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Credentialing Resources

Statement on OMS

What is Oral and Maxillofacial Surgery?

Oral and maxillofacial surgery is the specialty of dentistry which includes the diagnosis, surgical and adjunctive treatment of diseases, injuries and defects involving both the functional and esthetic aspects of the bone and soft tissues of the oral and maxillofacial region. The term "maxillofacial" refers to the area that encompasses the maxilla and the face. As oral and maxillofacial surgery is a recognized specialty of dentistry, it is therefore regulated by dentistry.

What is the background of an oral and maxillofacial surgeon?

Following graduation from dental school, oral and maxillofacial surgeons complete a dental, medical, and surgical postdoctoral program spanning a minimum of four years. Emphasis in OMS training is placed on the oral and facial area by spending a minimum of 30 months concentrating specifically on the diagnosis, treatment, and management of problems of the oral and maxillofacial region. In addition to their OMS training, whether residents are in a MD integrated or a single-degree-training program, all residents are required to complete the same surgical training, including the core surgical year. Residents also complete a structured, didactic course in physical diagnosis similar to that provided to medical students and often given jointly. This course is taught early in residency, enabling application throughout training. It is also a part of the training received during rotations to the medical, surgical, and anesthesia services where residents must function at the level of a resident in the respective services. Because of this specialized education, oral and maxillofacial surgeons are licensed to perform procedures that are also performed by physicians.

How are training programs accredited?

Oral and maxillofacial surgery programs are accredited by the ADA Commission on Dental Accreditation, a nationally recognized accrediting body, approved by the U.S. Department of Education and Council on Postsecondary Accreditation. As in all areas of dentistry and medicine, oral and maxillofacial surgery education has undergone significant changes in the past 20 years. These educational changes are most apparent in the length of training, the off-service experience, and the areas of training. Each program must be a minimum of 48 months of full-time training in a hospital-based residency as required in the Standards for Advanced Specialty Education Programs in Oral and Maxillofacial Surgery. One significant area of extended training and education leads to the granting of a MD degree followed by one or more years of accredited surgical training.

What is the scope of practice of oral and maxillofacial surgery?

Common procedures such as extraction of third molars immediately is associated with the practice of oral surgery. Based on their extensive background in maxillofacial surgery which dates back to the Civil War and injuries during times of the international conflict, oral and maxillofacial surgeons are performing surgical procedures in expanded areas of the specialty. Their knowledge and skills have enabled them to become proficient in the management of bony and soft tissue reconstruction of the entire maxillofacial skeleton as well as management of severe maxillofacial trauma. Other major areas in which oral and maxillofacial surgeons are trained include:

  • In-depth understanding of physical diagnosis, pathophysiology and clinical medicine. A comprehensive course in physical diagnosis and clinical medicine is required early in training. Basic surgical principles relating to all areas of oral and maxillofacial surgery are taught throughout OMS training.

  • Anesthesia requires in-depth knowledge of anatomy, physiology, and pharmacology as they are related to pain and anxiety management. Both didactic and clinical training are provided to a level of competence in all aspects of pain and anxiety control, including general anesthesia/deep sedation. A minimum of four months must be spent on an off-service anesthesia rotation which is supplemented by continuing experience throughout the four or six year training program in the administration of general anesthesia/deep sedation to a sufficient number of ambulatory patients, both pediatric and adult, to achieve competence. In addition, the OMS is trained in conscious sedation and local anesthetic techniques. All of these experiences must include appropriate patient monitoring modalities and certification in Advanced Cardiac Life Support (ACLS).

