Comorbid psychiatric conditions with temporomandibular disorders (TMD) in a tertiary referral clinic.

Patients with chronic pain have a higher prevalence of mood disorders with depression and anxiety contributing to higher pain intensity, emotional allodynia, and neuro-anatomical changes. We sought to quantify the prevalence of psychiatric comorbidities (PCs) in a tertiary referral clinic for temporomandibular disorders (TMDs). Medical records of all patients attending clinics run by three tertiary temporomandibular joint (TMJ) surgeons for the period January to April 2022 inclusive were audited for the prevalence of concomitant psychiatric conditions. A total of 166 patients were identified with a female to male ratio of 5:1 and mean (SD) age of 45.1 (15.2) years. A total of 124 (89.9%) patients were tertiary referrals and 72 (43.4%) patients had concomitant psychiatric diagnoses, with 58 (34.9%) being on some form of psychotropic medication (PM) (patients on anticonvulsants for neuropathic pain were not included). A majority of 136 (81.9%) patients had some form of intervention (including Dysport® and minimally invasive surgery) which appeared more common in patients with co-existing psychiatric issues (p < 0.05). A higher proportion of mental health issues exist among TMD patients in a tertiary referral clinic than would be expected in the general population. We suggest a holistic approach to patients with multidisciplinary care taking into account this prevalence to ensure decision-making that contextualises the patient and not simply the pathology.

Virtual learning in maxillofacial surgery in the post-COVID world: where are we now?

During the COVID-19 pandemic we developed a post-graduate virtual learning environment (PGVLE) in the West Midlands region for higher trainees in oral and maxillofacial surgery. We continued to develop this following the pandemic and sought to examine the trainee experience with this resource as restrictions eased. The PGVLE comprises a total of nine semesters mapping General Medical Council (GMC) learning objectives in the specialty across a total of 63 events using BigBlueButton™. Webinars are delivered on a weekly basis by subspecialty experts. Trainee feedback was sought using SurveyMonkey™ examining self-assessed confidence levels using visual analogue scores (VAS) and Likert items regarding trainers and content. A focus group was convened and the transcript analysed using grounded theory analysis (GTA). Likert items revealed overwhelmingly positive responses, with 96.2% (n = 281) of responses being positive regarding content and 97.5% (n = 475) agreeing with positive comments regarding faculty. VAS scores improved by an average of 39.0% and improvements were statistically significant for most sessions. The focus group highlighted the relevance of teaching to GMC learning objectives, the achievement of consistently high standards, the potential for conflict with clinical commitments and issues surrounding peer interaction. Satisfaction scores remain high with the PGVLE programme, which is very much here to stay in the post-graduate education of our trainees. With the easing of restrictions, we have moved to a hybrid method of learning with the potential for 'flipped classroom' methodology moving forwards.

Academic Training in Oral and Maxillofacial Surgery - when and how to enter the pathway.

Entering into surgical academia can seem a daunting prospect for an oral and maxillofacial surgery (OMFS) trainee. However, the streamlining of academic training by the NIHR to create the integrated academic training (IAT) pathway has simplified academic training and more clearly defined academic positions and entry points for trainees. In this article we review the current NIHR IAT pathway and the various grades and entry points available to OMF surgeons, both pre- and post-doctoral. We highlight the unique challenges facing OMF trainees and provide advice and insight from both junior and senior OMFS academics. Finally, we focus on the planning and application for a doctoral research fellowship - discussing funding streams available to OMF surgeons.

Botulinum toxin in the management of myalgia in temporomandibular disorders: are all injections equal?

Botulinum toxin (BTX) is becoming widely used as an adjunct to conservative management of myalgia-predominant temporomandibular disorders (TMDs) with reports of improved quality of life. There is, however, no consensus on the optimal dosage. Based on previous studies, dose regimens vary between clinicians, and we know of no standard dose protocol for the administration of BTX for the purpose of TMD management. A survey was sent to members of the British Association of Oral and Maxillofacial Surgeons (BAOMS) Temporomandibular Joint Sub-Specialty Interest Group (TMJ SSIG) and an international mailing list of high-volume TMJ surgeons (the TMJ Internetwork) to ascertain variations in dose regimens between different clinicians. The survey found that 41 respondents offered BTX to patients. The masseter muscle group was the most commonly injected site, and the majority of respondents (34/41) used Botox® (Allergan). Brands less commonly used included Dysport® (Ipsen), and Xeomin® (Merz Pharma). Botox® doses varied between 30 and 100 units, whilst Dysport® doses ranged from 50 - 300 units/muscle. The number of injection sites/muscle also varied. This survey demonstrates the wide variation in practice amongst clinicians with respect to BTX administration. To ensure optimal dose and response titration, further studies and evidence-based research are needed to standardise its use for the treatment of TMDs.

