Oral surgery and the Extraction Crisis: What are we going to do about it?
in Working Life
Megan graduated from King's College London (GKT) in 2012. Since then she has worked in private and NHS practices in Essex. Megan is currently the young dentist representative for the Essex local BDA.
"The reason for writing this article is because ultimately I feel that we have hit a crisis point with oral surgery referrals and I'm aware that there are plenty of enthusiastic young dentists who want to learn and develop oral surgery skills but haven't had the opportunity to do so." This article highlights the struggles and barriers that young dentists face when taking on oral surgery cases.
It's 10am and I'm in my surgery with a patient before me. She's in agony and has been for two days, bleary eyed, I can see the lack of sleep has started to take its toll. 'Please can you just rip this thing out' she half whispers holding her face. After my examination it's clear she requires an extraction, her lower 7 has a mesio-distal vertical fracture and the tooth cannot be saved. I wait with baited breath for the radiograph but it's as I feared; long divergent curved roots with good bone. There's no way I can get this out.
But if I don't take on challenging cases now then when will I? Worst-case scenario I try, it breaks and I refer – at least it will look like I've tried. Best-case I surprise myself, she's pain free and I skip home this evening feeling like a hero. I suddenly think of myself in front of the GDC having inevitably messed this up – asking if this was within my level of competency – I'm not sure 'no but I just wanted to help' really holds up. Besides, it will take me at least an hour to attempt this and I'm already behind on my UDA's. I can't be wasting time.
That's it. She's getting referred. I turn to explain the x-ray, pointing out all the difficulties involved, she's not looking up, in too much pain to concentrate...'So, I think it would be in your best interests to have this treated by an oral surgeon'. She suddenly looks up 'well how long will I have to wait for that?' I shrug 'worst case –eight weeks'. Tears fill her eyes and I feel like a complete monster. 'I can't wait that long', she sobs. I think quickly, "Would you consider a private referral?" I ask. She shakes her head, "I can't afford it." Final chance - I take the radiograph down to my principal; maybe he can impart some wisdom. He takes one look, 'refer' he states, passing it back. He then continues to point out that the roots are in 'close proximity' to the ID canal, and I should refer on these grounds. Both he and I know that root isn't going near that nerve, but he hasn't had his heartstrings pulled.
I curse myself for not taking on more as an undergraduate, it was so easy to call the consultant, who would take over your difficult surgical and still sign it off – he wasn't bothered. Where's that consultant when I need him now? Reluctantly and after much comforting, the patient signs the oral surgery referral and leaves.
I feel horrible – I came into dentistry wanting to help people, not to fob them off to make my life easier. I've always enjoyed challenges, they're exciting, invigorating and rewarding – but with the powers that be, we are increasingly wary of taking on such challenges – especially when five hard years of training and a future career are at stake. I know I am not alone. There are hundreds of young dentists out there in the same boat, and we have the oral surgery referral waiting lists to show for it.
I was urged to write this piece after attending an LDC meeting. I like going to LDC meetings. However, I came away feeling far less than content on this occasion. The committee had discussed the oral surgery triage and how they've been bombarded by inappropriate referrals. The term 'young dentists' was used constantly throughout the discussion. As young dentists representative I was asked continually – "why can't young dentists extract teeth?" Before I could answer, they were drawing up their own conclusions – "Young dentists aren't trained properly", "Young dentists only think about UDAs", "Young dentists can't be bothered." Are they right?
We aren't given the opportunities for training perhaps our predecessors were. I graduated just over two years ago, and to qualify I had to complete ten 'surgical' extractions, which I understand is quite a lot having spoken to friends from other Universities. These extractions could involve flap surgery, bone removal and sectioning. Did I raise any flaps? Perhaps one. Did I remove bone? Yes, with the consultant holding my hand all the way. Did I feel confident once I'd graduated? I most certainly did not.
The lack of skills training has been highlighted in M Kellehers latest article 'current controversies in training and/or education of dentists in the UK' . Our current institutions are qualifying 'educated' individuals rather than 'trained' individuals, which is a big problem - especially when it comes to a specialty like oral surgery. In fact a 2006 survey of vocational trainers and trainees found that both groups agreed oral surgery training was either 'poor' or 'very poor' .
But how do you become 'trained' in oral surgery? As a conscientious individual, aware that this has been a pitfall in my own dental education, I have set out to try. I didn't fancy a DF2 job – and many would say I'd made a rod for my own back. However, I love general dentistry, and having just started I really didn't want to give that up for an entire year. Having spoken to a number of colleagues who ventured into the world of maxillofacial surgery, I think I may have made the right decision. I was surprised to hear a friend undertaking an SHO job in a district hospital would only have one half day per fortnight extracting teeth, with little support from her superiors. Finishing this, she's still lacking confidence. The situation was not dissimilar at a teaching hospital in London, where another friend claimed most of the cases were tackled by the registrars or consultants, and he was merely the human instrument tray. I understand that my close cohort are not entirely representative of the UK DF2, but speaking to more and more DF2's it might be the case. How we be expected to take out an entire year when there are no guarantees that we will achieve what's promised to us?
I've tried to find oral surgery mentors – I've emailed, called and spoken to a number of oral surgery specialists – I've even gone and assisted a few in private practice and hospital. I'm not saying that I didn't learn anything, but there's nothing like doing it for yourself and learning from your own mistakes, which is paramount for oral surgery. The private practices were understandably not going to let me 'practice' on their paying patients and risk their reputation. The hospitals have strict guidelines and although I was able to assist, they certainly weren't going to let me extract teeth. It seems that there is no safe place to practise oral surgery. Even if you join an NHS practice with a principal who is experienced in oral surgery, the current contract does not remunerate for surgical extractions, so why would a business minded principal promote them?
I've been to numerous oral surgery lectures, and I've endured presentations on 'The Winters classification' for assessing lower 8's more times than I care to. I can read that in a book – it's not helpful. I've been to 'hands on' oral surgery courses, but chopping at pig's heads and suturing them back up again is a far cry from patients in the dental chair.
We may be moving forward with the FGDP certificate in minor oral surgery course for which I attended the open day, but my main concern is that this course is a preparation for implants, rather than a focus on extracting teeth. I might be wrong but I'm not willing to spend £5000 to find out. The most promising oral surgery training I have found came through dental town, an American online dental forum. Through this I found the course www.weteachextractions.com, which I am currently saving up the $3000 plus flights fee to attend.
Maybe we will have realised the desperate need for oral surgery training in the UK in the mean time, and I won't have to fly across the pond to access it.
1. M Kelleher 'Current controversies in training and/or education of dentists in the UK' Br Dental Journal 2014 217 497-498
2. J patel, K Fox, B Grieveson, C C Youngson 'Undergraduate training as preparation for vocational training in England: a survey of vocational dental practitioners' and their trainers' views'. Br Dental Journal 2006 201 9-15
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