Bare Minimum OMFS: A Brief Look at CODA Requirements

Frequently, I see and hear many different discussions pertaining to the numbers of procedures performed at oral surgery programs. What is not discussed is the context of these numbers and what the requirements are for a program to be accredited. In this quick article I wanted to dissect the CODA (Commission On Dental Accreditation) accreditation standards so everyone is aware of what the requirements are for someone graduating from an oral surgery program. This is not a complete look, but I have included a link to the standards for your own viewing. What I mainly want to include were the basic number of procedures and what their expectations are for an anesthesia rotation. There is an addendum to the standards that changes months to weeks but for the most part it is exactly the same. These standards are typically updated in part every year.

 

Bolded and italicized lines are taken directly from the CODA manual.  Normal text is my commentary. 

CODA Accreditation Standards

Time Requirements

• 4-1 An advanced dental education program in oral and maxillofacial surgery must encompass a minimum duration of 48 months of full-time study.
  • Nothing new here. Programs are at a minimum of four years duration
• 4-2 Each resident must devote a minimum of 30 months to clinical oral and maxillofacial surgery.
  • Defined minimum number of months of OMFS time.
• 4-2.1 Twelve months of the time spent on the oral and maxillofacial surgery service must be at a senior level of responsibility, 6 months of which must be in the final year.
  • Intent: Senior level responsibility means residents serving as first assistant to attending surgeon on major cases.
    • Further delineation of time on service and when it should occur. The emphasis is on quality OMFS time in your chief year.
    • The big difference among programs is how your time is spent as “first assistant.” Are you cutting or holding the sticks?
• 4-3.1 Anesthesia Service: The assignment must be for a minimum of 5 months, should be consecutive and one of these months should be dedicated to pediatric anesthesia. The resident must function as an anesthesia resident with commensurate level of responsibility
  • Some programs do more than 5 months, which the efficacy of is debatable. Also, the anesthesia rotation varies drastically among programs. Might be worth diving into the details when you are looking at a program about how their anesthesia rotation is run.  
• 4-3.2 Medical Service: A minimum of 2 months of clinical medical experience must be provided
  • Intent: This experience should be at the medical student/PGY-1 level or higher, and may include rotation on medical specialty services.
    • This minimum is for 4-year programs as 6-year programs satisfy this with their medical school rotations.
    • Important to note that this is an independent rotation off-service similar to anesthesia.
• 4-3.3 Surgical Service: A minimum of 4 months of clinical surgical experience must be provided. This experience should be achieved by rotation to a surgical service (not to include oral and maxillofacial surgery) and the resident must function as a surgery resident with commensurate level of responsibility.
  • Intent: The intent is to provide residents with adequate training in pre- and post-operative care, as well as experience in intra-operative techniques. This should include management of critically ill patients. Oral and maxillofacial surgery residents operate at a PGY-1 level of responsibilities or higher, and are on the regular night call schedule.
    • Another defined period of off-service rotations. This is known as your “gen surg” time. How this is set up varies wildly among residencies. Make sure to ask about this on interviews.
• 4-3.4 Other Rotations: Two additional months of clinical surgical or medical education must be assigned. These must be exclusive of all oral and maxillofacial surgery service assignments.
  • These extra two months will be baked into general surgery and anesthesia often, but like most things can differ among programs.

