Oral Surgery: When to extract, extirpate or refer… the dilemma
in Working Life
Claire has written this article to share her experience of surgical extractions during her dental foundation training. She hopes that this will provide advice for newly qualified dentists when undertaking surgical extractions.
Claire Kennedy graduated from Sheffield dental school in 2013. Claire is currently working as a DCT1 in Sheffield at the Royal Hallamshire Hospital.
I am a young dentist who qualified from Sheffield in 2013. I was enthusiastic as a student, which developed into a passion for oral and maxillofacial surgery. We each had a target for minor oral surgery: 5 cases, which included flap raising, bone removal, tooth division and suturing. I achieved my target, but was keen to improve my skills. I often bugged the tutors for more experience in oral surgery. As a result I emerged from dental school ready to meet the big wide world.
However, the first thing my DFT trainer asked when I arrived was "What do you want to improve this year?" I suddenly realised that now I was a fully qualified dentist, I was expected to be able to provide comprehensive care for my patients. They were no longer there for me to "practice on". They were going to be paying to see me with both their money and their time.
I looked at my trainer and realised that I wanted to improve upon everything. I didn't feel confident enough to provide care to my patients after only five years of BDS training. I didn't feel like a "proper" dentist. I told her that I wanted to get more experience in a wide variety of treatments ranging from the complex restorative crown and bridge work to partial dentures, molar endodontics and my ultimate goal, surgical extractions.
My trainer was very supportive and tailored my teaching sessions to meet my needs. This meant that the first surgical extraction I undertook in general practice was in a tutorial with my trainer. We had previously discussed the case and surgical techniques in detail. I felt totally prepared until I lifted up the scalpel. I froze; I completely forgot what we had discussed. I hadn't undertaken a surgical extraction since dental school. I tried to reassure the patient, but I couldn't be sure whom those reassuring words were meant for. I took a deep breath, felt the fear and did it anyway. It wasn't as scary as I thought.
A few weeks later a patient came to see me complaining of an abscess from a lower second molar. The radiograph revealed a root filled lower second molar with long bulbous roots and sub-gingival caries. My heart sank; this was going to be a surgical extraction. He was the last patient before lunch on a Friday. I could feel my nurse's eyes boring into the back of my head. "Please just give him antibiotics" I could feel her thinking. However, I couldn't delay this extraction. My patient was in pain and a referral could mean he would wait weeks to be seen. I asked my nurse to get the surgical kit out while I mentally reminded myself of all the stages of surgical extractions. When I had checked my patient was numb and raised my scalpel I felt reassured that if something went wrong I knew that my trainer would be able to come and help me. Fortunately, I never needed to call her. I managed to get the tooth out (in pieces) and when I next saw the patient he was so grateful that I had gone ahead.
I gained a lot of confidence from my first solo surgical extraction. However, I knew that not all extractions would be so simple. I, like many other people in my year, decided to apply for a Dental Core Trainee job. I am aware that this job isn't for everyone, but I could not recommend it highly enough to newly qualified dentists who want more "hands on" experience of surgical extractions. I have gained experience both in theatre and in my own MOS list as well as learning many more skills whilst being on call. Once you have cared for someone in the dead of night with a compromised airway or bleeding, not much in general practice can faze you.
I have always found that practical experience is the best way for me to learn. What would I suggest then to help a new graduate? My recommendation to any newly qualified dentist who feels slightly overawed by the thought of surgical extractions to consider a DCT job. District general hospitals with smaller Oral & Maxillofacial surgery units usually offer more "hands on" experience. If a year in a hospital does not seem like your cup of tea I would suggest you to try to undertake at least one surgical extraction, under the supervision of a trainer, during your DCT year. I was once told that anything you do not do in your FD year you will not do later. This does not just apply to oral surgery. Your FD year is the time when you can test yourself; your trainer is there to pick you up if you fall. I speak from personal experience having been picked up, dusted off and sent on my way again.
If this advice is a bit late for your stage of training I would say that it is never too late to try something new. I know of a few DCTs who have already worked in practice for over ten years and are now doing a hospital job to broaden their knowledge and skills. I would also direct people to the BAOS website for information regarding training opportunities and support in oral surgery. BAOS have a conference in Manchester September 23-25th, which should appeal to anyone wishing to further their career in oral surgery. They are offering opportunities for individuals to receive career advice, as well as lectures on current hot topics.
Or maybe you could re-think your next non-urgent referral for extraction. Discuss it with a more experienced colleague and set aside a designated time to undertake a surgical extraction when you are prepared for it. If all else fails and you are faced with a patient in pain, remember that extirpation of the pulp will at least help to relieve the immediate symptoms
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