Oral and maxillofacial surgery in China Dr. Li Ying and Robert A. Bruce, D. D.S., M.S., Ann Arbor, Mich.

UNIVERSITY OF MICHIGAN DEPARTMENT OF ORAI. AND MAXILLOFACIAL SURGERY

The primary author is a 41-year-old oral and maxillofacial surgeon on the attending staff of the Stomatology Hospital of Nanjing Medical University in Nanjing, China. He is currently a visiting scholar at

the University of Michigan and has a wide variety of experience in medicine and dentistry, including 11

years of general surgery, plastic surgery, and tumor surgery training in addition to his stomatology

education. His experiences during the past 20 years have prompted his American cotteagues to encourage

him to present his views with respect to oral and maxillofacial surgery in China today. The purpose of this

article is to promote understanding among colleagues in China and in the West. (ORAL SURG. ORAL MED. ORAL PATHOI.. 1987;63:300-3)

C hina is the third largest country in the world, with almost one fourth of the world’s population. It is slightly larger in land mass than the United States with four times the population. Most of the Chinese people live in about one third of the country’s eastern region, with the western portion consisting of barren mountains and deserts.

The climate is varied, with the summer tempera- tures averaging 80°F except in the mountains of Tibet and in the deserts. Inland temperatures aver- age 20°F in January, but coastal areas of southeast- ern China have warm, subtropical temperatures that remain the same throughout the year.

About 30% of the people live in cities, and 12 of the 50 largest cities in the world, including the largest (Shanghai) are in China.

China is one of the world’s oldest civilizations, with a written history dating back 3,500 years. Until the 1900s the government was always a monarchy, agriculture was the chief economic activity, and scholars were highly respected. China became a republic in 19 12 and, after a long civil war, became a socialist country in 1949.

EDUCATION IN CHINA

Before 1949, it was estimated that less than 25% of the population was literate. Since then, the gov- ernment has greatly emphasized education as a national goal. In general, primary (elementary) schooling lasts 6 years, followed by 3 years of middle school and 3 years of high school.

Following high school, students take a highly competitive university entrance examination, and each student is allowed to apply to 12 universities, ranking his preferences before the examination.

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There are three general types of universities: industrial science (example of subject area, engineer- ing), natural science (including medical sciences, biology, chemistry, and physics), and humanities (including literature, history, and political science).

Medical science universities are usually subdivid- ed into schools of medicine, stomatology, pharmacy, public health, and pediatrics. There are also tradi- tional Chinese medical institutes in some cities. Each school has a 5- or 6-year curriculum. It is interesting to note that pediatrics and medicine are taught in separate schools and that there is no distinction by degree between the physician and the stomatolo- gist.

All education in China is free except for board and relatively inexpensive textbooks, but competition is strong and only the better students progress to a higher level. Classroom facilities are adequate, but teaching equipment such as video tapes and comput- ers is seldom used. Student living facilities in univer- sities tend to be crowded, with six to eight students sharing a room and using bunk beds. Conversely, the libraries are modern and well equipped for studying. Classrooms are very orderly, and the teachers are highly respected.

STOMATOLOGY IN CHINA

Modern Chinese dentistry originated in 19 19 with the founding of the first dental school in Chengdu, which was formed as part of the medical university. Before 1950, there were small dental schools in Chengdu, Shanghai, Nanjing, and Harbin, graduat- ing approximately three hundred dentists.’

After 1950, the dental schools added divisions of oral medicine, oral and maxillofacial surgery, and

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Oral and maxillofacial surgery in China 301

prosthodontics, and they became known as schools of stomatology. Subsequently, more specialties were added, and now it is much like the situation in the United States.

By May 1982, there were 21 schools of stomatolo- gy affiliated with medical science universities, and most provinces now have a school. These schools have 561 professors and lecturers, 3,637 students, and 148 postgraduate students. Almost 8,000 stu- dents have graduated from schools of stomatology since 1950.’

At present, there are about 9,000 beds available for oral and maxillofacial surgery patients. This represents approximately 0.4% of the total available hospital beds in China.4

All stomatology schools are affiliated with hospi- tals, either specialized stomatology hospitals affiliat- ed with a medical science university or general teaching hospitals.

