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Dental Service in Hospitals—Its Problems and Their Solution*
BUREAU OF DENTAL HEALTH EDUCATION
DENTAL SERVICE IN HOSPITALS—ITS PROBLEMS AND THEIR SOLUTION* By SIGMUND W. A. FRANKEN, D.D.S.,|New York City D
E N T A L problems in hospitals d i vide themselves into tw o classes: general problem s, w hich hold good fo r all hospitals, and specific problem s, w hich arise in each in dividu al in stitu tio n. I t w ill cla rify a discussion o f these problems to refer to a plan described in The Journal of the American M edical Association1
w hich deals w ith the organi za tio n of a dental departm ent fo r w a rd services in any general hospital. T h is plan , called “ T h e L e n o x H i l l H o s p ita l P la n fo r D e n ta l Service” is a flexible one, easily adaptable to the size and re sources o f any in stitu tion. O f prim a l im portance is the proper organ iza tio n of the staff, w hich should consist, at a m in im u m , o f an experienced dentist, a dental intern and , if possible, a dental hygienist. T h e dental intern should take care o f the average w a rd w o rk , and the hygienist, in addition to oral prophylaxis, should assist in exam in ing and charting the patients. B u t it is * F r o m th e D e n ta l S e r v ic e o f th e L e n o x H ill H o s p it a l. * R e a d b e f o r e th e S e ctio n o n M o u t h H y g ie n e and
P re v e n tiv e
D e n t is t r y
at
th e
S even ty-
F ir s t A n n u a l S e ss io n o f th e A m e r ic a n D e n ta l A s s o c ia t io n , W a s h i n g t o n , D . C ., O ct. 9, 1929. 1. P la n
F ra n k e n , S. W . A . : L e n o x H i l l H o s p it a l fo r
D e n ta l
C a r e o f H o s p it a l P a tie n ts ,
J . A . M . A ., 8 3 :1 8 6 6 -1 8 6 8
( D e c . 6 ,)
Jour. A . D . A ., D ecem ber, 1929
1 924.
the attending dentist, and no one else, w h o is directly responsible fo r the ru n n in g o f the entire departm ent. W it h this basic interstaff relationship firm ly established, it is an autom atic procedure to increase the num ber o f interns, hygienists and associate dentists in proportion to the increase in w o rk . So m uch fo r a brief outline o f staff. N o w a fa r m ore difficult problem con fronts us in the successful functioning and adjustm ent o f w h a t is com paratively a new and alien departm ent in hospital ro utin e . Since o ur o w n standards in hos pital w o rk are in the m a kin g, it w ill facilitate this achievement to use the standards o f physicians and surgeons and to place ourselves as fa r as possible upon an equality basis w ith them . T h e attend ing dentist, therefore, m ust have the same ideals, am bitions and capabilities as the corresponding leaders in the v a ri ous departm ents th ro u gh ou t the in stitu tio n. T h is presupposes im m ediately that the m an in charge o f the dental division m ust be one w h o , like his m edical col league, has had experience in w a rd w o rk or an outpatient departm ent. H e m ust also, according to the same standard, be prepared to give tw o or three h a lf days a w eek to the hospital, as w e ll as holding him self in readiness fo r emergencies or necessary consultations.
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Bureau o f D en ta l H ea lth Education
O n a n a lyzin g several institutions where dental departm ents have n o t been successful, it is interesting to note th a t, in alm ost every instance, the attending dentist or dentists w ere content to shift their responsibilities to the interns, w hile their o w n sessions at the hospital w ere, after the first fe w m onths, sporadic and p e rfun ctory. T h e outcome of this type o f service is self-evident. Before leaving the qualifications o f the attending dentist, it m ig h t not be amiss to state th a t, c o n tra ry to the prevailing opinion, it is n o t necessary to have an oral surgeon head the departm ent. I n deed, on investigation, it was fo u n d th at one hospital had an orthodontist, another an oral surgeon and a th ird a general practitioner. I n short, it is the in dividu al and n o t his specialty th a t is the im por tan t po in t. L e t us n o w take up the problem o f the intern. M e d ic a l intern applicants re ceive an oral exam ination a fte r pre vi ously filing p re lim in ary application blanks and presenting letters o f recom menda tio n, after w hich the executive medical com m ittee makes its selection. T h e board of trustees then does the final appointing. T h is m ethod should be fo llo w ed in se lecting the dental in te rn . T h e dentist in charge should have a ll applicants appear an h our or tw o before the m eeting o f the executive com m ittee. T h is is to avoid a waste o f tim e fo r the applicants, w h o otherwise w o u ld have to appear tw ice. T h e attending dentist should o rally exam ine those presenting themselves, and select three fo r each vacancy. Th o s e chosen m ust not necessarily be the best scholastically, b u t should have good gen eral intelligence and an ab ility to orient themselves to institutional conditions. H a v in g sifted his applicants, the den tist in charge introduces the three men fo r each vacancy to the appointing com
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m ittee o f the hospital, and to the super intendent. T h e chairm an asks a fe w leading questions of each m an as he is introduced. A f t e r this has been done, the applicants are told th a t they w ill hear the decision w ith in a fe w days. A f t e r they are dismissed, the com m ittee dis cusses the applicants and selects one of the three, not solely fro m a dental stand po in t, bu t fro m a personality one as w e ll, and recommends him to the trustees, w h o , in tu rn , appoint h im . B y this means, sev eral things are accomplished: 1 . E q u a lity o f appointm ent of dental and m edical interns has been established. 2. N o one is error perfect. I f , du rin g his internship, the you n g dentist should behave him self in a m anner unbecom ing to a gentlem an, the executive committee n a tu ra lly shares the responsibility w ith the attending dentist. 3 . I t brings the executive com m ittee in touch w ith the dental departm ent, and m a ny valuable suggestions have thus been received by the dental departm ent. D e n ta l interns should be o f the cu r rent graduatin g class, w hich usually means th a t their ages are fro m 2 1 to 2 4 . N o m arried m edical interns are accepted, and the same rule applies to the dental interns. Before continuing, it m ig h t be advis able to touch on the compensation o f a dental in te rn . T h is should be equal to th a t o f the medical in te rn . I n most hos pitals, the medical intern gives his tim e and is repaid by experience. T h e next problem is the selection of the dental hygienist, provided the hos pital has appropriated funds fo r her em ploym ent. She should be selected as are any o f the graduate nurses o f the hos p ita l: on a basis o f her character, refer ences, professional aptitude and a bility to fit into the routine o f the institution.
