Developing confidence in oral and maxillofacial dental core trainees: a national review of the trainee experience

This study considers the confidence of dental core trainees (DCTs) as they mature and progress through their first six months in an oral and maxillofacial surgery (OMFS) training post. Trainees have different incentives for embarking on a year in OMFS: to develop additional skills before settling into general dental practice; as a step towards specialty training; and to help decide about their career direction. Traditionally, an OMFS year has been associated with creating well-rounded and confident clinicians. We surveyed 123 DCTs at three stages over a six-month period to monitor their confidence in 10 clinical domains: assessing dentofacial infection, mandibular fractures, midface fractures, intraoral/extraoral swellings, airway risks, intraoral/extraoral lesions (benign/malignant), CT/MRI scans, and performing intraoral/extraoral suturing. The study demonstrates an increase in trainee confidence across all domains over the first six months of an OMFS post, with a particularly significant increase in the assessment of dentofacial infection, mandibular/midface fracture, and both intraoral and extraoral lesions and swellings.     

Early experience of a nurse-led clinic in a tertiary centre

A busy head and neck or oral and maxillofacial (OMFS) National Health Service (NHS) clinic treats patients with many different conditions. A large proportion will have cancer of the head and neck, and they will be at different stages of their treatment. Their clinical needs may be different from a larger group of patients who have been referred through the “two-week wait” referral pathway, and who are present in the same clinic for their biopsy results. We present our early experience of “fast-track” referrals and their potential effect on the overall volume of work. They are only a small number of the patients who are typically seen in a nurse-led clinic.     

Perception of oral maxillofacial surgery by health-care professionals

Oral and Maxillofacial Surgery (OMFS), a dentistry specialty recognized by the Federal Dentistry Board in the mid-1960s, is responsible for the diagnosis, and clinical and surgical treatment of traumatic, congenital, developmental and iatrogenic lesions in the maxillofacial complex. Even today, difficulties are experienced owing to the lack of knowledge of the general public and health professionals concerning the scope of OMFS. To investigate recognition of the scope of OMFS, 400 questionnaires were sent to dentistry students, medical students, dentists and doctors, in 4 equal groups. The questionnaire covered 26 clinical situations in four different specialties (OMFS, Plastic Surgery, Ear Nose and Throat Surgery, Head and Neck Surgery) and an option with no specialty specified. Each interviewee had to correlate the clinical situation with the respective specialist. For facial trauma, dento-facial deformities, mandibular reconstruction and temporomandibular joint surgery, most respondents would consult the OMF surgeon for treatment (mean, 90%). In cases of oral biopsy and treatment of benign mandibular tumours the mean referral rate to OMFS was low (48%). On the basis of the questionnaire responses, a good level of knowledge of the scope of OMFS was found. In order to ensure the correct referral of all patients, the specialty needs to broaden its horizons.     

The specialist management of non-temporomandibular orofacial pain: maxillofacial surgery’s known unknown?

The management of orofacial pain is considered to be within the remit of oral and maxillofacial surgery (OMFS). In this study we aimed to provide an overview of the healthcare “journey” of a group of patients referred to a specialist unit with “complex” non-temporomandibular orofacial pain. We retrospectively reviewed all those who were referred over a six-month period and followed for up to three years. A total of 133 were included, 69% were female, and the mean (SD) duration of symptoms before assessment was 66.4 (88.8) months. Patients were treated for seven different conditions by a mean (SD) of 2.6 (1.2) specialties, and 3.2 (2.5) medications had been tried before assessment at the unit. A mean (SD) of 3.9 (3.3) appointments were attended over the three years, and 80% of patients were prescribed at least one medication. Patients were under the care of the unit for a mean (SD) of 11.9 (14.0) months, and 38% were still being seen at three years. Those with trigeminal neuralgia were most likely to remain in care at three years (p = <0.001), and those with burning mouth syndrome (p = <0.001) or persistent idiopathic facial pain (p = 0.005) were most likely to be discharged. In the current NHS climate, the lack of resources to treat facial pain and the focus on a mix of skills, mean that OMF surgeons are likely to have an increasing role in the treatment of these patients. This paper provides an important insight into these conditions.     

Intraoral melanoacanthoma

Two cases of melanoacanthoma occurring on oral mucous membranes are presented. Melanoacanthoma is considered to be a benign mixed tumor of keratinoacytes admixed with pigment-laden dendritic melanocytes. All intraoral melanoacanthomas reported thus far have been pigmented lesions of the buccal mucosa and have occurred in young to middle-aged black females. These tumors may grow rapidly and therefore they often mimic the radial growth phase of an intraoral melanoma. Because melanocanthomas have no distinguishing clinical features, biopsy is mandatory.     

