oral maxillofacial surgery VS Otolaryngology

[MaybeDent]

Can some one give me the some insight on this? I know alot of their training overlap and often share calls during residency, so you guys probably worked with them before/continue to work near them afterward.

From what I been reading here and in dent forum, it seems like OMFS is even better for life style, and get paid much more? They do their own anesthesia, and also can dump all the calls to ENT??

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[gary_ruska]

Can some one give me the some insight on this? I know alot of their training overlap and often share calls during residency, so you guys probably worked with them before/continue to work near them afterward.

From what I been reading here and in dent forum, it seems like OMFS is even better for life style, and get paid much more? They do their own anesthesia, and also can dump all the calls to ENT??

Gary "ENTs are nice guys too" Ruska here,

GR can only speak as an OMFS, but here are some observations:

1. OMFS and ENT overlap significantly in major academic centers with regard to trauma and to a lesser extent pathology and cosmetics (ENT tends to do much more pathology and cosmetics). They really only fight over these cases in academic centers - no one in private practice will fight over these cases because there's no $$$ in them. In fact, in GR's experience, in private practice, the fights are over the call schedule (i.e. everyone wants everyone else to take the call and do the emergency cases). ENTs may get the shorter end of the stick here, as they are more likely to require an affiliation with a hospital for their procedures (i.e. will require a main hospital OR for some of their cases). Being affiliated with a hospital usually means that you'll have to take call.

2. With rare, though notable, exceptions, ENTs in academic centers do not perform orthognathic/craniofacial or TMJ surgery. Conversely, only a minority of OMFS programs (about a dozen or so) do any reasonable amount of head and neck oncology with microvascular reconstruction (as the primary service).

3. In private practice, each specialty has their own money makers. For OMFS its "teeth and titanium" - wisdom teeth and dental implants. For ENT surgeons, it's sinus surgery, tonsils/adenoids, nasal procedures and cosmetics (rhinoplasty, blepharoplasty, facelifts, etc.).

4. The lifestyle is great for both (in private practice) and you will be financially secure going into either one. The make about the same in private practice and have similar hours.

5. There can be some ribbing between services during residency, but relationships are mostly collegial in private practice. In GR's community, this is largely due to the fact that the ENTs and OMFS guys don't overlap at all (i.e. they share trauma call, but the ENTs stick to sinuses, T+A and cosmetics and the OMFS guys do T+T, orthognathics and TMJ). There is more friction in GR's community between ENT and Plastics.

-GR

 

[MaybeDent]

I am just wondering...how often are OMFS associated with an hospital, or are alot of them exclusively work in their own office? Also...OMFS does their own general anesthesia, does ENT or Plastic do that or do they have to get a CRNA every time they want to put someone under? I have been told by an anesthesiologist that no one else is allowed to, however I also shadowed a GI who put patients into sleep when scoping. And for OMFS it is 4 years dent+4 years residency+2 year optional MD and then you are done right?

 

[gary_ruska]

I am just wondering...how often are OMFS associated with an hospital, or are alot of them exclusively work in their own office? Also...OMFS does their own general anesthesia, does ENT or Plastic do that or do they have to get a CRNA every time they want to put someone under? I have been told by an anesthesiologist that no one else is allowed to, however I also shadowed a GI who put patients into sleep when scoping. And for OMFS it is 4 years dent+4 years residency+2 year optional MD and then you are done right?

Gary "pass the propofol" Ruska here,

OMF Surgeons do in-office sedations (intravenous sedation) for their patients (usually ASA Class I or II) having minor procedures (wisdom teeth, implants, biopsies, minor bone grafts, etc.). They can thus bill for both the procedure and the administration of anesthesia.

OMFS are allowed to do this because they obtain permits to administer general anesthesia from their associated state dental board. In order to obtain a permit, one must be board certified in OMFS, have a dental degree and a dental license (this is one less-often-mentioned reason every OMFS has to have a dental degree). During OMFS residency, one must spend at least 4 months as an anesthesia resident, in order to be board eligible. Most programs do their anesthesia time during intern year. During subsequent residency years, the residents will run the sedations for the attendings, logging upward of 300-400 sedation cases prior to graduation from residency (in addition to all of the general anesthesia cases logged during the four months of anesthesia).

As an aside (as GR is certain that someone will come on here and claim that OMFS are killing patients left and right by doing IV sedation in their offices) - this practice has been validated as safe by a number of large scale studies and is supported by the American Society of Anesthesiology.

For OR cases, or those done in ambulatory ORs, such as orthognathic surgery/TMJ surgery/trauma surgery/large bone grafts, the anesthesia is always administered by an MD Anesthesiologist/CRNA.

The residency pathway for OMFS is a two-track system:

Track 1: 6 year residency, during which two years are spent obtaining a medical degree

Track 2: 4 year residency, without a medical degree. Some graduates of the 4-year track will obtain an MD after residency.

While there is no difference in the board certification process, many people will claim that the MD adds value, especially for fellowships, etc. Local politics will dictate who can do what, but, in GR's experience, the MD has been very helpful. GR gets along with the local PRS and ENTs just fine and has never had a problem with privileges for anything, including cosmetic surgery (though admittedly GR only does facial implants and rhinoplasties when combined with orthgonathic surgery).

OMFS are often associated with hospitals, but many are now shying away from hospital affiliations for a few reasons. First, it is not financially favorable to do hospital cases (trauma, orthognathic, TMJ, pathology) - these cases are riskier, take longer and pay much less per hour. Second, being affiliated with a hospital often means having to assume some of the on call responsibility for facial trauma and, in communities with few dentists, general dental call as well. Finally, with the rise of ambulatory surgical centers and the availability of MD/CRN anesthesiologists, it is becoming increasingly practical to do larger procedures outside the hospital. This is another significant difference with ENT, as many of their procedures (neck dissections, cranial base surgery, laryngeal surgery) still require hospital facilities because of the complexity of the cases and the often sick patients.

 

[Pir8DeacDoc]

Both are great fields, albeit for different reasons. I will echo the above by saying that the biggest difference is the bread and butter type stuff.

Good luck deciding. Both are good fields, but when you expose yourself to them you'll see they aren't terribly similar (except for trauma).

 

[Clemenza]

Can some one give me the some insight on this? I know alot of their training overlap and often share calls during residency, so you guys probably worked with them before/continue to work near them afterward.

From what I been reading here and in dent forum, it seems like OMFS is even better for life style, and get paid much more? They do their own anesthesia, and also can dump all the calls to ENT??

I'm actually a dentist who did a year-long oral surgery internship to try it out (I'm now a med student here in Cali). I'm not an oral surgeon, but I got a pretty good idea of what the field is like.

Oral surgery is actually a very diverse field. You'd be surprised just what kinds of things you can find oral surgeons doing. Basically, though, it seems as though there are two types of oral surgeons: 1. those who remember that they are specialists within the field of dentistry, and 2. those who don't. The ones who see themselves as dental specialists are the ones who tend to work in private practice and spend much of their time taking out teeth, placing implants, performing other dento-alveolar surgeries, managing pathologies of the jaws, and doing about one or two orthognathic cases a month. Some will also delve into TMJ surgery, although this has fallen out of favor in the last decade and a half or so. The second group are the ones who you'll find doing facial cosmetic surgery, treating head & neck cancer cases (with reconstruction) and performing craniofacial surgery, etc. etc. This group, it seems, would be offended if you asked them to remove a tooth (although a lot of these practices still offer exodontia as a service because it is so lucrative).

The problem with oral surgery, though, is that (it seems to me) that it's tough to make it as a "cosmetic surgeon" or a "head and neck surgeon". The referrals just aren't there. When a patient wants a nose-job, they think "plastic surgeon". When a physician finds a mass on a patient's neck, they refer to an ENT. By and large, the only referrals oral surgeons get are from dentists (for wisdom teeth, implants, etc. etc.) and from physicians (for teeth, and for facial trauma). If you want to do anything else as an oral surgeon, you're going to have to find it yourself. Hence, it's rare that you'll find an oral surgeon whose main source of income isn't dentoalveolar surgery (e.g. the kinds of things referred by general dentists).

Now, to be quite frank, I have a very hard time accepting the fact that there are oral surgeons doing cosmetic surgery or craniofacial surgery. They are as qualified to do this as ENTs, from what I understand--especially the oral surgeons with MD degrees--but that doesn't make it appropriate. Oral and maxillofacial surgery is a specialty of dentistry. One would be hard-pressed to find a sound explanation for how a facelift is related to dentistry in anything but the most comically indirect fashion.

