A breakdown of how an average undergraduate oral surgery clinic would run here in the Royal London Dental Hospital through the eyes of a third year student.
9:00 – Seminar
Seminars are always on a topic related to oral surgery - complications of extractions, management of medically compromised patients, prescription of antibiotics and analgesia or suturing/surgical technique etc.
9:30 – Clinic Starts
We all head down to the ground floor where we are handed Dental Emergency Clinic cards (a few day sheets and a covering form containing key patient information - hospital number, DOB, Name) We have no information about the patient’s complaint (unless they have been referred in), so it’s time to get them in the chair and see how we can help.(At this stage I’ll make sure I’m logged on to the NHS care records service so that I can see any previous radiographs, referral letters or relevant lab results)
The entrance to the oral surgery polyclinic.
9:35 – Patient in the chair
Once the bay is ready I call my patient through into my bay. Once they’re sat in the chair the first thing I do is introduce myself (I use my first name and state what year I’m in) Then I’ll confirm their name/DOB. (This is very important, before now I have called a patient only to then realise that they have the exact same name but a different DOB, luckily I checked and realised)
One of the bays in the Oral Surgery polyclinic.
I begin by asking them how I can help. Most patient’s will point to an area in their mouth and describe a form of dental pain but occasionally they will have been referred in for extraction of a currently non-symptomatic tooth prior to restorative treatment etc.
If they are in pain I make sure to show some empathy (no one likes being in pain and a little compassion goes a long way) then I take the rest of my history.
I go into greater detail about the history I take from patients in oral surgery in this article.
I usually elicit my history in the following order:
Complaint – In the patient’s own words as far as possible
History of presenting complaint – how long and what triggered it etc.
Medical History – allergies, relevant medical conditions
Social History – Living arrangements, alcohol, smoking, recreational drugs
Dental History – Registered GDP, previous experience, anxious or calm
After taking these histories I move on to examination of the patient.
Extra-oral – looking for swellings, pain on palpation etc.
Intra-oral – looking at oral hygiene, teeth present, any mucosal lesions or areas of concern
Tooth/area in question – looking for caries, periodontal pocketing, mobility, draining sinuses, tenderness to percussion, sensitivity to hot/cold/air
10:00 – Presenting the case
Once I have all of the relevant information it’s time to present the case to a clinical tutor. I run through the key points and the tutor usually performs a short examination. I’m then expected to suggest a provisional diagnosis and how I would like to proceed (Usually a radiograph).
10:05 – Special investigations
By far the most commonly requested special investigation is a radiograph, usually a periapical or a panoramic view. This usually takes about 20-30 minutes as the patient has to go up to the radiography dept. on the second floor.
10:30 – Diagnosis, treatment plan and consent
Now that the radiographs have been taken it’s usually possible to come to a definitive diagnosis by combining this information with the history and examination.
Diagnoses – Some of the most common diagnoses are:
Once this diagnosis has been agreed and confirmed with the tutor it’s time to get the patient back in, talk through our findings and the treatment options available.
Treatment plan – There are usually a couple of options open to patients, for example:-
Unsurprisingly, most patients in pain opt to have the tooth extracted. Once the preferred treatment option has been chosen we are legally bound to obtain valid and informed consent prior to operating.
Consent Form – This needs to fully state what the procedure is as well as the intended benefits (removal of pain, infection, restoration of function etc.) and potential risks (bleeding, bruising, pain, infection, swelling, numbness (temporary or permanent), damage to adjacent structure and risk of a surgical procedure etc. After the patient and I have signed, the tutor countersigns to confirm the consent.
10:45 – Administration of local anesthetic
Now that all of the paperwork has been done and all of the i’s dotted and t’s crossed, it’s time to actually begin the extraction!
Once I’ve administered the anesthetic and given a chance to work I’ll test for anaesthesia with a sharp probe. It’s a pretty simple test - if the patient doesn’t jump then it’s worked! It’s important to remind patients that they will feel pressure but shouldn’t feel sharpness, some expect to feel absolutely nothing, but we can’t take away the pushing sensation. It’s important to remember to note on the surgical safety checklist that anaesthesia has been achieved.
11:00 – The extraction
The first thing I double check at this stage is that I’m looking at the correct tooth. This is not a mistake you want to make and is something that is made easier by filling out the surgical safety checklist properly. The other important thing is positioning, the chair should be at the right height and inclination and you should be stood in a comfortable and stable position which allows for good vision, access and posture.
A Surgical Kit used for dental extractions.
Depending on the tooth to be extracted the technique will vary. However, in this example I am extracting a non-mobile lower right 6 with a stable crown. I first start with my coupland elevators I, II and III. Then, with any luck, the tooth will be at least slightly mobile. I can then seat my lower molar forceps. Once these have been placed onto the tooth I begin a slow figure of 8 motion whilst maintaining apical pressure (to reduce the risk of root fracture by lowering the fulcrum) gradually increasing the amplitude of the movements as the tooth loosens, when the tooth is ready to come out I deliver it buccally and inspect it and the socket to ensure that it has been delivered whole.
11:10-11:40 – Post operative phase
Now the tooth is out it’s time to make sure that we stop the bleeding and then do everything possible to ensure optimal healing of the surgical site. The first thing to do is give the socket a good squeeze, this compresses the bone back into position. Saline is then used to give the socket a good wash out and the patient is asked to bite on a damp gauze to encourage haemostasis. I usually take this opportunity while the patient is quiet to deliver post-operative instructions, this covers how best to take care of the extraction socket (no smoking, salt water rinses etc.) and what to do if it starts bleeding again.
After about 10 minutes or so the patient has normally stopped bleeding, the tutor comes over to double check and if everything looks good then the patient can leave along with their copy of the consent form and a pack of gauze to bite on in case the socket starts bleeding. At this point I write up my notes, complete the rest of the surgical safety checklist and discharge the patient.
Thanks for reading guys, hope you found it interesting.
Bye for now!