“Run-through” training at specialist training year 1 and uncoupled core surgical training for oral and maxillofacial surgery in the United Kingdom: a snapshot survey

Training in oral and maxillofacial surgery (OMFS) in the UK has undergone considerable changes during the last 10 years, and “core” surgical training has replaced “basic” surgical training. In 2014 a pilot “run-through” training programme from specialist training year one (ST1)-ST7 was introduced to facilitate early entry into the speciality. Run-through training guarantees that a trainee, after a single competitive selection process and satisfactory progress, will be given training that covers the entire curriculum of the speciality, whereas uncoupled training requires a second stage of competitive recruitment after the first one (for OMFS only) or two years of “core” training to progress to higher specialty training.The first two years of run-through training (ST1-ST2) are the same as for core surgical training. Dual-qualified maxillofacial aspirants and those in their second degree course are curious to know whether they should go for the uncoupled core surgical training or the run-through programme in OMFS. The General Medical Council (GMC) has now agreed that run-through training can be rolled out nationally in OMFS. To assess the two pathways we used an online questionnaire to gain feedback about the experience from all OMFS ST3 and run-through trainees (ST3/ST4) in 2016–2017. We identified and contacted 21 trainees, and 17 responded, including seven run-through trainees. Eleven, including five of the run-through trainees, recommended the run-through training programme in OMFS. Six of the seven run-through trainees had studied dentistry first. The overall mean quality of training was rated as 5.5 on a scale 0–10 by the 17 respondents. This survey gives valuable feedback from the current higher surgical trainees in OMFS, which will be useful to the GMC, Health Education England, OMFS Specialist Advisory Committee, and those seeking to enter higher surgical training in OMFS.     

Accuracy of the Head and Neck Cancer Risk Calculator in identifying maxillofacial malignancies

The OMFS urgent suspicion of cancer (USOC) referral pathway for head and neck cancer is costly in terms of time and resources, and despite NICE referral guidance, it has a low conversion rate with many inappropriate referrals. The Head and Neck Cancer Risk Calculator version 2 (HaNC-RC-v2) gives recommendations to primary care referrers on appropriate referral priority. To our knowledge, this is the first study to investigate the accuracy of the HaNC-RC-v2 in a cohort of maxillofacial referrals. Electronic patient records were reviewed for all malignancies diagnosed by OMFS in 2019 (n = 54), and a sample of USOC referrals to OMFS (n = 204). The HaNC-RC-v2 was applied to each patient, using information from the referral letter and the clinical notes from the new patient consultation. The mean and median HaNC-RC-v2 scores for patients with malignancy were 42.22% and 32.23%, respectively. For patients without malignancy, mean and median scores were 9.27% and 5.68%, respectively. There was a statistically significant relation between the presence/absence of malignancy and the recommendation made by the risk calculator (p = 0.0012). The calculator recommended USOC referral for 76% (41/54) of patients with malignancy, and only 41% (83/204) of patients without malignancy. The negative predictive value of the HaNC-RC-v2 was 99.2%. The calculator has the potential to reduce the number of inappropriate referrals to OMFS via the USOC pathway.     

耳后区和口内联合进路切除下颌下腺的近期疗效观察

目的:探讨耳后区和口内联合进路切除下颌下腺的可行性及美容效果。方法:对9例下颌下腺良性病损(4例下颌下腺炎并结石,3例慢性下颌下腺炎,2例多形性腺瘤)患者,采用耳后区切口和口腔内切口作下颌下腺切除术。结果:全部患者的下颌下腺被完整切除,切口愈合良好,无面神经下颌缘支和舌神经损伤。经平均6个月观察,肿瘤无复发,瘢痕隐蔽。结论:经耳后区和口内联合进路切除下颌下腺良性病损是可行的,可获得较理想的美容效果。     

Maxillofacial injuries associated with domestic violence: experience at a major trauma centre

Domestic violence continues to be a global public health issue, and facial injuries in these cases are common with a reported incidence of up to 94%. Our aims were to identify patients with facial injuries caused by domestic violence, and to find out how confident members of the oral and maxillofacial surgical (OMFS) team were at assessing them. In this 18-month retrospective study of patients seen at King’s College Hospital we identified 18 and obtained details on sex, age, nature of maxillofacial injury, mechanism of injury, time to presentation, and alleged assailant, from their electronic records. Most of the patients were female and the mean (range) age was 28 (16-44) years. In 10 cases, the alleged assailant was the patient’s current partner. A total of 15 patients presented on the same day as their injury, and only 3 the following day. Punching was the most common mechanism (n = 13) followed by use of a weapon. We also circulated a questionnaire among the OMFS team to gain an insight into their attitudes regarding screening for domestic violence. Most OMFS clinicians were only “somewhat confident” at recognising and asking about domestic violence, and few were “very” or “extremely confident”. Targeted training for frontline staff in OMFS teams is likely to increase their confidence to identify and manage these patients, and to refer them appropriately.     

