A R TIC L E
An improved three-person team approach was developed to increase efficiency in oral rehabilitation with the patient under general anesthesia. Directvision of the operating field and increased opportunity for anticipation of the sequence of procedures by all members of the dental team are improvements in this approach.
An approach to improving the six-handed technique in oral rehabilitation Philip C. Chiang, DDS, San Francisco Ronald Johnson, DDS, Philadelphia
T he recognition o f the im portance o f oral health in total health care has led m any dentists to provide dental care to patients in hospitals.1 B ecause of extensive dental decay, and m ental, physical, or em otional problem s, m any o f these patients are under general anesthesia w hen they are treated. H ow ever, G oldstein and D ragon2 said that, as a result o f hospitalization, the child suffers “ psy chic trau m a” because o f the strange environm ent and therefore should be treated only in the private office. G reen e and F alcetti3 and Legault and col leagues4 have successfully treated, w ithout seri ous com plications, am bulatory patients under general anesthesia in institutional clinics. C on trary to this approach, m any medical and dental anesthesiologists consider the adm inistration of general anesthesia in the dental office a risky pro ced u re.5 H illenbrand6 reported th at 1,022 hospi tals in the U nited States have dental facilities approved by the C ouncil on H ospital D ental S er vice of the A m erican D ental A ssociation. M any pedodontic training program s approved by the A m erican D ental A ssociation have been initiated in large, m etropolitan hospitals o r in university medical centers that include a hospital rotation as part of the resident’s training.7 With the increas 1020 ■ JADA, Vol. 96, June 1978
ing participation of residents in hospital dental services, there is a need for continual develop m ent o f im proved techniques for the operating room . Several articles on oral rehabilitation with the patient under general anesthesia describe hospital protocol and operating room p rocedures.8' 13 T he purpose o f this paper is to present a six-handed team approach for efficient oral rehabilitation of patients who are under general anesthesia. T he procedure is used now in the training o f first-year dental residents in the M artin L uther King, J r., G eneral H ospital and, because the first-year resi dent has had limited experience, the procedure satisfies the resident’s needs during his orienta tion to the operating room . In our view, the use o f general anesthesia has far greater inherent risks to patients as com pared to the use o f local anesthesia. T he occurrence of postoperative com plications with prolonged use o f general anesthesia has been docum ented.14 T hus, oral rehabilitation m ust be accom plished in the shortest time that is consistent with proper care. A m ethod to reduce tim e o f treatm ent is to maxim ize the efficiency o f the operating team .15 Johnson and colleagues1617 and D avis and col
A R T IC L E
leagues18 proposed positioning o f team and equipm ent on the basis o f the needs o f all the m em bers of the operating team . In one approach, the main op erato r is either a m em ber of the teach ing staff or a second-year resident; the first assis tan t is a dental assistant trained in four-handed assisting techniques; and the first-year resident serves as second assistant. If the second assistant is familiar with the procedures for oral rehabilita tion, the efficiency of the operating team is greatly enhanced. If he is positioned as shown in Figure 1, his view of the operating field is limited. H e is unable to anticipate the sequence of procedures and, consequently, cannot have the appropriate instrum ent or m aterial ready for transfer at the proper time. T hese disadvantages necessitate his dependence on vocal com m unication with other m em bers o f the team . Also, efficiency is reduced further if the o ther m em bers o f the team are slow to anticipate each o th ers’ needs. A nother disad vantage is the increase in transfers of instrum ents from the second assistant to the first assistant, which w astes time. A m odification of the three-person team ap proach for oral rehabilitation is shown in Figure 2A. Figure 2B shows a similar arrangem ent with the patient positioned obliquely on the operating room table for those hospitals in which a table m ust be used. T he second assistant is positioned opposite the first assistant, forming a triangle among the team m em bers, which perm its direct visibility o f the operating field and im proves an ticipation of the sequence o f the procedure (Fig 3). T he anesthesiologist and the anesthetic equipm ent are placed to the right and behind the operator or behind the second assistant, but close enough for the anesthesiologist to have a direct view o f the patient. A contoured dental chair or operating room table with mobile units and chairs for the doctor and the assistant should be avail able in the operating suite. F o r the dental team to function properly, the tasks of each m em ber should be defined and followed closely during the procedure.
