Organization of Dental Department
In the past, dentistry was considered a division of the
The Department of Surgery encompasses hospital dentistry as a constituent part rather than as an independent entity This integration has led to limitations in exposure, staffing, privileges, and patient care, particularly in routine and major extraoral surgeries Consequently, hospital dentistry has not received the recognition it deserves for its contributions and capabilities.
The dental department has evolved into a distinct and independent entity, akin to the Department of Surgery or the Department of Medicine This transformation allows for greater autonomy in staffing decisions, the development of operational protocols, and the establishment of comprehensive training programs.
The organization of a dental department should mirror the structure and approach utilized in surgical and medical departments within a hospital This ensures that dental staff operate with the same level of professionalism and efficiency as their counterparts in other clinical areas.
The Dental Department must adhere to the same rules and regulations as all clinical departments, holding equivalent authority and responsibilities Staff members are required to secure medical support for admission history, physical examinations, and the management of medical issues during a patient's hospital stay Additionally, the presence of experienced oral and maxillofacial surgeons is essential for effectively managing both casualty cases and inpatients.
MAJOR SER MAJOR SER MAJOR SER MAJOR SER
The major service units of dental departments focus on providing comprehensive care and specialized treatments These units are essential for ensuring optimal oral health and addressing various dental concerns By implementing advanced techniques and technologies, dental service units strive to enhance patient experiences and outcomes Their commitment to excellence in dental care is reflected in the quality of services offered, making them a vital part of the healthcare system.
DEP DEPAR AR AR ARTMENT AR TMENT TMENT TMENT TMENT
Within the departmental organization there are four major service units:
Admitting Ser Admitting Ser Admitting Ser Admitting Ser
Admitting Service vice vice vice vice
The admitting service enables general dentists and specialists to admit and manage patients in the hospital's operating room Typically, this service is utilized by general dentists treating patients with disabilities or mental challenges, as well as oral and maxillofacial surgeons who need surgical facilities Additionally, periodontists and pediatric dentists often require general anesthesia for their patients, necessitating a hospital environment The admitting service oversees the care, discharge, and follow-up of inpatients.
Outpatient Ser Outpatient Ser Outpatient Ser Outpatient Ser
Outpatient Service vice vice vice vice
In most hospitals the outpatient service performs the outpatient treatment, follow up of discharged patients.
In smaller hospitals, dental services include consultations provided by a diverse team of specialists, such as general dentists, oral and maxillofacial surgeons, pedodontists, orthodontists, periodontists, prosthodontists, endodontists, and conservative dentists Essential full-time faculty members include the first three specialists, while the remaining experts may serve as full-time or part-time consultants based on community needs and the specific demands of the practice.
Casualty Service vice vice vice vice
Emergency services, also known as urgent care, are essential for patients needing immediate attention for serious dental issues While most individuals do not seek emergency care for minor dental problems, those who arrive at hospital emergency departments often require the expertise of an oral and maxillofacial surgeon, particularly for complex cases involving faciomaxillary injuries or severe infections These surgeons frequently collaborate with other medical specialists to manage polytrauma cases, highlighting a significant opportunity to serve the community and showcase the capabilities of the dental profession.
Consultation Service vice vice vice vice
The recognition of the need for dental consultation in hospitals arose from the observation that patients with significant health conditions frequently experience orofacial and intraoral issues These dental concerns can significantly impact the effectiveness of essential surgical and medical treatments.
Bleeding gums, loose or decayed teeth, unexplained facial pain, and oral ulcerations are critical indicators that necessitate a dental consultation Additionally, the presence of oral manifestations of systemic diseases, intraoral infections, limited mouth opening, and oral metastatic disease further highlight the importance of seeking professional dental care.
Currently dental department respond to consultation requests from the following departments:
1 General medicine: The dental department helps to identify the focus of infection and oral manifestation of systemic diseases.
The dental department specializes in providing essential services for patients preparing for major cardiac surgeries, including presurgical dental extractions, oral prophylaxis, and restorative and periodontal therapies Individuals with a history of ischemic heart diseases, those with pacemakers or valve replacements, patients post-coronary artery bypass grafting (CABG), and those with rheumatic or congenital heart diseases are referred to the dental department for specialized care that necessitates careful attention.
The dental department plays a crucial role in supporting patients who need obturators and maxillofacial prostheses Collaborating closely with plastic surgeons, they focus on the management and rehabilitation of individuals with cleft palate, ensuring comprehensive care and improved outcomes.
4 Dermatology: Patients are often referred to the dental department to rule out oral focus of infection, oral manifestation of dermatological diseases, and for biopsy of oral lesions.
In the management of unexplained facial pain and sinusitis, dental consultations are frequently sought to eliminate any oral focus Additionally, the dental department plays a crucial role in fabricating surgical and final obturators following maxillectomy procedures.
