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Simple Summary Circulating tumour cells (CTCs) have shown potential to act as markers of disease and prognosis in head and neck squamous cell carcinoma (HNSCC). However, there are a number of methods and devices reported to isolate and characterise CTCs. Translating CTC markers to clinical practice, for patient benefit, requires a reliable, reproducible and standardised approach. We report the benefit of the Parsortix microfluidic CTC enrichment platform in HNSCC. We demonstrate consistent cell capture rates between 10 and 100 cells/mL of whole blood. Analysis of gene expression with unfixed cells before and after Parsortix enrichment demonstrated a cell stress response and downregulation of key genes. We highlight the benefit of using a fixative blood collection tube (Transfix) to increase cell capture rate and preserve the CTC marker expression profile. Such evidence is crucial when designing sample processing protocols for large cohort multi-centre clinical trials investigating CTCs in any cancer type. Abstract Introduction: Research demonstrates strong evidence that circulating tumour cells (CTCs) can provide diagnostic and/or prognostic biomarkers in head and neck squamous cell carcinoma (HNSCC) and a potential tool for therapeutic stratification. However, the question still remains as to the optimum method of CTC enrichment and how this can be translated into clinical practice. We aimed to evaluate the Parsortix microfluidic device for CTC enrichment and characterisation in HNSCC, seeking to optimise a sample collection and processing protocol that preserves CTC integrity and phenotype. Method: Spiking experiments of the FaDu and SCC040 HNSCC cell lines were used to determine the Parsortix capture rate of rare “CTC-like” cells. Capture rates of cancer cells spiked into EDTA blood collections tubes (BCTs) were compared to the Transfix fixative BCT and Cytodelics whole blood freezing protocol. The Lexogen Quantseq library preparation was used to profile gene expression of unfixed cells before and after microfluidic enrichment and enriched cell line spiked Transfix blood samples. An antibody panel was optimised to enable immunofluorescence microscopy CTC detection in HNSCC patient Transfix blood samples, using epithelial (EpCAM) and mesenchymal (N-cadherin) CTC markers. Results: Across a spiked cell concentration range of 9–129 cells/mL, Parsortix demonstrated a mean cell capture rate of 53.5% for unfixed cells, with no significant relationship between spiked cell concentration and capture rate. Samples preserved in Transfix BCTs demonstrated significantly increased capture rates at 0 h (time to processing) compared to EDTA BCTs (65.3% vs. 51.0%). Capture rates in Transfix BCTs were maintained at 24 h and 72 h timepoints, but dropped significantly in EDTA BCTs. Gene expression profiling revealed that microfluidic enrichment of unfixed cell lines caused downregulation of RNA processing/binding gene pathways and upregulation of genes involved in cell injury, apoptosis and oxidative stress. RNA was successfully extracted and sequenced from Transfix preserved cells enriched using Parsortix, demonstrating epithelial specific transcripts from spiked cells. In a proof-of-concept cohort of four patients with advanced HNSCC, CTCs were successfully identified and visualised with epithelial and epithelial-mesenchymal phenotypes. Conclusion: We have optimised a protocol for detection of CTCs in HNSCC with the Parsortix microfluidic device, using Transfix BCTs. We report a significant benefit, both in terms of cell capture rates and preserving cell phenotype, for using a fixative BCT- particularly if samples are stored before processing. In the design of large cohort multi-site clinical trials, such data are of paramount importance.