Intraoral Photography Recommendations for Remote Risk Assessment and Monitoring of Oral Mucosal Lesions

Oral cancer is a global health issue with substantial morbidity and a high mortality rate mainly because of late-stage diagnosis. Cancerous lesions are often preceded by potentially malignant lesions that may be detected during routine dental examinations. Not only is the oral cavity easily accessible for screening, but the clinical risk factors of the disease are also known. However, patients may not always be able to access screening services or receive follow-up for diagnosed lesions. In these circumstances, intraoral photos are crucial for timely triage, risk assessment, and monitoring of oral lesions. Further, photos form an integral part of a patient's records, facilitate patient education and communication between health care providers, and provide important information during the referral process. To ensure that intraoral photos are of good quality and standardised there is a need to establish recommendations regarding intraoral photography in oral mucosal screening. This article recommends methods to help health professionals and patients obtain interpretable intraoral photographs. Suggestions to achieve ideal lighting, mirror placement, camera angle, and retraction have been discussed. These recommendations are adaptable to easily available smartphone or point-and-shoot cameras and may be further used to develop future teledentistry platforms.     

Litigation in National Health Service oral and maxillofacial surgery: review of the last 15 years

Litigation claims are increasing in medicine but we know of little detailed analysis of those published concerning oral and maxillofacial surgery (OMFS) despite information being freely available from the NHS Litigation Authority (NHSLA) under the Freedom of Information Act. We obtained information from the NHSLA on clinical and non-clinical negligence claims in OMFS from April 1995 to August 2010, and analysed the data with outcomes and a further breakdown of subspecialty. During the period 318 claims relating to OMFS were registered. As expected, because of the high volume of patients treated, the highest number of claims related to dentoalveolar surgery and minor oral surgery. The total amount paid out was in excess of ￡5 million, and the highest claim (more than ￡300,000) during the period was for misdiagnosis of an oral cancer. Litigation in OMFS is increasing, as is the number of cases that necessitate compensation by the NHSLA. We discuss the trends and implications.     

Oral appliance therapy versus nasal continuous positive airway pressure in obstructive sleep apnea: a randomized,placebo-controlled trial on psychological distress

Objectives

The aim of this randomized placebo-controlled trail was to compare the effects of an objectively titrated mandibular advancement device (MAD) with those of nasal continuous positive airway pressure (nCPAP) and an intraoral placebo device on symptoms of psychological distress in OSA patients.

Materials and methods

In a parallel design, 64 mild/moderate OSA patients (52.0 ± 9.6 years) were randomly assigned to an objectively titrated MAD, nCPAP, or an intraoral placebo appliance. All patients filled out the Symptom Checklist-90-Revised twice: one before treatment and one after 6 months of treatment. The Symptom Checklist-90-Revised is a multidimensional symptom inventory designed to measure symptomatic psychological distress over the past week. Linear mixed model analyses were performed to study differences between the therapy groups for the different dimensions of the Symptom Checklist-90-Revised over time.

Results

The MAD group showed significant improvements over time in the dimensions “somatization,” “insufficiency of thinking and acting,” “agoraphobia,” “anxiety,” “sleeping problems,” and “global severity index” (F = 4.14–16.73, P = 0.048–0.000). These improvements in symptoms of psychological distress were, however, not significantly different from those observed in the nCPAP and placebo groups (P = 0.374–0.953).

Conclusion

There is no significant difference between MAD, nCPAP, and an intraoral placebo appliance in their beneficial effects on symptoms of psychological distress.

Clinical relevance

The improvement in psychological distress symptoms in mild/moderate OSA patients under MAD or nCPAP treatment may be explained by a placebo effect.

