An Oral Surgery Resident is on call 24 hours a day and can be reached during non-clinic hours by calling the University Hospital Page Operator at 617-638-7243, and request the Oral Surgery Resident.
4. The student has several administrative responsibilities after treating a patient:

   a. Record treatment and sign patient's record. It is the student's responsibility to have the instructor co-sign the record.

   b. Have the instructor sign all prescriptions.

5. Students will be given the opportunity to perform most of the simple extractions. Simple extractions on pediatric patients are sometimes an excessive challenge due to the patient's emotional state and might be best undertaken by the resident. Difficult impactions and surgery under general anesthesia will be done by the resident.

General Clinic Regulations

1. The clinic coordinator is there to see that patients are seen properly and their treatment carried out expeditiously. At this point in your career, she has had more experience than you, so listen to her and benefit from her suggestions.
2. Careful grooming and personal hygiene along with clean and neat appearance reflect essential traits of good surgical management. Shirt and necktie are appropriate for men and dress or pants for women are suitable attire when reporting to the Oral Surgery Department at 7:30 each morning. Dungarees are not appropriate. Hair of shoulder length should be tied or pinned back or a surgical cap should be worn. Students failing to meet departmental standards will not be permitted to be in attendance in the clinic. Clean white lab coats and nametag should worn.
3. The principal of asepsis is adhered to as far as possible. Rings and wristwatches should not be worn while treating patients. Students must wear surgical masks, gloves and eye protection and a surgical gown during examination and surgery.
4. Appointments for treatment and follow-up are to be given to patients by Oral Surgery staff personnel only.
5. If the clinic receptionist is busy, keep an eye out for patients who are waiting to be seen. Charts of patients waiting to be seen are kept in a rack at the clinic reception counter. If there is a patient waiting to be seen, do not keep him/her waiting. Seat the patient. Make your evaluation and present the patient to an instructor or resident.
6. Be sure that appropriate payment or payment arrangements have been made prior to treating any patient. Check with the receptionist. If the treatment plan changes, (i.e. from an examination to a surgical procedure) let the receptionist know. Also, tell the clinic receptionist what treatment was done before each patient leaves, so that the patient's bill can be adjusted appropriately.
7. It cannot be stressed too often that your clinic grade will depend in part on how thoroughly and clearly you present each case to the instructor. Use the standard format found on the next page.

Some Aspects of Clinic Work

Patients with complex problems will often be seen first by the attending or resident staff. Some situations will necessitate tact, therefore, discussion of the pathology and treatment may have to be carried on outside the operatory or after the patient has been dismissed. The student is advised in these situations not to question the patient or the instructor regarding treatment, etiology or prognosis unless so invited by the instructor. This eliminates additional embarrassment and fear by the patient especially in neoplastic diseases or those having questionable prognosis.

Private patients of the Oral Surgery Faculty Group Practice are seen in the Oral Surgery Clinic. In most cases, the faculty member will ask permission of the patient to allow dental students to enter the operatory to observe treatment. However, the faculty member may feel it prudent to have students in the operatory. Please respect the faculty member's judgment and do not enter the operatory unless invited to do so.

Students are also asked to exercise a degree of sensitivity while observing surgical procedures. Extraneous conversation and comments regarding the surgery being performed may accentuate an already anxious situation for the patient. Discussion of a patient's diagnosis, behavior, or treatment in public areas, i.e., elevator, cafeteria, or immediately outside the operatory, is unethical and in poor taste.

Format for Oral Surgery Records

• C.C. Statement of patient's problem or reason for referral to clinic
• H.P.I. History of Present Illness (only if applicable)
• P.M.H. Review patient medical history, record, pertinent findings
• Vital Signs. Blood pressure, pulse and temperature and respiration
• Allergies Report any allergies
• E.O.E. Describe facial anomalies such as swelling, redness, facial asymmetry.
• I.O.E. Performed an intraoral exam and describe pertinent findings. Always give the benefic to the patient of performing an oral cancer exam
• Radiographs Record radiographic findings
• Dx Diagnosis; state what treatment you propose
• Rx Include type of anesthetic, procedure, type of sutures used, complications
• Disp. (Disposition) Include prescriptions given, follow-up appt., special instructions

This format should be followed on all first-time patients. Subsequent visits can be abbreviated.

Clinic Regulations: General

1. Students should not be taking X-rays or using the developer without permission from a staff member .
2. Faculty will dispense prescription blanks as needed.
3. Students should not be requesting charts for their patients under Oral Surgery's name.
4. Clinic "working attire": A clean white coat over shirt, tie, trousers for men; dress, blouse, and skirt or slacks for ladies. Long hair must be confined, off the shoulders; no jewelry on hands or wrists. Students will be assigned a locker for their personal use.
5. When assigned to assist in the O.R. in the B.U. Clinic, "scrub suits" will be issued to students. Boston Medical Center issues "scrub suits" each day. Do not wear BU-issued attire when assigned to BMC.