Simple Summary Tumor infiltrating lymphocytes (TILs) have been demonstrated as prognostic biomarkers in multiple cancer types. Among the various TIL phenotypic sub-populations, T-cells are most abundant. Several studies have investigated the prognostic value of CD4+ and CD8+ T-cell TILs in head and neck squamous cell carcinoma (HNSCC). In this study we performed a systematic review and meta-analysis of available evidence for CD4+ and CD8+ TIL biomarkers in HNSCC. The primary aim was to investigate the correlation of TIL sub-population levels and overall survival in HNSCC anatomical sub-sites. We demonstrate for the first time that tumor location has a significant impact upon the prognostic utility of CD4+ and CD8+ TILs in HNSCC. Such data is of critical importance when incorporating TIL biomarkers into current prognostic models and clinical practice. Abstract Objective: It has been suggested that the presence of tumor-infiltrating lymphocytes (TILs) in the tumor microenvironment is associated with a better prognosis in different types of cancer. In this systematic review and meta-analysis, we investigated the prognostic role of CD4+ and CD8+ TILs in head and neck squamous cell carcinoma (HNSCC). Methods: PubMed, Cochrane, Embase, Scopus, and Web of Science were searched up to September 2020. This study was conducted following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) checklist. Risk ratios from individual studies were displayed in forest plots and the pooled hazard ratios (HR) of death and corresponding confidence intervals (CI) were calculated according to random-effects models. Risk of bias of the included studies was assessed through the Newcastle–Ottawa scale. Results: 28 studies met the inclusion criteria. Studies conducted on HNSCC subsites combined reported a significant reduction in the risk of death for both high CD4+ (HR: 0.77; 95% CI: 0.65–0.93) and high CD8+ TILs (HR: 0.64; 95% CI: 0.47–0.88). High CD4+ TILs were associated with significantly better overall survival among oropharyngeal HNSCC (HR: 0.52; 95% CI: 0.31–0.89), as well as high CD8+ TILS in Human papillomavirus −ve and +ve cancers (HR: 0.39; 95% CI: 0.16–0.93 and HR: 0.40; 95% CI 0.21–0.76 respectively). CD8+ TILs were also associated with improved survival in hypopharyngeal cancers (HR = 0.43 CI: 0.30–0.63). No significant association emerged for patients with cancer of the oral cavity or larynx. Conclusions: The findings from this meta-analysis demonstrate the prognostic significance of CD8+ and CD4+ TILs in HNSCC and variation in tumor subsite warrants further focused investigation. We highlight how TILs may serve as predictive biomarkers to risk stratify patients into treatment groups, with applications in immune-checkpoint inhibitors notable areas for further research.

Rates of loco-regional recurrence and distant metastasis remain high among head and neck squamous cell carcinoma (HNSCC) patients, despite advancing cancer treatment modalities and therapeutic agents. One area that has generated considerable interest is the immune landscape of the tumour, heralding a wave of immune checkpoint inhibitors with notable efficacy in recurrent/metastatic HNSCC patients. However, HNSCC remains poorly served by biomarkers that can direct treatment in a personalised fashion to target the tumour heterogeneity seen between patients. Detection and analysis of circulating tumour cells (CTCs) in HNSCC has provided a previously unseen view of the metastasis forming cells that are potentially contributing to poor clinical outcomes. In particular, identifying CTC expression of phenotypic and druggable protein markers has allowed CTC sub-populations to be defined that hold prognostic value or are potential therapeutic targets themselves. The aim of this systematic review was to examine the role of CTC immune-marker expression as prognostic/therapeutic biomarkers in HNSCC by evaluating progress to date and discussing areas for future research. Our results highlight how few studies have been able to demonstrate prognostic significance of immune-marker expression in CTCs. As expected, the immune checkpoint PD-L1 was the most widely investigated marker. However, no studies evaluated CTC target immune marker expression in immunotherapy cohorts. Despite these findings, the data presented demonstrate promise that CTCs may be a source of future biomarkers for immunotherapy and will provide valuable information regarding the potential immune evasion of these metastasis forming cells.

Oral and Maxillofacial Surgery (OMFS) remains an enigmatic specialty in Irish medicine and many students are unaware of its scope and the unique career pathway involved. We completed a multicentre cross-sectional study to identify their ability to identify the requirements for entry to specialty training year 3 (ST3) in OMFS, to assess their awareness of OMFS surgeons, and their general awareness of, and exposure to, the specialty. Data were collected through an electronic questionnaire. Participants were asked to select the most suitable surgical specialty to treat a number of common conditions in the head and neck, and to choose the requirements they deemed essential for specialist training. Knowledge was measured by the number of correct responses. A total of 443 medical students participated (University College Cork (UCC) n=328, 74%; Royal College of Surgeons in Ireland (RCSI) n=113, 26%). A total of 318/374 (85%) had had no previous experience of OMFS, 38/374 (10%) had had theoretical teaching only, and 18/374 (5%) had had clinical experience. A total of 212/329 (64%) wished for greater exposure as a student, but only 34/329 (9%) would consider a career in the specialty. The median (IQR) number of correct responses for OMFS procedures was 3.0/10 (2.0), with women, direct entrants, and RCSI students scoring highest. Only 11/367 (3%) could identify the minimum entry requirements for a post of specialist registrar. This study has identified a potential gap in the undergraduate curriculum. Although medical students are rarely taught about OMFS, they show an interest in learning more.