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T h e Journal of the Am erican D en ta l Association
N o w th a t the staff has been discussed, some o f the m ore specific problems can be considered. Possibly the one question m ost fre q u en tly asked concerns the ta kin g of roentgenogram s. N o n e o f the other spe cialties in a hospital are expected to make their film exposures, and ju st w h y the dental departm ent should be singled o u t fo r differentiation has never been clear. T h e m om ent the dental departm ent takes its o w n film s, an inequality is established w hich w ill inevitably lead to fu rth e r diffe re n tiation s; therefore, the depart m ent takin g the film s fo r the entire hos pital should also take them fo r the dental departm ent. I f there is a special dental x -ra y m achine, the roentgenologic de p artm e nt should supply the technician, w h o , w hen properly trained and under the jurisdiction o f the roentgenologist, is better than an ever-changing dental in te rn . Besides, if the dental intern makes the exposures fo r the w a rd patients, w h o then w o u ld be expected to do this w o rk fo r private patients o r dental patients of the outpatient departm ent? T h e interpretation o f the dental films is another question. F e w physicians are proficient in this, and as the num ber o f dental films taken in a general hospital is apt to be large, fo r speed and accuracy in interpretation a good m ethod is to have an experienced dental roentgenologist on the dental staff. H is duties should be to interpret the dental film s o f all patients, private as w e ll as outpatient departm ent and w a rd . T o do this properly, he m ust arrange to w o rk every other day fo r approxim ately one-half to one h o u r. F ilm s should be ready fo r interpretation w hen he arrives, and a secretary fro m the roentgenologic departm ent should be present to takg his dictation. N e x t , the question o f a separate dental w a rd in a hospital is often discussed. In
every w e ll-ru n in stitu tio n, each patient receives a physical exam ination and has routine la bo ra to ry tests m ade soon after admission. T h e reason fo r this is obvious, and needs no fu rth e r discussion. Id e a lly, this procedure should be fo llo w ed fo r all p u re ly dental hospital pa tie n ts; bu t are dentists qualified by tra in in g or experi ence to do this? Y o u k n o w the a nsw e r: as a class they are not. Fu rth e rm o re , besides the in te rn , a m em ber o f the at tending staff m ust look afte r the patients d a ily ; and v e ry fe w dentists w o u ld be able or w illin g to go daily to the hospital. T h e r e are tw o answers to this problem o f the establishment o f a separate dental w a rd . O n e is the m ethod em ployed thus fa r at the L e n o x H i l l H o s p ita l. T h e den tal departm ent has at its service about five beds. Th ese are scattered over the various w a rd s : surgical, m edical and children’s. F o r exam ple, a patient need ing a th ird m o lar rem oved is, w h en hos p ita liza tio n is advisable, a dm itted, pre ferably to one o f the surgical w ards. I f no bed is available, he is placed in the medical w a rd . I n either event, he re ceives the routine physical and laboratory exam inations fro m the medical intern. T h e use o f a m o uth w ash, compress or w h a te ve r dental care is necessary is looked a fte r by the dental in te rn . W h e n all reports are satisfactory and the choice o f anesthesia has been m ade by the a t tending dentist (aided by consultation w ith the ph ysician ), the patient is oper ated on. T h e operation is perform ed by some one in the dental departm ent. A strict rule o f all hospitals is th a t no m edical in te rn m ay operate w ith o u t the presence o f a mem ber of the attending staff, and, re ferrin g again to the equality basis, the same rule should hold fo r the dental departm ent. O ccasionally, a patient w ith an adenitis due to a sup pu ratin g tooth m erely requires the extrac
Bureau of D en ta l H ea lth Education
tion of a loose first perm anent m o la r. W h e n it is impossible fo r the attending dentist to be present, one o f the adjuncts o f the surgical staff should be in the room , the rule o f the hospital being thereby fo llo w e d . In c id e n ta lly, it be comes impressed on the physician that ffirno*
Sjill
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T h e plan o f having separate w ards fo r the pu re ly dental conditions m ay be solved in another m anner. I f the medical intern assigned to the specialty service, such as nose and th ro a t, is made respon sible fo r the physical and laboratory exam inations o f the dental patients, then, ^ospitai
O r a l E xa m in a tio n
Systemic Diagnosis
Missing Teeth
To be extracted
Crowns and Bridges
Condition (Soft Tissues) Remarks;
Signed._____________________ _ O r a l e x a m in a t io n c h a r t u s e d
e very sw elling o f the face due to an abscess need not necessarily call fo r lanc in g exte rn a lly. T h is m ethod o f handling the patient again acts as a w e ldin g in flu ence on the tw o departm ents.
