Happy New Year! I hope you had a peaceful Christmas and are all set to take on 2019. I thought this would be a good time to update you on Council activity and also remind you of up and coming events for this year.
Rita, Ruth and Shelley continue to work hard behind the scenes. Sophie is due back from maternity leave in April – a big thank you to Ruth for covering so efficiently.
Annual Conference 2018 & 2019
2018 was another greatly enjoyable Edinburgh meeting. Thank you for all your feedback – we have certainly taken this on board in the planning of our Bristol meeting this September. A lot of the feedback related to the cost of the delegate fees – it is nearly impossible to produce a high-quality conference for a low delegate fee and Council strives to maintain a reasonable balance between the two. We just broke even in 2018 so I can assure you that every penny of your delegate fee is invested in the conference. Neither do Council get free entry – everyone pays to attend except the speakers and the admin team.
As for Bristol 2019, we are planning to try and keep costs down whilst still providing an outstanding academic programme – initial details are on the website https://www.baos.org.uk/annual-conference-2019/ and the programme will be up by March.
Paul Coulthard organized a very successful second BAOS commissioning day in Manchester on Tuesday 6th November. Representatives from the English and Welsh CDO offices attended as well as MCN chairs, LDN chairs and commissioners. David Geddes appeared positive and supportive and he and Eric Rooney presented along with Rhian Jones, Vas Sivarajasingam and Victoria Taylor from Wales. Ben Squires, Tariq Drabu and Paul Coulthard presented from Manchester. The day went well with a good mix of people and lots of positive interaction.
We are still working with the BDA regarding the GDC CESR mechanism for entry onto the Specialist lists and have a meeting with the GDC later this month.
Welsh Oral Surgery is progressing well thanks to very positive communication between Adrian Thorp, Rhian Jones and Colette Bridgman, the Welsh CDO.
The Journal committee have made the difficult decision to discontinue paper copies of the Journal this year (also agreed at the 2018 AGM). I know this will come as a disappointment for many (myself included). However, I support this decision most importantly because of the carbon footprint of our Journal (printed in Singapore and shipped over with a non-recyclable cover). A digital version will not have nearly the same environmental impact (and will be consistent with 97% of the other Journals Wiley produces which are exclusively on-line). Wiley are developing an app through which Members will be able to download and read the Journal. The Journal is currently available to view online through the Members’ area – past copies are also available. The office will notify Members when each new edition is available.
Dr Helen Petersen, Editor-in-Chief, has planned a special ‘pain’ edition of the Oral Surgery Journal for later this year which is being guest-edited by Professor Justin Durham. Application to Medline will go ahead in 2020.
Eligibility to sit MOral Surg
We wrote to the Tri Collegiate Board in November 2018 regarding eligibility to sit the MOral Surg exam (the mechanism that allowed candidates to sit the exam by portfolio application was unaccountably removed in 2012, making it difficult for SAS grades to objectively demonstrate appropriate knowledge via a nationally accredited examination). Unfortunately, the reply was not what was hoped for and the Board declined to change the current criteria. We have written again requesting clarification with regard to their decision and will keep you informed of the outcome. The letters are available on our website: https://www.baos.org.uk/for-professionals/.
E-learning and training
Greg Gerrard and Adrian Thorp are collaborating with the DDU with regards to a joint e-learning module (similar to this https://www.theddu.com/learn-and-develop/free-cpd-modules-from-the-bsp-and-the-ddu) which should be a great tool for practitioners as well as giving guidance on preventing and managing nerve injuries.
Greg Gerrard, Tara Renton, Nikolas Palmer and Noha Seoudi have written a series of antimicrobial e-learning modules https://www.baos.org.uk/elearning/ which give interactive accredited CPD along with links to the latest evidence for gold standard antimicrobial prescribing. These have been hugely successful and have not only been highlighted in the FGDP’s response to the draft Northern Irish AMR 5 year action plan but also referenced by the GDC in their update for anti-microbial prescribing. BAOS, FGDP and ACOM were the three named Dental organisations who supported World Antibiotic Awareness Week and the modules were also referenced in the press release for this. Greg is in communication with some Spanish colleagues who are keen to adapt them for Spain. This is terrific for BAOS – many thanks to all the authors.
