Dentaltown New Grad Edition 2019 - 37

Fig. 6: A CBCT panoramic reconstruction shows
extraction sites of the mandibular third molars on
the fifth postoperative day.

Fig. 7: A tangential CBCT slice shows bony
sequestration, as well as a retained root fragment
in proximity to the inferior alveolar canal.

Case 2
This case brings up another concern about what I'm seeing
in practice lately. A healthy 16-year-old girl was seen for routine
examination by her dentist after a hygiene visit. The dentist noted
four impacted third molars and recommended that the patient be
scheduled with the itinerant oral surgeon who comes to his office
once per month. The patient subsequently had the two lower
wisdom teeth removed in the office under local anesthesia. The
procedure took about 45 minutes, according to the patient. She
experienced increased pain and swelling in the days after the surgery
and called the dental office on the fifth postoperative day. She was
told that the doctor who removed the teeth was not available, and
the doctor who owned the practice couldn't help her, and so she
was referred to my office.
On exam, there was moderate swelling in the face over the
left angle of the mandible. Intraorally, the incision in the #17 area
was inflamed and swollen, with pus visible in the socket. A CBCT
image was obtained, which showed the defects in the mandible
from the surgery (Fig. 6).
Both lower third molars appeared to have been partial-bony
mesioangular impactions. Examination of the #17 extraction socket
showed three bony sequestra, as well as air and fluid densities (Figs.
7 and 8). The patient was started on amoxicillin and scheduled for
debridement of the socket the following day. A significant amount of
infected granulation tissue was debrided from the socket, along with
two necrotic bony sequestra and a residual root fragment. The patient
was significantly improved by the next day and continued to improve.
Again, a number of issues are raised by this case. First is the
increasing use of itinerant exodontists and other specialists in private
practices. Practice gurus are advising dentists to avoid the urge to
refer patients to the local specialist, because more money can be
made by keeping the patient in-house and retaining most of the
revenue. Ideally, the practice owner furthers his or her education
to be able to provide additional procedures and services in the
office. Some feel it makes more sense to hire someone else to get
their hands dirty.
When an itinerant specialist is brought into the practice,
one of the biggest concerns is a deficiency in continuity of care
and availability of the traveling doctor to manage postoperative

Fig. 8: The coronal CBCT projection
demonstrates bony sequestration
and air pockets within inflammatory
soft tissue. This is indicative of infection
in the extraction site.

complications. If the practice owner and staff do not do surgery
on a regular basis, they may not have the training and experience
to deal with anything but normal postsurgical care.
The American Association of Oral and Maxillofacial Surgeons
long ago addressed the issue of itinerant surgeons in its comprehensive
Code of Professional Ethics. Addressing the issue that occurred here,
the code mandates a duty to the patient in the postoperative period:
"It is unethical for a surgeon to delegate postoperative care to a person
who is not similarly qualified to recognize, treat and manage all
surgical complications. ...Therefore, if an oral and maxillofacial
surgeon performs itinerant surgery, they shall be responsible for the
outcome of the postsurgical care and shall maintain communication
to ensure the patient receives proper continuity of care."
This standard of care for postoperative management is the same
whether the treating doctor is a specialist or general practitioner.
In surgical residency, we are taught to perform only procedures for
which we can handle the complications. This seems to be ignored
in the age of the "super dentist."
Not only are there ethical issues with this activity, but there
is the potential loss of patient confidence in the practice owner as
well as the delegated treating doctor. Patients are not dumb; if they
feel that their care in the office was subpar, they're very unlikely
to return to that practice. None of us can afford to lose patients
because of therapeutic misadventures.

Final note
We all need to reassess our priorities and ensure that patient
care comes above all else. I fully support general practitioners
performing surgical procedures, if they enjoy doing surgery and
want to learn new skills or improve their current ones. It just has
to be done in the right way and for the right reasons.
Seek training from the most qualified and experienced doctors you
can. Learn the limitations of your training, experience and comfort
zone. Proper training is essential. Proper judgment is paramount.
Heed this advice and you are likely to sleep well at night. n
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