Duties of the first assistant T o prepare the operating room , the following should be done. — Prepare and sterilize with an autoclave the preset dental instrum ent trays (Fig 4, 5). R estor ative, prosthetic, endodontic, space m ainten ance, and surgical instrum ents may be needed.
OP -O p e ra to r A S - A ss is ta n t P - P a tie n t A n es - A n esthe siologist A M - A n e s th e s ia machine OU - O p e -a tiv e Unit (m obile) MC - M obile cabinet
Fig 1 ■ P ositioning of team ana equipm ent. Second assistant is located behind operator and firs t a ssista nt.'7 (Courtesy Dr. R. Johnson.)
W hen necessary, have available a C avitron unit or a spot welder. Also, have available the dental cart, mobile cabinet, M ayo stands, anes thesia m achines, intravenous poles, instrum ent trays, chairs, and the operating table. Place body drapes, tow els, towel clips, throat packs, gauze, ophthalm ic ointm ent, w ater basins, sterile w ater, hem ostats, m outh props, tape, germ icidal, sterile sponges, and tong forceps on the M ayo stand. T hese m aterials are used in the initial preparation o f the patient.
THE AUTHORS
CHIANG
JOHNSON
Dr. Chiang is assistant professor, departm ent of pediatric dentistry, University of the P acific S chool of Dentistry, San Francisco, Calif 94115, and chief o f pedodontics, Family Health fou nda tion o f Alviso, Calif. Dr. Johnson is professor and chairm an, departm ent of o rthod ontics and pedodontics. School of Dental M edicine, Uni versity of Pennsylvania. A ddress requests fo r rep rin ts to Dr. Chiang.
C hiang— Johnson: SIX-HANDED TECHNIQUE IN ORAL REHABILITATION ■ 1021
ANES CART
AS CART
MAYO STAND (WORK AREA)
OP - OPERATOR AS - ASSISTANT P - PATIENT ANES - ANESTHETIST AM - ANES MACHINE OU - OPERATIVE UNIT
F ig 2A ■ P o s itio n in g o fte a m a n d e q u ip m e n tw ith s e c o n d a s s ls ta n t Fig 4 ■ A rrangem ent o f preset dental instrum ent tray positioned
located opposite firs t assistant.
on firs t assistant's cart.
MAVO STAND (PREP)
I.V. POLE
OP - OPERATOR AS - ASSISTANT P
- PATIENT
ANES - ANESTHETIST AM * ANES MACHINE OU - OPERATIVE UNIT
Fig 2B ■ M odified three-person team approach w ith patient posi tioned obliquely on table.
Fig 5 ■ A rrangem ent of preset instrum ent and m edicam ent tray and additional equipm ent positioned on operative u n it and Mayo stand, respectively.
— C heck the operation o f the handpieces, air controls, and suctions. Inspect the treatm ent plan and radiographs for instrum ent and equipm ent needs. Post the radiographs on the illum inator and have available a clipboard for the treatm ent plan. 1022 ■ JADA, Vol. 96, June 1978
A fter the patient has been brought into the operating room and anesthetized, the following should be accom plished: — Equipm ent, instrum ent trays, chairs, cab inets, table, and intravenous pole should be positioned; the height o f the o p erato r’s and assis ta n t’s chairs and the overhead light should be adjusted. — A ssist the operator with eye protection, head and body drape, head donut, and shoulder towels (the patient is draped so that only the oral cavity and the surrounding area are exposed). A ssist in the placem ent o f a sterile throat pack by retracting the patient’s tongue with a m outh m irror or cheek retractor. F o r radiographs not taken previously, position the head of the X-ray machine after the film is positioned by the operator, and be sure that the film is developed. Rem ove jew elry from the patient and, depending on the hospital’s stan dards, com plete a five- or ten-m inute surgical scrub. — A ssist the operator in prophylaxis, scaling,
A R T IC L E
used for all procedures (Fig 6). — U se sterile gloves when extractions or other surgical procedures are perform ed. A clean and dry operating field m ust be m aintained through efficient use o f high-velocity suction. A fter the oral rehabilitation is com pleted, the following should be accom plished: — A ssist in the removal of the throat pack and transfer of the patient to a gurney, rem ove equip m ent and instrum ents from the operating area, em pty the suction bottle, and m ake sure the operating area is reasonably clean. Sterilize and reset instrum ent trays.
