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We studied the progression from dysplasia to invasive carcinoma and subsequent second primaries or locoregional recurrences in 11 patients with recurrent squamous cell carcinoma (SCC). Between one and six samples were sequenced/patient. DNA samples were prepared, and libraries multiplexed to between 40 and 80 samples/lane of an Illumina HiSeq 3000 and sequenced with 2 × 100 bp paired end sequencing. Copy number data were generated by CNAnorm (Bioconductor package). Samples of recurrent SCC showed unique patterns of descent when compared with earlier samples from the primary tumour, and three main patterns emerged. In four patients there was convincing evidence that the later lesion was descended directly from cells from the first, and in a further four there were no detectable genomic events between the two lesions. Three patients had some shared events between the early and later lesions, but although there were enough differences to deduce that the two lesions had a shared ancestor, they were not directly descended from each other. We present the patients’ characteristics in detail, including the overall survival in each group. There was a distinct genomic pattern after a second episode of SCC in all the groups. A larger study that uses similar methods and a longer duration could provide reliable conclusions with respect to survival. With the use of new techniques, genomic data can be available to clinical teams during the planning of treatment.

Oral squamous cell carcinoma is the most common intraoral malignancy, for which we advocate radical primary resection with adjuvant treatment where indicated. The main aims of this paper are to identify the overall survival of a consecutive series of patients and to relate survival to clinical and pathological factors. Kaplan-Meier curves were produced for site, sex, TNM status, and use of postoperative radiotherapy. The data were analysed using IBM SPSS Statistics for Windows and probabilities of less than 0.05 were accepted as significant. A total of 921 patients were recorded in the database with a diagnosis of oral squamous cell carcinoma out of a total of 1958 with salivary gland conditions or other cancers of the head and neck (43.1%). The earliest date of diagnosis was 1973, and the data were censored at 31 March 2016. The database comprised 340 women (36.9%) and 581 men (63.1%). A total of 339 patients died (34.5%): 117 women (33.7%) and 222 men (65.5%). The mean (range) age at death was 73.4 (31.4-97.5) years for women and 68.7 (33.3-95.5) years for men (t (337)=3.28, p=0.001). Our overall survival was somewhat better than the 56% five-year survival reported for oral cancer in England in 2010, which may be a reflection of the treatment. This work supports the view that aggressive management may improve overall survival.

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.

The Adult Comorbidity Evaluation (ACE)-27 is a validated scoring system for comorbid conditions. We have evaluated the correlation between it and the duration of hospital stay, readmission within 30 days, complications, and two-year survival in patients having primary surgical treatment for squamous cell carcinoma (SCC) of the head and neck. We studied patients with SCC who had selective neck dissection, resection of the tumour, and reconstruction between 2007 and 2013. Patients who had palliative procedures were excluded. We studied the casenotes of 231 patients and recorded the following outcome measures: TNM staging, ACE-27 score, number of days spent in hospital, readmission within 30 days, complications, and mortality at two years.The relation between the ACE-27 score and duration of hospital stay was significant (p=0.000001). The relations between complications and ACE-27 score, and complications and tumour stage, were also significant (p

In the surgical management of oral squamous cell carcinoma (SCC) we aim to resect the tumour with clear margins in all planes. The aim of this study was to identify and compare overall survival in a group of 591 patients who had resections, and to relate this to the clearance of margins at the tumour bed. We used life tables to calculate survival at one, two, three, five, and 10 years after diagnosis by margin (clear=5mm or more; close=2-5mm; and involved=less than 2mm). Kaplan-Meier curves were produced for the margins alone, which were defined as clear in 480 patients (81%), close in 63 (11%), and involved in 48 (8%). Five-year survival was 81%, 75%, and 54% for clear, close, and involved margins, respectively, which highlights the importance of clear margins for survival. There is a significant prognostic implication associated with close, and particularly with involved, margins.

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.