BackgroundCpG methylation in cancer is ubiquitous and generally detected in tumour specimens using a variety of techniques at a resolution encompassing single CpG loci to genome wide. Analysis of samples with very low DNA inputs, such as formalin fixed (FFPE) biopsy specimens from clinical trials or circulating tumour DNA has been challenging and has only been typically at single CpG sites. Analysis of genome wide methylation in these specimens has been limited because of the relative expense of techniques need to carry this out. We present the results of low input experiments into the Illumina Infinium HD methylation assay on FFPE specimens and ctDNA samples.MethodsFor all experiments, the Infinium HD assay for Methylation was used. In total, forty-eight FFPE specimens were used at varying concentrations (lowest input 50ng), eighteen blood derived specimens (lowest input 10ng) and six matched ctDNA input (lowest input 10ng) / fresh tumour specimens (lowest input 250ng) were processed. Downstream analysis was performed in R/Bioconductor for QC metrics and differential methylation analysis as well as copy number calls.ResultsCorrelation coefficients for CpG methylation at the probe level averaged R2=0.99 for blood derived samples and R2>0.96 for the FFPE samples. When matched ctDNA/fresh tumour samples were compared R2>0.91. Results of differential methylation analysis did not vary significantly by DNA input in either the blood or FFPE groups. There were differences seen in the ctDNA group as compared to their paired tumour sample, possibly because of enrichment for tumour material without contaminating normal. Copy number variants observed in the tumour were generally also seen in the paired ctDNA sample.ConclusionsThe Illumina Infinium HD methylation assay can robustly detect methylation across a range of sample types, including ctDNA, down to a input of 10ng. It can also reliably detect oncogenic methylation changes and copy number variants in ctDNA.

Open access (OA) publication has become an increasingly common route for dissemination of scientific research findings. However, it remains a contentious issue with continued debate as to its impact on the peer-review process and a potential change in the quality of subsequent evidence published. There is little research that looks into OA in oral and maxillofacial surgery.We investigated the OA policy in the 30 relevant journals listed in the Institute for Scientific Information Web of Knowledge journal citation report, comparing bibliometric data and quality of evidence produced in journals offering OA and those with subscription-only policies.3474 articles were graded for evidence level and the results correlated to journal OA status. 76.7 % of journals offered authors OA services. There was no difference between impact factor, self-citation rate, total citations or quality of evidence between OA and subscription journals.These findings should send clear messages to both clinicians and researchers and should re- assure readers that scientific findings that are disseminated in open access form do not differ in quality to those in subscription-only format. It should reinforce that open access formats are a credible way to display research findings in oral and maxillofacial surgery.

Graphical abstract, Predictive tools, utilising biomarkers, aim to objectively assess the potential response to a particular clinical intervention in order to direct treatment. Conventional cancer therapy remains poorly served by predictive biomarkers, despite being the mainstay of treatment for most patients. In contrast, targeted therapy benefits from a clearly defined protein target for potential biomarker assessment. We discuss potential data sources of predictive biomarkers for conventional and targeted therapy, including patient clinical data and multi-omic biomarkers (genomic, transcriptomic and protein expression). Key examples, either clinically adopted or demonstrating promise for clinical translation, are highlighted. Following this, we provide an outline of potential barriers to predictive biomarker development; broadly discussing themes of approaches to translational research and study/trial design, and the impact of cellular and molecular tumor heterogeneity. Future avenues of research are also highlighted.

Head and neck squamous cell carcinoma (HNSCC) manifests in the mucosal epithelial lining of the oral cavity, oropharynx, hypopharynx, nasopharynx or larynx and has a tremendous disease burden worldwide. Smoking and alcohol consumption were once major risk factors, but HPV-associated infection has emerged as the major contributor to HNSCC occurrence in developed countries. Circulating biomarker evaluations in biofluids, also known as liquid biopsy, are an attractive alternative for cancer screening as they are minimally invasive, potentially low cost, and easily repeatable on a serial basis. This review summarizes the current knowledge and potential of assessing circulating blood and salivary HPV DNA and HPV antibodies for the surveillance of HPV-positive HNSCC. Additionally, the biological underpinnings of the presence and relevance of circulating HPV DNA is discussed.