a t L e n o x H i l l H o s p it a l.
and o n ly then, should the dental depart m ent assume a separate service. E v e r y hospital has a large percentage o f patients requiring prophylaxis, em er gency treatm ents and extractions. H o w ,
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T h e Journal o f the Am erican D en ta l Association
w h en and by w h o m these shall be treated is the n e xt problem . A good ru le , and one th a t should be constantly checked by the dental director, is to have every patient in the hospital receive a dental exam ination, w ith in tw e n ty -fo u r hours a fte r admission. T h e dental findings should be recorded on a simple ch art, the paper o f w h ich should be a distinctive color, and signed b y the dental in te rn . T h is chart should be part and parcel o f the general history. T h e distinctive color used by the L e n o x H o s pital is a lig h t green. T h e purpose of this is to m ake the dental findings readily discernible to the attending physicians or surgeons. A l l am bulatory patients in a nonfebrile state should receive prophy lactic care, bu t the necessary extractions should be done o n ly w ith the know ledge and consent o f the m edical or surgical staff. T h e green chart, besides h aving the nam e, w a rd , history num ber and sys temic disease, carries the fo llo w in g den tal fin d in g s: teeth to be e xtra c te d ; teeth to be fille d ; teeth carrying crowns and bridges; condition o f soft parts, and re m arks as to abnorm al findings. T h e symbols used in charting are the numbers 1 to 8 fo r each quarter o f the ja w , a h o rizo n ta l line indicating upper and lo w e r, and a vertical line bisecting the h o rizo n ta l denoting m edian line, the m outh being thus divided into fo u r quarters. T o po in t o u t still another reason fo r not h aving the chart w h ite : I t w ill be remembered th a t, besides the usual w h ite paper and charts on every hospital pa tie n t’s h isto ry, there are also several colored sheets— pin k ones fo r bedside notes, b ro w n ones fo r laboratory findings, etc. F o llo w in g out the equality theory, the differentiation o f color in the dental sheets, though a v e ry sm all m a tte r, never
theless serves to again classify the dentist as a p a rt o f the general w o rk in g staff o f the in stitution. Cooperation between dentist and phy sician is one o f the largest problem s, but it can be bro u g h t to a high plane in a general hospital. T o this end, the den tist should take the initiative. F o r ex am ple, w h e n he receives a request fro m a physician fo r a consultation, he should see the patient the same day and report his opinion, n o t to some m edical in te rn , b u t on the general history chart on the sheet designated fo r bedside notes. T h e dental intern should take d o w n w h a t is dictated by the attending dentist, and the opinion should be expressed in clear, con cise language. In vo lve d sentences w ith m a n y h ig h ly specialized dental terms should be avoided in fa vo r of simple ex pressions com m on to both professions. W e should endeavor to learn the physician’s la n g u a g e ; la te r, he w ill learn ours. In the m eantim e, use his w ords w henever possible in order to establish a better understanding between us. T h e entire problem o f cooperation is not so sim ply solved. O ft e n the surgical service requests extractions at the same tim e th a t an epitheliom a o f the m o uth is being rem oved. I n such an instance, the dental departm ent should have a repre sentative ready to do and capable o f doing the w o rk . T h is leads to another point th a t is at times most a w k w a rd , nam ely, the proper technic to be em ployed fo r preparing oneself to operate in the m od ern surgical room o f a hospital. M o s t dental interns and dentists are sadly re miss, not o n ly in the know ledge and sig nificance o f scrubbing and sterilizin g their hands, b u t even in the do nning of sterile gowns and gloves. T h is is n o t the tim e to describe these proceedings: I w ish m erely to strongly urge a ll dentists w h o are affiliated in any capacity w ith a
Bureau o f D en ta l H ea lth Education
hospital to become fam ilia r w ith the principles o f operating rciom behavior. Indeed, it is not o n ly in the operating room th at the young intern w ill find h im self at loss. H e probably w ill not k n o w the m ethod o f m akin g cultures. Ig n o r ance is no crim e, bu t continued ignorance is u nfo rg iva b le . T h e re fo re , he should either be ta u gh t by the attending dentist o r sent to the pathologic la bo ra to ry to ask questions and learn. I have yet to find a physician or laboratory w o rk e r w h o did n o t take the tim e to answer a reasonable question. I t is n o t necessary to point out fu rth e r illustrations o f cooperation. I f it be borne in m in d th a t cooperation means not ta lk , b u t actual w o rk and a reciprocal process, it w ill be fo un d to w o rk n a tu ra lly. T h is problem o f teaching the dental intern is next in im portance, and still again the q u a lity m ethod solves it. H o w do the m edical interns receive their tra in ing? B y continual repetition— m aking the rounds o f w a rd s, attending the v a ri ous m edical and surgical conferences and being present at necropsies. A n d , n a tu r a lly , they assist in the operating rooms and laboratories. T h e dental in te rn should fo llo w the same m ethod. H e need n o t attend every conference, or there w o u ld not be time fo r dental w o rk . A good w a y to acquire a general m edical and surgical under standing has been outlined elsewhere,2 but a resume w o u ld do no h a rm . H a v in g gained sufficient dental experience in col lege and the outpatient departm ent, the you n g denist should begin his official in ternship w ith w eekly attendance at rounds w ith the m edical staff. T h e m o n th ly m edical and surgical meetings should find him present. W h e n e v e r pos-