     

Oral and Maxillofacial Surgery (OMFS) Consultant Workforce in the UK: reducing consultant numbers resulting from recruitment issues,pension pressures,changing job-plans,and demographics when combined with the COVID backlog in elective surgery,requires urgent action

Mean retirement age for UK doctors is 59.6 years, giving the average OMFS consultant approximately 20 years of practice. Current pension tax regulations, new consultant posts typically restricted to a maximum of 10 sessions (40 hours), increasing proportions of consultants working less than full time (LTFT), all combined with the backlog of elective care created by COVID-19 will create a significant gap between workforce capacity and clinical demand. The age of current OMFS consultants was estimated using the date of their primary medical/dental qualification. Changes in job plans were estimated using data from the BAOMS Workforce Census and from recently advertised posts. Reports of unfilled posts were collated by OMFS Regional Specialty Professional Advisors (RSPAs). First degree dates were identified for 476 OMFS substantive consultant posts. Estimated current average age of OMFS consultants was 52.7 years (minimum 35.9, maximum 72.1), 75th centile age 59.0 and 23% of the current consultant workforce above the average retirement age for doctors. The 10 sessions of new OMFS consultants posts is significantly less than existing consultants' average of 12.1 sessions (48.4 hours). Unfilled consultant posts in Great Britain are 13% of the total compared to 20% in Northern Ireland and Ireland. Many (23%) of the OMFS consultant workforce are above average retirement age. Forty-hour contracts; new consultants working LTFT; and early loss of senior colleagues because of pension pressure will reduce NHS’ capacity to treat OMFS disorders and injuries. This paper suggests increasing consultant posts, increasing trainee numbers, and actively retaining senior surgeons to maintain capacity.     

Our experience of a nurse-led oral and maxillofacial surgical clinic in a tertiary centre: two years on

We describe our two-year experience of a nurse led clinic (NLC) in a tertiary centre oral and maxillofacial surgical (OMFS) department. The clinic is run by a specialist nurse, in parallel with a consultant’s clinic and focuses on the management and review of non-malignant lesions. Increased clinical flexibility, reduced waiting times, and tailored educational resources have contributed to an improved experience for the patients.     

Oral lichen planus: clinical presentation and management

Oral lichen planus (OLP) is a chronic mucosal condition commonly encountered in clinical dental practice. Lichen planus is believed to represent an abnormal immune response in which epithelial cells are recognized as foreign, secondary to changes in the antigenicity of the cell surface. It has various oral manifestations, the reticular form being the most common. The erosive and atrophic forms of OLP are less common, yet are most likely to cause symptoms. Topical corticosteroids constitute the mainstay of treatment for symptomatic lesions of OLP. Recalcitrant lesions can be treated with systemic steroids or other systemic medications. However, there is only weak evidence that these treatments are superior to placebo. Given reports of a slightly greater risk of squamous cell carcinoma developing in areas of erosive OLP, it is important for clinicians to maintain a high index of suspicion for all intraoral lichenoid lesions. Periodic follow-up of all patients with OLP is recommended.     

The Role of Intraoral Scanners in the Shade Matching Process: A Systematic Review

Purpose

The variation in findings with regards to the accuracy and precision of intraoral scanners for shade selection are no doubt confusing for clinicians who may find it difficult to make evidence-based decisions. The aim of this systematic review is to provide a comprehensive and in-depth assessment of available studies to determine the viability of using intraoral scanners for the purpose of shade matching. The PICO-guided research question is as follows: when shade matching, are intraoral scanners as valid as visual or other digital shade measuring devices in determining tooth colors.

Methods

Electronic databases including PubMed/MEDLINE, SCOPUS, EBSCO, Cochrane, and ProQuest were systematically searched for articles published between January 1, 2011 and December 30, 2021 using the main search terms: “intraoral scanners,” “scanners,” “TRIOS,” “CEREC,” “Planmeca,” “Medit,” “digital dentistry” in concurrence with one of the following keywords: “EasyShade” OR “shade selection” OR “shade matching” OR “shade” OR “tooth color” OR “tooth shade” OR “digital shade matching.” Bibliographies of included articles and the following journals were searched for relevant articles: Journal of Prosthetic Dentistry, Journal of Prosthodontics, Journal of Esthetic and Restorative Dentistry, Journal of Advanced Prosthodontics, and Journal of Dentistry. A total of 15 articles were included in the review.

Results

Intraoral scanners are highly repeatable for shade matching, and outperformed visual shade matching. Accuracy varied significantly between studies, with the majority recommending the use of visual shade matching to confirm/verify the intraoral scanner results. Setting intraoral scanners to the Vita 3D Master shade guide improved both accuracy and precision. Shade matching with intraoral scanners may be influenced by external factors such as ambient light sources and incorrect use or manipulation.

Conclusion

Intraoral scanners set to the Vita 3D Master shade guide may be used for shade matching, but shade should be verified with visual shade matching. Further studies are required to address limitations of current studies.     