Oral ranulas are cysts in the floor of the mouth that result from the extravasation of mucous. Historically there has been little consensus on the ideal first-line treatment, but currently, definitive treatment involves excision of the sublingual gland, which can injure the lingual nerve and submandibular duct. Minimally invasive surgical alternatives such as marsupialisation have been proposed, but so far have been associated with a high rate of recurrence. The aim of this pilot study was to evaluate the success of a simple, modified suture technique for the treatment of oral ranulas that can be done in the outpatient department. We retrospectively analysed outcomes after the technique was used as a first-line treatment in 15 consecutive patients between 2011 and 2013. Although 2 attempts were needed in 4 patients, complete resolution of the ranula was seen in 13. Other than the need for a second attempt, and recurrent failure in 2 cases, there were no complications. This minimally invasive and quick procedure is a suitable first-line alternative to other less successful or higher risk options.

This review summarises all orthognathic and related papers published between January 2011 and December 2012 in the British Journal of Oral and Maxillofacial Surgery (BJOMS). A total of 36 articles were published, a high proportion of which (78%) were full-length papers. The remainder consisted of short communications and technical notes. The topics included operative planning and postoperative outcomes, and there was a strong focus on distraction osteogenesis. There were fewer orthognathic articles published in BJOMS than articles on other subspecialties such as trauma or head and neck oncology. Only 8 (29%) of the full-length articles were prospective studies or randomised trials, which highlights a need for well-designed clinical studies in orthognathic research.

This paper is a synopsis of all articles relating to oral surgery that were published in the British Journal of Oral and Maxillofacial Surgery (BJOMS) between January 2011 and December 2012. Of the 57 published, 40 (70%) were full-length articles that predominantly focused on implantology, dentoalveolar surgery, and bisphosphonate osteonecrosis of the jaws (BONJs). In addition, a number of short communications, technical notes, and letters to the editor described rare cases, unusual complications, and novel surgical techniques.

The use of circulating biochemical molecular markers in head and neck cancer holds the promise of improved diagnostics, treatment planning, and posttreatment surveillance. In this review, we provide an introduction for the head and neck surgeon of the basic science, current evidence, and future applications of circulating tumor DNA (ctDNA) as a biomarker and liquid biopsy to detect tumor genetic heterogeneity in patients with head and neck squamous cell carcinoma (HNSCC).

Tissue engineering is a rapidly advancing discipline that combines the attributes of biochemical and biomaterial engineering with cell transplantation to create bio-artificial tissues and organs. For the oral and maxillofacial surgeon, the reconstruction of maxillofacial defects in hard and soft tissues is an ongoing challenge. While autologous grafts and vascularised free flaps are the current gold standard, they are not without complications at both the donor and reconstructed sites. Tissue engineering, which aims to create tissue-matched, prefabricated, prevascularised bony or soft tissue composite grafts, or both, therefore has the potential to revolutionise practice in maxillofacial surgery. We review the technology of tissue engineering and its current and future applications within the specialty, and discuss contemporary obstacles yet to be overcome.

Introduction Oral and maxillofacial surgery (OMFS) trainees in the UK have traditionally completed their dental undergraduate studies prior to returning to medical school. Recently, there have been increasing numbers of medical graduates who return to dental school before embarking on OMFS specialist training. There is limited research into the career motivation within this group and little guidance on how they may integrate the dental undergraduate course into their postgraduate training path. This study aims to evaluate these factors in more detail. Methods Questionnaires and focus groups were used to evaluate prior surgical experience of qualified medics who return to dental school with the intention of pursuing a career in OMFS, along with the factors that affect the timing of their return to dental school. Results The average age of medical graduates entering dental school decreased during the study period. The average number of months each cohort of students spent as a practicing doctor prior to starting dentistry also reduced. Postgraduate experience in OMFS was highly variable, but the numbers of students who received alternative exposure to OMFS, such as undergraduate special study modules, medical school elective or taster weeks, increased. The key barriers that were carefully considered by these trainees before returning to university included the perceived increase in the length of training, trainees' prior surgical experience, financial implications and the impact on quality of life. Conclusions A trainee's decision to return to study dentistry is a multifactorial process. Understanding when trainees decide to return to sit their dental degree is vital not only to provide guidance for future trainees but also to assist future workforce planning, thus aiding training, education and development within OMFS.

