An investigation in oral surgery services and training with particular reference to South Australia

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IIAN _I NVEST I GAT ^I ORAL ^{S RGERY ERV I CES D IN IN} WITH PARTI ^{REFERENCE SO} AUSTRAL A.il

L.H. Mayne B.Sc., B.D.Sc',

F'R'A'C'D'S'

Thesis submitted

in Part Fulfi

^lmenl

for

the Degree

of

Master

of

Dental ^Surgery'

Under

the

SuPervision ^of

J.A. Cran B.D.Sc., M.D'S', D'D'Sc" F'R'A'C'D'S"

F. R.C. ^Path.

and

D.M.

Roder B.D.S., M.P'H',

F'R'A'C'D'S'

DEPARTMENT OF ^{ORAL PATHOLOGY AND} ORAL ^SURGERY

UNI VERS ITY ^{OF ADELAI DE} 1916

î,"arrú,

^{ft^,y'''}

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TABLE OF ^CONTENTS

Declaration

Acknow ^I edgements

Abstract Pr6cis Preface

I ntroduct ^{i on}

Aim

I

ii

ttt iv

1

5

I

9

9 53 53 54 54 60

61

71 91 91 94 96 9B 9B 108 109 't 10

vii

4 7

138

52 113 54

60 91

76

B5

94 96 98 Review

of

background information

A. Atlitudes

concerning

the appropriate

^scope and

pre-requisite for oral

^surgeons'

B.

^{Trai n i ng} programmes

for

ora

I

surgeons '

1

.

Undergraduate

trai

^{ni ng.}

2.

Postgraduate

traïning.

2.1

^{United Kingdom.}

2.2

United

Sfates of

^America'

2.2.1

rrEssentials

of

^{an Advanced} Educational Program

in

^Ora

I

^SurgerYrr'

2.2.2

rrGuidelines

for

Biomedical science Education

in Oral

^SurgerYrt

2.3 Australia.

2,3.1 UniversitY of

Queensland'

2.3.2

^{Un i vers}

ity of

Western Austra ^{I í a} _'

2.3.3

^{Un ivers}

itY of

^Me lbourne.

2.3.4 UniversitY of

^SYdneY.

2.3.5

^{Un i ve rs i}

tY of

^{Ade I a i de.}

2.4

^{New Zealand.}

2.5

^{PeoP I}

ers

^{RePub I i}

c of

^{Ch i na'}

2.6lnternationalAssociationofOralSurgeons.

-

¹⁰⁸

-

¹⁰⁹

-

¹¹⁰

-

¹¹³

I

ì l

l

C. Specîalty registration for oral

^surgery

1.

South

Australia.

2,

Queens ^I and.

3.

New South Wales.

4. Victoria.

5.

^{Tasman i} a.

6.

Western Austra I i a.

1, Australian Capital Terrítory.

B,

^Northern

Territory.

9.

^Comments.

D.

0ra

I

^{surgery servi ces.}

E.

^Report

of

^enquî

ry lnto

South Ausfral

ian health

services.

F.

Ora

I

Surgery servi

ces

ⁱ n South Austra ^{I i a.}

G.

Ora

I

surgery servi

ces

ⁱ

n

Queens ^I and.

H.

^The

role of the oral

surgeon.

l.

The scope

of oral

^surgery.

J.

The changing scope

of oral

surgery.

K. Referral lo specialisls.

L. 0ral surgery in the

undergraduate curriculum.

Materials

and methods.

A.

^Samp les.

1. All dentists.

1.i

^South

Aùstralia.

1

.2

Queens ^{I an} d.

2.

Approved

dentists.

3,

^{New Zea I} and ora

I

^surgeons.

B.

Questionnai res.

C.

^{Data process i ng.}

D. Statistical

^analysis

E.

^Treatment optlons.

113

-

113 113

-

114

-

115 115 115

-

116 116 116

-

117

-

119

-

123

-

125

-

126

-

132

-

135 135

-

136

-

139

-

139

-

139

-

139

-

140

-

141

142

-

143 143 144 144

117

114 115

116

117 119 123 124 126 132 134

136 138

144 143 141 140 141 142 143

Results and comments

A.

^Descri

pti

^ve characteri

sti cs of

denti

sts.

1.

^Age

distribution bY

location.

1.1

^Soufh

Australia.

1

,2

Queens ^{I an d .}

1.3

South Austra I i

a

and _Queens ^I and.

2,

^{Fi na}

I

undergraduate

year by

^{I ocafi on} '

2.1

South Austra I îa.

2.2

Queens land.

