Bethany Moniz DH2

Clinical Dental Hygiene 4

Instructor: T. Maahs
11/16/14
DENTAL OFFICE SPECIALTY OBSERVATION
ORAL MAXILLOFACIAL & IMPLANT SURGERY
Date of Observation: November 13, 2014
Time: 7:15 10:30am.
Northwest Oral Maxillofacial & Implant Surgery
Dr. Tim Welch
911 Country Club Rd, Suite 100
Eugene, OR 97401
Dr. Welch requested that I arrive by 7:15am to attend the daily morning meeting.
The entire staff met in his office and we went through the entire days schedule.
Each patient was discussed, films were displayed on a large screen for the entire
room to view I-Cat images or a panoramic radiograph. This was an open discussion
meeting that allowed staff to add input such as if a new radiograph image was
needed at the appointment, allergies to medicines, and any significant information
for the appointment.
7:45am 9:00am: Consultations
Assistants brought the client to an office where they reviewed medical history and
medications, took vitals, weighed the patient to know the maximum recommended
dose for agents that may be used during treatment. Once completed and all notes
were recorded both on the paper chart and computer record, the assistant would
have Dr. Welch come in to discuss treatment plans. The assistant also addresses
and notes who will be the patients escort to and from appointment. They tell the
patient that someone needs to stay with them for at least one hour (preferably all
day) from the time they arrive home to monitor them. Patients are told they will
feel groggy and tired following treatment.
Consultation # 1: Extraction on tooth # 1 and possibly # 31 due to a crack in
tooth.
Dr. Welch reviews films with the patient. The patient asked about rinsing with
hydrogen peroxide and Dr. Welch explained that hydrogen peroxide is good for
necrotic tissue, but not for health because it can alter the bacterial balance in your
mouth. He explained that the pain will be greater in the mandible because of the
bone density. Dr. Welch also discussed nutritional counseling because the patient
drinks several sodas per day. He explained that although it may be satisfying to the
taste, there is no benefit to your body from soda and the risk factors include
decalcification of enamel.
Consultation # 2: Patient has been advised by Dentist to remove teeth #1, 16,
and 32 (wisdom teeth). Patient is in his late 30s, and this is a concern because the
roots are fully developed. When discussing extraction of mandibular teeth with
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roots that are fully developed, Dr. Welch takes care in radiographs to determine the
relationship/distance from the apex of the root to the Inferior Alveolar nerve. The
reason for this is because there is a risk of having a permanent numb sensation in
the lip upon extraction. An alternative procedure would be a coronectomy. The
patient was concerned about returning to work within 3 days post surgery and if he
needs to refrain from his crossfit exercise program. Dr. Welch explained that the
patient may bleed most of the first day, however, patient may be the most swollen
on the 3rd day. Additionally, the patient was advised to avoid exercise for 5 days
after the surgery. Dr. Welch requested an I-CAT image for more diagnostic
information to decide on treatment plan for tooth # 32.
Consultation # 3: Patient has an abscess and bone loss on tooth # 30. He is also
experiencing pain on tooth # 3 and 15 due to severe infection Dr. Welch advises
extracting those maxillary 1st molars as well. The patient wanted to know if he
could have a root canal on tooth # 30 versus extraction. Dr. Welch explained the
success rate of a root canal would be low because the tooth is imploded. This
patient smokes pack of cigarettes daily, and Dr. Welch discussed that the patient
needs to avoid smoking during the healing process because nicotine shrinks blood
vessels, which prevents your body from healing itself. Additionally, Dr. Welch
explained that smoking must be avoided during maxillary extractions because the
roots penetrate the sinus and can leave the patient with a hole in the gums, which
when drinking fluids, can come out through the nose. The patient admitted he was
looking for a good reason to quit smoking, and that is a pretty good reason.
[During the procedures, Dr. Welch had me stay with him so I did not get to observe
the assistants preparing equipment, instruments, and infection control procedures.]
Procedure # 1 Observed: Extraction of tooth J and 13A.
13 year old patient had a supernumerary tooth 13A posterior to tooth J. Assistants
had already administered local anesthesia (Lidocaine and Epinephrine 18mg,
Septocaine with epinephrine 68mg) and patient had nitrous oxide. Patient was
already in the supine position, and vitals were displayed on the monitor, including
pulse oximeter. Tooth # J did not have root attached upon removal, however, tooth
# 13 A root was attached. A full thickness mucoperiosteal flap was elevated around
the teeth and an appropriate amount of buccal bone was conservatively removed
using a small straight elevator and dental hand piece. The teeth were elevated
from the bony alveolus using a small straight elevator and dental forceps. Any
irregular bone edges were smoothed with a bone file. The tissue flap was
reopposed with the use of Fibrinogen.
Procedure # 2 Observed: Implant # 10, non usable stent
Reviewed I-CAT images with Dr. Welch
Assistants administered anesthesia prior to Dr. Welch entering room, warm blanket
was placed on patient, and patient was in the supine position. Dr. Welch
administered the IV site and used Midazolam/Versed 5mg, Fentanyl 50mcg, Atropine
0.4mg, Dexamethasone 4 mg, and Clindamycin 150 300mg. Dr. Welch used a
methylene blue surgical stent to mark the implant site and confirmed using a
micrometer and the cone beam data. A # 15 blade was used to make an incision
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and a limited full thickness mucoperiosteal flap was gently elevated to increase
buccal keratinized tissue. A series of dental implant burs were used to prepare the
osteotomy. The healing abutment was placed in a one stage procedure. Sutures
were used to replace the tissue flap.
After surgery, the assistants walk the patient to a recovery room. Vitals and pulse
oximeter continue to be monitored during recovery and displayed on the monitor for
the assistant to view. The oxygen within normal limits is > 96% SaO2. As the
patient is recovering, the escort (driver) views the post op video for care
instructions. Patients must be able to ambulate all four extremities upon leaving
the office. Assistants personally walk out the patient and escort to the vehicle.
Other

services provided by this specialty office include:

Bone Grafting
Wisdom teeth extractions
Biopsies
Jaw Fractures
Implant Uncovering
Sinus Lifts
Ramus Grafts

The entire staff is made up of 13 people. There is one surgeon, seven assistants,
one assistant/sterilization member, two billing specialists, one front office assistant,
and a Business Manager. There is not a hygienist employed with this office.
Surgeon responsibilities:
o Meets with patient to talk about the surgery during the consultation
appointment
o Conducts morning meetings
o Performs the surgery
Assisting responsibilities:
o Review medical history with the patient during consultations
o Update medical history at each appointment and complete chart notes
o Take radiograph: Panoramic, I-CAT image, or both
o Clean each room following infection control procedures
o Launder scrubs Full laundry room at office, all scrubs stay on site
o Assist the surgeon during surgeries two assistants required in the
room with every surgery
o Assist and stay in the recovery waiting area with patients
o Assist with sterilizing instruments, re-stocking supplies
o Train new employees
Billing Specialists:
o Stays in contact with both patients and medical insurance companies
o Thorough knowledge of billing and coding
o Discusses payment plans and options with patients
Front desk assistants:
o Schedule appointments
o Confirm appointments
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o Filing and documenting patient charts

Business Manager:
o Lark is the Business Manager who also assists the front desk. She was
my contact person at this office. She also processes Accounting and
Payroll for this office.

Equipment used during treatment includes pulse oximeter, blood pressure monitor,
and saliva ejectors. Oxygen tanks are available in each room. Oxygen levels and
vitals are displayed on a monitor at all times during treatment. Water lines are not
used in this office, only Sodium Chloride is delivered via bulbs that the assistant
uses during treatment to clean and rinse the area during surgery. Sharps containers
are in every operating room and both the clean and dirty side of the sterilization
area.
Instruments required on every tray include: Mirror, Injection Syringe, Suction, 2x2
and 4x4 gauze, Bite Blocks, Cotton Forceps, Cheek Retractor, Seldon, Bib Blip,
Suture Holder, Bone File, Unibevel, Scissors, Ronguer, Kelly, East-West, Small
Straight/Large Straight, Periosteal, and 15 Blade.
Components of the client record that are specific to the specialty practice include
diagnosis, procedure, treatment indications, anesthesia, pre-operative data that
includes height weight vitals and pre-op rinse and if any changes in health,
which assistants assisted Dr. Welch, monitors used during treatment, operative data
including time frame from beginning to end of procedure vitals are electronically
recorded every 5 minutes. Additional components include total anesthesia time,
description of procedure, all agents and medications used, and discharge data.
Data also includes anxiety levels, movement of patient after recovery, and who
their escort is.
The sterilization area consists of both a clean and dirty side, divided by a large wall.
On the dirty side there are two sterilizing machines, and a cold sterilizer that can
hold plastic instruments for up to 10 hours. The assistant runs the instruments in
the ultra-sonic before sterilizing. This office has large sterilization bags that hold all
the instruments needed on a tray. The main disinfectant used at this office is Opticide. Opti-cide is a virucidal, fungicidal, bactericidal, and tuberculocidal that can be
used as a surface sanitizer and disinfectant. Overhead lights in the operation rooms
are not covered with barriers, only the handle has a cover for directing the light, the
chairs are covered with a large plastic barrier, and the trays have barriers as well.
All instruments after the procedure are transported to the sterilization (dirty side) in
a large plastic container with a lid. This container and lid are disinfected after each
use.
The rational for referral of a client from a general dentist to this specialty practice is
when surgical management is required in the oral and maxillofacial region are
needed. Patients may also be referred to an Oral Surgeon when general anesthesia
is recommended for patients.
This office was extremely efficient. There was one assistant in the back that
directed the flow of all staff. She wrote on a dry erase board outside each operating
room that included the procedure and she wore a wireless blue tooth on her ear so
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she could be contacted by the front desk as patients arrived. She would also stay
near the recovery rooms and often recorded vitals. All scrubs stay at the clinic; they
have a full laundry room and take turns on rotation for washing scrubs and patient
blankets. Scrubs are neatly hung in a closet. All staff have a locker available to
them in the break room. There is only one restroom available in the break room.
Patients are requested to use a restroom outside of the office in the hallway of Floor
1. The staff were very welcoming and helpful with me in viewing all areas of the
office. One assistant showed me all of the daily/weekly/monthly checklists that are
kept including medical emergency supplies and medications, equipment check,
general office supplies and equipment, etc. Dr. Welch was very friendly and talked
me through each consultation and operation prior to meeting with the patients. He
made me feel very welcome, as if I were a part of the team.