As for anesthesia training, this is one area that really enhances the field of oral surgery. Being able to perform your own sedations is an immensely powerful tool to have at your disposal, and it is the one thing I will sorely miss by being in medicine rather than dentistry. And FYI, oral surgeons are qualified to provide general anesthesia (i.e. GETA), but to my knowledge cannot be the surgeon while administering anesthesia in that fashion.

 

[resxn]

They are as qualified to do this as ENTs, from what I understand--especially the oral surgeons with MD degrees--but that doesn't make it appropriate.

I agree with 99% of what you wrote. I also agree with the latter half of this sentence. I do only take exception that oral surgeons are as qualified as ENT's to perform cosmetic or craniofacial surgery. I'm glad you didn't say head and neck surgery because that would be a ludicrous claim. There are components of plastics surgery and craniofacial that they are as qualified to do but I virtually guarantee an OMFS does not have the experience coming out of residency doing septorhinoplasty as does an ENT so there are some things that they don't equal an ENT in.

I think many ENT's would take exception to the thought of an OMFS even coming close to being capable of what we do, but they'd be wrong. I'd bet even that many OMFS programs get better training in several areas including cleft palates. I'm sure we're better with facial trauma above the anterior face of the maxilla. I'm sure OMFS is better at mandibular fracture repair.

I'd also bet that most ENT's would say that OMFS is a far more lucrative practice. They'd be right about that.

 

[Clemenza]

I agree with 99% of what you wrote. I also agree with the latter half of this sentence. I do only take exception that oral surgeons are as qualified as ENT's to perform cosmetic or craniofacial surgery.

It depends on the residencies, really. But you and I both know that craniofacial surgery isn't exactly part of mainstream otolaryngology. (Nor is it part of mainstream oral surgery). There are training / fellowship programs in each. In fact, I'd imagine that some of these programs are willing to accept ENTs and oral surgeons alike.

When I say, "as qualified", what I mean is that both ENTs and oral surgeons possess the same understanding and mastery of the various skills and techniques necessary for performing surgeries on the hard and soft tissues of the head and face. Beyond that, some will have acquired experience in different areas, depending on the residency.

I'm glad you didn't say head and neck surgery because that would be a ludicrous claim.

There are a few head/neck surgery fellowships in oral surgery, where oral surgeons can be trained to manage tumors of the head/neck (for example, performing radical necks, etc.). University of Maryland comes to mind, but there are others.

There are components of plastics surgery and craniofacial that they are as qualified to do but I virtually guarantee an OMFS does not have the experience coming out of residency doing septorhinoplasty as does an ENT so there are some things that they don't equal an ENT in.

I think it would depend on the residency. There are indeed some oral surgery programs that are quite cosmetics-heavy. On the average, though, you're probably right with regard to the majority of oral surgeons. Again, it would depend on the residency.

I think many ENT's would take exception to the thought of an OMFS even coming close to being capable of what we do, but they'd be wrong. I'd bet even that many OMFS programs get better training in several areas including cleft palates.

I'm not so sure about this, because CLP repair is almost always a multi-disciplinary process, and oral surgeons are usually needed for the bone grafting that is often needed to fix a cleft palate and alveolar ridge. But there are certainly many exceptions to this rule. I know, personally, a couple of oral surgeons who address the soft-tissue aspects of CLP repair as well as the hard-tissues.

From what I understand, though, single-degree oral surgeons (i.e. those without an MD) are less likely to be on CLP teams than ENTs and plastic surgeons. Come to think of it, for the life of me, I cannot understand why ENTs are not considered to be the experts on CLP.

I'm sure we're better with facial trauma above the anterior face of the maxilla. I'm sure OMFS is better at mandibular fracture repair.

I'm not so sure about that. Treating facial trauma above the maxilla (e.g. ZMC and sinus fractures, frontal sinus fractures, nasal fractures, NOE fractures, LeForts 1, 2, and 3 etc. etc.) is, to my knowledge, universally considered to be a standard skill possessed by oral surgeons.

Where most oral surgeons won't go, however, are injuries that go "deeper" into the head. How do I know this? Because I know very little about them! I've had virtually no exposure to them.

But you're right. Oral surgeons are better than ENTs at dealing with fractures that affect the dentition.

I'd also bet that most ENT's would say that OMFS is a far more lucrative practice. They'd be right about that.

That's because oral surgeons charge somewhere between $300 and $500 for a bony-impacted wisdom tooth (often 'up-grading' the codes inappropriately), plus another $400 or so for the IV sedation. That's $2000 to $3000 worth of production from a procedure that rarely takes more than 1hr from start to finish (i.e. from the time they start the IV, to the time the patient is getting out of the chair). Let there be no doubt about the fact that oral surgeons make their money by doing the work that general dentists send them. They'll never get rich by playing "ENT" or "plastic surgeon".

And if you ask me, four years in an oral surgery residency is a lot of training just to spend your days shucking teeth. I matched into a program, but after learning more about the discrepency between academic oral surgery and private practice oral surgery, decided I'd rather be in medicine.

 

[resxn]

It depends on the residencies, really.

Again, I agree with 99% of what you said, but take exception to the idea that OMFS is as qualified to deal with the hard and soft tissues of the head and neck as an ENT.

Each specialty has it's niche, it's realm, it's area of expertise. One of the greatest threats to medicine is the battle over scope of practice. Nurse practitioners want to be called doctors. PA's want to be called Physician Associates. Audiologists want the ability to diagnose and treat independent of a physician. Dentists have sought in at least 12 states to expand their scope of practice to include "treatment of diseases of the oral cavity and regional anatomy" which by definition includes brain surgery. Many OMFS whether getting the MD or not want to believe they're facial plastics guys. Some general surgeons feel they should be doing parotidectomies even without an H&N fellowship.

I'll be the first to say that although I am trained to do carotid bodies, I am not a vascular surgeon. I have no business taking out one of those because I am not equipped to deal with the common and well-known complications such as intraluminal injury. I've been approached by multiple family practice residents asking why they can't just do PE tubes themselves. Assuming credentialing wasn't an issue, they could. But my question is what do they do when they encounter a high-riding jugular bulb, dehiscent carotid, glomus tumor, or put a tube into the middle ear? They don't do those procedures not because it's outside their skill set. They don't do those procedures because the potential risks are outside their skill set.

Are there OMFS who do great H&N work? Of course. Dr. Lydiatt at UNMC is a very well respected H&N surgeon who was originally trained in OMFS. That does not qualify the specialty as a whole to claim the same ability.

I respect anyone who has training in their field to do their work. I do not respect a person who claims that their field is qualified to do that same work because a select few within it are capable.

I don't believe that's your point in particular, but it's quite clear that there are others out there (nurse practitioners) who do.

 

[OneMoreForSurg]

Both really are fantastic specialties --- with alot of overlap - In some areas one is stronger.... in other areas the other is stronger. I think we are both very capable of operating in the head and neck. I love the ENT guys at my program they're some of my favorite residents out there.

I disagree with a couple things resxn says and agree with some of his other points.

Facial Trauma:
- I do believe regarding facial trauma we are just as well if not more qualified than any other sub-specialty. OMFS has built its itself upon the manipulation of the bony structures of the face. Orthognathic surgery (which we do a TON of) is basically creating and favorably repairing facial fractures of the Maxilla and Mandible. In addition, in the vast majority of the centers that OMFS has a presence (that I am aware of) - OMFS does usually the majority of mandibles (in my center all of them), they do at least a third of mid-face, splitting with plastics and ent -- sometimes all of midface. I don't think that any objective analysis would claim that we are not extremely qualified in the area of facial and mandibular trauma

Cosmetics:
- There are few things that can be done to a face that are more drastic or esthetically impressive than manipulating the bone of the face (once again orthognathics). In addition, there are many omfs programs that get other cosmetic exposure - at my instituition we reconstruct many mohs resection cases and do a fair amount of facial cosmetics -- including noses, blephs, lasers, local facial flaps. Also usually the OMFS guys who do alot of facial cosmetics in private practice do fellowships - therefore they are adequately trained.
I totally agree with the comment resxn made regarding qualification to do procedures:
- "I respect anyone who has training in their field to do their work."

I feel like we all get so caught up and scared about scope of practice issues... when the best thing that we can do is to go out into our communities and be the best surgeon that we are capable of... and our work will speak for itself.

 

[Pir8DeacDoc]

I love the ENT guys at my program they're some of my favorite residents out there.

Facial Trauma:
- OMFS does usually the majority of mandibles (in my center all of them), they do at least a third of mid-face, splitting with plastics and ent -- sometimes all of midface. I don't think that any objective analysis would claim that we are not extremely qualified in the area of facial and mandibular trauma

Your ENT residents don't do any mandibles? So when ENT is on face call they refer all the mandibles to OMFS? I'm curious how it works other places..