Clinical Requirements

• 4-9.1 The cumulative anesthetic experience of each graduating resident must include administration of general anesthesia/deep sedation for a minimum of 300 cases. This experience must involve care for 50 patients younger than 13. A minimum of 150 of the 300 cases must be ambulatory anesthetics for oral and maxillofacial surgery outside of the operating room.
  • Intent: The cumulative experience includes time on the anesthesia rotation as well as anesthetics administered while on the oral and maxillofacial surgery service. Locations for ambulatory anesthesia may include dental school clinics, hospital clinics, emergency rooms, and oral and maxillofacial surgery offices.
    • What this means is that on your anesthesia rotation you have to complete 150 cases, 50 of which are pediatric. The standards do not define the requirements further than this. I.e. there is not a minimum number of intubations or other anesthesia maneuvers that must be performs. Purely, “administration of…”
    • Where programs run into trouble sometimes is getting their number of oral and maxillofacial surgery sedations outside of the OR (150). Make sure to ask about this on interviews.
• 4-9.4 Advanced Cardiac Life Support (ACLS) must be obtained in the first year of residency and must be maintained throughout residency training.
  • This has to be renewed every 2 years.
• 4-9.5 Each resident must be certified in Pediatric Advanced Life Support (PALS) prior to completion of training.
  • Not sure why the language of this requirement is different than ACLS.
  • Like ACLS, it expires every 2 years.
• 4-11 For each authorized final year resident position, residents must perform 175 major oral and maxillofacial surgery procedures on adults and children, documented by at least a formal operative note. For the above 175 procedures there must be at least 20 procedures in each category of surgery. The categories of major surgery are defined as: 1) trauma 2) pathology 3) orthognathic surgery 4) reconstructive and cosmetic surgery. Sufficient variety in each category, as specified below, must be provided. Surgery performed by oral and maxillofacial surgery residents while rotating on or assisting with other services must not be counted toward this requirement.
  • Intent: The intent is to ensure a balanced exposure to comprehensive patient care for all major surgical categories. In order for a major surgical case to be counted toward meeting this requirement, the resident serves as an operating surgeon or first assistant to an oral and maxillofacial surgery teaching staff member. The program documents that the residents have played a significant role (diagnosis, perioperative care and subsequent follow-up) in the management of the patient.
    • This is the important part. How many to be considered proficient. To delineate:
      • Total: 175 procedures as operator or first assist
      • Trauma: 20 cases minimum
      • Pathology: 20 cases minimum
      • Orthognathic surgery: 20 cases minimum
      • Reconstructive/Cosmetic surgery: 20 cases minimum
    • Doing the bare minimum of these, as you can imagine, is not a lot. This is why finding out what the case numbers are for the chief residents is important.
    • Notice that dentoalveolar is not included in the above categories. The key word is “major.”
• 4-13 In the pathology category, experience must include management of temporomandibular joint pathology and at least three other types of procedures.
• 4-17.1 Each resident must be certified in Advanced Trauma Life Support (ATLS) prior to completion of training.
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Resident Eligibility and Miscellaneous

• Eligible applicants to advanced dental education programs accredited by the Commission on Dental Accreditation must be graduates from:
  • a. Predoctoral dental programs in the U.S. accredited by the Commission on Dental Accreditation; or
  • b. Predoctoral dental programs in Canada accredited by the Commission on Dental Accreditation of Canada; or
  • c. International dental schools that provide equivalent educational background and standing as determined by the program.
    • This section has been discussed further in another post, Applying to OMFS as a Foreign Trained Dentist
• 5-1 If the program has determined that graduates of U. S. or Canadian accredited medical schools are eligible for admission, the candidate must obtain a dental degree from a predoctoral dental education program accredited by the Commission on Dental Accreditation prior to starting the required 30 months of core OMS training.
  • In other words, medical school graduates cannot enroll directly into an oral surgery program. A dental degree is required.
• 6-1 Each graduating resident must demonstrate evidence of scholarly activity.
  • A research project must be completed prior to graduation.
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Discussion

•             I apologize for the dry content, but I thought it was necessary since it appears no one takes the time to look at these standards. What I do find interesting is the paucity in hard number requirements. This means there is a great deal of variation among programs. For instance, there are no dentoalveolar requirements. Some programs you could extract two teeth and in others you could extract 2000. Another interesting find is the lack of emphasis on hard implant numbers. You can technically graduate a program and only place one implant based on the language provided.

  Considering the majority of oral and maxillofacial surgeons who graduate go into private practice where they typically place implants and extract teeth, there is a lack of emphasis on this in oral surgery training. I am guessing this is assumed. With the increasing emphasis on good implant placement and tissue management, I wonder if the lack of emphasis on implants in oral surgery training will lead to a further erosion of implant placement by OMFS to periodontists and other dental practitioners.

  Another aspect that is not dscussed are resident work hours. For medical residencies regulated by ACGME, work hours have been limited to 80 hours of work per week. Since oral and maxillofacial surgery is regulated by CODA, this work hour restriction is not applicable. It is uncertain at this point if this hour restriction will make its way into oral surgery or not. The pros and cons of work duty hours are a discussion for another post.

  While discussing implants and other regulations, I do not mean to distract from the other important aspects of oral surgery. First and foremost, we receive the respect we do because of the major procedures we perform. Therefore, it makes sense that there is an emphasis on the major procedures. Although 4 to 6 years seems like a long time, in regards to the training we do we have to cover a lot of ground and sometimes this can be difficult. This is why I think the takeaway from this article should be that there is a great deal a variation among programs and that’s why it is very important to ask the questions regarding number of procedures and how any rotations away are structured.