Our website is constantly refreshed, and updated versions of our patient information leaflets will soon be available. Members can also access the BAOS King’s College surgical teaching videos – a great training resource (please see the Members’ area to access these).
We also have a Core CPD course planned for May in Leeds (free to the Regional Reps to thank them very much for all their hard work – details out soon), a joint meeting with RCSI, ABAOMS and IAOS in November in Belfast, Regional Study Days planned for the next three months https://www.baos.org.uk/events/, another ‘Training the Trainers’ course planned for November and, of course, our 2019 Annual Conference in Bristol – no shortage of great CPD and networking opportunities!
I would like to thank Council so much for all their hard work for the Association – I am extremely proud to be working with such an active, engaged and dynamic group. A special thank you to Pete Brotherton, and Mark Gormley, stalwart members of Council who left us at the end of 2018 and a very warm welcome to Judith Jones and Sarah Ali who join us at the start of 2019.
A very happy, healthy and prosperous New Year to you all!
With very best wishes
BAOS Council Member
Look at how oral surgery is developing in its own right! Our most recent list of consultants in the specialty now numbers over 100 and the numbers are rising. NHS Trusts are finally realising the benefits of employing consultants in terms of service improvement, clinical governance, training of junior staff and waiting list management, and of course primarily in order to improve patient care. It is encouraging to see that many district general hospitals are now appointing consultants – these were previously the preserve of only OMFS consultants.
Teamwork – none of us work in isolation and developing and maintaining close working relationships with our professional colleagues is vital. Oral surgeons bring a unique set of skills, which are a valuable asset to any team. The BAOS CAST (Consultant and Senior Trainers’ Group) aims to support both consultants and senior trainers throughout their careers. We acknowledge the history of oral surgery and the difficulties that senior colleagues have and indeed do still face in gaining recognition of their skills and in securing consultant posts. Our meeting at the Conference in September 2018 was well attended and several issues were discussed, this group will link directly to Council and we have links with the BDA.
With increasing consultant numbers we have greater opportunities to have our voices heard and to drive the agenda for the benefit of both our patients and our working lives. In an ever-changing NHS and healthcare landscape, this has never been more important.
BAOS Council Member
Oral Surgery on the Move
Within my locality there appears to be a growing demand for the provision of oral surgery within private practice undertaken by oral surgeons. The obvious benefits are the treatment of patients within their own practice setting, assisted by familiar faces, which helps to relive patient anxiety. It also generates practice income and avoids delays in patients receiving treatment. What are the benefits for us?
I enjoy providing a peripatetic oral surgery service to my local region. I have a box of essential equipment including my surgical motor and a few favoured luxators, which I transport from place to place. I provide a kit list to the practice to ensure that my basic surgical instruments and consumable items are all available when needed, although you’d be surprised how many times I am handed a clip to suture with! I work on a fixed rolling rota every 2 weeks, so my diary is set and organised many months in advance. I am able to review my diary beforehand, so I avoid any inappropriate referrals and I can divert referrals as necessary.
I find that patients are more confident and relaxed within their own familiar dental environment and are well supported due to the existing report with staff. Treatment plans can be discussed directly with the clinicians and modified accordingly. I enjoy the variety of my job plan and find it very rewarding, although Christmas party time can be more complex when negotiating dates between 7 practices!
BAOS Council Member
How and why we got to Montgomery
A breach of duty in negligence is found to exist where the defendant fails to meet the standard of care required by law. The objective test, which is also known as the reasonable man test was set out in Blyth v Birmingham Waterworks Company (1856) 11 Ex Ch 781, where the defendant is expected to meet the standard of a reasonable prudent person.