  • Esthetic surgery is an important aspect of the training of the oral and maxillofacial surgeon. During training, residents must be able to recognize and diagnose congenital, developmental, and acquired esthetic facial deformities. Both skeletal and soft tissue alterations of facial form must be provided, including but not limited to esthetic surgery such as rhinoplasty, blepharoplasty, rhytidectomy, genioplasty, lipectomy, facial implants, otoplasty, and scar revision. The enclosed list reflects esthetic procedures completed in 108 OMS training programs in one year. Some oral and maxillofacial surgeons completed residency before facial esthetic surgery was a requirement in OMS training. To ensure a level of training, the enclosed credentialing guidelines are offered. These guidelines may be helpful in training in advanced procedures and techniques as they evolve.

  • Cleft Lip/Palate and Craniofacial Surgery training includes cleft lip and palate surgery and correction of craniofacial deformities, incorporating the concepts of multidisciplinary treatment planning, indications for surgery in this area, risk factors, accepted standards of care and the assessment of outcomes, and comprehensive management of patients with these deformities.

  • A broad range of dentoalveolar surgical procedures, including management of dentoalveolar injuries, infections, and pathologic conditions and other hard and soft tissue surgery related to the alveolar structures are major aspects of OMS training and practice. Diagnosis of oral disease and lesions of systemic diseases manifested in the oral cavity and various hard and soft tissue biopsy techniques, the removal of erupted and impacted teeth, the use of hard and soft tissue grafts, and preparation of the mouth for prostheses represent significant areas of OMS training.

  • Reconstruction of the oral and maxillofacial region with implant devices designed to support various prostheses combined with an in-depth knowledge of bone and soft tissue physiology, biomaterials, and the biomechanics of implant reconstruction is an important part of oral and maxillofacial surgery. This includes an in-depth understanding of indications and contraindications for implants, dental occlusion, and methods of prosthetic reconstruction and surgical procedures available for implant placement, hard and soft tissue management and grafting, and the use of implants in a variety of clinical situations including completely and partially edentulous cases and bone and soft tissue adjunctive procedures.

  • Microneurosurgery is covered through clinical correlations of pathophysiology of nerve dysfunction and repair, testing modalities for neurosensory and neuromotor defects and methods of repair. OMS are trained in the diagnosis and treatment planning of individuals suffering from neurosensory and neuromotor deficits, including experience in repair or revision of a damaged sensory nerve of the face.

  • Surgical correction of skeletal deformities of the oral and maxillofacial region must be taught to a level of competence in orthognathic surgery, including the analysis of facial form, diagnosis of malocclusions and their relationships of facial form, the biomechanics of orthodontics, comprehensive treatment planning and surgical procedures. Included are the correction of deformities of the mandible and maxilla as well as other deformities of the facial skeleton, correction of functional and esthetic orofacial and craniofacial deformities of the mandible, maxilla, zygoma and other facial bones, including but not limited to ramus and body procedures, subapical segmental osteotomies, LeFort I, II and III procedures and craniofacial operations.

  • The oral and maxillofacial surgeon is competent in the evaluation and management of patients with hard and soft tissue defects of the maxillofacial region, involving reconstructive procedures, which restore form and function. In addition, the OMS is competent in the assessment, treatment planning, and surgical and comprehensive management of the patient. This includes both bone grafting and soft tissue grafting procedures, vestibuloplasties, augmentation procedures, temporomandibular joint reconstruction, management of continuity defects, and other reconstructive surgery.

  • The diagnosis and management of temporomandibular joint disorders are part of the OMS training, including evaluation of patients with TMD, as well as differential diagnosis of head, neck, and facial pain, non-surgical treatment options, and the surgical management of TMJ abnormalities. The comprehensive long-term management of the patient following surgery is an important aspect of the OMS's training and practice.

  • Comprehensive management of trauma of the oral and maxillofacial region is an integral part of the OMS's training. Learning principles of shock management, fluid and electrolyte balance, resuscitation, and surgical airway procurement and assessment management and treatment of maxillofacial and multiple systems trauma are required. The OMS must successfully complete an Advanced Trauma Life Support (ATLS) course. Trauma management includes, but is not limited to, surgical management of the airway, including performance of tracheostomies, treatment of fractures of the dentoalveolar, mandible, maxilla, zygoma, nose, orbit, naso-frontal-orbital-ethmoidal and midface region and repair of soft tissue of the head and neck region. The OMS is rained in the emergency department and during training must be available to the emergency services at all times.

