Oral Surgery Consult / Pre-operative Evaluation
Patients in Oral Surgery will either be walk-in for treatment/consults or scheduled referrals. The latter will usually have documentation complete in axiUm including surgical request forms and consent forms. The first group may have an outside referral or an internal referral from the emergency in the main clinic. In this case, there is no documentation, hence, you will need to complete consent forms and SOAP notes (see below). The student who will be removing the tooth is in charge of discussion to accomplish informed consent [for the tooth plan to be extracted] - NO EXCEPTIONS (always check for informed consent prior to any extraction).
1. Verify which teeth are planned for extraction. You MUST check the treatment plan in the chart on the treatment record notes, the consent form, and check the surgical request form. It is your responsibility to make sure that there is proper consent to the extractions planned.
2. Before you call the patient back to the surgery rooms, you will want to review any available information including referral source, medical history, allergies, drugs, x-rays and double check that the room is set up properly.
3. Seat the patient, complete any missing medical history information, and complete an examination. You can get an exam cassette in the drawer near the OS dispensary window. In order to avoid mistakes, you are required to do a so called time-out at this point to verify the tooth/teeth to be extracted. You MUST count teeth with your partner out load while using an instrument in the patients’ mouth to point to the teeth. If you are not paired up with another student, please bring another student from another operatory in for the time-out. You MUST also verify why the tooth/teeth needs to be extracted and what type of extraction(s) it will be (i.e. surgical or routine; partially impacted, complete bony). If you are unsure, ask one of the instructors. Once you have determined the type of extraction, you can verify with or record this information on the treatment plan in axiUm (depending on where the patient is coming from).
If the patient has a long, complex health history, the most important information to find out is as follows:
Surgical vs. Routine extractions– Look at the radiographs first to see what the roots look like. If the roots are straight and the bone is not too dense and the anatomic crown is intact, then the procedure will probably be “routine”. If the roots are divergent and/or dilacerated the procedure will probably be surgical. There is no real formula for determining surgical instead of routine. Generally, if you need to remove bone to extract the tooth because of dense bone, gross decay, broken down tooth, or RCT/post, then the procedure is surgical. If there is no need to remove bone or reflect a flap, then the procedure is routine.
4. Determine which type of anesthesia will be used for the procedure, whether it is local anesthesia, nitrous oxide, or I.V. sedation. You also select whether it is appropriate for a student/resident/faculty to complete the procedure. For routine extractions, and most surgical extractions local anesthetic is sufficient. However, comfort does depend on the anxiety level of the patient and the degree of invasiveness of the procedure. Nitrous oxide is helpful for more involved procedures or for anxious patients, and IV sedation is a good choice for heavily involved surgical extractions in anxious patients. Promoting patient comfort via nitrous or IV does require an additional charge, and for IV sedation, you have to complete two additional consent forms. Of course, all options and changes in the expense to the patient MUST be discussed with the patient.
5. Complete the pre-operative evaluation (SOAP Note > Templates > OS Consult). Don’t forget to determine the patient’s ASA Classification. To complete this, you will need to determine what important medical information is most relevant. Ask a third year for help with your first oral surgery consult note.
6. Complete the consent forms. Make sure to read through the first portion of the informed consent with the patient and check off each item. It is very important to inform the patient that routine procedures can become a surgical procedure. Always inform the patient of the potential risk of paresthesia if you are removing a lower tooth. This information is not to scare the patient, but rather to inform them of all of the possible complications of surgery.
7. Verify payment plan. All patients must pay for the extractions before they are performed. You must inform the patient of this, let them know what their cost will be, and that it will be due on the day they perform the extractions. The patient may be in a contract also for the surgical services and you will need to check those patients are on schedule with payments. If the extraction has not been treatment planned for the patient, the student doctor must first
complete treatment planning of the extraction before getting financial approval.
8. Present the case (typically not with the patient present) to the OS faculty. Congratulations, you have completed your first oral surgery consult! You can test case an OS treatment plan presentation competency as soon as you can handle the consult process successfully by yourself.