2,307
sible, he should attend necropsies. H e should also attend clinical society m eet ings at the hospital. I n addition, he should always assist the attending den tist, or w hoever has charge o f the oral surgery. A n d last, bu t fa r fro m least, as m uch tim e as possible should be spent in the general surgical operating room to observe the fundam ental laws o f sur gery. T h e n , at the end o f his serv ice, the dental intern w ill k n o w th at the m o uth is bu t a p a rt o f the hum an body w hich responds to the general laws o f physiology, surgery and pathology. M u c h tim e could be spent in discussing the various branches of dentistry prac ticed in general hospitals. B rie fly , a ré sumé o f m ore than 330 answers to ques tionnaires sent to hospitals th rou gh ou t the U n ite d States, C an a d a and the P h il ippines3 disclosed the fact that m inor oral surgery, including extractions, is practiced universally in the hospitals, w hile the other phases o f dental w o rk depend a great deal on the financial con dition o f the in stitu tion, as w e ll as on the specialty o f the director o f the dental departm ent. A t the L e n o x H i l l H o s p ita l, the prob lem has been handled in a fashion w hich I believe is readily applicable to any gen eral hospital. B rie fly, w e undertake no w o rk th a t cannot be accomplished w ith in the period th at the patient is to rem ain in the hospital. W e do n o t undertake to m ake prosthetic appliances (except fracture s p lin ts ), and w e do only root canal w o rk th a t occasionally m ust be done in preparation fo r root resection. O rth o d o n tia , fo r the reason above stated, is also eliminated fro m the régime. D is crim ination against these branches of 3.
F ra n k e n , S. W . A . : D e n t a l In t e r n s h ip s
F r a n k e n , S. W . A . : D e n ta l C a r e o f H o s in G e n e r a l H o s p it a ls o f U n it e d S tates, C a n a d a a n d P h ilip p in e s , J. A . D . A ., 1 5 :7 6 8 -7 7 6 p ita l I n -P a t ie n ts — L e n o x H i l l H o s p it a l P la n , ( A p r i l ) 1928. D e n t. C o s m o s , 6 7 :6 0 3 -6 0 6 ( J u n e ) 1925. 2.
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T h e Journal of the Am erican D en ta l Association
dentistry is w e ll advised. R e v e rtin g to the original equality basis: after an am putation o r abdom inal operation, the surgical departm ent is n o t expected to provide an artificial lim b or tru ss; there fore, the dental departm ent in a general hospital should not be asked to restore missing teeth. Fu rth e rm o re , the hospital is thus saved fro m not infrequent abuse by the patient. F o r exam ple, a restored tooth m ay be too lo n g, too short or w h a t n o t, w ith the attending possibility o f a law suit fom ented by an idle la w y e r. A n d , ve ry often , there w o u ld be demands fo r free repairs on w o rk done several years previously. Perhaps, before closing the subject, it w o u ld not be amiss to m ention the w o rk th a t w e do engage in . W e are w e ll equipped fo r extractions, oral sur gery, prophylaxis, pyorrhea (to a lim ited e x te n t), palliative fillings and some ce m ent and am algam fillings. T h e outpatient departm ent is another m a tte r. In general, w e fo llo w the same rules as to the branches o f dentistry per fo rm ed . F o r a description o f the o u t patient departm ent, a separate paper w o u ld be required, and it is therefore left out o f the present discussion.
fro m n or exist separately fro m other m edical activities.” I n other w o rds, it should be on an equality basis w ith the other specialties. 2 . T h e re should be proper staff o r g a nizatio n and selection, and the estab lishm ent of a regular routine. 3. D e n ta l roentgenogram s should be taken in the roentgenogram departm ent or by a technician fro m th a t departm ent ; and should be interpreted by a competent dentist. 4 . T h e re should be a separate, distinc tive and simple dental sheet properly entered w ith every patient’s history. 5. T h e re should be constant coopera tion w ith all the various departments o f the hospital. 6. D e n ta l w o rk should be o f a nature th at it can be finished w ith in the tim e the patient remains in the hospital.
7 . Perhaps most im po rtan t o f a ll, the dental director should be selected entirely on his previous experience in hospital w o rk . T h is cannot be stressed suffi ciently. M a n y institutions have dispensed w ith the dental departm ent, not because of a lack o f need, b u t because o f the neg SUM M ARY ligence or in ability of the m an appointed T o recapitulate: In dental service in a as director. T h e re fo re , all frate rn a l, general hospital, the fo llo w in g should be political and social considerations should remembered : be ignored, ability and experience in hos 1. A s stated so ably by B r o w n 4 : “ T h e pital w o rk being the only basis o f select dental section . . . neither to be apart ing the head o f the departm ent. 4 . B r o w n , J . L . : U . S. N a v . M . B ., 2 5, N o . 2.
