Potential no man's land for the 4th year dental graduate.

The Royal College of Surgeons of England stipulates that to hold a substantive specialty or associate specialist (SAS) grade post a person must be a minimum of 4 years post-graduation and have at least 2 years' experience in their chosen speciality. We have noticed an increasing number of excellent applications for specialty doctor adverts posted by our trust without the necessary 4 years of post-graduate experience. Many of these applicants who do not comply with the RCS stipulations may be forced to take a job outside of their chosen career path. The reasons for this may be multifactorial, but it could have a worrying impact on their own future career and hospital service provision. We looked at the number of SAS grade adverts placed on NHS jobs in the year 2019 and the type of job advertised. We also considered the possible reasons for a rise in the number of applicants for SAS roles in oral surgery and oral and maxillofacial surgery, and what changes, if any, could be made to support this group of clinicians.

Can we justify the continued use of botulinum toxin A in the management of myofascial pain?

We initially conducted a pilot study to evaluate the impact of botulinum toxin A (BtA) on increased masseteric mass associated with pain. After injection we assessed its impact on the muscle mass and the impact, if any, on reported pain, in a group of 10 patients who were refractory to conservative management. Results of this pilot study indicated that clenched and unclenched muscle dimensions showed no significant reduction (-0.82 clenched and -1mm unclenched). However, what did prove to be significant was an improvement in their pain scores as measured on a visual analogue scale (VAS). The mean VAS score before the injection was 8.2, and at six weeks after the injection it was 1.8. Following the pilot study we focused only on patients' pain scores. Our main study included 48 patients (81 muscles) who suffered with pain secondary to increased masseteric size, and had recorded their pain score out of 10 on the VAS before placement of BtA into each affected muscle and again six weeks after the injection. Results showed a mean pre-injection pain score of 7.9 and a mean post-injection pain score of 2.9. Following the results of this study on reported pain alone, our Trust has allowed funding to provide the intramuscular injection of BtA in appropriately selected patients.

Implementation of "local safety standards for invasive procedures (LocSSIPs)" policy: not merely a tick-box exercise in patient safety.

The importance of patient safety in medicine and dentistry cannot be understated. Wrong tooth extractions account for approximately 25% of wrong-site surgery, and the implications for the patient, the team, and the institution can be profound. The development of national safety standards for invasive procedures (NatSSIPs) has led to the introduction of specialty-specific local safety standards for invasive procedures (LocSSIPs), with the aim of improving safety further. The implementation of outpatient LocSSIPs is recommended in clinical dentistry when surgical interventions regularly take place. We have implemented an outpatient LocSSIPs checklist for all procedures done under local anaesthesia in the oral and maxillofacial surgical unit of a large district general hospital. Feedback from a staff survey six months after its introduction was positive from both clinicians and nursing staff. Since its implementation 18 months ago no serious incidents have been reported and staff think that safety has improved. The reporting of incidents, for example, missing clinical notes and faulty equipment, has become more common (showing better awareness) and the development of a team-led approach has improved the running of the department.

Plain radiographs for the assessment of coronectomy: not always a case of black or white.

In recent years, coronectomy of impacted lower third molar teeth has become an increasingly popular alternative to removal. Traditionally, orthopantomograms of mandibular third molars have been used to indicate features that show that the tooth is in close proximity to, or in an intimate relation with, the inferior dental nerve. Some authors advocate coronectomy as opposed to surgical removal to reduce the risk of damage to the nerve. In our Trust during the last two years, there has been a noticeable increase in the prescription of coronectomy for the management of pericoronitis associated with mandibular third molars. The purpose of this study therefore was to examine the differences among clinicians in their assessment of the need for coronectomy using plain-view radiographs. An online survey was completed by 25 clinicians with different levels of experience from six units across the UK and Republic of Ireland. We found a wide variation in the number of coronectomies prescribed (intraclass correlation 2.67), and when prescribed, a lack of agreement about the radiographic feature that had influenced the decision. These judgments are not straightforward. They are, to some extent, subjective, and in certain cases may benefit from a team-led approach.

Effect of a domiciliary facial cooling system on generic quality of life after removal of mandibular third molars.

To evaluate quality of life (QoL) and patients' perceptions of a domiciliary facial cooling system (Hilotherm®, Hilotherapy UK Ltd, Coventry, UK), we asked 30 patients to complete a paper-based EQ-5D-3L QoL questionnaire (EuroQol Group 1990, Rotterdam, The Netherlands) each day for seven days after the removal of mandibular third molars. They were returned by 14 of the 20 patients who had not used the system and by all 10 who had. Patients aged between 18 and 25 who had their teeth removed in outpatients (in accordance with National Institute for Health and Care Excellence guidelines) under general anaesthesia (American Association of Anesthesiologists (ASA) class I or II) and did not smoke, were included. They were all treated by the same surgeon in the day surgery unit of a district general hospital. Patients found the system helpful and easy to use. They had no complications, their QoL was significantly improved (p<0.001), and the time taken to return to normal activities was reduced. The Hilotherm® domiciliary facial cooling system is safe and helps in the management of postoperative pain and swelling. Our findings confirm recently published meta-analyses that show the effectiveness of hilotherapy after facial surgery.

Measurement of generic compared with disease-specific quality of life after removal of mandibular third molars: a patient-centred evaluation.

Our aim was to evaluate patients' perceptions and their responsiveness to a generic quality of life (QoL) scale after removal of mandibular third molars. We asked 40 consecutive patients who met NICE guidelines for removal of third molars to rank items from the generic EuroQuol three-dimensional questionnaire (EQ 5D 3L) and the disease-specific Oral Health Impact Profile (OHIP-14) based on what they perceived to be important outcomes. Each item was then assigned a numerical value that depended on its rank, and an overall score calculated. Fifty consecutive patients were then invited to complete a paper-based EQ 5D 3L QoL questionnaire daily for seven days after removal of third molars. Most of the generic QoL items ranked more highly than disease-specific ones. The generic EQ 5D 3L questionnaire indicated an initial fall in QoL after removal of the teeth, before improving for all participants over the first seven postoperative days. The responses to questions about "overall QoL", "pain/discomfort", and "anxiety/depression" in the EQ 5D 3L tool were strongly correlated. The EQ 5D 3L is used to assess fluctuations in QoL during the early postoperative period after removal of third molars, and describes items that are perceived by patients to be more important than those recorded by the disease-specific OHIP-14 QoL questionnaire. It is therefore more relevant for counselling patients preoperatively. Development of measures of early outcomes after removal of third molars should incorporate generic items to remain useful.

An Interesting Association of Cystic Hygroma of the Neck and Lymphangioma Causing a Paediatric Swollen Tongue.

Up to 75% of lymphatic malformations occur in the head and neck region. Of these, cystic hygromas and lymphangiomas have been widely reported; however they rarely occur in the same patient. We report the case of a 5-year-old girl who presented to the Department of Paediatrics of a district general hospital with a short history of recurrent, painful swelling of the anterior one-third of her tongue. She was reviewed under the joint care of the Oral and Maxillofacial Surgery and Otolaryngology Teams. Relevant past medical history included a previously excised cystic hygroma from her right neck when she was aged 2 years. Diagnosis of lymphangioma was made and of the potential management options available active monitoring was favoured due to the patient's age. To our knowledge the occurrence of both tongue lymphangioma and cystic hygroma has not been previously reported in a paediatric patient. This case report therefore shows a rare association between a cystic hygroma of the neck and lymphangioma of the tongue.