At present, there are six nationally supported major schools of stomatology located in Beijing, in Sichuan, in Hubei, at the Second Medical University in Shanghai and Beijing, and at the Fourth Army Medical University. In 1982, on the average, there were 262 students in a school, 87 beds in the oral and maxillofacial surgery units, and135 dental units or chairs. All six major schools have research institutes and/or special research laboratories.’

Even with such growth and development, China desperately needs dentists. In Beijing, a city with a higher percentage of dentists, the dentist/population ratio is 1: 10,000 and in Hunan Province, an isolated area, the ratio is 1:270,000.’

The stomatology school curriculum is somewhat similar to the American dental school curriculum, with students taking general basic science courses during the early years and engaging in more specific dentally related studies during the later years. How- ever, there are more medically related courses in the curriculum.

Students in stomatology are able to obtain a great deal of practical experience, since patients are readily available and a fifth year stomatology student, by gov- ernmental decree, is expected to have some experience in major oral surgical procedures, such as removal of impacted teeth, sublingual and submandibular glands, tumor surgery, and cleft lip surgery.

After graduating from school, the stomatologist works for the government at a general hospital, at a stomatological hospital, at a medical research insti- tute, at a middle level dental school (training dentists and technicians), or at the major school of stomatol- ogy associated with a medical university. Stomatolo- gists can obtain a Master of Science degree (after 3 years) and a Ph.D. degree (after 3 additional years).

Generally, there is no private practice of stomatology or oral surgery in China.

ORAL AND MAXILLOFACIAL SURGERY RESIDENCY TRAINING IN CHINA

After 6 years of study, students take a national board examination that certifies their abilities in stomatology. The graduates are then assigned to areas of need as determined by the Ministry of Health. The assignments are usually made by a committee composed of the school’s dean, two or three professors, and a Communist Party secretary. If possible, preferences are considered, but students cannot always expect to be sent to the location or facility of their choice, or to serve in the specialty of their choice.

Although the system is presently in transition, there is no formal residency program in oral surgery, as in the West. The residency might last 10 or more years, and there is no specific quantification of required surgical procedures. The training could be compared with a lengthy preceptorship without a board or fellowship certification at the completion of training.

Because of the tremendous number of patients and the lack of doctors, the trainees, however, gain considerable experience as a result of both the types and the number of cases, and there is an effort by the staff to give the residents a graduated type of program that consists of dental alveolar surgery in the early years and advances to more major cases as they become more proficient. Professional advance- ment and financial remuneration are established by the ministers of health and education on the basis of ability and the length of training.

It is not unusual for a stomatologist to work and train in an ENT, a head and neck, or a plastic surgery department, depending on the needs at that particular hospital.

SCOPE OF ORAL AND MAXILLOFACIAL SURGERY IN CHINA

The scope of oral and maxillofacial surgery in China is broad, with many areas of crossover among medical specialists, but there is minimal conflict, perhaps because patient numbers are so great, indi- vidual economic gain is minimized (all doctors are salaried), and stomatology is a specialty of medi- cine.

Oral and maxillofacial surgeons in China treat primary oral cancers, including neck metastases. Radical oral and neck procedures are carried out much as they are in the United States, and recon- structions with musculocutaneous and compound osteomusculocutaneous flaps are commonly used, as

302 Li and Bruce Oral Surg. March, I987

FREQUENTLY ASKED QUESTIONS ABOUT CHINA AND CHiNESE ORAL SURGERY

Salaries for oral and maxillofacial surgeons are low by Western standards, but the cost of living is also very low. A resident oral surgeon at a stomatol- ogy hospital will receive $20.00 (equivalent of Amer- ican money) per month, with an increase to $30.00 per month and, ultimately, $50.00 to $70.00 per month for a senior staff oral surgeon; however, a two-bedroom apartment in a city might cost $2.00 per month.

Generally, all university-trained personnel in com- parable positions receive equivalent salaries; for example, a junior engineer is paid the same amount as a junior oral surgeon or teacher.

The Communist Party in our hospital is involved in the daily activities of all health professionals. For example, a stomatology hospital will have a dean or director and also a Communist Party secretary to monitor political functions and education.