The oncology department emphasizes the importance of dental consultation and treatment for patients preparing for chemotherapy and radiotherapy Essential dental care includes the removal of focal infections, restoration of carious lesions, and ongoing maintenance throughout the treatment process.
7 Intensive care unit: Patients in intensive care unit who require diagnosis and treatment of orofacial and dental diseases that is associated or exacerbate acute diseases need dental consultation.
Sleep apnea syndrome laboratories have become widely recognized in Western countries, yet they remain underappreciated in India The dental department plays a crucial role by assisting in the creation of anti-snoring devices and preparing patients for surgical interventions aimed at correcting skeletal deformities that contribute to the condition.
Thus, by providing the necessary services to the above category of patients, the dental department forms an integral member of multidisciplinary health care team.
Admission and Medical Record
Hospitals have specific procedures and protocols that must be adhered to from the time of admission to discharge These guidelines are designed to establish an accurate diagnosis, facilitate necessary investigations, and document the patient's progress throughout their hospital stay.
ADMISSION PROCESS OCESS OCESS OCESS OCESS
A patient may be admitted to the hospital in either of the following ways:
Patients are admitted to the hospital for surgical procedures or specialized investigations that require close monitoring and optimal treatment Hospital dental care is essential for various conditions that necessitate such comprehensive attention.
Patients with complex medical issues, such as those who have undergone valve replacement and are on anticoagulant therapy, often require oral surgical or dental procedures like tooth extractions Additionally, other medical conditions may necessitate blood transfusions or the administration of parenteral medications during dental treatments.
2 Emotionally or mentally challenged patients or pediatric cases incapable of tolerating dental procedures in conventional settings.
3 Major maxillofacial surgical procedures which requires treatment under general anesthesia.
5 Procedures that may cause localized swelling and air way compromise.
Nonelective Admissions Nonelective Admissions Nonelective Admissions Nonelective Admissions
Nonelective admissions in the dental unit primarily involve maxillofacial trauma and severe odontogenic infections Patients with maxillofacial trauma, particularly those who are unconscious or have multiple injuries, are typically admitted to trauma or general surgery units, which then consult the dental service for further care Similarly, patients with severe odontogenic infections, especially those with significant comorbidities like diabetes, may be admitted to medical units before requesting dental consultations However, if a patient presents without other injuries or serious systemic conditions that require urgent medical attention, they may be directly admitted to the dental service Key conditions necessitating nonelective admissions to the dental unit include maxillofacial trauma and severe odontogenic infections.
1 Fractures of the facial bone requiring reduction and fixation in the operation theater.
2 Extensive soft tissue injuries that require wound care and observation.
3 Conditions requiring administration of intravenous fluids or parenteral antibiotics.
4 Rapidly spreading odontogenic infections requiring incision and drainage.
5 Infection or injury that are likely to compromise the airway.
The medical record is the document that charts the patient’s stay in the hospital from admission till discharge.
The medical record serves to document essential patient information and facilitate communication among healthcare team members Each member involved in patient care contributes to the creation of the medical record The seven major components of a medical record include:
2 Progress notes and doctors orders.
4 Preoperative, operative and postoperative notes.
Accurate and legible medical records are essential for effective patient management and play a crucial role in medicolegal considerations Careful documentation helps prevent errors and omissions, ensuring the integrity of patient care and legal compliance.
Any corrections made should be signed All entries must be signed and show the date and time they were made.
Abbreviations should be kept to the minimum possible.
The article outlines the key factors contributing to a patient's hospital admission, detailing the chief complaint, the history of the illness, and past medical and dental history It also examines the patient's habits, family history, and results from the physical examination, culminating in a tentative diagnosis.
When admitting patients with drug allergies, uncontrolled systemic diseases, bleeding diathesis, anticoagulant therapy, head injuries, cervical spine injuries, or medicolegal cases such as road traffic accidents and assaults, it is essential to prominently note these conditions on the cover page of the medical record This practice ensures that all members of the healthcare team are immediately aware of critical patient information.
Prog Progress Notes and Doctors Orders ress Notes and Doctors Orders ress Notes and Doctors Orders ress Notes and Doctors Orders ress Notes and Doctors Orders
This article outlines the preoperative and postoperative progress of patients in the hospital, detailing the daily administration of medications, intravenous fluids, and nutritional management It also includes a list of any new laboratory tests and consultations needed for quick reference For instance, a diabetic patient on insulin will need regular assessments of blood sugar and urine sugar, along with medical consultations to adjust insulin dosages as necessary Including all these elements in the progress note ensures easy access to vital patient information.
Laborator ator ator ator atory Results y Results y Results y Results y Results
All examination results, including blood, urine, sputum, ECG, and blood group, must be documented on the designated sheet When repeating investigations, it is essential to note the date and time of each result Additionally, positive findings from radiographic examinations, CT or MRI scans, and biopsy reports should be recorded, with the complete report attached to the case record.