2.3

South Austra I i

a

and _Queens ^I and.

3,

^Location

of basic dental

^education.

3.1

South Austra ^{I i a.}

3.2

Queens ^{I an d .}

3.3

South AusÌra ^{I i}

a

and _Queens ^{I and.}

4.

^{Emp loymenl}

authority by

^location.

4.1

South Austra ^{I i} a.

4.2

Queens ^{I an} d.

4.3

South Auslra ^{I i}

a

and _Queens ^I and.

5.

Postgraduate qual i

fications.

5.1

South Austra I î a.

5.2

Queens land.

5.3

South Austra I i

a

and _Queens ^I and.

6. Proximity to

an

oral

^surgeon

by location' 6.1

^Soufh

Auslralia.

6.2

Queens land.

6.3

South Austra ^{I i}

a

and _Queens ^I and.

1, Availability of

adequate

hospital

^and

anaestheti

st

^{servi ces}

for

5psci

fied

^{ora I}

surgîcal

Procedures.

1

.1

South Austra I i a.

1

.2

Queens ^{I an} d.

7.3

Soufh Austra ^{I i}

a

and _Queens ^I and.

B.

SummarÎsing remarks.

145

-

²¹²

145

-

¹⁶⁵

145

-

¹⁴⁸

145

-

¹⁴⁶

146

-

¹⁴⁷

148

\49 -

¹⁵¹

149 't50

150

-

¹⁵¹

151

-

¹⁵³

151

-

¹⁵²

152

152

-

¹⁵³

153

-

¹⁵⁵

153

-

¹⁵⁴

154

-

¹⁵⁵

155

155

-

¹⁵⁹

155

-

¹⁵⁷

151

-

¹⁵⁸

158

-

¹⁵⁹

159

-

¹⁶¹

159

-

^'160

160

-

¹⁶¹

161

162

-

¹⁶³

162

162

-

¹⁶³

163

\63 -

¹⁶⁵

B Deci

sions of

general

practitioners provision of various

treatments.

-

^44.

regarding the

S umma r" i s i ng comments ^.

Referra

I

^{tendency by Sf a-les.}

Referra

I

^tendency

by

locati on ^w ith ⁱ

n

Stafes.

Provision of treatment,

because an oral surgeon was

nof

^readi

ly

avaí

lable,

^{bY State.}

Provision of treatment,

because an oral

surgeon

is not readily available,

^bY

location.

Classification of treatmenf,

as

pertaining

predominantly

to the

general

practitioners, oral

surgeon,

or neither.

Decisíon

of

trapprovedrr

dentists

regarding ^the provi ^{s i} on

of

vari ous treatments.

1

.

^Re

lative

^{I ike I ihood}

of

rrapproved'r

denlists to

provi de routi ne

care,

bY Stafe.

2, Relative lÎkelihood of

rrapprovedri

dentists

and general

practifioners to provide

^roufine

care in

^South

Australia

and Queensland.

3. Relative likelihood of

itapprovedil

dentists to provide roufine care, by

^grade

of denlist' 4, Relalive likelihood of

'rapprovedrrdentists

lo

provide specified cafegories of care,

^by

grade

of dentist.

4.1

Care

classified

^as

within the

^realm

of

the genera

I

^practi

tioner.

4.2

^Care

classified

as between

the

realm

of

the

general practitioner

and

oral

^surgeon.

4,3

Care

classified

^as

within the

^realm

of

the ora

I

surgeon.

4.4

^The

relative

^tendency

of different

^grades

of

rrapprovedtr

dentists to provide care

^routine

ly' 5.

Summarising comments.

1

¿.6

45. ¹ 45.2 45.3 45.4 45.5

165

-

¹⁹⁹

199

-

²⁰⁵

199 200

200

-

²⁰¹

201

-

²⁰²

202

-

²⁰⁵

205

-

²¹⁰

205

206

206

-

²⁰⁷

-207

-

²¹⁰

207

-.208

208

208

-

²⁰⁹

209

-

²¹⁰

210

Decisions

of

^general

practitioners

regardîng ^the

provision of certain treatments, by specified characteristics of the dentist or practice.

Decisions bY sex.

Decisions bY Year

of

graduation.

Decisions

by origin of basic

^dental

qual

iflcation.

Decisions bY tYPe

of Practice.

Decísions by possession

of addifional qualificalions.

Decisions by

proximlty of oral

^surgeon'

Decislons

by availability of

^{complele hospital}

arid anaestheti

c

support services.

Discussíon, ^Concl usìqns and Recommendations

D

1.

2.