 

[gd152]

Now, to be quite frank, I have a very hard time accepting the fact that there are oral surgeons doing cosmetic surgery or craniofacial surgery. They are as qualified to do this as ENTs, from what I understand--especially the oral surgeons with MD degrees--but that doesn't make it appropriate. Oral and maxillofacial surgery is a specialty of dentistry.

Wouldn't you agree that this is a very limited way of thinking? Medicine and surgery is not one-dimensional and static. It is constantly breaking new boundaries. Would you say that Bernard Devauchelle overstepped his boundaries by performing the first facial transplant? Or did he do it simply because he was the most qualified at the time?

If somebody has educated themselves to perform something well that they didn't learn in a residency, is that really a bad thing? Would medicine ever really evolve if nobody ever did just a little more than they were taught? You think maxillofacial surgeons should stick with "dentistry" or just "teeth". I think that's ******ed; they're no longer dentists and are allowed to work on the head, neck, face and jaw region, hence maxillofacial surgeon. There will be some who will be very good at evolving the field and paving way for the future, developing new techniques and procedures. I'm all for this advancement and see your view of a "profession" as very limiting.

 

[bobby6]

Mandibles are a requirement for an ENT residency. A program will be cited if they do not provide training in mandibular fractures.

Some institutions may have an agreement whereby isolated mandible fractures will go to OMFS and isolated nasal fractures will go to ENT. Isolated meaning that it is the only injury.

In many institutions, OMFS does not manage frontal sinus fractures, facial nerve or parotid duct injuries, and definately no temporal bone or skullbase trauma.

 

[OneMoreForSurg]

Dear Bobby6 and Pir8DeacDoc...

Yes... you are correct of course, in that a certain number of mandibles are a requirement for ENT residents... my understanding of how this works with the ENT residents at my institution is that they go elsewhere for a certain amount of time to get their mandible requirement... Similarly, we go elsewhere to do microvascular, parotids, and cancer resections... We all do nasal fractures, frontal sinuses... and all of midface... They generally take care of skull base fractures... You know how it goes... its crazy... but it works out well for all of us... we all get great training here!

I totally agree with absolutely everything gd152 says..... Perfectly said!

 

[Clemenza]

Wouldn't you agree that this is a very limited way of thinking? Medicine and surgery is not one-dimensional and static. It is constantly breaking new boundaries. Would you say that Bernard Devauchelle overstepped his boundaries by performing the first facial transplant? Or did he do it simply because he was the most qualified at the time?

If somebody has educated themselves to perform something well that they didn't learn in a residency, is that really a bad thing? Would medicine ever really evolve if nobody ever did just a little more than they were taught? You think maxillofacial surgeons should stick with "dentistry" or just "teeth". I think that's ******ed; they're no longer dentists and are allowed to work on the head, neck, face and jaw region, hence maxillofacial surgeon. There will be some who will be very good at evolving the field and paving way for the future, developing new techniques and procedures. I'm all for this advancement and see your view of a "profession" as very limiting.

Oral surgeons are "no longer dentists"?

They have dental degrees after their names. That makes them dentists, buddy.

In America, oral and maxillofacial surgery is a specialty of dentistry, not medicine. Oral surgeons got where they are by going to dental school, not by going to medical school.

Moreover, it was the dental profession that gave oral surgeons the support they needed in order to expand their scope legally.

As a general dentist, it'll be a cold day in hell before I refer a third molar case or an implant case to an oral surgeon whose business card doesn't contain the words "Oral" and "DDS". If oral surgeons so badly want to be considered as transcendent above and beyond dentistry, and effectively shed the dental profession, then I say let them try and survive as a medical specialty. That would be worth a good laugh!

 

[resxn]

now that was perfectly said

 

[280040]

Oral surgeons are "no longer dentists"?

They have dental degrees after their names. That makes them dentists, buddy.

In America, oral and maxillofacial surgery is a specialty of dentistry, not medicine. Oral surgeons got where they are by going to dental school, not by going to medical school.

Moreover, it was the dental profession that gave oral surgeons the support they needed in order to expand their scope legally.

As a general dentist, it'll be a cold day in hell before I refer a third molar case or an implant case to an oral surgeon whose business card doesn't contain the words "Oral" and "DDS". If oral surgeons so badly want to be considered as transcendent above and beyond dentistry, and effectively shed the dental profession, then I say let them try and survive as a medical specialty. That would be worth a good laugh!

:

It seems like oms residents want nothing more than to shed their dentist title and practicing oms want nothing to do with surgery except their dentist referrals. First and foremost, a dentist I will be during and after my OS residency. I love the dental community and glad to be part of it!!

On a side note, let the record show that dmd is not equal to dds in your referral book

 

[armorshell]

:

It seems like oms residents want nothing more than to shed their dentist title and practicing oms want nothing to do with surgery except their dentist referrals. First and foremost, a dentist I will be during and after my OS residency. I love the dental community and glad to be part of it!!

Here here. I've met the people you mentioned ("I went into OMS so I wouldn't have to do dentistry") types, but they're fewer and far betweener than I had originally expected

 

[DREDAY]

Are there OMFS who do great H&N work? Of course. Dr. Lydiatt at UNMC is a very well respected H&N surgeon who was originally trained in OMFS. That does not qualify the specialty as a whole to claim the same ability.

Although most OMFS residents get experience performing cancer surgery in residency, I don't think there are any OMFS doing neck dissections right out of residency. Those that do perform head and neck oncology surgery have done an ablative or microvascular fellowship.

In our case, one of our hospitals has ENT attendings but no ENT residents. OMFS residents are the ENT residents. OMFS residents run the ENT clinic, take all ENT call, and are 1st assist for all the ENT surgeries, from thyroidectomies and tonsilectomies, to mandibular swings and septorhinoplasties. There are other programs in the country with similar situations.

The specialty as a whole does not claim to be experts in septorhinoplasties and neck dissections. Just take a look at our website. Those that do, likely had extensive experience in residency and in the case of neck dissections did a fellowship following residency.

 

[DREDAY]

Now, to be quite frank, I have a very hard time accepting the fact that there are oral surgeons doing cosmetic surgery or craniofacial surgery. They are as qualified to do this as ENTs, from what I understand--especially the oral surgeons with MD degrees--but that doesn't make it appropriate. Oral and maxillofacial surgery is a specialty of dentistry. One would be hard-pressed to find a sound explanation for how a facelift is related to dentistry in anything but the most comically indirect fashion.

The appropriateness of performing a certain surgery does not come with the title of your specialty. The appropriateness should be determined by the surgeons ability to perform the surgery and deal with all complications that come with it. It comes with the experiences that you have had and the skills that you have mastered during residency, fellowship and practice.

 

[armorshell]

Oral and maxillofacial surgery is a specialty of dentistry. One would be hard-pressed to find a sound explanation for how a facelift is related to dentistry in anything but the most comically indirect fashion.

Claiming this as a reason that OMFS shouldn't be doing these procedures is equally as ridiculous as claiming ENT should be doing facelifts because a facelift involves neither the ear, nose or throat, except in the most comically indirect fashion.

 

[GoLytely]

"Yeah, you kept saying that last night, but really - you're just a dentist."

 

[bobby6]

The official name of the specialty is actually Otolaryngology/Head & Neck Surgery/Facial Plastic Surgery.

Who do you think are doing the majority of facelifts and parotidectomies? Parotidectomies require intimate knowledge of the location of the facial nerve and all its branches along with facial fascial planes which are all important when doing a facelift.

Can't imagine many OMFS residencies providing enough training to do parotidectomies right out of residency let alone a facelift. Looking at many hospital credentialing surgical privileges for OMFS at major medical centers, most of them do not allow privileges in parotid surgery.

The gold standard in board certification is the American Board of Medical Specialties and see its definition of Otolaryngology:

An Otolaryngologist-Head and Neck Surgeon, provides comprehensive medical and surgical care for patients with diseases and disorders that affect the ears, nose and throat, the respiratory and upper alimentary systems, and related structures of the head and neck. The Otolaryngologist diagnoses and provides medical and/or surgical therapy or prevention of diseases, allergies, neoplasms, deformities, disorders and/or injuries of the ears, nose, sinuses, throat, respiratory and upper alimentary systems, face, jaws and the other head and neck systems. Head and neck oncology, facial plastic and reconstructive surgery and the treatment of disorders of hearing and voice are fundamental areas of expertise.

http://www.abms.org/Who_We_Help/Consumers/About_Physician_Specialties/otolaryngology.aspx

Claiming this as a reason that OMFS shouldn't be doing these procedures is equally as ridiculous as claiming ENT should be doing facelifts because a facelift involves neither the ear, nose or throat, except in the most comically indirect fashion.