26 E a s t 3 6th S treet.
DENTAL SERVICE IN HOSPITALS—ITS PROBLEMS AND THEIR SOLUTION* By SIGMUND W. A. FRANKEN, D.D.S.,|New York City D
E N T A L problems in hospitals d i vide themselves into tw o classes: general problem s, w hich hold good fo r all hospitals, and specific problem s, w hich arise in each in dividu al in stitu tio n. I t w ill cla rify a discussion o f these problems to refer to a plan described in The Journal of the American M edical Association1
w hich deals w ith the organi za tio n of a dental departm ent fo r w a rd services in any general hospital. T h is plan , called “ T h e L e n o x H i l l H o s p ita l P la n fo r D e n ta l Service” is a flexible one, easily adaptable to the size and re sources o f any in stitu tion. O f prim a l im portance is the proper organ iza tio n of the staff, w hich should consist, at a m in im u m , o f an experienced dentist, a dental intern and , if possible, a dental hygienist. T h e dental intern should take care o f the average w a rd w o rk , and the hygienist, in addition to oral prophylaxis, should assist in exam in ing and charting the patients. B u t it is * F r o m th e D e n ta l S e r v ic e o f th e L e n o x H ill H o s p it a l. * R e a d b e f o r e th e S e ctio n o n M o u t h H y g ie n e and
P re v e n tiv e
D e n t is t r y
at
th e
S even ty-
F ir s t A n n u a l S e ss io n o f th e A m e r ic a n D e n ta l A s s o c ia t io n , W a s h i n g t o n , D . C ., O ct. 9, 1929. 1. P la n
F ra n k e n , S. W . A . : L e n o x H i l l H o s p it a l fo r
D e n ta l
C a r e o f H o s p it a l P a tie n ts ,
J . A . M . A ., 8 3 :1 8 6 6 -1 8 6 8
( D e c . 6 ,)
Jour. A . D . A ., D ecem ber, 1929
1 924.
the attending dentist, and no one else, w h o is directly responsible fo r the ru n n in g o f the entire departm ent. W it h this basic interstaff relationship firm ly established, it is an autom atic procedure to increase the num ber o f interns, hygienists and associate dentists in proportion to the increase in w o rk . So m uch fo r a brief outline o f staff. N o w a fa r m ore difficult problem con fronts us in the successful functioning and adjustm ent o f w h a t is com paratively a new and alien departm ent in hospital ro utin e . Since o ur o w n standards in hos pital w o rk are in the m a kin g, it w ill facilitate this achievement to use the standards o f physicians and surgeons and to place ourselves as fa r as possible upon an equality basis w ith them . T h e attend ing dentist, therefore, m ust have the same ideals, am bitions and capabilities as the corresponding leaders in the v a ri ous departm ents th ro u gh ou t the in stitu tio n. T h is presupposes im m ediately that the m an in charge o f the dental division m ust be one w h o , like his m edical col league, has had experience in w a rd w o rk or an outpatient departm ent. H e m ust also, according to the same standard, be prepared to give tw o or three h a lf days a w eek to the hospital, as w e ll as holding him self in readiness fo r emergencies or necessary consultations.
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Bureau o f D en ta l H ea lth Education
O n a n a lyzin g several institutions where dental departm ents have n o t been successful, it is interesting to note th a t, in alm ost every instance, the attending dentist or dentists w ere content to shift their responsibilities to the interns, w hile their o w n sessions at the hospital w ere, after the first fe w m onths, sporadic and p e rfun ctory. T h e outcome of this type o f service is self-evident. Before leaving the qualifications o f the attending dentist, it m ig h t not be amiss to state th a t, c o n tra ry to the prevailing opinion, it is n o t necessary to have an oral surgeon head the departm ent. I n deed, on investigation, it was fo u n d th at one hospital had an orthodontist, another an oral surgeon and a th ird a general practitioner. I n short, it is the in dividu al and n o t his specialty th a t is the im por tan t po in t. L e t us n o w take up the problem o f the intern. M e d ic a l intern applicants re ceive an oral exam ination a fte r pre vi ously filing p re lim in ary application blanks and presenting letters o f recom menda tio n, after w hich the executive medical com m ittee makes its selection. T h e board of trustees then does the final appointing. T h is m ethod should be fo llo w ed in se lecting the dental in te rn . T h e dentist in charge should have a ll applicants appear an h our or tw o before the m eeting o f the executive com m ittee. T h is is to avoid a waste o f tim e fo r the applicants, w h o otherwise w o u ld have to appear tw ice. T h e attending dentist should o rally exam ine those presenting themselves, and select three fo r each vacancy. Th o s e chosen m ust not necessarily be the best scholastically, b u t should have good gen eral intelligence and an ab ility to orient themselves to institutional conditions. H a v in g sifted his applicants, the den tist in charge introduces the three men fo r each vacancy to the appointing com
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m ittee o f the hospital, and to the super intendent. T h e chairm an asks a fe w leading questions of each m an as he is introduced. A f t e r this has been done, the applicants are told th a t they w ill hear the decision w ith in a fe w days. A f t e r they are dismissed, the com m ittee dis cusses the applicants and selects one of the three, not solely fro m a dental stand po in t, bu t fro m a personality one as w e ll, and recommends him to the trustees, w h o , in tu rn , appoint h im . B y this means, sev eral things are accomplished: 1 . E q u a lity o f appointm ent of dental and m edical interns has been established. 2. N o one is error perfect. I f , du rin g his internship, the you n g dentist should behave him self in a m anner unbecom ing to a gentlem an, the executive committee n a tu ra lly shares the responsibility w ith the attending dentist. 3 . I t brings the executive com m ittee in touch w ith the dental departm ent, and m a ny valuable suggestions have thus been received by the dental departm ent. D e n ta l interns should be o f the cu r rent graduatin g class, w hich usually means th a t their ages are fro m 2 1 to 2 4 . N o m arried m edical interns are accepted, and the same rule applies to the dental interns. Before continuing, it m ig h t be advis able to touch on the compensation o f a dental in te rn . T h is should be equal to th a t o f the medical in te rn . I n most hos pitals, the medical intern gives his tim e and is repaid by experience. T h e next problem is the selection of the dental hygienist, provided the hos pital has appropriated funds fo r her em ploym ent. She should be selected as are any o f the graduate nurses o f the hos p ita l: on a basis o f her character, refer ences, professional aptitude and a bility to fit into the routine o f the institution.