Oral epithelial dysplasia grading is currently recognised as the most useful prognostic indicator for predicting conversion of potentially malignant disorders of the oral cavity to squamous cell carcinoma. It is also used as a basis for deciding management options. However, the diagnosis of oral epithelial dysplasia is subjective and thus unreliable. Surgery is currently recommended for removal of high-risk lesions; however, the evidence for its success is lacking, and in some cases, there have been reports of increased recurrence of malignancy following surgical excision. Molecular and genetic markers have been identified and show promising results in identifying which potential malignant disorders are at risk of malignant transformation. The current evidence available for prognosis of potential malignant disorders and its treatment is based on observational and retrospective data. No randomised control trials have been conducted to date to assess the efficacy of surgery in oral epithelial dysplasia. Until good quality evidence is available from well-designed randomised control trials, experts still recommend the surgical removal of potential malignant disorders which are regarded as high risk.

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a chronic condition of the oral cavity resulting in mucosal ulceration and exposure of underlying necrotic bone, and the ensuing secondary complications. As a relatively newly recognised condition, the epidemiology of BRONJ is poorly described. In a 2012 position statement by the UK Faculty of General Dental Practice, an estimated incidence of 10 patients per year per million population was stated.1 This would indeed classify it as a rare condition, with a GP expecting to see only a handful of cases in their career. However, with increased numbers of patients on bisphosphonate (BP) therapy, all GPs should be aware of the risk factors for BRONJ and the pre-assessment advice they give to patients commencing BP therapy. BPs inhibit the action of osteoclast cells, decreasing bone turnover and increasing bone density.2 The mechanism by which BPs cause osteonecrosis is not proven but is probably due to a combination of decreased bone remodelling, poor wound healing, and an antiangiogenic effect leading to ischaemic changes and subsequent necrosis in response to a local traumatic insult.2 The main indications for the use of BPs are for the treatment of post-menopausal osteoporosis, steroid-induced osteoporosis, Paget’s disease, and the complications of metastatic bone lesions and multiple myeloma, namely, hypercalcaemia and bony pain. It is outside the scope of this article to discuss BP …

This case report presents an unusual incidental radiographic finding on a dental panoramic radiograph that caused diagnostic confusion. A 46-year-old female presented with symmetrical sclerotic cortical thickening of the anterior mandible visible on radiograph, with no other major clinical examination findings. The patient subsequently showed no change in radiographic appearance over a 6 year period. Based on this evidence, and the benign nature of the history, we propose a diagnosis of Worth syndrome. This report aims to clarify the difference in terminology and presentation of two conditions known to produce mandibular osteosclerosis: Worth syndrome and Van Buchem disease, both of which are often quoted synonymously in the literature.

We present a pilot study to investigate the impact of introducing a hospital-specific smartphone application into a cohort of British junior doctors. We created the iPhone application ‘iTreat’ that contained disease management and antibiotic dosing guidelines specific to our hospital, together with a postgraduate education department really simple syndication feed, a contact number phonebook and a favourites section. This intervention was trialled in a group of 39 foundation grade junior doctors, in a UK hospital, for a time period of 4 months. Mixed methods data capture, utilising survey and semi-structured interviews, was used to evaluate application usage patterns and potential barriers to endorsement of smartphone technology in the hospital setting. Sixty eight per cent of participants felt the application saved them time during clinical activities, with a decrease in the frequency of participants not referring to hospital clinical guidelines. The findings from this pilot study point towards the internal hospital environment as having a major impact upon smartphone usage. Participants viewed smartphone use as unprofessional in the ward-based setting, with a perceived negative attitude from other healthcare staff. An understanding of how healthcare staff choose to utilise smartphones in the clinical environment is crucial to enable the successful assimilation of smartphone technology into the hospital setting. This pilot study provides experience and parameters for future substantive studies being carried out by this group.

Standard magnetic resonance imaging (MRI) and computed tomography continue to be the imaging modalities of choice in staging and reviewing patients with head and neck cancer. Diffusion-weighted MRI (DW-MRI) is an advanced imaging modality that records the molecular diffusion of protons and thus provides an opportunity to further assess tissue character. Interest in DW-MRI of the head and neck continues to grow, especially its application to the assessment and treatment of head and neck cancer. We highlight the potential role of DW-MRI in the delineation, characterization, and lymph node staging of head and neck tumours. Furthermore, we discuss the ability of DW-MRI to provide a real opportunity to differentiate post-treatment tumour recurrence from chemoradiotherapy-induced local tissue changes. The future impact of these findings upon the clinical practice of the head and neck surgeon is discussed.