There are though many opportunities in law where the level of this standard of care can be raised (or lower) as the individuals have represented themselves as having more (or less) than average skills or abilities. For example a learner driver is expected to meet the same standards as a reasonable competent driver Nettleship v Weston  2 QB 691 even though not fully qualified. In comparison as in medicine or dentistry, the standard of care of the individual is increased compared with that of a reasonable person.
The initial test that became enshrined in law as the benchmark for medical negligence was ‘The Bolam Test’ Bolam v Friern Hospital Management Committee  1 WLR 582. It was used to disclose all risks including any treatment, and a test for breach, was therefore, whether a responsible body of medical opinion would have supported the doctor’s conduct.
The drawback was that it gave legal sanctions to self-regulation for the medical profession not the courts that decided what is ‘reasonable’. It seems therefore that the medical profession was above the law.
Bolitho v. City and Hackney Health Authority  4 All ER 771 turned Bolam on its axis and it was the courts that became the final arbitrator of a medical breach. It was established that a doctor could be liable for negligence despite a body or professional opinion sanctioning their conduct when the judge was not satisfied that the opinion relied on was reasonable or responsible.
It was determined by Lord Browne-Wilkinson that the assessment of professional negligence within the court setting must always consider expert medical opinions but these must not outweigh legal principles.
Although there has been a plethora of case law on negligence, moving forward to Montgomery v Lanarkshire Health Board  UKSC 11. This case gives uncertainty concerning whether the ruling has really clarified the position for both the medical profession and potential claimants.
The Courts initially rejected Montgomery’s case as evidence provided that a responsible body of medical opinion would have acted as the doctor and would not have warned of the risks. However the Supreme Court reversed the decision.
Montgomery means there is now a lengthy and meaningful discussion between doctor and patient of what amounts to ‘material risks’ including proposed treatment and alternatives giving the risks of both. The focus of material risk is determined by whether a reasonable person in the patient’s position would likely to attach significance to the risk.
Montgomery indicates what is being asked of the medical profession, is now clearly time-consuming; it is though deemed professional good practice.
There are reservations whether Montgomery has provided a new position or whether it merely confirms how the case law has progressed incrementally since Bolam. There is certainly a move towards the ‘reasonable patient’ being at the heart of the standards to apply rather than the standard being that of the reasonable doctor.
There are areas for discussion in Montgomery, as Lords Kerr and Reed during their judgment stated that material risks couldn’t be reduced to percentages as the significance of risk was determined by other variables as well as the magnitude of risk and would be different to all patients. Percentages though do form an integral part of risk assessment in medicine and therefore consideration must be given to these when talking to patient about inherent risks.
Clearly though, the judgment in Montgomery does reinforce that doctors should participate in a meaningful dialogue with each patient, and the their duty goes beyond mere provision of information.
We all sufferer failure occasionally with our local anaesthetic, especially with the so called “hot pulp” but do you know why and the how to overcome this? At the BAOS annual conference we had an excellent lecture from Professor Ken Hargreaves, Professor and Chair of the Department of Endodontics at the University of Texas in San Antonio. He provided the scientific explanation as to why this occurs and the solution.
Only 20-70% of IDB procedures are successful when treating inflamed mandibular molar pulps. The inflamed tissues within the pulp release prostaglandins that lead to hyperalgesia. The prescription of NSAID’S prior to undertaking potentially painful procedures will help by reducing the effects of the inflammatory markers, reducing patient pain and improving the effectiveness of local anaesthetic.
By supplementing a lignocaine IDB with an articaine buccal infiltration, you will achieve effective anaesthesia 3.6 times better than in combination with a lignocaine infiltration. When treating symptomatic irreversible pulpitis, articaine IDB provided no additional benefit to lignocaine IDB, so there is no advantage in utilising articaine as an IDN block, but there is a significant advantage to using it as a localised buccal infiltrate in order to achieve more predictable effective local anaesthesia.
In the midst of all this beautiful Summer sunshine and almost a year into my Presidency (though it feels like a month), I thought it would be good to update you all as to exactly what Council and the BAOS office have been doing for the past 8 months.