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N o w th a t the staff has been discussed, some o f the m ore specific problems can be considered. Possibly the one question m ost fre q u en tly asked concerns the ta kin g of roentgenogram s. N o n e o f the other spe cialties in a hospital are expected to make their film exposures, and ju st w h y the dental departm ent should be singled o u t fo r differentiation has never been clear. T h e m om ent the dental departm ent takes its o w n film s, an inequality is established w hich w ill inevitably lead to fu rth e r diffe re n tiation s; therefore, the depart m ent takin g the film s fo r the entire hos pital should also take them fo r the dental departm ent. I f there is a special dental x -ra y m achine, the roentgenologic de p artm e nt should supply the technician, w h o , w hen properly trained and under the jurisdiction o f the roentgenologist, is better than an ever-changing dental in te rn . Besides, if the dental intern makes the exposures fo r the w a rd patients, w h o then w o u ld be expected to do this w o rk fo r private patients o r dental patients of the outpatient departm ent? T h e interpretation o f the dental films is another question. F e w physicians are proficient in this, and as the num ber o f dental films taken in a general hospital is apt to be large, fo r speed and accuracy in interpretation a good m ethod is to have an experienced dental roentgenologist on the dental staff. H is duties should be to interpret the dental film s o f all patients, private as w e ll as outpatient departm ent and w a rd . T o do this properly, he m ust arrange to w o rk every other day fo r approxim ately one-half to one h o u r. F ilm s should be ready fo r interpretation w hen he arrives, and a secretary fro m the roentgenologic departm ent should be present to takg his dictation. N e x t , the question o f a separate dental w a rd in a hospital is often discussed. In
every w e ll-ru n in stitu tio n, each patient receives a physical exam ination and has routine la bo ra to ry tests m ade soon after admission. T h e reason fo r this is obvious, and needs no fu rth e r discussion. Id e a lly, this procedure should be fo llo w ed fo r all p u re ly dental hospital pa tie n ts; bu t are dentists qualified by tra in in g or experi ence to do this? Y o u k n o w the a nsw e r: as a class they are not. Fu rth e rm o re , besides the in te rn , a m em ber o f the at tending staff m ust look afte r the patients d a ily ; and v e ry fe w dentists w o u ld be able or w illin g to go daily to the hospital. T h e r e are tw o answers to this problem o f the establishment o f a separate dental w a rd . O n e is the m ethod em ployed thus fa r at the L e n o x H i l l H o s p ita l. T h e den tal departm ent has at its service about five beds. Th ese are scattered over the various w a rd s : surgical, m edical and children’s. F o r exam ple, a patient need ing a th ird m o lar rem oved is, w h en hos p ita liza tio n is advisable, a dm itted, pre ferably to one o f the surgical w ards. I f no bed is available, he is placed in the medical w a rd . I n either event, he re ceives the routine physical and laboratory exam inations fro m the medical intern. T h e use o f a m o uth w ash, compress or w h a te ve r dental care is necessary is looked a fte r by the dental in te rn . W h e n all reports are satisfactory and the choice o f anesthesia has been m ade by the a t tending dentist (aided by consultation w ith the ph ysician ), the patient is oper ated on. T h e operation is perform ed by some one in the dental departm ent. A strict rule o f all hospitals is th a t no m edical in te rn m ay operate w ith o u t the presence o f a mem ber of the attending staff, and, re ferrin g again to the equality basis, the same rule should hold fo r the dental departm ent. O ccasionally, a patient w ith an adenitis due to a sup pu ratin g tooth m erely requires the extrac
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tion of a loose first perm anent m o la r. W h e n it is impossible fo r the attending dentist to be present, one o f the adjuncts o f the surgical staff should be in the room , the rule o f the hospital being thereby fo llo w e d . In c id e n ta lly, it be comes impressed on the physician that ffirno*
Sjill
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T h e plan o f having separate w ards fo r the pu re ly dental conditions m ay be solved in another m anner. I f the medical intern assigned to the specialty service, such as nose and th ro a t, is made respon sible fo r the physical and laboratory exam inations o f the dental patients, then, ^ospitai
O r a l E xa m in a tio n
Systemic Diagnosis
Missing Teeth
To be extracted
Crowns and Bridges
Condition (Soft Tissues) Remarks;
Signed._____________________ _ O r a l e x a m in a t io n c h a r t u s e d
e very sw elling o f the face due to an abscess need not necessarily call fo r lanc in g exte rn a lly. T h is m ethod o f handling the patient again acts as a w e ldin g in flu ence on the tw o departm ents.