Fig 6 ■ First assistant pa rticipatin g in six-handed transfer o f in strum ents.
Duties of the second assistant T he second assistant should assist the first assis tant in the previously described duties. A lso, he should pass and retrieve handpieces, selected in strum ents, dental m aterials, and m edicam ents for the first assistant or operator on their verbal com m ands (Fig 7, 8). H ow ever, when properly positioned, the second assistant should be able to anticipate the needs o f the dental team . T he sec ond assistant also records com pletion and chang es o f procedures that are listed in the treatm ent plan, and escorts the patient to the recovery area.
Fig 7 ■ Second assistant passing and retrieving handpieces to operator.
Duties of the operator
Fig 8 ■ Second assistant passing and retrieving instrum ents to firs t assistant.
reexam ination, réévaluation of treatm ent plan, placem ent of the m outh prop and rubber dam by quadrant, restoration of all cariously involved teeth, fluoride treatm ent, extractions, and place m ent o f sutures. Six-handed instrum ent transferís
— R eevaluate the record of the p atien t’s physical exam ination, history, laboratory results, consul tations, orders, and progress. C heck the equip m ent, instrum ents, dental m aterials, and m edi cam ents before the procedure, and ensure proper positioning o f equipm ent and team m em bers. —T ake any necessary radiographs not obtained before the procedure. C om plete a five- or tenm inute surgical scrub. W ear sterile gloves when extractions or other surgical procedures are per formed. C om plete draping of the patient, protec tion of the eyes, packing o f the throat, radio graphs, and other dental procedures (using rub ber dam by quadrants). — A nticipate and inform assistants o f the se quence o f instrum ents and m edicam ents that will be used. Inform the anesthesiologist o f any un usual changes in the patient’s skin color, respira tion, position o f the head or throat pack, potential loss o f blood during surgery, and projected term i
Chiang— Johnson: SIX-HANDED TECHNIQUE IN ORAL REHABILITATION ■ 1023
A R TIC L E
nation o f the procedure. — C om plete the procedure in the shortest time w ithout sacrificing quality. Irrigate and th o r oughly suction the oral cavity. Rem ove the throat pack, assist the anesthesiologist in extubation and in the transfer o f the patient to a gurney for the return to the recovery area.
uses the hospital for oral rehabilitation w ith the patient under general anesthesia. This m odified approach m ay not be practical for dentists who use only one assistant during hospital procedures. H ow ever, in those situations w here tw o experi enced dentists and a dental assistant or a dentist and tw o dental assistants com pose the operating team , this approach should prove beneficial.