Preoperative and postoperative care are essential components of successful surgical outcomes Proper preoperative assessments ensure patients are prepared for surgery, while effective postoperative management aids in recovery and minimizes complications Attention to detail in both phases is crucial for patient safety and overall satisfaction.
Patients scheduled for surgery under general anesthesia must have a preanesthetic consultation one to two days prior to the procedure For those with cardiac conditions, obtaining cardiologist clearance is essential before proceeding with the preanesthetic evaluation Additionally, physician approval is recommended for patients with systemic diseases It is crucial to complete routine blood examinations, including total leukocyte count (TLC), differential count (DC), hemoglobin (Hb), erythrocyte sedimentation rate (ESR), and bleeding time (BT), prior to the preanesthetic assessment.
CT, Blood Sugar, Blood Urea (Liver function test, Renal function test and Serum electrolytes when ever it is required). b Urine examination: Albumin, Sugar, Deposits; and
Acetone in diabetic patients. c Blood grouping and cross matching. d ECG: All leads. e X-ray chest: PA view. f Any other relevant investigation results particular to the case.
While writing preanesthetic consultation, the following points should be included for the information of the
Anesthesiologists need essential information prior to surgery, including the scheduled time and date, the required type of anesthesia (general or local), and the patient's diagnosis They must also know the specific type of surgery being performed, the anticipated duration of the procedure, and whether hypotensive anesthesia is necessary Additionally, it is crucial to assess the likelihood of severe bleeding and the amount of blood prepared for the operation, as well as the type of intubation required, whether orotracheal or oronasal.
The above information will be of invaluable help to the anesthesiologist in the preanesthetic eva- luation of the patient and planning the anesthetic procedure.
The article summarizes the key events that take place during and immediately after surgery, detailing the patient's journey from the operating theater to the recovery room It includes the Anesthesiologist’s Notes, which document the anesthesia induction, the procedure, and the patient's recovery from anesthesia, typically recorded by the anesthesiologist or an assistant Additionally, the Surgeon’s Notes provide a concise overview of all activities that occurred during the surgery, highlighting essential details for a comprehensive understanding of the surgical process.
• Name of surgeons and anesthesiologists
• Type and duration of anesthesia used
The surgical procedure begins with an incision, followed by a brief overview of the operative steps taken and the findings observed during the operation Any complications encountered are discussed, along with details regarding the type and location of drains used The paragraph also outlines the type of suture materials and the suturing techniques employed Additionally, it includes a description of the pathology specimen collected and specifies whether it was sent for frozen section analysis or routine histopathological examination.
• Amount and type of fluids including blood transfusion.
• Patient’s condition on leaving the OT.
Casualty Service
Advanced hospitals have a dedicated dental team to handle dental, oral, and maxillofacial emergencies Dental surgeons, as specialists in diagnosing and treating traumas and diseases of the mouth, face, and neck, play a crucial role in the hospital's casualty service After triage officers conduct initial assessments, dental surgeons are called to evaluate and treat patients needing dental and oral surgical care.
WHA WHAT IS ON CALL ? T IS ON CALL ? T IS ON CALL ? T IS ON CALL ? T IS ON CALL ?
The term "on call" refers to the responsibility of the duty doctor or resident medical officer to be readily available for emergency care in the casualty department or for inpatient consultations.
Resident dentists and maxillofacial surgeons may be on call either physically at the hospital or reachable by pager or phone from home Physical presence is preferred, as being absent can be viewed as neglect by hospital administration Relying on pagers or phone calls is often seen as undesirable, as it can delay necessary assistance, leading to potential issues in patient care.
The resident dentist gains minimal experience in managing emergency patients, resulting in a missed opportunity to enhance the dental department's visibility in the emergency care setting.
On-call hours present a unique opportunity for dental practitioners to enhance their knowledge and skills, as they encounter unexpected medical and surgical issues that demand immediate attention This availability for consultation and intervention fosters significant learning and teaching experiences in the field.
A great deal of learning and teaching occurs during on-call hours
Physical presence in the hospital is the preferred form of on call
Absence from the building is considered as dereliction of duty.
The final diagnosis of dental, oral, or maxillofacial conditions must be conducted by a qualified member of the Dental casualty service to ensure optimal patient care It is essential that treatment for these issues is not delegated to other services, as specialized care from dentists and Oral and Maxillofacial surgeons is crucial These professionals are equipped to address a wide range of conditions, from minor toothaches to severe facial injuries and swellings that could obstruct the airway Immediate interventions in the casualty setting are vital for effective treatment.