a t L e n o x H i l l H o s p it a l.
and o n ly then, should the dental depart m ent assume a separate service. E v e r y hospital has a large percentage o f patients requiring prophylaxis, em er gency treatm ents and extractions. H o w ,
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T h e Journal o f the Am erican D en ta l Association
w h en and by w h o m these shall be treated is the n e xt problem . A good ru le , and one th a t should be constantly checked by the dental director, is to have every patient in the hospital receive a dental exam ination, w ith in tw e n ty -fo u r hours a fte r admission. T h e dental findings should be recorded on a simple ch art, the paper o f w h ich should be a distinctive color, and signed b y the dental in te rn . T h is chart should be part and parcel o f the general history. T h e distinctive color used by the L e n o x H o s pital is a lig h t green. T h e purpose of this is to m ake the dental findings readily discernible to the attending physicians or surgeons. A l l am bulatory patients in a nonfebrile state should receive prophy lactic care, bu t the necessary extractions should be done o n ly w ith the know ledge and consent o f the m edical or surgical staff. T h e green chart, besides h aving the nam e, w a rd , history num ber and sys temic disease, carries the fo llo w in g den tal fin d in g s: teeth to be e xtra c te d ; teeth to be fille d ; teeth carrying crowns and bridges; condition o f soft parts, and re m arks as to abnorm al findings. T h e symbols used in charting are the numbers 1 to 8 fo r each quarter o f the ja w , a h o rizo n ta l line indicating upper and lo w e r, and a vertical line bisecting the h o rizo n ta l denoting m edian line, the m outh being thus divided into fo u r quarters. T o po in t o u t still another reason fo r not h aving the chart w h ite : I t w ill be remembered th a t, besides the usual w h ite paper and charts on every hospital pa tie n t’s h isto ry, there are also several colored sheets— pin k ones fo r bedside notes, b ro w n ones fo r laboratory findings, etc. F o llo w in g out the equality theory, the differentiation o f color in the dental sheets, though a v e ry sm all m a tte r, never
theless serves to again classify the dentist as a p a rt o f the general w o rk in g staff o f the in stitution. Cooperation between dentist and phy sician is one o f the largest problem s, but it can be bro u g h t to a high plane in a general hospital. T o this end, the den tist should take the initiative. F o r ex am ple, w h e n he receives a request fro m a physician fo r a consultation, he should see the patient the same day and report his opinion, n o t to some m edical in te rn , b u t on the general history chart on the sheet designated fo r bedside notes. T h e dental intern should take d o w n w h a t is dictated by the attending dentist, and the opinion should be expressed in clear, con cise language. In vo lve d sentences w ith m a n y h ig h ly specialized dental terms should be avoided in fa vo r of simple ex pressions com m on to both professions. W e should endeavor to learn the physician’s la n g u a g e ; la te r, he w ill learn ours. In the m eantim e, use his w ords w henever possible in order to establish a better understanding between us. T h e entire problem o f cooperation is not so sim ply solved. O ft e n the surgical service requests extractions at the same tim e th a t an epitheliom a o f the m o uth is being rem oved. I n such an instance, the dental departm ent should have a repre sentative ready to do and capable o f doing the w o rk . T h is leads to another point th a t is at times most a w k w a rd , nam ely, the proper technic to be em ployed fo r preparing oneself to operate in the m od ern surgical room o f a hospital. M o s t dental interns and dentists are sadly re miss, not o n ly in the know ledge and sig nificance o f scrubbing and sterilizin g their hands, b u t even in the do nning of sterile gowns and gloves. T h is is n o t the tim e to describe these proceedings: I w ish m erely to strongly urge a ll dentists w h o are affiliated in any capacity w ith a
Bureau o f D en ta l H ea lth Education
hospital to become fam ilia r w ith the principles o f operating rciom behavior. Indeed, it is not o n ly in the operating room th at the young intern w ill find h im self at loss. H e probably w ill not k n o w the m ethod o f m akin g cultures. Ig n o r ance is no crim e, bu t continued ignorance is u nfo rg iva b le . T h e re fo re , he should either be ta u gh t by the attending dentist o r sent to the pathologic la bo ra to ry to ask questions and learn. I have yet to find a physician or laboratory w o rk e r w h o did n o t take the tim e to answer a reasonable question. I t is n o t necessary to point out fu rth e r illustrations o f cooperation. I f it be borne in m in d th a t cooperation means not ta lk , b u t actual w o rk and a reciprocal process, it w ill be fo un d to w o rk n a tu ra lly. T h is problem o f teaching the dental intern is next in im portance, and still again the q u a lity m ethod solves it. H o w do the m edical interns receive their tra in ing? B y continual repetition— m aking the rounds o f w a rd s, attending the v a ri ous m edical and surgical conferences and being present at necropsies. A n d , n a tu r a lly , they assist in the operating rooms and laboratories. T h e dental in te rn should fo llo w the same m ethod. H e need n o t attend every conference, or there w o u ld not be time fo r dental w o rk . A good w a y to acquire a general m edical and surgical under standing has been outlined elsewhere,2 but a resume w o u ld do no h a rm . H a v in g gained sufficient dental experience in col lege and the outpatient departm ent, the you n g denist should begin his official in ternship w ith w eekly attendance at rounds w ith the m edical staff. T h e m o n th ly m edical and surgical meetings should find him present. W h e n e v e r pos-