Discussion T he m odified arrangem ent o f the three-person team has been im plem ented in the pedodontic training program of the M artin L uther King, Jr., G eneral H ospital for the past tw o years. T o date, m ore than a hundred cases have been com pleted with use o f this approach. T he opinions o f the team m em bers and especially the first-year resi dents have been consistently favorable. D irect view o f the operative field and increased opportu nity for anticipation o f the sequence o f procedures are im provem ents that w ere m entioned. T he resi dent becom es aw are o f the im portance of his role and soon discovers that, if he is slow and disorga nized, the team effort is seriously affected. A fter acting as second assistant during several oral rehabilitations, the first-year resident should be able to assum e the role of operator. Initially, he should attem pt a portion o f the procedure before being given total responsibility. A lthough the m odified three-person team approach is func tional, often several procedures are required b e fore the first-year resident is working in syn chronization with the other team m em bers. U su ally, the problem is the resident’s failure to antici pate, rem em ber, and perform the defined tasks. T he im portance of this im proved six-handed approach is realized w hen the team m em bers are seated com fortably and the procedures proceed efficiently and quickly. F u rth er investigation into its effectiveness by the use of tim e and motion studies is indicated. Although this im proved six-handed approach has been developed in training program s, the re sults could benefit the private practitioner who
1024 ■ JADA, Vol. 96, June 1978
1. Goldman, H.M., and Guernsey, L.H. The role of the dental specialist in the hospital. Dent Clin North Am 19:665 Oct 1975. 2. Goldstein, I.C., and Dragon, A.I. Restorative dentistry under general anesthesia for the exceptional child— as an office proce dure. J Dent Child 34:395 Sept 1967. 3. Greene, N.M., and Falcetti, J.P. A program of general anes thesia for the dental care of mentally retarded patients. Oral Surg 37:329 March 1974. 4. Leagault, J.V.; Diner, M.H.; and Auger, R. Dental treatment of children in a general anesthesia clinic; review of 300 cases. J Can Dent Assoc 38:221 June 1972. 5. Bennett, R. The role of the dentist in anesthesiology. Clinical Anesthesia. Philadelphia, F. A. Davies, 1974, p 298. 6. Hillenbrand, H. The dentist’s role in total health care from the viewpoint of the dental administrator. J Hosp Dent Pract 5:5 Jan 1971. 7. Ripa, L.W. Hospital related activities in pedodontic specialty training programs. J Dent Educ 37:9 March 1973. 8. Bachman, L., and Freeman, A. General anesthesia for dental procedures in handicapped patients. Dent Clin North Am 4:443 July 1960. 9. Tocchini, J.J.; Levitas, T.C.; and Redig, D.F. The child patient and general anesthesia in the hospital. J Dent Child 35:198 May 1968. 10. Allen, G.D., and Sim, J. Full mouth restoration under general anesthesia in pedodontic practice. J Dent Child 34:488 Nov 1967. 11. Musselman, R.J., and Roy, E.K. Hospital management of the handicapped child. Dent Clin North Am 18:699 July 1974. 12. Album, M.M. Acquainting the dental student with general anesthesia procedures for handicapped children. J Dent Educ 19:197 May 1955. 13. Vandam, L. The unfavourable effects of prolonged anaes thesia. Can Anaesth Soc J 12:107 March 1965. 14. Phillips, O., and Capizzi, L. Anesthesia mortality. Clinical Anesthesia. Philadelphia, F. A. Davis Co, 1974, p 220. 15. Kilpatrick, H.C. Production increases due to chairside as sistance. JADA 82:1367 June 1971. 16. Johnson, R.; Full, C.A.; and Redig, D.F. Efficient dental re habilitation with the patient under general anesthesia. JADA 77:309 Aug 1968. 17. Johnson, R., and Full, C.A. Effective team and equipment positioning for dental procedures performed In hospitals. JADA 87:651 Sept 1973. 18. Davis, W.R., Jr.; McConnell, B.A.; and Oldenburg, T.R. Dental procedures in the hospital operating room, placement of equip ment and the efficient use of dental auxiliaries. J Dent Child 35:342 July 1968.
An improved three-person team approach was developed to increase efficiency in oral rehabilitation with the patient under general anesthesia. Directvision of the operating field and increased opportunity for anticipation of the sequence of procedures by all members of the dental team are improvements in this approach.