Senior surgeons as role models in the operating theatre: a thematic analysis through the lens of aristotelian ethics.

BACKGROUND: Surgeons are commonly evaluated by surgical skills and outcomes rather than their character traits. We sought to examine role model behaviours of senior surgeons through the lens of Aristotelian (virtue) ethics. METHODS: Semi-structured focus group interviews were undertaken of anaesthetic trainees at a large university hospital NHS Foundation Trust and transcripts were subjected to thematic analysis to yield themes and subthemes. Participation of the trainees was entirely voluntary and focus groups were conducted using Zoom™. RESULTS: The overarching themes identified were 'Teamwork makes the dream work', 'Captain of the ship' and 'Strong foundations'. CONCLUSION: We hope to take lessons learnt in conjunction with our previous work to help refocus surgical training towards a process of character reformation, rather than simply imparting technical skills to trainees.

Modification of an extended total temporomandibular joint replacement (eTMJR) classification system.

The aims of this paper were to validate a modification of an extended total temporomandibular joint replacement (eTMJR) classification system and develop a classification schematic for ease of reference. High-volume TMJ surgeons were asked to score 20 separate eTMJR devices using the updated classification system, and inter-rater variability was calculated. Using the modified classification system developed, a Conger's kappa (κ) coefficient of 0.53 was returned, suggesting moderate to good levels of agreement. The final classification system was then developed in a series of standardised graphic illustrations as visual representations of the different subcategories of eTMJR devices.

Character failings in the surgeon fallen from grace: a thematic analysis of disciplinary hearings against surgeons 2016-2020.

Surgeons are commonly evaluated with respect to outcomes and adherence to rules and regulations, rather than a true holistic examination of the character of the surgeon in question. We sought to examine the character failings of surgeons who faced fitness to practice enquiries under the Medical Practitioner Tribunal Service in the UK. In particular, we examined the absence of virtue as perceived through the lens of Aristotelian ethics using thematic analysis of tribunal hearing transcripts from 2016 to 2020. We identified three overarching themes that are explored in depth: 'the god complex', 'reputation over integrity' and 'wounded pride'. We hope to use this as the foundation for a re-examination of the place of phronesis in postgraduate surgical education, which we argue should be perceived as an exercise in character development and reformation rather than the simplistic teaching of skills to standardised outcomes.

Human disease/clinical medical sciences in dentistry: Current state and future development of undergraduate assessments in the UK and Ireland.

INTRODUCTION: The United Kingdom and Ireland teachers of Human Disease/Clinical Medical Science for Dentistry (HD/CMSD) group continue to work together and most recently collaborated to review current and future assessments. MATERIALS AND METHODS: The first part of the review of assessments in HD/CMSD took place at a face-to-face meeting with presentations from delegates on assessments in their home institutions. The second and larger part comprised an online survey where all eighteen schools in the UK and Ireland participated. RESULTS: All schools had some element of formative assessment, and the majority had a stand-alone summative assessment at the end of the HD/CMSD teaching block. Most schools had a written paper and practical elements to their assessments, most commonly a combination of a multiple-choice type question combined with an objective structured clinical examination (OSCE). There was a trend towards the use of single best answer (SBA) questions and a willingness amongst participants to share a question bank. All schools incorporated elements of HD/CMSD in their final examinations. DISCUSSION AND CONCLUSION: This collaboration promoted the sharing of developments in assessment for HD/CMSD and demonstrated a willingness to cooperate between institutions. Assessment in HD/CMSD in the UK and Ireland continues to be refined by those responsible for its content and delivery, and assessment methods are progressing following evidence-based best practice.

"Flipped classrooms" in training in maxillofacial surgery: preparation before the traditional didactic lecture?