Oral dysplastic lesions may have an increased chance of becoming oral squamous cell carcinoma, but to date their management remains controversial. The aim of this survey was to explore the current practical aspects of the management of patients with dysplasia by oral and maxillofacial consultants in the UK. In the survey we asked consultants about the numbers of patients they see with oral premalignant lesions, the frequency and specialty of designated hospital clinics, their use of photographs and biopsy, factors that influence their decision whether to biopsy a lesion at the first appointment, the procedure for treatment and follow-up and their use (if any) of chemopreventive agents. We found a wide variation in the practical aspects of managing patients with dysplasia, and the lack of consistency among clinicians supports the idea of an initiative to establish more robust national guidelines to use as a gold standard in the future.

Histological analysis of tumour resection for squamous cell carcinoma (SCC) of the tongue yields prognostic information. We analysed histological slides of biopsy and tumour resection specimens using an adapted malignancy grading score and analysed variables of neck dissections. There was moderate correlation between biopsy and tumour resection using malignancy grading scores (correlation coefficient 0.45); good agreement of tumour grade (79%), tumour depth (76%), and type of invasive front (80%), but correlation was only fair to moderate (κ = 0.38, κ = 0.51, and κ = 0.41, respectively). Correlation of the biopsy grading score and invaded nodes in the neck, extra capsular spread, and soft tissue disease was not significant.

Patients who present with squamous cell carcinoma (SCC) in the head and neck have a serious risk of coincident thoracic malignancy. The aim of this study was to identify the incidence of thoracic malignancy in newly diagnosed, previously untreated, oral and oro-pharyngeal SCC, and to evaluate the role of thoracic computed tomography (CT) in its management. Of 116 consecutive patients who were identified prospectively 81(70%) had oral and 35 (30%) oropharyngeal SCC. Ten patients (9%) had suspicious thoracic CT findings. After investigation or follow up, four (3.5%) of these patients were shown to have coincident thoracic malignancies. This large prospective series of newly diagnosed oral and oropharyngeal SCC had a lower incidence of coincident thoracic malignancy than had previously been shown.

In a previous publication we reviewed the future career plans of 169 dental graduates who entered medical school from 1986 to 1991 inclusive. The aim of the present study was to find out what happened to this group after qualification from medical school. The 169 individuals were traced and a questionnaire was sent to them by mail. A reminder was sent and some data for non-respondents were obtained from public sources such as registers and directories. In the original study, 120 of the 154 respondents (78%) intended to become oral and maxillofacial surgeons. We found in this follow up survey that the overall return rate to oral and maxillofacial surgery (OMFS) had dropped to 66%. For those not returning to the speciality, a wide range of alternative specialities had been chosen, with general medical practice (n=9) and oral medicine (n=8) being the most popular. Amongst those returning to OMFS, most undertook basic surgical training in general surgery and trauma. Two thirds of those eligible possessed the FRCS, with 43 (83%) holding the FRCS (Clinical Surgery in General) and six (12%) having the FRCS Ed (oral and maxillofacial surgery). Within the group, opinions were mixed about the changes caused by ‘Hospital doctors: training for the future’ (Calman Report) [Working Group on Specialist Medical Training. Hospital doctors: training for the future. London: Department of Health, 1993]. Concerns were voiced about the potential reduction in clinical experience, comparatively longer training for OMFS, and particularly the abrupt end of training with no protection whilst seeking a consultant appointment. Half thought that OMFS will become concentrated in supraregional centres, or head and neck units with related specialities.

The surgical outcome of planned movements of Le Fort I osteotomies is dependent on the surgeon's ability to achieve such movements intraoperatively. Our aim was to assess the surgical accuracy achieved for 30 consecutive patients undergoing Le Fort I osteotomies treated by one maxillofacial surgeon and his team. Method : Intraoperative control of the mobilized maxilla vertically was achieved by a combination of a nasion screw as the external reference point and bony marks above and below the osteotomy cuts intraorally. Movements horizontally and transversely were controlled with occlusal wafers. The surgical accuracy of maxillary movements vertically and horizontally (anteroposteriorly) were assessed by standard lateral cephalometric tracings of radiographs taken within two weeks prior to operation and 48 hours afterwards. Audit targets were arbitrarily set to be satisfactory when the difference between planned movements and actual movements as measured on the cephalometric tracings were 2 mm or less. Results : The mean (SD) difference from planned vertical movements of the anterior maxilla was 0.37 mm (SD 0.64) and horizontal movements 0.85 mm (SD 0.91). Ninety-seven percent (29/30) of anterior maxillary movements in the vertical dimension, 90% (27/30) of anterior maxillary movements in the horizontal dimension and 87% (26/30) of movements in both dimensions had a difference of 2 mm or less. These results were comparable with the reported 'gold standard'. Conclusion : Good surgical accuracy in positioning the mobilized maxilla in Le Fort I osteotomies can be achieved with the use of external and internal reference points.