There is no system of handling malpractice claims as known in the United States. Patient complaints are monitored and arbitrated by departmental chair- men and, if necessary, Communist Party members at the hospital. If the patient’s complaint is justified, a sanction will be enforced against the doctor, and perhaps the patient’s medical care will be free. There is no concept of financial settlement.

Medical care for employees is covered by the place of employment, but farmers, for example, must pay for the service themselves. The removal of an impact- ed molar costs about $1 .OO, and a radical neck dissection may cost about $10.00.

The Cultural Revolution lasted 10 years and, although the issue is complex, generally it had negative influences on doctors and medicine in Chi- na. Doctors were not made to do manual labor, but many were forced to practice in remote villages and to live as peasants. The length of schooling was shortened, and very little research was allowed. Conversely, doctors who had lived in cities all their lives gained an understanding of the common man in such a vast and complex country.

As a developing socialist country, China has opened her doors to the entire world in recent years. Tremendous efforts are being made to upgrade the quality of medicine in general and oral surgery in particular, and Chinese oral and maxillofacial sur- geons welcome visitors from the West.

REFERENCES

I. Wang, Lei. Reconstruction and development of education of stomatology science in China. J Stomatol Western China 1984;1:65-73.

are autogenous and allogeneic bone grafts. Oral surgeons are intimately involved with chemotherapy and immunotherapy in the treatment of advanced disease, and cancer research is currently being undertaken at the major stomatology centers.*s3

Chinese oral and maxillofacial surgeons treat patients with cleft lip and cleft palate. The incidence of cleft lip has been reported to be 1:616 in Beijing, 1:768 in Shanghai, 1:1,151 in Sichua, and 1:1,533 in Wuhan.3 Generally, the lip is closed at the age of 1 month to 6 months, the palate is closed at the age of 4 to 6 years, and pharyngeal flap procedures are used in cases of palatal pharyngeal incompetence. Second- ary orthognathic surgical procedures to correct the dentofacial defect in cleft patients have been carried out only recently in a few centers in China.

Because of the lack of dentists and a low dental health awareness, many patients consult dentists for the removal of teeth. The Nanjing Stomatological Hospital is a medium-sized hospital among the 21 stomatologic hospitals in China. The staff consists of one chief of staff, three attending staff members, and seven residents in oral and maxillofacial surgery. This staff works 6 days a week, sees 600 patients a week, operates on patients who represent major cases 4 days a week, and cares for patients in the 30-bed stomatology hospital. Of the patients seen in the outpatient clinic, 85% require dental extractions. Impacted third molars that cause pericoronitis are common, and patients with odontogenic infections are seen daily. Chisels and mallets are commonly used in dental-alveolar surgery since high-speed surgical drills are in short supply. Few dental assis- tants work at the clinics, and it is not uncommon for residents to assist one another.

Orthognathic surgery has only recently been car- ried out at a few centers, and preprosthetic surgery for conditions other than cancer surgery is rare. Correction of alveolar ridge deficiencies with allo- plasts and nonbiologic materials is at a very elemen- tary level. Outpatient sedation for dental alveolar surgery is rarely used, and, although widely publi- cized in the West, acupuncture is not commonly used for oral and maxillofacial surgical procedures.

Because of the low number of automobiles, the incidence of facial trauma is less than in the West. Chinese oral and maxillofacial surgeons treat all facial bone fractures.

Surgery on the temporomandibular joint is under- taken in cases of ankylosis and, occasionally, for treatment of destructive processes of the condyle. Surgery for internal derangement of the joint is not currently popular in China.

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2. Chang Xi-zhe. Summary of the National Second Conference of the Chinese Stomatology Association. Nanjing, China, May, 198.5, lecture.

3. Wa, He-quang, Ran, Rui-tu. Chinese surgery. Vol. 1 Chaps. 17, 18, 19, 20, and 23. Lancaster: MTP Press Limited, 1984.

4. Communique on the statistics of 1985 economic and social

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development issued on February 28, 1986, by the State Statistical Bureau, Beijing Review 1986;29:27-30.

Reprint requests to:

Dr. Robert Bruce University of Michigan Dental School Ann Arbor. MI 48104

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