While virtual learning environments (VLE) can be used in medical education as stand-alone educational interventions, they can also be used in preparation for traditional "face-to-face" training sessions as part of a "flipped classroom" model. We sought to evaluate the introduction of this model in a single module on maxillofacial radiology from a course on trauma skills. Course delegates were randomised into two groups: one was given access to an e-learning resource (test group) and the other attended a traditional didactic lecture (control group). Knowledge and confidence were assessed before and after the course with a 20-question single-best-answer paper and a 10-situation 100mm visual analogue scale (VAS) paper, respectively. All participants were then given free access to the VLE for 30days and were invited to take part in an e-survey. Neither group showed improvements in the single-best-answer scores, but both groups showed comparable improvements in VAS (control: median (range) values improved from 40.8 (17.7-82.5) mm to 62.8 (35.3-88.7) mm, p=0.001; test group: from 47.7 (10.9-58.1) mm to 60.5 (32.4-75.6) mm, p=0.005). Half of the respondents stated that they preferred the "flipped classroom" approach, and 22/22 stated that they would be "likely" or "very likely" to use an e-learning resource with expanded content. The "flipped classroom" approach was well received and there were comparable improvements in confidence. As maxillofacial radiology lends itself to online instruction with its reliance on the recognition of patterns, and problem-based approach to learning, a piloted e-learning resource could be developed in this area.

Free flaps for head and neck cancer in paediatric and neonatal patients.

PURPOSE OF REVIEW: To review recent literature on the subject of free tissue transfer options in paediatric head and neck surgery, with a particular emphasis on highlighting the advantages and disadvantages of different reconstructions in the paediatric patient. RECENT FINDINGS: Free tissue transfer in paediatric patients is predictable and applicable for a wide range of congenital and acquired defects in the head and neck. The free fibula flap is a mainstay of mandibular reconstruction and allows excellent implant-supported prosthodontic rehabilitation and growth potential at the recipient site with little or no donor site morbidity. Other less commonly explored options include the deep circumflex iliac artery flap, scapula flap and medial femoral condyle flap. The gracilis mucle remains the mainstay for facial reanimation with other options including pectoralis minor, rectus abdominis, extensor digitorum brevis and latissimus dorsi. There are compelling arguments for centralization of services and creative strategies in postoperative rehabilitation (e.g. play therapy). SUMMARY: Free flaps in paediatric patients are a viable option and may even have advantages relative to adults because of the absence of atherosclerosis, purported lower risk of vasospasm and proportionally larger vessel size. Transfer earlier in life maximizes functional potential and 'normalizes' treatment.

Training in surgery of the temporomandibular joint: the UK trainers' perspective.

Surgery of the temporomandibular joint (TMJ) is increasingly recognised as a subspecialist area of interest within our specialty and many procedures such as arthroscopy, arthroplasty, and replacement of the TMJ are becoming increasingly centralised and restricted to certain regions. We previously made a national survey of trainees and have sought to augment this with a survey of trainers to find out the nature of practice and patterns of referral nationally. We have also examined the consultants' expectations of competent final-year trainees. To do this we made an electronic survey of Fellows of the British Association of Oral and Maxillofacial Surgeons (BAOMS) and received 82 responses (26%). Many just provided simple treatments within their clinical practice, only 16 did arthroscopy, and 14 alloplastic joint replacements. From those who answered the question, only 10 would allow a competent final-year trainee to do an alloplastic joint replacement under supervision. Referrals for TMJ subspecialist care were predominantly made to the West Midlands, East Midlands, and North West, with 24 respondents stating they would either refer open TMJ surgery centrally within or outside the region. Centralisation of services means that training opportunities in surgery of the TMJ are reduced, and restricted to only a few regions. Other models of training may need to be introduced such as simulation, "taster" sessions, and brief clinical attachments. For the budding subspecialist, however, a dedicated Fellowship may become essential to ensure adequate exposure before starting independent consultant practice.

Use of a virtual learning environment for training in maxillofacial emergencies: impact on the knowledge and attitudes of staff in accident and emergency departments.

Many graduates will take up junior roles in accident and emergency (A&E) departments to which a large proportion of patients present with facial injuries caused by interpersonal violence. However, it is widely recognised that undergraduates and postgraduates have few opportunities for training in oral and maxillofacial surgery. We aimed to assess the impact of a specifically designed maxillofacial emergencies virtual learning environment (VLE) on the knowledge and confidence of junior doctors in two A&E departments. They were given free access to the VLE for one month, and were asked to complete multiple choice questions and to rate their confidence to deal with 10 common situations on visual analogue scales (VAS) at baseline and one month after training. A total of 29 doctors agreed to pilot the website, 21 (72%) completed both sets of questions, and 18 (62%) completed both VAS assessments. The mean (SD) multiple choice score improved from 10 (2.52) to 13 (3.56) out of a maximum of 20 (p=0.004) and the mean (SD) VAS improved from 29.2 (19.2) mm to 45.7 (16.6) mm out of a maximum of 100 mm (p=0.007). This was a small pilot study with limited numbers, but it showed improvements in the knowledge of maxillofacial emergencies and in confidence, although the latter remained low. Further work is needed to examine how these brief educational interventions affect the attitudes of frontline staff to maxillofacial emergencies.