 

[DREDAY]

The official name of the specialty is actually Otolaryngology/Head & Neck Surgery/Facial Plastic Surgery.

Who do you think are doing the majority of facelifts and parotidectomies? Parotidectomies require intimate knowledge of the location of the facial nerve and all its branches along with facial fascial planes which are all important when doing a facelift.

Can't imagine many OMFS residencies providing enough training to do parotidectomies right out of residency let alone a facelift. Looking at many hospital credentialing surgical privileges for OMFS at major medical centers, most of them do not allow privileges in parotid surgery.

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As with any specialty, there are strengths and weaknesses to each program. You are right in saying that there are OMFS programs where there is minimal experience doing parotidectomies or facelifts. Residents graduating from those programs are not performing those procedures. Likewise there are programs which are very strong in providing residents with those experiences. Residents graduating from those programs are trained to perform those procedures if they choose. You cannot judge an entire specialty based on one program. There are limited programs in every specialty.

BTW as a DENTAL STUDENT I scrubbed in and assisted parotidectomy, and multiple neck dissections done by OMFS.

 

[bobby6]

I'm not saying the OMFS can't do those things. The majority if not all OMFS doing those procedures have completed specialized fellowship training.

Hospitals will dictate what you can do and can't do based on the surgical privileges you have been given. Its going to be real hard to get those surgical privileges as OMFS at a hospital without documentation of fellowship training. At my hospital, OMFS are not credentialed to do parotids, neck dissections, or malignant neoplasms without documentation of completion of a fellowship program and submission of a case log. In my opinion, it takes about 20-30 parotidectomies and about 40 or so neck dissections to be somewhat comfortable doing those cases alone. I find it hard to believe that any OMFS program is able to provide those case numbers as a resident especially with more and more patient opting for chemotherapy and radiation instead of surgery.

I did a ton of microvascular cases as a resident, around 20, also did the microvascular anastomosis, and practiced in the microvascular lab on rats. Even with that experience, it still would be tough for me to get surgical privileges to do free flaps because I didn't do a fellowship in microvascular surgery. Some large academic medical centers, even general plastic surgeons either need extra documentation or fellowship training to be credentialed to do free flaps.

As with any specialty, there are strengths and weaknesses to each program. You are right in saying that there are OMFS programs where there is minimal experience doing parotidectomies or facelifts. Residents graduating from those programs are not performing those procedures. Likewise there are programs which are very strong in providing residents with those experiences. Residents graduating from those programs are trained to perform those procedures if they choose. You cannot judge an entire specialty based on one program. There are limited programs in every specialty.

BTW as a DENTAL STUDENT I scrubbed in and assisted parotidectomy, and multiple neck dissections done by OMFS.

 

[DREDAY]

I agree with you. The OMFS that do perform neck dissections or microvascular surgery have done an additional 1 year fellowship following residency. As far as cosmetics, several programs (not all) log plenty of procedures for residents to gain privileges out of residency without doing a fellowship.

I'm not saying the OMFS can't do those things. The majority if not all OMFS doing those procedures have completed specialized fellowship training.

Hospitals will dictate what you can do and can't do based on the surgical privileges you have been given. Its going to be real hard to get those surgical privileges as OMFS at a hospital without documentation of fellowship training. At my hospital, OMFS are not credentialed to do parotids, neck dissections, or malignant neoplasms without documentation of completion of a fellowship program and submission of a case log. In my opinion, it takes about 20-30 parotidectomies and about 40 or so neck dissections to be somewhat comfortable doing those cases alone. I find it hard to believe that any OMFS program is able to provide those case numbers as a resident especially with more and more patient opting for chemotherapy and radiation instead of surgery.

I did a ton of microvascular cases as a resident, around 20, also did the microvascular anastomosis, and practiced in the microvascular lab on rats. Even with that experience, it still would be tough for me to get surgical privileges to do free flaps because I didn't do a fellowship in microvascular surgery. Some large academic medical centers, even general plastic surgeons either need extra documentation or fellowship training to be credentialed to do free flaps.

 

[DREDAY]

I agree with you. The OMFS that do perform neck dissections or microvascular surgery have done an additional 1 year fellowship following residency. As far as cosmetics, several programs (not all) log plenty of procedures for residents to gain privileges out of residency without doing a fellowship.

I'm not saying the OMFS can't do those things. The majority if not all OMFS doing those procedures have completed specialized fellowship training.

Hospitals will dictate what you can do and can't do based on the surgical privileges you have been given. Its going to be real hard to get those surgical privileges as OMFS at a hospital without documentation of fellowship training. At my hospital, OMFS are not credentialed to do parotids, neck dissections, or malignant neoplasms without documentation of completion of a fellowship program and submission of a case log. In my opinion, it takes about 20-30 parotidectomies and about 40 or so neck dissections to be somewhat comfortable doing those cases alone. I find it hard to believe that any OMFS program is able to provide those case numbers as a resident especially with more and more patient opting for chemotherapy and radiation instead of surgery.

I did a ton of microvascular cases as a resident, around 20, also did the microvascular anastomosis, and practiced in the microvascular lab on rats. Even with that experience, it still would be tough for me to get surgical privileges to do free flaps because I didn't do a fellowship in microvascular surgery. Some large academic medical centers, even general plastic surgeons either need extra documentation or fellowship training to be credentialed to do free flaps.

 

[280040]

I find it intriguing that OS residents are on here arguing about what an OMS is capable of.

You are arguing with educated medical professionals, seems like ENTs. They aren't here making rash decisions or slinging mud. They likely DON'T see any OMS in their hospital, they DON'T run into them at surgical conferences, they DON'T see any impact that an OMS can provide because the OMS are in their private practice making bank.

How can you blame the ENT/H&N/Facial Cosmetics folks (what a ridiculous name btw) for protecting their $$$/surgical turf when it appears to them that OMS aren't putting in their fair share.

AND, this contemporary scope of OMS is not part of every residency. Even if the ENTs can see OMS residencies at their home program, they are likely not going to be overwhelmed by their Head and Neck experience. This was very clear to me when I interviewed places. We have a HUGE difference in our training programs. Thus fellowships fill a very needed void.

OMS owes the medical profession major thanks I feel. They welcome 50% of new residents into medical degree programs now, they give up 4-6 months per OS resident in anesthesia time, lots of months on medicine, ENT, plastics, Gen Surg, etc. The OMS community gets more out of these rotations than the medical community gets back by having the OMS bodies/paper pushers.

You and me will continue to get this push back from ENT and plastics and surgical derms until OMS have a presence in the hospitals. But I think most OMS don't care anyway, the $$$ is in dental surgery.

 

[Clemenza]

The appropriateness of performing a certain surgery does not come with the title of your specialty. The appropriateness should be determined by the surgeons ability to perform the surgery and deal with all complications that come with it. It comes with the experiences that you have had and the skills that you have mastered during residency, fellowship and practice.

I've gotta disagree with you there, DREDAY.

Each medical (and dental) specialty has a definition, around which there is some room for interpretation. But to say that a urologist is justified in entering a cosmetic surgery fellowship and performing breast implants is simply outlandish. Specialties exist for a reason, and while there is (and should be) some wiggle room here and there, members of certain specialties should stick to the work that falls within the current definition of their specialty.

There is no way in hell that nose jobs and facelifts fall within the definition of dentistry. I don't give a damn what kind of training an oral surgeon has. I don't care if he has an MD degree either. An oral surgeon is a specialist within the field of dentistry, and by that token has no business doing facelifts. Cleft lip and palate? Sure. Facial trauma? Yep. Treating tumors of the jaws, oral cavity, and immediately surrounding structures? Absolutely. But performing neck dissections? No. And facial cosmetic surgery? No. Those go well beyond the scope of dentistry, and become the practice of medicine. (And an OMFS with an MD degree is still practicing dentistry).

 

[Clemenza]

Claiming this as a reason that OMFS shouldn't be doing these procedures is equally as ridiculous as claiming ENT should be doing facelifts because a facelift involves neither the ear, nose or throat, except in the most comically indirect fashion.

Armorshell, that is a lousy comparison. Allow me to explain:

Otolarhinolaryngology is just a name, and you're taking it too literally. Medical and surgical management of conditions involving the head and neck is traditionally part of the specialty. In fact, in many cases, ENT is referred to as "Otolaryngology and Head & Neck Surgery". Am I mistaken on this account? Regardless of the name, when you consider what has traditionally been considered within the realm of otolaryngology, incorporating cosmetic facial surgery into the specialty is a very minor expansion of the field.