1 Establish and maintain a patent airway.
The oral and maxillofacial surgeons have traditionally been the first dental professionals called to provide casualty consultations They provide advice and care for a multitude of problems:
INJURIES OF THE MAXILLOF THE MAXILLOF THE MAXILLOF THE MAXILLOFA THE MAXILLOF A A A ACIAL REGION CIAL REGION CIAL REGION CIAL REGION CIAL REGION
The face is the most visible and expressive part of the human body, making it vulnerable to trauma Recently, there has been a significant rise in cases of maxillofacial injuries, highlighting the need for on-call casualty dental surgeons to be knowledgeable about the fundamental management of these injuries.
Trauma mortality exhibits a trimodal distribution with three distinct peaks The initial peak occurs within seconds to minutes of the incident, where the severity of injuries makes survival nearly impossible, even under optimal conditions This immediate mortality is primarily attributed to critical damage to the brain and major cardiovascular structures, including the heart and large blood vessels.
The second peak in mortality typically occurs within minutes to a few hours following an event, primarily due to unrecognized complications like airway obstruction, hemorrhage, and head injuries This critical phase, often called the "Golden Hour," highlights the importance of timely professional intervention to save patients' lives The implementation of Advanced Trauma Life Support (ATLS) protocols plays a crucial role in addressing these serious complications effectively.
(ATLS), first popularized and promulgated by the
American College of Surgeons Committee of Trauma, has standardized the management of trauma in many countries in the world.
The third peak occurs days to weeks after the event, when multiorgan failure and sepsis leads to death This often occurs as a result of inadequate treatment in the
The concept of the "golden hour" emphasizes the critical importance of immediate and proactive intervention in Advanced Trauma Life Support (ATLS), which has significantly decreased mortality rates among patients during the third peak of trauma cases This aggressive resuscitation strategy is effective in minimizing the occurrence of late organ failure, ultimately improving patient outcomes.
Hence, a multidisciplinary approach involving various surgical specialists is essential for the proper management of a patient with faciomaxillary injury in a polytrauma patient.
The maxillofacial region's surgical anatomy is intricate due to its proximity to critical structures such as the base of the skull, nasopharynx, orbital contents, cranial nerves, and paranasal sinuses A comprehensive understanding of this anatomy is crucial for recognizing injury patterns, anticipating potential complications, and devising effective management strategies.
Injuries of the face involving the middle third and the lower third of the facial skeleton
The facial skeleton can be easily understood by dividing it into three sections: the lower third, middle third, and upper third The lower third is primarily composed of the mandible, while the middle third is defined by a line extending from the zygomatico-frontal suture across the fronto-nasal and fronto-maxillary sutures to the corresponding zygomatico-frontal suture on the opposite side, with its lower boundary marked by the occlusal plane of the upper teeth or the alveolar crest in edentulous individuals.
FIGURE 3.1: Bony component of the middle third and lower third of face
The posterior boundary is defined by the spheno-ethmoidal junction and the free edges of the pterygoid laminae, while the upper third of the facial skeleton consists of the frontal bone.
Injuries of the middle third and/or the lower one third
(mandible) of the facial skeleton are called maxillofacial injuries.
Primary care in maxillofacial injuries is essential for effective management and treatment It involves the initial assessment and stabilization of patients with facial trauma Early intervention can significantly improve outcomes and reduce complications Comprehensive care includes pain management, infection control, and referral to specialists when necessary Understanding the complexities of maxillofacial injuries is crucial for healthcare providers to deliver optimal care.
Maxillofacial injuries can occur independently or in conjunction with critical emergency situations Therefore, it is essential to conduct a preliminary examination and provide immediate care to address these emergencies before thoroughly evaluating the fracture and developing a treatment plan.
FIGURE 3.2: Patient after facial trauma (note the nasotracheal tube placed)
Two important factors that can lead to the death of a patient are:
2 Massive hemorrhage leading to shock.
Severe maxillofacial injuries can lead to the death of the patient primarily due to respiratory obstruction leading to asphyxia, particularly in patients who are unconscious.
The factors which are responsible for an inadequate airway in these situations are:
1 Obstruction of the nasal and oral airway by blood clot, vomitus, saliva, bone, teeth, dentures and foreign bodies or inhalation of any of these.
2 In bilateral parasymphyseal fractures of the mandible, a bodily backward displacement of the tongue and its attachments can lead to closure of both the nasopharynx and oropharynx (Fig 3.4).
3 A downward and backward displacement of the fractured maxilla can occlude the oro-nasopharynx
4 Airway obstruction may occur as a result of a large hematoma formation in the floor of the mouth or due to pharyngeal or laryngeal edema or surgical emphysema.
FIGURE 3.4: Comminuted fracture of the symphysis. Tongue has fallen back Airway is obstructed
FIGURE 3.3: Immediately after fixation of fracture and closure
ABCD of Maxillofacial Trauma Management