  • The evaluation and treatment of infectious, inflammatory, and benign neoplastic lesions involving the oral and maxillofacial region are significant parts of the OMS practice. The surgeon is experienced in the overall evaluation and management of patients with malignant disease of the head and neck, and demonstrates competence in the management of non-malignant pathologic entities of the oral and maxillofacial region. Some OMS are trained in the management of malignant tumors of the head and neck and regional metastasis, head and neck ablative surgery, including the management of complications and parenteral/enteral nutritional support.

What degree(s) is necessary to perform the above procedures?

The scope of oral and maxillofacial surgery privileges is not based upon the professional degree, which the individual possesses. Rather, privileges are granted based upon the OMS's education and training in accordance with the previously mentioned Standards. Typically, disputes develop because one specialty claims jurisdiction over particular clinical procedures. Recognition of the principle that in most cases no one specialty group should have exclusive authority over any clinical service should alleviate jurisdictional conflicts.

The 1979 AMA House of Delegates established a policy, which follows the JCAHO guidelines for credentialing a medical staff member. The AMA policy states that individual character, training, competence, experience, and judgement should be the criteria for granting privileges in hospitals; and that practitioners representing several specialties can and should be permitted to perform the same procedures if they meet the criteria.

JCAHO Medical Staff Standards For Credentialing And Privileging

The Credentialing Process

The medical staff is responsible for a credentialing process. The credentialing process includes a series of activities designed to collect relevant data that will serve as the basis for decisions regarding appointments and reappointments to the medical staff, as well as delineation of clinical privileges for individual members of the medical staff. Although the specific information used to make decisions regarding appointments and reappointments is at the discretion of the individual organization, the range of information used should be explicit. In addition, within, and at the discretion of, an organization, the specific information required for appointment may differ from the information required for reappointment. The required information should include data on qualifications such as licensure and training or experience, and data on actual performance that is collected and assessed initially and in an ongoing process.

MS.5
The organization establishes mechanisms for hospital-specific appointment and reappointment of medical staff members and for granting and renewing or revising hospital-specific clinical privileges.

MS.5.4
The mechanisms provide for professional criteria that are specified in the medical staff bylaws and uniformly applied to all applicants for medical staff membership, medical staff members, or applicants for delineated clinical privileges. These criteria constitute the basis for granting initial or continuing medical staff membership and for granting initial, renewed, or revised clinical privileges.

MS.5.4.3.1
For an applicant for initial appointment to the medical staff and for initial granting of clinical privileges, the hospital verifies information about the applicant's licensure, specific training, experience, and current competence provided by the applicant with information from the primary source(s) whenever feasible.

MS.5.15
Whenever mechanism for granting and renewal or revision of clinical privileges is used, evidence indicates that the clinical privileges are hospital specific and based on the individual's demonstrated current competence.

MS.5.15.1
Privileges are related to:

MS.5.15.1.1
an individual's documented experience in categories of treatment areas or procedures;

MS.5.15.1.2
the results of treatment; and

MS.5.15.1.3
the conclusions drawn from organization performance-improvement activities when available.

MS.5.15.3
When privilege delineation is based primarily on experience, the individual's credentials record reflects the specific experience and successful results that form the basis for the granting of privileges.

MS.6
Individuals who admit patients are granted specific privileges to do so.

MS.6.2
A patient admitted for inpatient care has a medical history taken and an appropriate physical examination performed by a qualified physician.

MS.6.2.1
Qualified oral and maxillofacial surgeons may perform the medical history and physical examination if they have such privileges, in order to assess the medical, surgical, and anesthetic risks of the proposed operative and other procedure(s).