Oral and maxillofacial surgery, however, is a different animal. It's a specialty of dentistry. And as a specialty--whose membership is open to and consists mainly of doctors possessing only dental degrees--its scope had outgrown the scope of dentistry that was defined by the previous ADA definition of dentistry. In response, the ADA dubiously modified its definition of dentistry specifically to make oral surgeons who do facelifts more "legal" in their practices.

Ultimately, it boils down to medicine vs. dentistry. Facial cosmetic surgery -- at least, above the mouth -- is not a part of dentistry. I know many oral surgeons, and the ones who do it justify it by saying that they spend more time on the head and neck than plastic surgeons. I have yet to hear an oral surgeon claim that facial cosmetic surgery falls within the practice of dentistry.

 

[armorshell]

Otolarhinolaryngology is just a name, and you're taking it too literally.

Oral and maxillofacial surgery, however, is a different animal. It's a specialty of dentistry.

Dentistry is just a name, and you're taking it too literally.

I don't understand how you can fault me for implying ENT is just a name, and admit at the same time that though oral surgeons are trained and qualified to do these procedures, they shouldn't simply because they hold a DDS.

Your implication seems to be this: Put an oral surgeon and ENT side by side, and have them complete, say, a facelift. They were trained by the same attendings in the same way, use all the same techniques, all the same instruments, and have the same outcome. You think that the oral surgeon should not be allowed to do this procedure, because on some incredibly superficial level, they would be practicing dentistry, and dentistry has nothing to do with facelifts.

How do you reconcile this with your argument that my assertion about ENT is lousy?

Now, to be quite frank, I have a very hard time accepting the fact that there are oral surgeons doing cosmetic surgery or craniofacial surgery. They are as qualified to do this as ENTs, from what I understand--especially the oral surgeons with MD degrees--but that doesn't make it appropriate.

 

[DREDAY]

According to your logic, how is facial trauma (anterior table frontal sinus recon, orbital floor recon,) any more within the scope of practice of "dentistry" than cosmetics? The specialty is oral and maxillofacial surgery. Look at our track record performing the surgeries, it speaks for itself. A few of the biggest contributors to head and neck pathology and cancer are omfs. Maybe you are overlooking the contributions of dierks, schmidt, hirsch, ord, Marx, fernandes and many more. Or maybe you are overloking the fact that there are omfs who sit on committees within the American head and neck society. Or maybe you are overlooking omfs like rui fernandes who is the only head and neck microvascular surgeon south of Atlanta. I think you received a pretty limited understanding of omfs at whatever internship you did. Take a look at omfs programs like ucsf, jacksonville, parkland, Michigan, Oregon, lsu, loma Linda, washington, mayo, nyu just to name a few. If omfs shouldn't be performing neck dissections Or cosmetic surgery you would think these programs would prevent omfs from doing so? Obviously there is a reason omfs at these programs and others are doing neck dissections and cosmetic surgery. Hospitals require evidence for priviledges not opinions from experience at a 1 year internship.

I've gotta disagree with you there, DREDAY.

Each medical (and dental) specialty has a definition, around which there is some room for interpretation. But to say that a urologist is justified in entering a cosmetic surgery fellowship and performing breast implants is simply outlandish. Specialties exist for a reason, and while there is (and should be) some wiggle room here and there, members of certain specialties should stick to the work that falls within the current definition of their specialty.

There is no way in hell that nose jobs and facelifts fall within the definition of dentistry. I don't give a damn what kind of training an oral surgeon has. I don't care if he has an MD degree either. An oral surgeon is a specialist within the field of dentistry, and by that token has no business doing facelifts. Cleft lip and palate? Sure. Facial trauma? Yep. Treating tumors of the jaws, oral cavity, and immediately surrounding structures? Absolutely. But performing neck dissections? No. And facial cosmetic surgery? No. Those go well beyond the scope of dentistry, and become the practice of medicine. (And an OMFS with an MD degree is still practicing dentistry).

 

[bobby6]

Or maybe you are overlooking omfs like rui fernandes who is the only head and neck microvascular surgeon south of Atlanta.

Quite a claim. I think you are going to offend the multiple programs with American Head & Neck Society accredited fellowships in Florida such as Miami and South Florida who has multiple head and neck microvascular surgeons on staff.

The vast majority of the approximately 100 otolaryngology residencies have at least one or more microvascular surgeon and at least one academic facial plastic surgeon

The percentage of OMFS programs doing any microvascular or head and neck surgery pales in comparison. The scope of OMFS head & neck fellowships can't compare as I can't imagine them doing many thyroid, laryngeal, or skull base malignancies which are all part of contemporary full scope head & neck surgery. The referrals patterns just aren't there.

 

[DREDAY]

It should have read,

"Currently, Dr. Fernandes is the only head and neck microvascular surgeon south of the University of Georgia in Atlanta and north of Mofftt Cancer Center in Tampa who performs these complex procedures. His practice referral base ranges from South Georgia; North, Central, and South Florida; and southeast Alabama. Recently Dr. Fernandes has received international referrals from South America and Middle East for resection and reconstruction of complex head and neck tumors and defects."

It is off of the University of Florida College of Medicine - Jacksonville Department of Surgery newsletter.

The link is:
www.hscj.ufl.edu/surgery/documents/USurgeons_Spring2010.pdf

I am not saying OMFS and ENT scopes are identical. Despite being different specialties they have areas of overlap.

I am refuting the statement that OMFS should not be doing neck dissections or cosmetics if adequately trained.

Some OMFS oncological fellowships limit their scope to oral path. Some OMFS oncological fellowships like Jacksonville will do laryngeal and thyroid path as well.

Quite a claim. I think you are going to offend the multiple programs with American Head & Neck Society accredited fellowships in Florida such as Miami and South Florida who has multiple head and neck microvascular surgeons on staff.

The vast majority of the approximately 100 otolaryngology residencies have at least one or more microvascular surgeon and at least one academic facial plastic surgeon

The percentage of OMFS programs doing any microvascular or head and neck surgery pales in comparison. The scope of OMFS head & neck fellowships can't compare as I can't imagine them doing many thyroid, laryngeal, or skull base malignancies which is all part of contemporary full scope head & neck surgery. The referrals patterns just aren't there.

 

[bobby6]

Really looks like DREDAY must be a resident. When you get out into practice, referral patterns will strongly dictate what kinds of things you will do. No physician is going to refer a laryngeal or thyroid malignancy to an OMFS trained person unless they are dual-trained in otolaryngology like the guys in Oregon. Just because you can technically do a procedure doesn't mean you will get referrals.

The OMFS guys doing head & neck are getting most if not all of their referrals from their dental colleagues. Though dentists are really good at what they do, they aren't going to be referring any thyroid or laryngeal cancer patients anytime soon.

Burn out in Head & Neck and microvascular surgery are extremely high. A good number of guys will give up their microvascular practice within 5 years and have the new young buck microvascular surgeon take on the new cases. The cases are labor and time intensive along with poor reimbursement. You'll need to be available at any moment within the 1st week in the event the flap is not doing well for immediate exploration. When free flaps fail, its usually a catastrophe with prolong hospital stay...sometimes greater than a month hospital stay, and wound care issues.

It should have read,

"Currently, Dr. Fernandes is the only head and neck microvascular surgeon south of the University of Georgia in Atlanta and north of Mofftt Cancer Center in Tampa who performs these complex procedures. His practice referral base ranges from South Georgia; North, Central, and South Florida; and southeast Alabama. Recently Dr. Fernandes has received international referrals from South America and Middle East for resection and reconstruction of complex head and neck tumors and defects."

It is off of the University of Florida College of Medicine - Jacksonville Department of Surgery newsletter.

The link is:
www.hscj.ufl.edu/surgery/documents/USurgeons_Spring2010.pdf

I am not saying OMFS and ENT scopes are identical. Despite being different specialties they have areas of overlap.

I am refuting the statement that OMFS should not be doing neck dissections or cosmetics if adequately trained.

Some OMFS oncological fellowships limit their scope to oral path. Some OMFS oncological fellowships like Jacksonville will do laryngeal and thyroid path as well.

 

[armorshell]

Really looks like DREDAY must be a resident. When you get out into practice, referral patterns will strongly dictate what kinds of things you will do. No physician is going to refer a laryngeal or thyroid malignancy to an OMFS trained person unless they are dual-trained in otolaryngology like the guys in Oregon. Just because you can technically do a procedure doesn't mean you will get referrals.