This review summarises the articles relating to the temporomandibular joint (TMJ) that were published in the British Journal of Oral and Maxillofacial Surgery (BJOMS) between January 2011 and December 2012. In total 24 papers were published. Of these, 16 (67%) were full-length articles, which included prospective, retrospective, and laboratory-based studies as well as reviews. The remaining 8 papers were short communications, technical notes, and letters to the editor, which report on, amongst other things, unusual cases, rare complications, and novel surgical techniques.

The rise in popularity of smartphones has seen a surge in the number of smartphone-specific software applications (apps) available. Among these apps, many are medical and healthcare related, of benefit to both the general public and healthcare staff. With this improved technology comes the ability to display full-colour images and videos, for which medical images could be utilised. We reviewed current clinical photography guidelines in relation to the publishing of medical images in smartphone apps. Of the 5 relevant guidelines, none discussed hand-held electronic media or smartphone app publishing. This creates confusion for clinicians as to how to interpret current guidelines for this purpose. Medical illustrators, clinicians and NHS Trusts need to be aware of the changes in technology and the ethical considerations of allowing medical images to be published within smartphones. We discuss the issues surrounding consent and provide practical tips for obtaining informed consent from patients to publish medical images in smartphone apps.

This review summarises all trauma and related papers published in the British Journal of Oral and Maxillofacial Surgery (BJOMS) from January 2010 to December 2011. In total 45 articles were published, of which 42% (19) were full-length articles. These articles primarily focused on the management of mandibular condyle and orbital fractures, with several papers discussing maxillofacial surgery by the British military. There were no articles discussing midfacial fractures or massive facial trauma. The remaining papers included short communications, technical notes, and letters; and provided discussion of interesting cases, new surgical techniques and fracture classifications. The number of trauma papers published in BJOMS appears to be less than other sub-specialties such as head and neck oncology. The number of prospective and randomised studies remains low, highlighting a need to foster further research within maxillofacial trauma.

Background and purpose of the study Although traditionally a "dentistry first, medicine second" training route, UK Oral and Maxillofacial surgery is increasingly populated with medicine-first trainees at ST3 level. Despite this, there is little evidence suggesting any increase in exposure at medical undergraduate level. We sought to evaluate the current level of awareness of OMFS as a medical specialty and potential career pathway amongst ‘first-degree' medical undergraduates. Method We distributed an on-line survey amongst 253 medical undergraduates divided between two UK universities. Findings A total of 72.3% of undergraduates received no exposure to OMFS in any form. Those with exposure had an improved understanding of the scope of the specialty. Regardless of previous exposure to the specialty, only 27.7% correctly identified the essential requirements for entry in OMFS specialty training. Nevertheless, a vast majority (76.7%) wanted more guidance on the possibility of pursuing a career in OMFS. Conclusions Undergraduate exposure to OMFS in UK medical schools is limited. Even a small degree of exposure to OMFS improves understanding of the scope of the specialty. Although medical students do not fully understand the career pathway, they wish to explore OMFS as a career option. It is therefore important that UK undergraduate surgical curricula offer greater exposure to the specialty, the career pathway and the clinical opportunities it can provide.

The operative note needs to be an accurate and legible account of events occurring in the surgeon's theatre. We set out to discover if operative notes within a British District General Oral and Maxillofacial Surgery department adhered to Royal College of Surgeons (England) guidelines.We audited 100 consecutive Oral and Maxillofacial Surgery operations performed within general theatres. As an intervention we designed and piloted a paper based Operative Note Proforma and re-audit was undertaken.Initial audit showed results lacking in certain areas. At re-audit all audit criteria showed improvement. The mean percentage of data point inclusion rose from 76.1 to 98.3% (0.001 P-value 0.005).Previous papers have discussed various methods of improving operative note standards. We present statistical evidence for the use of an Operative Note Proforma to improve operative note standards within Oral and Maxillofacial Surgery.

Oral and maxillofacial surgery has the longest training pathway of any medical specialty in the UK. Peter Brennan and colleagues look at ways to shorten this