MS.6.5
The management of each patient's care is the responsibility of a qualified licensed independent practitioner with appropriate clinical privileges.

Competencies of the Oral and Maxillofacial Surgeon at the Completion of Training

At the completion of a 48 month accredited oral and maxillofacial surgery training program, the oral and maxillofacial surgeon is imminently qualified to perform a variety of services for his/her patients. The skills which he/she possess, have been gained through a broad clinical experience as well as rotations on surgical and medical services.

A minimum of thirty months is spent on the oral and maxillofacial surgery service providing a broad scope of specific surgical experience for the resident. At least eighteen months are spent on off-service rotations on a variety of medical/surgical services which are applicable to the oral and maxillofacial surgeon. There are several required rotations, including a minimum of four months of inpatient hospital anesthesia, two months on the clinical medicine service, and four months on the general surgery service. In addition, at least eight months is spent on a variety of other services, including rotations in plastic surgery, otolaryngology, neurosurgery, infectious disease, and pediatric surgery. During this time, residents learn management of both adult and pediatric patients.

At the end of the training period, the oral and maxillofacial surgeon is competent to perform a detailed history and physical examination. A formal physical diagnosis course is provided in the first year of training and the resident performs a large number of complete history and physical examination during the subsequent four years. The resident is credentialed during this year by a staff member who is qualified to perform history and physical examinations.

During an anesthesia rotation of at least four months in duration, the surgeon learns the techniques of intubation for general anesthesia in a hospital setting. In addition, during the minimum of 30 months of rotation on the oral and maxillofacial service, many surgical procedures are performed on patients who have been sedated at either a light or deep level, as well as patients who have been administered a general anesthetic. These sedations and anesthetics are provided by the oral and maxillofacial surgery residents. Therefore, the anesthesia training is a broad experience which is quite intense, and is distributed over a full four year period, providing the resident with an excellent background in anesthesia. In addition to the general anesthesia training, the residents all become certified in advanced cardiac life support, and are trained in advanced trauma life support.

The basis science portion of the training program is provided at weekly seminars and conferences in which topics such as anatomy, including growth and development, physiology, pharmacology, microbiology and immunology, and pathology are provided. These are usually small group seminars which lead to in-depth discussions of these topics.

The resident's outpatient experience is very broad, as a substantial amount of surgical activity is provided in this setting. Each oral and maxillofacial surgery resident sees over 3,000 patients per year on an ambulatory basis.

The oral and maxillofacial surgeon admits and manages a large number of patients in the hospital for major medical procedures. These patients fall into a variety of categories, including trauma, reconstruction, orthognathic surgery, pathology, and esthetic surgery.

In the area of trauma, the resident becomes competent to manage mandibular and midface fractures, including fractures at the level of the base of the skull, zygomatico-maxillary complex, frontal sinus, supraorbital rim fractures, naso-orbital-ethmoid fractures, and in some situations, fractures of the hyoid bone.

In the area of pathology, the residents become competent to manage all benign pathology of the soft and hard tissues of the oral and maxillofacial region. This also includes management of temporomandibular joint pathology, maxillary sinus pathology, pathology of the major and minor salivary glands, minor and major infections of the head and neck, and management of injuries and maladies of the fifth cranial nerve. In some training programs, residents gain experience and competency in the management of malignant neoplasms of the maxillofacial region.

The resident surgeon also becomes competent in orthognathic surgery. This involves the correction of deformities of the mandible as well as the middle third of the facial skeleton. The resident becomes competent in comprehensive case management, including the surgical correction of the functional and esthetic orofacial and craniofacial deformities of the face.