The OMFS guys doing head & neck are getting most if not all of their referrals from their dental colleagues. Though dentists are really good at what they do, they aren't going to be referring any thyroid or laryngeal cancer patients anytime soon.

Burn out in Head & Neck and microvascular surgery are extremely high. A good number of guys will give up their microvascular practice within 5 years and have the new young buck microvascular surgeon take on the new cases. The cases are labor and time intensive along with poor reimbursement. You'll need to be available at any moment within the 1st week in the event the flap is not doing well for immediate exploration. When free flaps fail, its usually a catastrophe with prolong hospital stay...sometimes greater than a month hospital stay, and wound care issues.

Who are you arguing with? Is it this guy?

Re-read what people in this thread are saying. Here's a nice quote for you from the post immediately before yours:

I am not saying OMFS and ENT scopes are identical. Despite being different specialties they have areas of overlap.

I am refuting the statement that OMFS should not be doing neck dissections or cosmetics if adequately trained.

This argument has nothing to do with referral patterns, burn out, African OR European swallows. Stay on target Luke .

 

[armorshell]

Who do you think are doing the majority of facelifts and parotidectomies? Parotidectomies require intimate knowledge of the location of the facial nerve and all its branches along with facial fascial planes which are all important when doing a facelift.

Personally, I find it ironic that you can say something like this, implying OMFS are incapable of gaining the knowledge to perform these procedures, while simultaneously expressing incredulity at someone implying that you can't grasp the science of occlusion as well as a dentist.

Is 4 years of doing facelifts plus didactics in residency not good enough to get a grasp on that?

Occlusion may be complex but 4 years of fixing mandibles in residency plus didactics is enough to get a grasp on it. You're making it sound like the ENT and Plastics who are doing these mandibular fixations for at least 4 years of residency training have no clue about occlusion.

No one ever said that you can master what you need to know about occlusion in the few hours/week. ENT and Plastics spend at least 4 years of residency training with countless didactics, taking facial trauma call, and performing fixation of mandles/facial fractures. I'm not suggesting an ENT can do a better ORIF of an mandible or facial fracture than an oral surgeon and vice versa. But to suggest that an ENT or Plastics is clueless about occlusion is denigrating.

 

[Clemenza]

I don't understand how you can fault me for implying ENT is just a name, and admit at the same time that though oral surgeons are trained and qualified to do these procedures, they shouldn't simply because they hold a DDS.

Armorshell, this statement of yours suggests to me that your primary goal here is to create debate rather than put forth any valid points. You know perfectly well that, even without nose jobs and facelifts, oral surgeons perform a hell of a lot of procedures that go way beyond the denotative, literal meaning of the word "dentistry" (i.e. "dent" meaning tooth combined with "ry" which denotes occupation"). Hell, even as a general dentist I treat conditions that go well beyond the tooth!

Your implication seems to be this: Put an oral surgeon and ENT side by side, and have them complete, say, a facelift. They were trained by the same attendings in the same way, use all the same techniques, all the same instruments, and have the same outcome. You think that the oral surgeon should not be allowed to do this procedure, because on some incredibly superficial level, they would be practicing dentistry, and dentistry has nothing to do with facelifts.

Precisely! If oral surgeons wanted to practice medicine, they should have gone to medical school (more on this in a moment) and completed medical residencies. What they are doing by dipping into facial cosmetic surgery is no different than advanced-practice nurses dipping into responsibilities that were once solely physicians'. Both are practicing medicine without going through the proper procedures.

And mind you, even the dual-degree oral surgeons don't have genuine medical degrees as far as I'm concerned. First off, there's no standardization among the various 6-year residencies with regard to the years of medical school that will be undertaken. Some require the 3rd and 4th, others require the 2nd and 3rd, and others require the 1st and 2nd, and others require parts of multiple years, if I'm not mistaken. No matter which parts of medical school the resident goes through, he has not completed a four-year medical education. Something is going to be missing. Don't forget that I've been through dental school, so I know exactly what oral surgeons spent the first two years of their professional education doing. Dental students take less than half of the biomedical sciences that medical students take, and simultaneously spend more than half of their time taking courses on dentures, crown & bridge, gum disease, root canals, cavities, and so on -- disciplines that have very little to do with medicine. In fact, every dental curriculum incorporates a great deal of lab-time into the curriculum. And I don't mean anatomy lab! In these labs, dental students will spend several hours a week drilling on plastic teeth, melting wax and setting denture teeth, and many other tasks that also have nothing to do with medicine. I was an excellent dental student -- graduated near the top of my class and kicked a.ss on both parts of my dental board exams. But when I got to medical school, I found the material to be challenging. Indeed, less than half of it was material I had seen in dental school. There is no way I could have tacked on two years of medical school and considered myself an "MD".

Sure, dual-degree oral surgeons had to pass all three steps of the USMLE. Some of them even do well on the exam. But let's face it, the USMLE does not test everything you've learned in medical school. Passing it is not the equivalent of a medical education.

 

[Clemenza]

Personally, I find it ironic that you can say something like this, implying OMFS are incapable of gaining the knowledge to perform these procedures, while simultaneously expressing incredulity at someone implying that you can't grasp the science of occlusion as well as a dentist.

Is 4 years of doing facelifts plus didactics in residency not good enough to get a grasp on that?

Armorshell, I'm telling you this as a dental professional:

You know that your statement in bold-face is grossly misleading. As dental professionals we should be above that, and leave that kind of misrepresentation and dishonesty to the nursing associations who are pushing to have nurses function as doctors.

I was a dental student at a school with an oral surgery residency that did a lot of cosmetics, and I can assure you that cosmetic cases were infrequent at best - no more than a dozen or so each year. (I know this because I asked).

So don't say that oral surgery residents at any program spend "4 years doing facelifts." That is a gross misrepresentation of the experience. And quite frankly, it's not even believable. There are so many teeth to be taken out, so many odontogenic infections to treat, so many OKC's and ameloblastomas to treat, so many mandible fractures to treat, and a half-way decent supply of orthognathic cases, etc. etc., that OMFS residencies fit cosmetics in only when there's time!

And by the way, Armorshell: occlusion isn't that complicated. In dental school, we had two one-credit courses on occlusion and a three-credit orthodontics course. That was plenty. And for an ENT or a plastic surgeon reducing a mandible fracture, they need only to identify the patient's bite, which is a fairly easy task. Besides, I've seen a few jaw fracture cases treated by OMFS where the resultant occlusion was way off.

 

[armorshell]

Armorshell, I'm telling you this as a dental professional:

You know that your statement in bold-face is grossly misleading. As dental professionals we should be above that, and leave that kind of misrepresentation and dishonesty to the nursing associations who are pushing to have nurses function as doctors.

I was a dental student at a school with an oral surgery residency that did a lot of cosmetics, and I can assure you that cosmetic cases were infrequent at best - no more than a dozen or so each year. (I know this because I asked).

So don't say that oral surgery residents at any program spend "4 years doing facelifts." That is a gross misrepresentation of the experience. And quite frankly, it's not even believable. There are so many teeth to be taken out, so many odontogenic infections to treat, so many OKC's and ameloblastomas to treat, so many mandible fractures to treat, and a half-way decent supply of orthognathic cases, etc. etc., that OMFS residencies fit cosmetics in only when there's time!

I was mirroring (exactly) the statement bobby6 made to prove a point, not to imply that OMFS spend all day doing cosmetics. I understand this subtlety was probably lost on the internet, so no harm no foul.

However, your subjective experience of being at a "good cosmetics program" and "asking about it" doesn't necessarily translate to real life. I interviewed at a few places where I reviewed documented cosmetics numbers greatly in excess of what you just mentioned. Is this every oral surgery program? No. Is every OMFS looking for blanket rights to do all facial cosmetics? No. We're talking about people with surgical training doing the things they were trained to do, and for some reason, in your opinion, there's a problem with that.

And by the way, Armorshell: occlusion isn't that complicated. In dental school, we had two one-credit courses on occlusion and a three-credit orthodontics course. That was plenty. And for an ENT or a plastic surgeon reducing a mandible fracture, they need only to identify the patient's bite, which is a fairly easy task. Besides, I've seen a few jaw fracture cases treated by OMFS where the resultant occlusion was way off.

And what about all the time you spent making dentures for patients, treating orthodontic patients, full mouth crown and bridge, making occlusal guards, etc... You didn't learn anything about occlusion from those two years? It saddens me to see another dental professional who considers the science of occlusion such a cheap one.