First and most importantly, BAOS would not exist without all our stalwart members – please do share any news, comments or feedback with us. We have a Twitter feed and Facebook page now so sharing has never been easier. It is always good for Council to hear from any members – if you think we can help with something (be it job advertisements, career advice or publications), please do ask.
Firstly, big thanks are due to Rita, Ruth & Shelley who have been working hard behind the scenes. They have had to contend with an office move as well as Sophie being off on maternity – (I was lucky enough to meet gorgeous baby Johnny in May). They all continue to do stalwart work with the co-ordination of all the Regional Rep Days, organisation of the Teaching and Learning Course as well as all the membership work and finances – not to mention the Annual Conference which fast approaches.
Thanks to Pete Brotherton and Andrew Clark (Nextnorth web design), BAOS now has a smart new website with our new logo and specially designed image (from my friend Amar Naru, a dentist and a superb medical illustrator) – please do check it out if you haven’t already and try and spot all the pathology!
Council representatives have had two positive and productive meetings with David Geddes, Head of Commissioning for NHSE, the upshot of which is that BAOS and NHSE are planning a joint second commissioning day in early November this year.
We also had a very productive meeting with the MDU and DDU last month. We plan to collaborate on some e-learning material on risk management in Oral Surgery for the new website which Greg Gerrard is kindly leading on.
We are also due to meet with Colette Bridgeman, Welsh CDO in September.
Specialist List and CESR
Pippa Blacklock and I wrote to the BDA on behalf of BAOS to ask them to address the issue with the GDC of lack of access for dentally qualified SAS grades to the Specialist List via the CESR route (medically qualified SAS grades all have a mechanism to apply to their lists via the GMC and CESR). We have been invited to attend a meeting in September arranged by the BDA for all Stakeholders to discuss this important issue and hope to make some progress.
Divya Keshani and our invaluable network of Regional Reps continue to do an outstanding job with organising study days across the country. Yorkshire and the West Midlands held great meetings last month with Scotland and the South East following in October and November of this year. The BAOS Regional Reps day will be held in London in December this year which allows us to thank the Regional Reps for all their hard work. There are some vacancies coming up so if you would like to apply, please keep an eye out – it is a great way to get involved with BAOS.
We also have a Core CPD Course planned for next year in Sheffield, a joint meeting with RCSI, ABAOMS and IAOS in November 2019 in Dublin and of course our 2019 Annual Conference in Bristol – lots of opportunity for great CPD and networking.
Annual Conference Edinburgh 2018
The annual conference this year is to be held in a new venue for us – the wonderfully appointed Edinburgh International Conference Centre (EICC). This is a bigger venue than the Royal College, which means we do not have to restrict delegate numbers. The outstanding academic programme and exceptional evening entertainment promise to make it a tremendous meeting. We have accepted 27 open papers and 80 posters for presentation.
The larger venue inevitably means costs have risen and Council are all aware of trying to contain costs for delegates whilst trying to provide a really high quality meeting which can be difficult, but we hope we have struck the right balance this year. I personally love attending the Conference, which is definitely the annual highlight for the Association. I have been to all bar one since the inaugural NCCG Nottingham meeting in 1998 and I have always found it a fantastic way to get my Oral Surgery CPD whilst catching up with old friends as well as making new ones. I really hope to see as many of you there as can make it. Roll on September!
With very best wishes to you all.
BAOS Council Member
Risk Reduction in Oral Surgery
Visiting the excellent ‘Teeth’ exhibition at the Wellcome Collection was a good reminder of just how much the profession of dentistry has changed. Removing teeth remains the mainstay of our work but the way we treat our patients with respect for their autonomy has completely transformed from the paternalistic approach of the past. The demands of treating today’s patients bring some challenges – chiefly a rising tide of litigation and a regulatory system that the GDC themselves recognise needs urgent reform1.