The resident surgeon becomes competent in the reconstruction of the maxillofacial region. In order to perform the reconstruction procedures, bone graft harvesting from the cranium, rib, ilium, tibia, and elsewhere is included in the training program. Additionally, the harvesting of soft tissue such as fat, split thickness skin, and full thickness skin and mucosa from a variety of locations throughout the body is also included. The specific reconstructive procedures which are treated include vestibuloplasty, various ridge augmentation procedures, certain types of esthetic surgery including rhinoplasty, blepharoplasty, and face lift surgery, temporomandibular joint reconstruction, and the management of continuity defects following ablative surgery or infections. Placement of implants both intraorally and extraorally and providing sufficient bone and soft tissues to support them is mastered. Management of facial clefts is also included.

Finally, the oral and maxillofacial surgery resident spends a substantial amount of time in the emergency room gaining experience in the management of the acutely injured patient.

In summary, completion of an accredited oral and maxillofacial surgery program, the surgeon is competent to perform the wide variety of diagnostic and surgical procedures for the comprehensive management of the diseases, injuries and defects involving both the functional and esthetic aspects of the hard and soft tissues of the oral and maxillofacial regions.

Evolution of Dentistry and its Recognized Specialties

Stedman's Medical Dictionary Definitions

  • Maxillofacial — pertains to the jaws and the face, particularly with reference to specialized surgery of this region.
  • Craniofacial — relating to both the face and the cranium.

ADA Definition of Dentistry

Dentistry is defined as the evaluation, diagnosis, prevention and/or treatment (nonsurgical, surgical or related procedures) of diseases, disorders and/or conditions of the oral cavity, maxillofacial area and/or adjacent and associated structures and their impact on the human body; provided by a dentist, within the scope of his/her education, training and experience, in accordance with the ethics of the profession and applicable law.

ADA recognized specialties that are trained to specialize and limit their practices to the specialty area that treat conditions of the maxillofacial area are:

Oral and Maxillofacial Pathology

Deals with the nature, identification, and management of diseases affecting the oral and maxillofacial regions.

Oral and Maxillofacial Surgery

Includes the diagnosis, surgical and adjunctive treatment of diseases, injuries and defects involving both the functional and esthetic aspects of the hard and soft tissues of the oral and maxillofacial region.

Orthodontics and Dentofacial Orthopedics

Correction of the growing or mature dentofacial structures, including those conditions that require movement of teeth or correction of malrelationships and malformations of their related structures and the adjustments of relationships between and among teeth and facial bones by the application of forces and/or the stimulation and redirection of functional forces within the craniofacial complex

Prosthodontics

Restoration of natural teeth and/or the replacement of missing teeth and contiguous oral and maxillofacial tissues with artificial substitutes.

Oral and Maxillofacial Radiology

Use of imaging and associated technology for the diagnosis and management of diseases affecting the oral and maxillofacial regions.

If oral and maxillofacial surgeons cannot operate in the regions of the ADA defined specialty area, there are five other recognized dental specialties that also are not able to fulfill their specialty designation, training programs, etc. In accordance with the ADA Ethics, specialists must limit their practice to the specialty.

Definition of Dentistry and Oral and Maxillofacial Surgery

ADA Definition of Dentistry

Resolved, that dentistry is defined as the evaluation, diagnosis, prevention and/or treatment (nonsurgical, surgical or related procedures) of diseases, disorders and/or conditions of the oral cavity, maxillofacial area and/or the adjacent and associated structures and their impact on the human body, provided by a dentist, within the scope of his/her education, training and experience, in accordance with the ethics of the profession and applicable law.

(Adopted, American Dental Association House of Delegates, 10/27/97)

ADA Definition of Oral and Maxillofacial Surgery

Oral and maxillofacial surgery is a recognized specialty of dentistry. The designation of oral and maxillofacial surgery was adopted by the ADA House of Delegates in 1977 from the previous specialty designation of "oral surgery" to be representative of the procedures performed by oral and maxillofacial surgeons. The ADA definition of the specialty states:

Oral and maxillofacial surgery is the specialty of dentistry that includes the diagnosis, surgical and adjunctive treatment of diseases, injuries and defects involving both the functional and esthetic aspects of the hard and soft tissues of the oral and maxillofacial regions.