Besides, I've seen a few jaw fracture cases treated by OMFS where the resultant occlusion was way off.

Glad to see even us dental professionals are still slinging ridiculously subjective experiences from the hip as proof of concept.

 

[Leforte]

I think I've addressed this before, but I'll go at it again. I have no problem with any surgeon, from any specialty, performing any procedure for which they have received adequate training and consistently achieve results that are considered within the standard of care for the area in which they practice. Period. In cosmetics, If an ENT/Plastics/OMFS/Oculoplastics/etc wants to do a Blepharoplasty, and they have received quality training that includes this, then it should not matter what specialty they are trained in. There is overlap among many specialties, which is a good thing, IMHO. If an area lacks an ENT, but has OMFS, they can fill in for PTA's, trauma, neck abscesses (obviously this would be more rural). Same thing goes for GS/ENT and thyroids, etc. If we use the regional debate to say who should operate where, then why aren't ENT's doing carotid endarterectomies? I mean GS/Vascular/Neurosurg, etc are doing these, and they are in the neck, right? The reason is because we do not get training in the operation, nor in the complications that may result from it. Similarly, for approaches for ACDFs, NS/GS/ENT are all doing these. Sure, I have seen my share of superior laryngeal nerve paralysis from other specialties pinching the nerve in the retractors, so should I say that only ENTs should be doing these? How about Pec flaps? Should a head and neck surgeon be doing these since they are clearly outside of the typical "realm" of where we operate? Of course not. We do these because we have received the training to perform them, have performed them under supervision and have achieved results that are consistently within the standard of care to maintain privileges. If a surgeon form another specialty achieves the same training/results for another procedure, who am I to say what they can and cannot because I fear the collapse of my specialty?

Perhaps a better question to ask if you want your specialty to maintain control of a specific procedure, is why are people within your specialty training surgeons in other specialties to do it?

Honestly, I see this even within my specialty. Many neurotologists want to maintain control of stapedectomies, etc and do not feel that a generalist should be doing these. Others feel that is within the scope of a generalist who has adequate training and performs a certain number per year to maintain proficiency.

In the end, many of you are correct. Your referral patterns will dictate what you do in practice. If you are an OMFS and your main source of referrals are dentists, it is unlikely that you will be doing much cosmetic work anyway. Probably not too much H&N either. Yes, you'll get the oral leukoplakia that a general dentist sees, and if that biopsy comes back as cancer, chances are you will refer it to an ENT anyway because that partial glossectomy, SOHND will net you about $1100, take you 3 hours, you'll need to round on your patient in the hospital, cordinate his cancer care, medical oncologist, radiation oncologist, PET scan, CT's, etc OR in the same 3 hours you can take out 4 patients wisdom teeth for $1500 a pop (total of $6k), all of them go home and you are done by lunch with no rounding.

Which would you choose?

 

[armorshell]

Armorshell, this statement of yours suggests to me that your primary goal here is to create debate rather than put forth any valid points. You know perfectly well that, even without nose jobs and facelifts, oral surgeons perform a hell of a lot of procedures that go way beyond the denotative, literal meaning of the word "dentistry" (i.e. "dent" meaning tooth combined with "ry" which denotes occupation"). Hell, even as a general dentist I treat conditions that go well beyond the tooth!

My primary goal in any debate (which this already was) is to put forth valid points and invalidate your points. The latter was the goal of that statement.

Precisely! If oral surgeons wanted to practice medicine, they should have gone to medical school (more on this in a moment) and completed medical residencies. What they are doing by dipping into facial cosmetic surgery is no different than advanced-practice nurses dipping into responsibilities that were once solely physicians'. Both are practicing medicine without going through the proper procedures.

First of all, I'm glad we agree that you're mostly just hung up on the superficial aspect this dentistry vs. medicine issue.

Secondly, in my understand, this is nothing like what's going on with advance practice nurses. They're trying to advocate for solo-practice privileges through work experience. OMFS are receiving this training in the same setting as ENT/Plastics, from the same attendings, in the same manner (as you agreed). The comparison is much more analogous to say, ENT moving into the facial cosmetics field (Which as I recall, was not a part of the original scope of ENT).

It really seems that you are grasping at straws here. If you really think that someone who is adequately trained in the same manner as an ENT/PRS resident shouldn't be allowed to perform whatever procedures they have learned because of their title and nothing else, then you are beyond convincing. Privileges should be based on training, not nomenclature.

And mind you, even the dual-degree oral surgeons don't have genuine medical degrees as far as I'm concerned. First off, there's no standardization among the various 6-year residencies with regard to the years of medical school that will be undertaken. Some require the 3rd and 4th, others require the 2nd and 3rd, and others require the 1st and 2nd, and others require parts of multiple years, if I'm not mistaken. No matter which parts of medical school the resident goes through, he has not completed a four-year medical education. Something is going to be missing. Don't forget that I've been through dental school, so I know exactly what oral surgeons spent the first two years of their professional education doing. Dental students take less than half of the biomedical sciences that medical students take, and simultaneously spend more than half of their time taking courses on dentures, crown & bridge, gum disease, root canals, cavities, and so on -- disciplines that have very little to do with medicine. In fact, every dental curriculum incorporates a great deal of lab-time into the curriculum. And I don't mean anatomy lab! In these labs, dental students will spend several hours a week drilling on plastic teeth, melting wax and setting denture teeth, and many other tasks that also have nothing to do with medicine. I was an excellent dental student -- graduated near the top of my class and kicked a.ss on both parts of my dental board exams. But when I got to medical school, I found the material to be challenging. Indeed, less than half of it was material I had seen in dental school. There is no way I could have tacked on two years of medical school and considered myself an "MD".

Sure, dual-degree oral surgeons had to pass all three steps of the USMLE. Some of them even do well on the exam. But let's face it, the USMLE does not test everything you've learned in medical school. Passing it is not the equivalent of a medical education.

It's funny that all of these medical schools which actually grant the degrees seem to disagree with you, and I'm going to open up my book of logical fallacies and appeal to authority that they've spent a lot more time thinking about it then you or I have. Again, you're substituting your subjective experience of dental and medical school for a generalized reality, which is likely far from the truth. I could argue about this for hours, but I'll keep it short because it's irrelevant to the point.

 

[DREDAY]

Well said. I would like to add that the OMFS doing oncology at university medical centers receive an equal number of referrals from both physician and dentists. However, in private practice most receive referrals from dentists like you said.

I think I've addressed this before, but I'll go at it again. I have no problem with any surgeon, from any specialty, performing any procedure for which they have received adequate training and consistently achieve results that are considered within the standard of care for the area in which they practice. Period. In cosmetics, If an ENT/Plastics/OMFS/Oculoplastics/etc wants to do a Blepharoplasty, and they have received quality training that includes this, then it should not matter what specialty they are trained in. There is overlap among many specialties, which is a good thing, IMHO. If an area lacks an ENT, but has OMFS, they can fill in for PTA's, trauma, neck abscesses (obviously this would be more rural). Same thing goes for GS/ENT and thyroids, etc. If we use the regional debate to say who should operate where, then why aren't ENT's doing carotid endarterectomies? I mean GS/Vascular/Neurosurg, etc are doing these, and they are in the neck, right? The reason is because we do not get training in the operation, nor in the complications that may result from it. Similarly, for approaches for ACDFs, NS/GS/ENT are all doing these. Sure, I have seen my share of superior laryngeal nerve paralysis from other specialties pinching the nerve in the retractors, so should I say that only ENTs should be doing these? How about Pec flaps? Should a head and neck surgeon be doing these since they are clearly outside of the typical "realm" of where we operate? Of course not. We do these because we have received the training to perform them, have performed them under supervision and have achieved results that are consistently within the standard of care to maintain privileges. If a surgeon form another specialty achieves the same training/results for another procedure, who am I to say what they can and cannot because I fear the collapse of my specialty?

Perhaps a better question to ask if you want your specialty to maintain control of a specific procedure, is why are people within your specialty training surgeons in other specialties to do it?

Honestly, I see this even within my specialty. Many neurotologists want to maintain control of stapedectomies, etc and do not feel that a generalist should be doing these. Others feel that is within the scope of a generalist who has adequate training and performs a certain number per year to maintain proficiency.

In the end, many of you are correct. Your referral patterns will dictate what you do in practice. If you are an OMFS and your main source of referrals are dentists, it is unlikely that you will be doing much cosmetic work anyway. Probably not too much H&N either. Yes, you'll get the oral leukoplakia that a general dentist sees, and if that biopsy comes back as cancer, chances are you will refer it to an ENT anyway because that partial glossectomy, SOHND will net you about $1100, take you 3 hours, you'll need to round on your patient in the hospital, cordinate his cancer care, medical oncologist, radiation oncologist, PET scan, CT's, etc OR in the same 3 hours you can take out 4 patients wisdom teeth for $1500 a pop (total of $6k), all of them go home and you are done by lunch with no rounding.