1

211

-

²¹²

211 211

211 212

212 212

212

213

-

²²¹

4 5.

6 7

Append ^X

. (i) . (ii) .(iii)

Appendix I ^I

Appendix I I ^I Appendi

x

^{I V}

Appendi

x

^V

References and Bibl iograPhY Persona

I

^{Commun i cati ons}

i-xv î-xv

| - vlll

| - vl ll

Declaration

This thesis is

^submitled

in.parf

^f

ulf

^i'lment

of the

requirements

for lhe

Degree

of

^Master

of

Dental Surgery

in the University of

^Adelaide'

Candídature

for the

Degree was

sátisfied by

a

Qualifying

Examinalion in

1976.

This thesls

contains no

material which,

^{except where} due mention

is

^made, has been accepled

for the

award

of

^any

other

^degree

or

^{diploma in}

any

University.

^To

the best of

my knowledge,

this thesìs contains

^no

malerîal prev¡ously

^{publ ished}

or written by

another person, ^except where due reference has been made

in the texl.

tt

Acknow ^I edqements.

Had

it not

^been

for the kindly interest,

enthusiasm ^and encouragement

of Dr. J.A.

Cran

this study

^would

nol

have ^been commenced, and

without the untiring

encouragement, ^guidance and

constructive criticism of Mr.

D.M. Roder

it

^may

not

^have

reached

completion.

^{To each}

I

^{extend my}

sincere

^thanks.

I

would

like to

exPress

appreciation to Mr' P'

^Leppard

for his

advice and assistance

with

computer

material, to Mr. D.

Smale, and Miss

K. Taylor for their

assistance with

the

mai

ling of questionnaires, Mrs. D.

^{Rossi and}

Mrs. A.

^Jones

for the Letraset work,

^and

Mr.

& Mrs.

H.R.F.

Andersen

for thelr

informative

^guided

lour of

a

sl.

^{John Ambulance}

cenfre

^and

Em-Care Vehicle.

Final

ly but importantly I

^wish

to

^{express my}

sincere

^thanks

to

Miss M. Pearce

for her patience

and

skill in the typlng

^of

the

manuscri

pt.

)

ttt

Abstract

ln order to provide efficient oral

^surgery

services of

the

highesl standard, there

must be competent

oral

surgeons ^and

general

praclitioners

^who have graduated from

trainíng

^programmes

of

an app rop r i

ate

^{qua I i}

ly.

lv.

Préci s

Whereas al

I

^forms

of

surgery

origínal ly

were performed by

lhe

medical

profession, it

became

evident that the study of dentistry

was

of prime

importance

lo lhe

treatment

of disorders of the

moufh

and

jaws. Therefore, oral

surgery developed as

a specialty of

denti

slry.

Previous ^{pub I}

ications

have presented

the

general

opinion that oral surgery is a specialty of dentisfry

and necessari

ly

must be based

on

thaf

profess

ion

^{(Thoma 1g5-/}

,

^Amies 1966, Cameron 1968, Hayward 1968,

Shira

1969, Hayward 1971, De

Fries

1971,

Hale

1974).

Some controversy

also is evident

regarding

lhe

^need

or

^otherwise

of

a medical as

well

as

a dental qualificalion for this specialty.

The concensus

of opinion evidently is

^opposed

to the claim that

bolh qual

ificalions are

necessary,

partly

on

the basis of

^{perceived waste}

of resources. Whilsf

^medlcal courses were

relevant to this discipline, lhey evidenlly offer

no advantage

that could not

be obtained from

dental

course

with

subsequent postgraduate

traîning tai lored to

the needs

of the speclalty

(Christensen _1963,

Fitzpatrick

1965, Amies 1966, Hayward 1971, Laskin 1972,

Hillenbrand

1973,

Hall

1973, Eisenbud 1973, Edelberg Tryon and

Jerge

1973, Porterf

ield

^19-t-3,

Pleasanls

^1914).