Planning the content of a brief educational course in maxillofacial emergencies for staff in accident and emergency departments: a modified Delphi study.

It is well known that staff in accident and emergency (A&E) departments lack the knowledge and confidence needed to deal with maxillofacial emergencies, and that it is related to limited education at undergraduate and postgraduate levels. We therefore aimed to design a syllabus for a short course to educate staff about the most common emergencies. To find out which learning outcomes should be included and to reach a consensus, we did a 3-stage modified Delphi study of the opinions of members of the British Association of Oral and Maxillofacial Surgeons (BAOMS). Of a possible 890 members, 188 responded (21%) in the second round and 105 in the third (12%). Eighteen (37%) of the 49 proposed learning outcomes were rated very important and all of them were retained in the syllabus after the third round. Thirty (61%) items were retained with a consensus of 51% or above in the final round. The Delphi technique is a useful addition to the armamentarium of those involved in education, and has been used effectively in syllabus design. We achieved good consensus on the items to be included and the syllabus will be piloted locally.

Metastatic involvement of the maxillary antrum from an uncommon source.

UNLABELLED: Metastatic involvement of the jawbones is uncommon, particularly in the maxilla. Case reports of such metastases from renal cell primaries are few, making a consensus on treatment difficult to establish. We present a case of metastatic involvement of the maxilla two years following a nephrectomy for renal cell carcinoma. The case exemplifies the broad range of symptoms attributable to metastases in the maxilla and the management dilemmas. CLINICAL RELEVANCE: The case highlights the role of practitioners in primary dental care in identifying the potential for such pathology based on clinical and radiographic features.

Panton-Valentine leukocidin-positive Staphylococcus aureus osteomyelitis of the tibia in a 10-year-old child.

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is increasing in prevalence among asymptomatic carriers and in cases of paediatric soft-tissue infections alike. CA-MRSA may express virulence factors such as Panton-Valentine leukocidin, which makes soft-tissue and hard-tissue infections due to such organisms challenging to treat. We report a case of osteomyelitis of the proximal tibia in a 10-year-old boy and discuss its management in what is to the authors' knowledge the first case report of Panton-Valentine leukocidin-positive CA-MRSA osteomyelitis in a child in the UK.

Designing written patient information in primary dental care: the right tools for the job.

UNLABELLED: There is a good evidence base in the literature for the use of written patient information in healthcare settings to enable patients to retain information concerning procedures and treatments following initial consultations. A number of tools exist to help in the design of written patient information. These include checklists such as the Department of Health Toolkit for Producing Patient Information, EQIP and DISCERN tools, readability scores such as the Flesch-Kincaid Formula and Flesch Reading Ease score, as well as cultural sensitivity scores. These tools are presented and their possible role in dental primary care discussed. CLINICAL RELEVANCE: The tools provided here will enable clinicians to develop a better standard of patient information literature concerning procedures and treatments on offer.

A library-based ecological study to investigate the contribution of ethnicity to the incidence of oral cancer within health authorities in England and Wales.

Our aim was to investigate the incidence of oral cancer in three ethnic groups, Indian, Pakistani, and Bangladeshi residents of the UK, to try to establish a link between ethnic background and the incidence of oral cancer. We used data from the 1991 and 2001 censuses to calculate approximate percentages of the number of Indian, Pakistani, and Bangladeshi residents in each Health Authority (HA) region and correlated these with rates of oral cancer from the Office of National Statistics (ONS) cancer atlas for the same period. Data about lung cancer and oesophageal cancer were used as proxies for the confounding variables of smoking and alcohol, respectively, in a multiple regression analysis. There was a strong significant correlation between figures for lung cancer and variations in oral cancer rates among HAs (p<0.001). Ethnicity contributed weakly and insignificantly to variations in rates of oral cancer among HAs. In summary, we found only a weak correlation between ethnicity and oral cancer in the UK population, unlike previously published studies, while simultaneously showing a stronger relation with the proxy for smoking trends. There are various drawbacks inherent in library-based ecological studies in general, and in this study in particular, that may have been responsible for this.