Which would you choose?

 

[bobby6]

I agree with Leforte, I have no issues with anyone or any specialty doing any procedure as long as they have adequate training and consistently achieve results that are considered within the standard of care. Its about patient safety.

From personal experience after my 4th year of otolaryngology residency, was I comfortable doing composite cancer resections, neck dissections, parotidectomy, facelifts, rhinoplasty, blepharoplasty alone without backup? No.

My 5th year allowed me act as the teaching resident taking junior residents through these cases with an attending present to assist as needed which taught me to be competent and comfortable in doing those procedures alone.

OMFS is a 4 year residency with one 1 year of general surgery and as much as 6 months of anesthesia so that leaves 2 1/2 years doing actual OMFS. Is that enough to be competent in doing head and neck surgery and facial plastic surgery right out of residency?

Another thing to think about is whether or not your malpractice insurance will cover you to do those procedures. At many institutions, as an OMFS applying for cosmetic privileges, in addition of submitting a case log, there has to be documentation that they have malpractice insurance to cover them for those procedures which may not necessarily part of the standard malpractice insurance for OMFS.

 

[DREDAY]

The USMLE board exams are in place to address exactly what you have just stated "standardization of education". Infact, with those USMLE scores an OMFS can apply to any other medical residency.

The USMLE board exams also give foreign medical graduates the ability to practice in the United States without ever taking a class in the US. Should we question their medical education? Who knows what they learned in medical school? Again that's why USMLE board exams are in place.

IF OMFS have not received the equivalent of a medical education, why are medical schools throughout the US issuing OMFS MD? Give me a break.

To correct you, you are wrong. Programs require 2-3 years of medical school. Most programs require years 2, 3, and half of year 4. A couple of programs require years 3 and 4. NO PROGRAMS REQUIRE YEARS 1 AND 2 ONLY. All MD integrated programs require 1-2 years of General Surgery.

Once again, hospitals use evidence of competence to grant privileges to perform procedures.

And let me make it clear to you. There is nothing that I learned I learned in medical school, which I didn't learn in dental school which would help me perform a facelift or rhinoplasty. In fact, the head and neck anatomy that I received in dental school was more complete than in medical school.

Where did you go to dental school? Unlike you, I found a lot of redundancy in my medical education.

Where did you do your internship?

And mind you, even the dual-degree oral surgeons don't have genuine medical degrees as far as I'm concerned. First off, there's no standardization among the various 6-year residencies with regard to the years of medical school that will be undertaken. Some require the 3rd and 4th, others require the 2nd and 3rd, and others require the 1st and 2nd, and others require parts of multiple years, if I'm not mistaken.

Sure, dual-degree oral surgeons had to pass all three steps of the USMLE. Some of them even do well on the exam. But let's face it, the USMLE does not test everything you've learned in medical school. Passing it is not the equivalent of a medical education.

 

[DREDAY]

OMFS is a 4 year residency with one 1 year of general surgery and as much as 6 months of anesthesia so that leaves 2 1/2 years doing actual OMFS. Is that enough to be competent in doing head and neck surgery and facial plastic surgery right out of residency?

Head and neck surgery: no. All will do an additional oncology fellowship.

Facial cosmetics: some programs yes. Others will do an additional cosmetic fellowship.

 

[DREDAY]

OMFS is a 4 year residency with one 1 year of general surgery and as much as 6 months of anesthesia so that leaves 2 1/2 years doing actual OMFS. Is that enough to be competent in doing head and neck surgery and facial plastic surgery right out of residency?

The minimum requirement to be accredited is 30 months of OMFS. The amount of time on service will vary by program ranging between 30 months to 42 months. I believe the average is 34 months in OMFS service.

 

[5150]

Good lord there are a lot of defensive OMFS people on this forum. Most activity ive seen here in over a year, haha.

 

[Clemenza]

I was mirroring (exactly) the statement bobby6 made to prove a point, not to imply that OMFS spend all day doing cosmetics. I understand this subtlety was probably lost on the internet, so no harm no foul.

However, your subjective experience of being at a "good cosmetics program" and "asking about it" doesn't necessarily translate to real life. I interviewed at a few places where I reviewed documented cosmetics numbers greatly in excess of what you just mentioned. Is this every oral surgery program? No. Is every OMFS looking for blanket rights to do all facial cosmetics? No. We're talking about people with surgical training doing the things they were trained to do, and for some reason, in your opinion, there's a problem with that.

No. We're talking about people sticking to their professions, and not cherry-picking work from other professions.

Think about it, Armorshell: How would oral surgeons feel about ENTs making wisdom teeth extractions a part of their practice? Do you think oral surgeons would accept this? ENTs are every bit as intimately familiar with the anatomy of the hard and soft tissues in the area. And the task of troughing, sectioning, and elevating the teeth are well within the surgical abilities of an ENT. But would oral surgeons tolerate this? Absolutely not! They'd go ballistic! They'd scream that exodontia is not a part of otolaryngology, and that extracting third molars requires a great deal of knowledge about dentition that ENTs don't possess (which is utter nonsense).

And what about all the time you spent making dentures for patients, treating orthodontic patients, full mouth crown and bridge, making occlusal guards, etc... You didn't learn anything about occlusion from those two years?

No. And neither did you. Denture occlusion is a different animal than natural occlusion. And since no dentist in his right mind sets his own denture teeth, we really don't pay much attention to denture occlusion to begin with.

And as for "full mouth crown and bridge", that kind of occlusion is well beyond the scope of any surgeon. Oral surgeons sure as hell don't deal with occlusion that extensively.

It saddens me to see another dental professional who considers the science of occlusion such a cheap one.

Our very own dental profession considers it to be "cheap". It's really not that complicated.

 

[Clemenza]

First of all, I'm glad we agree that you're mostly just hung up on the superficial aspect this dentistry vs. medicine issue.

I'm sorry, Armorshell, but the difference between medicine and dentistry is hardly a "superficial" matter. And the difference between an MD and a DDS is much more than a minor technicality, despite your wishes.

Secondly, in my understand, this is nothing like what's going on with advance practice nurses. They're trying to advocate for solo-practice privileges through work experience. OMFS are receiving this training in the same setting as ENT/Plastics, from the same attendings, in the same manner (as you agreed). The comparison is much more analogous to say, ENT moving into the facial cosmetics field (Which as I recall, was not a part of the original scope of ENT).

Wrong. Oral surgeons are dentists trying to practice medicine.

It really seems that you are grasping at straws here. If you really think that someone who is adequately trained in the same manner as an ENT/PRS resident shouldn't be allowed to perform whatever procedures they have learned because of their title and nothing else, then you are beyond convincing. Privileges should be based on training, not nomenclature.

Armorshell, if you're willing to let a psychiatrist perform your colonoscopy because he's received adequate training in it, then you go right ahead. But as far as I'm concerned, people should stick to the scope of their professions. That's why we have defined specialties, rather than a hodge-podge of physicians each of whom have a potpourri of training in the lucrative and/or exciting procedures.

It's funny that all of these medical schools which actually grant the degrees seem to disagree with you, and I'm going to open up my book of logical fallacies and appeal to authority that they've spent a lot more time thinking about it then you or I have. Again, you're substituting your subjective experience of dental and medical school for a generalized reality, which is likely far from the truth. I could argue about this for hours, but I'll keep it short because it's irrelevant to the point.

So let me get this straight: you acknowledge that I've experienced dental school and medical school first-hand, but then turn around and criticize my statements as being subjective rather than objective while you yourself don't know a goddamned thing about medical school. Are you still being argumentative, or are you just too dumb to realize that you're arguing with someone who has more facts than you?

And as for the medical schools granting MD degrees to OMFS residents, there are likely many more factors at play. Who knows? Maybe these medical schools feel that the OMFS residents get 'just enough' to warrant an MD degree, whereas the actual medical students who make it through the full curriculum get 'more than enough' to earn an MD.

And again, Armorshell, the numbers just don't add up. The first two years of dental school are not equivalent to the first two years of medical school. Approximately half of those two years, if not more, are devoted to dental-specific sciences. This is a fact. So where do the OMFS residents make up the difference? (And don't say "as part of their residency training", because we both know they are awarded the MD degree as soon as they complete the two years of medical school, which is usually by the third year of the 6 year program).