An approach to improving the six-handed technique in oral rehabilitation Philip C. Chiang, DDS, San Francisco Ronald Johnson, DDS, Philadelphia
T he recognition o f the im portance o f oral health in total health care has led m any dentists to provide dental care to patients in hospitals.1 B ecause of extensive dental decay, and m ental, physical, or em otional problem s, m any o f these patients are under general anesthesia w hen they are treated. H ow ever, G oldstein and D ragon2 said that, as a result o f hospitalization, the child suffers “ psy chic trau m a” because o f the strange environm ent and therefore should be treated only in the private office. G reen e and F alcetti3 and Legault and col leagues4 have successfully treated, w ithout seri ous com plications, am bulatory patients under general anesthesia in institutional clinics. C on trary to this approach, m any medical and dental anesthesiologists consider the adm inistration of general anesthesia in the dental office a risky pro ced u re.5 H illenbrand6 reported th at 1,022 hospi tals in the U nited States have dental facilities approved by the C ouncil on H ospital D ental S er vice of the A m erican D ental A ssociation. M any pedodontic training program s approved by the A m erican D ental A ssociation have been initiated in large, m etropolitan hospitals o r in university medical centers that include a hospital rotation as part of the resident’s training.7 With the increas 1020 ■ JADA, Vol. 96, June 1978
ing participation of residents in hospital dental services, there is a need for continual develop m ent o f im proved techniques for the operating room . Several articles on oral rehabilitation with the patient under general anesthesia describe hospital protocol and operating room p rocedures.8' 13 T he purpose o f this paper is to present a six-handed team approach for efficient oral rehabilitation of patients who are under general anesthesia. T he procedure is used now in the training o f first-year dental residents in the M artin L uther King, J r., G eneral H ospital and, because the first-year resi dent has had limited experience, the procedure satisfies the resident’s needs during his orienta tion to the operating room . In our view, the use o f general anesthesia has far greater inherent risks to patients as com pared to the use o f local anesthesia. T he occurrence of postoperative com plications with prolonged use o f general anesthesia has been docum ented.14 T hus, oral rehabilitation m ust be accom plished in the shortest time that is consistent with proper care. A m ethod to reduce tim e o f treatm ent is to maxim ize the efficiency o f the operating team .15 Johnson and colleagues1617 and D avis and col
A R T IC L E
leagues18 proposed positioning o f team and equipm ent on the basis o f the needs o f all the m em bers of the operating team . In one approach, the main op erato r is either a m em ber of the teach ing staff or a second-year resident; the first assis tan t is a dental assistant trained in four-handed assisting techniques; and the first-year resident serves as second assistant. If the second assistant is familiar with the procedures for oral rehabilita tion, the efficiency of the operating team is greatly enhanced. If he is positioned as shown in Figure 1, his view of the operating field is limited. H e is unable to anticipate the sequence of procedures and, consequently, cannot have the appropriate instrum ent or m aterial ready for transfer at the proper time. T hese disadvantages necessitate his dependence on vocal com m unication with other m em bers o f the team . Also, efficiency is reduced further if the o ther m em bers o f the team are slow to anticipate each o th ers’ needs. A nother disad vantage is the increase in transfers of instrum ents from the second assistant to the first assistant, which w astes time. A m odification of the three-person team ap proach for oral rehabilitation is shown in Figure 2A. Figure 2B shows a similar arrangem ent with the patient positioned obliquely on the operating room table for those hospitals in which a table m ust be used. T he second assistant is positioned opposite the first assistant, forming a triangle among the team m em bers, which perm its direct visibility o f the operating field and im proves an ticipation of the sequence o f the procedure (Fig 3). T he anesthesiologist and the anesthetic equipm ent are placed to the right and behind the operator or behind the second assistant, but close enough for the anesthesiologist to have a direct view o f the patient. A contoured dental chair or operating room table with mobile units and chairs for the doctor and the assistant should be avail able in the operating suite. F o r the dental team to function properly, the tasks of each m em ber should be defined and followed closely during the procedure.
Duties of the first assistant T o prepare the operating room , the following should be done. — Prepare and sterilize with an autoclave the preset dental instrum ent trays (Fig 4, 5). R estor ative, prosthetic, endodontic, space m ainten ance, and surgical instrum ents may be needed.