Representatives of Council and our President recently met with senior leaders at the Medical Defence Union to discuss issues of mutual concern. We are keen to find ways in which we can support our members to provide safe, effective care that leaves patients satisfied and avoid complaints and litigation. We practice in a risky area of dentistry, performing procedures that come with the certainty of unpleasant side effects and the possibility of complications that can affect patients for the rest of their lives. Much can be achieved by remembering the basics – be friendly, listen well, think of consent as a process (not an event) and write good notes.
Some hazards are harder to mitigate. For those members seeing the bulk of their patients on referral, there is the obvious immediate risk that we are meeting them for the first time. We have not had the opportunity to build up a reserve of goodwill over the years that many general dental practitioners can rely upon if problems with treatment arise. Since the ruling of Montgomery v Lanarkshire2, there is a greater expectation that we understand our patients as individuals and consider which risks they might attach particular significance to. This poses a significant challenge when we may have only 15 minutes with the patient and means we need some additional help from primary care colleagues in the detail of their referral to convey some of their knowledge of the patient.
Whilst there are many areas of our practice where the standard of care is easily established, there are some areas that attract more controversy and for many surgeons, uncertainty about which options to present to patients and how the risks and benefits should be framed. These include the role of coronectomy, the early management of nerve injuries and the necessity of cone beam imaging of high risk wisdom teeth (especially for colleagues without easy access to CBCT equipment).
We plan to create a joint e-learning package with the MDU on risk management in Oral Surgery which will hopefully prove as successful as the module that they have co-authored with the British Society of Periodontology. Council will also consider whether BAOS should provide best practice consensus guidelines in specific areas that are not covered by other guidance.
One specific area of concern from the MDU relates to their difficulty in defending cases where a nerve injury has been identified following wisdom tooth removal but no referral to a specialist nerve injury centre has been made. Many of these cases have been settled due to the lack of referral rather than the occurrence of the injury. This is certainly an area in which BAOS may be able to help by signposting members to centres providing these services along with a treatment algorithm depending on the nature of the injury.
In addition to these projects, there are already some great resources on our newly relaunched website about patient safety and LocSSIPs which should now be in use across dentistry to prevent wrong tooth extractions. We have also published revised patient outcome and experience measures that can help drive quality improvement for oral surgery providers in both primary and secondary care3.
1. General Dental Council. Shifting the balance: a better, fairer system of dental regulation. Updated 9 March 2017. Available at: https://www.gdc-uk.org/about/what-we-do/regulatory-reform (accessed May 2018).
2. Montgomery v Lanarkshire Health Board  SC 11  1 AC 1430.
3. Gerrard G, Jones R, Hierons RJ. How did we do? An investigation into the suitability of patient questionnaires (PREMs and PROMs) in three primary care oral surgery practices. British dental journal. 2017 Jul;223(1):27.
BAOS Spotlight article June 2018
CESR – Veni, vidi, vici?
The BAOS Council have been aware for some time now of the problem facing a large proportion of our Staff Grade, Associate Specialist and Speciality Dentists (SAS) members with regard to specialist list entry. As many will know, a large number of SAS missed being grandfathered onto the specialist list and despite providing high level Oral Surgery (OS) services in secondary care have no mechanism to apply for entry.
This is at odds with our medical SAS colleagues who do have a way to apply for specialist status via the GMC Certificate of Eligibility for Specialist Registration (CESR) route which has been functioning successfully for some years. In all other aspects of the grade there is no contractual distinction and national terms and conditions are exactly the same.
There will soon be a widening workforce gap in Oral Surgery as the older generation of specialists retire as there are not enough new specialists being generated at present to fill this gap. We currently have 41 specialist training posts generating around 13-14 new OS specialists a year – not nearly enough to deliver the service, teaching and training essential for good patient care.
This gap could potentially be filled by the large number of experienced Oral Surgery practitioners via a robust CESR route. To this end, BAOS have written to the BDA to ask for a review of the current systems in place for entry onto specialist lists. We very much hope that, in collaboration with the BDA, CCHDS and other Stakeholders, we can find a way forward via CESR that would benefit our speciality and ensure gold standard OS treatment for all. Unlike the hapless Julius, there may yet be a happy ending!