It is

considered

essential fhat training

programmes should be so

structured lhat

^graduates

are

competent

to

manage

all

^aspects

of

oral

surgery

^(sh

ira

¹⁹⁶⁹

,

^{Revzin 1973, Ha I}

I

^19-13,

Pizer

^{19-73, Bear 1973,}

P I easants ^{191 4) .}

The present

socio-political benefits for oral

^surgeons

lo

^possess

a

medical ^qual

ification

neverlheless

are

noted (Christensen ^1963,

Fi

tzpalri ck

^{1965, HaYward 1971) .}

A number

of writers

^have

slressed the

competence

of oral

^surgeons

in the

complete management

of oral surgery

(Hayward 1961,

North

^1965,

HÌ I lenbrand 196-7, Cameron 1968, Hayward 1968,

Shira

^{1969, De}

Fries

^1971'

Levant ^1g-: 1, Hi llenbrand ^1973,

Hall

^1973,

Pizer

1973, Poore ^1913' wi

lson

^1913, Eisenbud 1973,

Hale

1g74), and

the

phi losophy

of a

feam

approach

to the oro-facial region

^{has been presented}

(North

^1965'

Hayward ^1968,

Glass lglo,

Levant ^1g11

,

^Chase 1g-r.1, smal

I

^{19-71, De Fries}

1g11,

Fickling

1912, sissman 1913, ^Wi

lson

1973' Bear 1973,

Bright

^1913,

Health Services Seminar

1974).

^With

the desîrabilily of a multidîsciplinary

approach, emphasîs

is

^{placed on}

the

apparent need

for

equal

status of

al ^I

members

of the

^team,

with the oral

surgeon

being

accorded

primary

^res- ponsibï ^I

Ìfy for

^areas

within his

^scope'

ln a

review

of training

programmes, ^some

varialion

^{has been found}

in the lenglhs of oral

^{surgery courses and}

fhe

requirement

for a

^medical

qual i

ficalion.

^Even

so, the

indispensÎbi ^I

ity of dental lraining

^is

stressed

unanimously, and

a

common grouping

of essentîal subject

^matter

is

^evi dent.

According

fo fhe

^sfandards

outl

^ined

at the

Madrid workshop (1974), adequale

training is attainable in Australia, bui only in

Adelaide ^where

the

course

is the sole

one accepled

by the

Royal

Australian

^{College of} Dental ^surgeons as

a satisfactory pre-requisile for the

Dlploma

at

^an

Advanced

Level in 0ral

^SurgerY.

vl.

A survey by

questionnaire of

⁹⁹⁰

registered dentists În

^south

Auslralia

and Queensland

eliciled information

^regarding

their

^des-

criptive characteristics.

^The

decision of general practilioners

and

denfists,

^{who were} "approved" by

the

commonwealth Department

of Social Security for their patienfs to receive

reimbursement

for

^some

oral surgery,

was analysed

wilh

^regard

to the provision of certain

aspects

of oral

surgerY.

Simi

lar

information was obtained forrrapprovedtt

dentists

^lhroughoul Auslral

ia

^{and some} comparisons made belween

information for dentisls

classi

fied

^accordÎng

to various descriplive

^features.

The purpose

of the

survey was

to

dÎscern whal

oral

^{surgery services}

were being provided by these personnel, ^who were expected

to provide

^a

representative

^range

of denfal practice.

Associations ^{between these}

services

^and

certain descriptive characteristics

were analysed'

lnformation

^from

the

survey revealed

lhat

^advanced

traíning

^was

requi

red for the provision of

comprehensive

oral

surgery services.

Al

present

fhe ful I

^scope

of practice is

being _Provided by

only

^a

few

practltioners,

^and

the provision of care is

concentrated ma¡nly in

lhe capitals.

It

^seems

that

undergraduate

training

^{has been}

orienlated

^towards

the

treafment

of

hard as ^opposed

to soft lissues.

^{The survey revealed}

lhat

general

practitioners were less likely lo provide oral

^surgery

thal

ⁱ

s not

di recl

ly "footh

^{re I afed'r.}

General

ly,

Queensland

dentists

were more

likely to

provide oral surgery treatment than

their

^south

Australian

counterparls.

vt

l;

From

the information

compi

led, certain

conclusions were drawn

and recommendations made

to facilitate Ihe

^{more ready}

availability of

high

^qual

ity oral

surgery

services

throughout ^{urban and}

rural

^areas.

Furlher investigation is

^{requi red}

to

^detai

I

^speci

fic quantitative oral

surgery needs

in indivîdual

locafions.

Country areas

mighf

requi

re

^general

practitioners wlth

^extended

oral

surgery

training

^p

lus

^special

ist oral

surgery

centres

^{supported by}

rapid transit

^systems.

To guarantee

appropriale

^standards

of care, national accreditalion

of lraining

courses and

specialty registration

^seem

relevanl,

^with

specialty hospital

appointmenls

restricted to registered

^special

ists.

Oral

surgeons

withoul

^medi

cal

backgrounds should

not

^receive

prejudicial lreatment. In fact, the author

^considers

that fhe pursuif

of a

medical degree

as a

precursor

to specialising in oral

^surgery

should be dîscouraged.