OP -O p e ra to r A S - A ss is ta n t P - P a tie n t A n es - A n esthe siologist A M - A n e s th e s ia machine OU - O p e -a tiv e Unit (m obile) MC - M obile cabinet
Fig 1 ■ P ositioning of team ana equipm ent. Second assistant is located behind operator and firs t a ssista nt.'7 (Courtesy Dr. R. Johnson.)
W hen necessary, have available a C avitron unit or a spot welder. Also, have available the dental cart, mobile cabinet, M ayo stands, anes thesia m achines, intravenous poles, instrum ent trays, chairs, and the operating table. Place body drapes, tow els, towel clips, throat packs, gauze, ophthalm ic ointm ent, w ater basins, sterile w ater, hem ostats, m outh props, tape, germ icidal, sterile sponges, and tong forceps on the M ayo stand. T hese m aterials are used in the initial preparation o f the patient.
THE AUTHORS
CHIANG
JOHNSON
Dr. Chiang is assistant professor, departm ent of pediatric dentistry, University of the P acific S chool of Dentistry, San Francisco, Calif 94115, and chief o f pedodontics, Family Health fou nda tion o f Alviso, Calif. Dr. Johnson is professor and chairm an, departm ent of o rthod ontics and pedodontics. School of Dental M edicine, Uni versity of Pennsylvania. A ddress requests fo r rep rin ts to Dr. Chiang.
C hiang— Johnson: SIX-HANDED TECHNIQUE IN ORAL REHABILITATION ■ 1021
ANES CART
AS CART
MAYO STAND (WORK AREA)
OP - OPERATOR AS - ASSISTANT P - PATIENT ANES - ANESTHETIST AM - ANES MACHINE OU - OPERATIVE UNIT
F ig 2A ■ P o s itio n in g o fte a m a n d e q u ip m e n tw ith s e c o n d a s s ls ta n t Fig 4 ■ A rrangem ent o f preset dental instrum ent tray positioned
located opposite firs t assistant.
on firs t assistant's cart.
MAVO STAND (PREP)
I.V. POLE
OP - OPERATOR AS - ASSISTANT P
- PATIENT
ANES - ANESTHETIST AM * ANES MACHINE OU - OPERATIVE UNIT
Fig 2B ■ M odified three-person team approach w ith patient posi tioned obliquely on table.
Fig 5 ■ A rrangem ent of preset instrum ent and m edicam ent tray and additional equipm ent positioned on operative u n it and Mayo stand, respectively.
— C heck the operation o f the handpieces, air controls, and suctions. Inspect the treatm ent plan and radiographs for instrum ent and equipm ent needs. Post the radiographs on the illum inator and have available a clipboard for the treatm ent plan. 1022 ■ JADA, Vol. 96, June 1978
A fter the patient has been brought into the operating room and anesthetized, the following should be accom plished: — Equipm ent, instrum ent trays, chairs, cab inets, table, and intravenous pole should be positioned; the height o f the o p erato r’s and assis ta n t’s chairs and the overhead light should be adjusted. — A ssist the operator with eye protection, head and body drape, head donut, and shoulder towels (the patient is draped so that only the oral cavity and the surrounding area are exposed). A ssist in the placem ent o f a sterile throat pack by retracting the patient’s tongue with a m outh m irror or cheek retractor. F o r radiographs not taken previously, position the head of the X-ray machine after the film is positioned by the operator, and be sure that the film is developed. Rem ove jew elry from the patient and, depending on the hospital’s stan dards, com plete a five- or ten-m inute surgical scrub. — A ssist the operator in prophylaxis, scaling,
A R T IC L E
used for all procedures (Fig 6). — U se sterile gloves when extractions or other surgical procedures are perform ed. A clean and dry operating field m ust be m aintained through efficient use o f high-velocity suction. A fter the oral rehabilitation is com pleted, the following should be accom plished: — A ssist in the removal of the throat pack and transfer of the patient to a gurney, rem ove equip m ent and instrum ents from the operating area, em pty the suction bottle, and m ake sure the operating area is reasonably clean. Sterilize and reset instrum ent trays.