Legislation for Oral and Maxillofacial Surgery (OMFS) in the UK lags behind the patient care we provide: an illustrative timeline and recommendations for the future

OMFS is the surgical specialty which bridges dentistry and medicine. As the specialty of OMFS emerged from the dental specialty of Oral Surgery during the 1980s the Dentists Act 1984, whose purpose included preventing medical practitioners providing unregulated general dental care, was published. In 2008 the Postgraduate Medical Education and Training Board (PMETB) review of training in OMFS concluded that dual qualification was essential and recommended that OMFS specialists should only be required to register with one regulator, the General Medical Council. For OMFS to continue to provide high quality patient care, and to help the GDC and GMC in their roles regulating our specialty, BAOMS has identified 5 areas for regulatory change: (1) All OMFS specialists should be able to practice the full curriculum of OMFS with only GMC registration if they wish to – this was recommendation 4 of the PMTEB Review of OMFS in 2008. (2) If an OMFS specialist or trainee is registered with both the GMC and GDC. (3) A Memorandum of Understanding between the GMC and GDC should prevent any fitness to practice concerns being processed by both regulators. (4) Dually registered OMFS specialists should be able to indicate that they have had “appraisal of the full scope of practice” to comply with GDC Continuing Professional Development (CPD) regulations. (5) Oral Surgery specialist list should retain Route 11 for OMFS specialists as the Oral Surgery Curriculum is entirely within the OMFS curriculum. Legislative changes may be the best route to deliver these recommendations. Until these changes happen, the GMC, GDC and BAOMS should work together in the best interests of patients.     

Variation of pediatric and adolescents head and neck pathology in the city of Jeddah: A retrospective analysis over 10 years

This study was conducted to present a comprehensive view of the most common head and neck pathologies among the pediatric and adolescent population of the city of Jeddah, Saudi Arabia. Data were collected from the oral and maxillofacial surgery (OMFS) records at King Abdulaziz University Hospital and King Fahad Hospital Jeddah (KFHJ) from the period 1998 to 2009. All patients who were 18 years of age and younger were included in the study. Identified lesions were classified into four categories: cystic, neoplastic, vascular and fibro-osseous. Age and sex distribution of the lesions were also calculated. A total of 155 patients were included in this study. Of all the lesions, 143 (92.26%) were benign and 12 (7.74%) were malignant; 63 (40.65%) were cysts; 48 (30.97%) were neoplasms; 23 (14.84%) were vascular and 21 (13.55%) were fibro-osseous tumors. The most common lesions were hemangioma (20 cases; 12.9%) followed by retention cyst (19 cases; 12.26%) and dentigerous cyst (15 cases; 9.68%). The most common benign odontogenic neoplasm was odontoma (7 cases; 4.52%), of which central giant cell granuloma (6 cases; 3.87%) was the most frequent benign nonodontogenic tumor and lymphoma (6 cases; 3.87%) was the most common malignant one. Although this study might benefit clinicians in guiding them through differential diagnosis of pediatric and adolescent head and neck pathology in reference to their sex and age groups, governmental efforts are badly needed to establish a Saudi childhood pathology registry.     

Multiple intraoral melanoacanthomas: a case report with unusual findings

Melanoacanthoma is a rare, benign, mucocutaneous pigmented lesion characterized by colonization of acanthotic epithelium by dendritic melanocytes.(1,2) The most common intraoral sites are the buccal(3,4) and masticatory mucosa subject to chronic irritation.(1,5) The pathogenesis of oral melanoacanthoma remains uncertain, although its clinical behavior is suggestive of a reactive cause.(3,4,6,7) The clinical appearance of melanoacanthoma is nondiagnostic, and biopsy is mandatory.(2,3,5,6,8) The lesion, however, requires no treatment(5) and elimination of local irritants as well as periodic observation are the recommended interventions.(1,8) We describe a 39-year-old black patient with a recently reported palatal melanoacanthoma who developed additional lesions in other intraoral sites approximately 3 months after the initial lesion was biopsied. This article also documents the reactive and reversible nature of intraoral melanoacanthoma in a rare case of multiple lesions.     

NICE guidelines and their relevance to the dental team

The National Institute for Health and Clinical Excellence (NICE) of the National Health Service (NHS) produces guidance for the health sector on a range of issues. Specific guidance on dental subjects has been issued in relation to third molar removal, dental recall interval and HealOzone therapy. In addition, there are examples of more generic guidance which may also be relevant to dental practice. This paper discusses the background and functions of NICE and summarizes the guidance of relevance to the dental team. Clinical Relevance: NICE guidance provides an authoritative summary of the current state of knowledge on certain clinical issues and gives guidance for healthcare workers. The authors discuss how this guidance should impact upon clinical practice.