Patient Management Protocol

1. Patients first must be registered by the receptionist before being seated in room.
2. Patient with scheduled appointments must be treated first before seeing any other patient that was not on the list, i.e. Endo emergency.
3. Patients first must make payment before any surgery is performed.
4. Students should let receptionist know what type of surgery is going to be performed on an emergency patient so that she can send the patient to the business office to make payment before any surgery is performed.
5. Before surgery, faculty and students should discuss the procedure with the patient and have patients sign the consent forms (before putting on gloves).
6. Make sure radiographs are returned to the chart after seeing a patient.

Patient Chartwork and Presentation

1. When presenting a patient to resident or staff always have a mirror or tongue depressor in the room.
2. When seeing patient prior to presenting staff, an updated medical history should be documented, including, but not limited to: age, all present medications and dosages, allergies, operations, signs of illnesses, etc.
3. Format for chart write-ups, consults and treatment-Strict SOAP format. (Problem Oriented, or WEED system)
4. Students should be familiar with the instruments, and their proper use, before they do any extractions.
5. All students must have a resident or clinic instructor supervise each patient under all circumstances.
6. All entries must be signed by student and countersigned by resident/staff member
7. Prior to performing a procedure, with the exception of emergencies, a signed treatment plan should be in the patient's record.

Hygiene, Clean-up, Sterilization

1. Students must remove their gloves and masks whenever they are not directly treating a patient. No gloves or masks are to be worn when writing records or escorting patient to front desk.
2. No needles, blades or sharp disposable instruments are to be left on the floor or counter. They should be placed in the red disposable containers in the treatment room or the sterilizing room.
3. After surgery, the tray should be removed from the room, placed in the sterilizing room, emptied, and all the instruments placed in sink.
4. Students are responsible for cleaning the rooms they use or in which they assist. Chairs, sink, tables, floors, etc., are to be cleaned of blood, debris, and instruments from previous patients. Remove soiled barriers on light handles, chair controls and replace with clean ones.
5. After each use of suction, cold water is to be run through for 15 seconds, the suction tip removed and suction hung on wall. Clean outside of tubing with gauze impregnated with disinfectant.
6. Do not touch the instruments on clean, set-up trays in the sterilizing room. Use the transfer forceps, not hands.

Oral Surgery Clinical Behavioral Objectives

After having participated in the lecture series in Exodontia and Minor Oral Surgery and having observed exodontia in the clinic, the student will exhibit proficiency in simple exodontia and minor oral surgery to the satisfaction of the clinical instructor by:

1. Demonstrating the taking and recording of a standard medical history and performing a thorough examination including the vital signs.
2. Demonstrating acceptable professional attitude in personal appearance and establishment of rapport with the patient.
3. Educating the patient as to the diagnosis and treatment plan.
4. Demonstrating verbally the arrival at a correct diagnosis and explanation of etiology and sequelae to the instructor.
5. Demonstrating verbally the selection of a logical and complete plan for treatment and assessment of difficulty of the surgery contemplated.
6. The selection of proper instruments to perform the contemplated surgery.
7. The proper use of instruments and application of the principles of surgery and exodontia.
8. Exercising proper care of tissues and control of forces used.
9. Administering the proper post-operative instructions and medications.
10. Making the appropriate entry in the patient's record according to the format and examples.
11. Performing proper surgical scrub, venipuncture, administration of N2O sedation, participation in i.v. sedation and general anesthesia techniques as employed in oral surgery practice.

Clinical Hospital Rotation: Instructional Objectives

By the end of the clinical rotation, the student, with the aid and supervision of the resident staff, will:

1. Write admission orders for hospitalized oral surgery patients.
2. Perform a medical history review, assist in the physical examination of hospitalized patients, and record the work-up according to format #1.
3. Evaluate patient's medical risk status from the history, physical and lab tests.
4. Assist in operating room procedures.
5. Write post-operative patient orders.
6. Evaluate patient's daily progress and write progress notes (see format #2)
7. Verbally present the patient's work-up and progress to attending staff during rounds according to format #3.
8. Evaluate patients seen on consultation for other hospital services.
9. Verbally present patients seen in consultation to attending staff.

Student evaluation is based on progress toward competency as defined by the statements of Clinical and Behavioral Competencies. Further details are contained in the course syllabi.

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