Fig 6 ■ First assistant pa rticipatin g in six-handed transfer o f in strum ents.
Duties of the second assistant T he second assistant should assist the first assis tant in the previously described duties. A lso, he should pass and retrieve handpieces, selected in strum ents, dental m aterials, and m edicam ents for the first assistant or operator on their verbal com m ands (Fig 7, 8). H ow ever, when properly positioned, the second assistant should be able to anticipate the needs o f the dental team . T he sec ond assistant also records com pletion and chang es o f procedures that are listed in the treatm ent plan, and escorts the patient to the recovery area.
Fig 7 ■ Second assistant passing and retrieving handpieces to operator.
Duties of the operator
Fig 8 ■ Second assistant passing and retrieving instrum ents to firs t assistant.
reexam ination, réévaluation of treatm ent plan, placem ent of the m outh prop and rubber dam by quadrant, restoration of all cariously involved teeth, fluoride treatm ent, extractions, and place m ent o f sutures. Six-handed instrum ent transferís
— R eevaluate the record of the p atien t’s physical exam ination, history, laboratory results, consul tations, orders, and progress. C heck the equip m ent, instrum ents, dental m aterials, and m edi cam ents before the procedure, and ensure proper positioning o f equipm ent and team m em bers. —T ake any necessary radiographs not obtained before the procedure. C om plete a five- or tenm inute surgical scrub. W ear sterile gloves when extractions or other surgical procedures are per formed. C om plete draping of the patient, protec tion of the eyes, packing o f the throat, radio graphs, and other dental procedures (using rub ber dam by quadrants). — A nticipate and inform assistants o f the se quence o f instrum ents and m edicam ents that will be used. Inform the anesthesiologist o f any un usual changes in the patient’s skin color, respira tion, position o f the head or throat pack, potential loss o f blood during surgery, and projected term i
Chiang— Johnson: SIX-HANDED TECHNIQUE IN ORAL REHABILITATION ■ 1023
A R TIC L E
nation o f the procedure. — C om plete the procedure in the shortest time w ithout sacrificing quality. Irrigate and th o r oughly suction the oral cavity. Rem ove the throat pack, assist the anesthesiologist in extubation and in the transfer o f the patient to a gurney for the return to the recovery area.
uses the hospital for oral rehabilitation w ith the patient under general anesthesia. This m odified approach m ay not be practical for dentists who use only one assistant during hospital procedures. H ow ever, in those situations w here tw o experi enced dentists and a dental assistant or a dentist and tw o dental assistants com pose the operating team , this approach should prove beneficial.
Discussion T he m odified arrangem ent o f the three-person team has been im plem ented in the pedodontic training program of the M artin L uther King, Jr., G eneral H ospital for the past tw o years. T o date, m ore than a hundred cases have been com pleted with use o f this approach. T he opinions o f the team m em bers and especially the first-year resi dents have been consistently favorable. D irect view o f the operative field and increased opportu nity for anticipation o f the sequence o f procedures are im provem ents that w ere m entioned. T he resi dent becom es aw are o f the im portance of his role and soon discovers that, if he is slow and disorga nized, the team effort is seriously affected. A fter acting as second assistant during several oral rehabilitations, the first-year resident should be able to assum e the role of operator. Initially, he should attem pt a portion o f the procedure before being given total responsibility. A lthough the m odified three-person team approach is func tional, often several procedures are required b e fore the first-year resident is working in syn chronization with the other team m em bers. U su ally, the problem is the resident’s failure to antici pate, rem em ber, and perform the defined tasks. T he im portance of this im proved six-handed approach is realized w hen the team m em bers are seated com fortably and the procedures proceed efficiently and quickly. F u rth er investigation into its effectiveness by the use of tim e and motion studies is indicated. Although this im proved six-handed approach has been developed in training program s, the re sults could benefit the private practitioner who
1024 ■ JADA, Vol. 96, June 1978
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