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sible, he should attend necropsies. H e should also attend clinical society m eet ings at the hospital. I n addition, he should always assist the attending den tist, or w hoever has charge o f the oral surgery. A n d last, bu t fa r fro m least, as m uch tim e as possible should be spent in the general surgical operating room to observe the fundam ental laws o f sur gery. T h e n , at the end o f his serv ice, the dental intern w ill k n o w th at the m o uth is bu t a p a rt o f the hum an body w hich responds to the general laws o f physiology, surgery and pathology. M u c h tim e could be spent in discussing the various branches of dentistry prac ticed in general hospitals. B rie fly , a ré sumé o f m ore than 330 answers to ques tionnaires sent to hospitals th rou gh ou t the U n ite d States, C an a d a and the P h il ippines3 disclosed the fact that m inor oral surgery, including extractions, is practiced universally in the hospitals, w hile the other phases o f dental w o rk depend a great deal on the financial con dition o f the in stitu tion, as w e ll as on the specialty o f the director o f the dental departm ent. A t the L e n o x H i l l H o s p ita l, the prob lem has been handled in a fashion w hich I believe is readily applicable to any gen eral hospital. B rie fly, w e undertake no w o rk th a t cannot be accomplished w ith in the period th at the patient is to rem ain in the hospital. W e do n o t undertake to m ake prosthetic appliances (except fracture s p lin ts ), and w e do only root canal w o rk th a t occasionally m ust be done in preparation fo r root resection. O rth o d o n tia , fo r the reason above stated, is also eliminated fro m the régime. D is crim ination against these branches of 3.
F ra n k e n , S. W . A . : D e n t a l In t e r n s h ip s
F r a n k e n , S. W . A . : D e n ta l C a r e o f H o s in G e n e r a l H o s p it a ls o f U n it e d S tates, C a n a d a a n d P h ilip p in e s , J. A . D . A ., 1 5 :7 6 8 -7 7 6 p ita l I n -P a t ie n ts — L e n o x H i l l H o s p it a l P la n , ( A p r i l ) 1928. D e n t. C o s m o s , 6 7 :6 0 3 -6 0 6 ( J u n e ) 1925. 2.
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T h e Journal of the Am erican D en ta l Association
dentistry is w e ll advised. R e v e rtin g to the original equality basis: after an am putation o r abdom inal operation, the surgical departm ent is n o t expected to provide an artificial lim b or tru ss; there fore, the dental departm ent in a general hospital should not be asked to restore missing teeth. Fu rth e rm o re , the hospital is thus saved fro m not infrequent abuse by the patient. F o r exam ple, a restored tooth m ay be too lo n g, too short or w h a t n o t, w ith the attending possibility o f a law suit fom ented by an idle la w y e r. A n d , ve ry often , there w o u ld be demands fo r free repairs on w o rk done several years previously. Perhaps, before closing the subject, it w o u ld not be amiss to m ention the w o rk th a t w e do engage in . W e are w e ll equipped fo r extractions, oral sur gery, prophylaxis, pyorrhea (to a lim ited e x te n t), palliative fillings and some ce m ent and am algam fillings. T h e outpatient departm ent is another m a tte r. In general, w e fo llo w the same rules as to the branches o f dentistry per fo rm ed . F o r a description o f the o u t patient departm ent, a separate paper w o u ld be required, and it is therefore left out o f the present discussion.
fro m n or exist separately fro m other m edical activities.” I n other w o rds, it should be on an equality basis w ith the other specialties. 2 . T h e re should be proper staff o r g a nizatio n and selection, and the estab lishm ent of a regular routine. 3. D e n ta l roentgenogram s should be taken in the roentgenogram departm ent or by a technician fro m th a t departm ent ; and should be interpreted by a competent dentist. 4 . T h e re should be a separate, distinc tive and simple dental sheet properly entered w ith every patient’s history. 5. T h e re should be constant coopera tion w ith all the various departments o f the hospital. 6. D e n ta l w o rk should be o f a nature th at it can be finished w ith in the tim e the patient remains in the hospital.
7 . Perhaps most im po rtan t o f a ll, the dental director should be selected entirely on his previous experience in hospital w o rk . T h is cannot be stressed suffi ciently. M a n y institutions have dispensed w ith the dental departm ent, not because of a lack o f need, b u t because o f the neg SUM M ARY ligence or in ability of the m an appointed T o recapitulate: In dental service in a as director. T h e re fo re , all frate rn a l, general hospital, the fo llo w in g should be political and social considerations should remembered : be ignored, ability and experience in hos 1. A s stated so ably by B r o w n 4 : “ T h e pital w o rk being the only basis o f select dental section . . . neither to be apart ing the head o f the departm ent. 4 . B r o w n , J . L . : U . S. N a v . M . B ., 2 5, N o . 2.
26 E a s t 3 6th S treet.