The 169 dental graduates known to have entered UK medical schools between 1986 and 1991 inclusive were sent a questionnaire requesting personal and professional information. A total of 154 graduates (91%) responded, 126 (82%) males and 28 (18%) females, all with a mean age of 27 years. Over the 6 years studied, both the average fees paid and the number of students paying fees increased. During the same period, the average grant received and number receiving grants both decreased. Of the 154 responding, 141 (92%) intended to pursue a career in oral and maxillofacial surgery at the time they entered medical school, and this had fallen to 120 (78%) by the time of the survey. An estimate of the number of those medical students who may return to the specialty was made based on previous surveys (range of 12–26 trainees/year).

Radial forearm free flaps (RFFFs) are safe, but critical ischaemia of the hand has been described and is catastrophic. Every effort should therefore be made to improve the safety margin even further. Colour flow duplex ultrasound (US) is a simple, non-invasive and effective assessment tool. We compared it with Allen's test to identify serious vascular anomalies. We studied 121 patients who were listed to have a RFFF harvested, all of whom had both duplex US assessment and Allen's testing of the selected arm. The significance of differences in proportions was assessed using McNemar's test. Five of the 121 patients had an alternative flap selected as a consequence of the duplex assessment. A single flap failed. There were no ischaemic vascular complications that affected the hand.

Complex surgery with curative intent as part of the care of patients with head and neck cancer, who also have serious coexisting conditions is sometimes viewed critically as being unduly, optimistic. We have used American Society of Anesthesiologists' (ASA) grading by a single anaesthetist prospectively as a baseline to investigate a possible link between coexisiting conditions and disease-free survival in 114 patients with head and neck cancer patients treated by the same anaesthetist and surgical team, and found that the ASA grade is not a reliable predictor of disease-free survival. There was no significant association between ASA grade and overall mortality, but there was a significant association between ASA grade and mortality associated with metastatic disease. However, the test for trend was not significant, which suggested that deaths from metastatic disease did not increase in line with ASA grading. All patients in ASA grades II and III were alive 2 years after their initial operation and the risk of mortality after 2 years may increase by up to 10%.

Reliable assessment of the perfusion of free tissue transfers has always been a challenge for reconstructive microsurgeons. The complexities of flap microcirculation are often difficult to assess despite all the subjective and objective examination techniques available today, particularly when the free tissue transfer is buried, and not visible for monitoring. We investigated the post-operative management of free tissue transfers to the head and neck in the United Kingdom. Selected results from our survey show that the majority of units performed between two and five free tissue transfers to the head and neck region per month ( n = 60, mean = 4.13, range 1–12). Clinical tests were used to monitor the flaps post-operatively in all units questioned. Hand held doppler was the most commonly used adjunctive technique, being routinely used for post-operative monitoring by twenty six units, and available for use in eighteen other units with the most common indications for use were, slow capillary refill and pale colour. Frequency and location of monitoring post-operatively was highly variable. Nurses were responsible for the routine monitoring of flaps in almost every unit. Thirty four units (57%) had a written protocol in place governing the monitoring of free tissue transfers post-operatively. We note the wide variation in practice on a national level, and make certain recommendations.

The overall survival rate for patients with head neck squamous cell carcinoma remains disappointingly static despite improved locoregional control. This has been attributed to the development of distant metastases and second primary malignancies in these patients, a large proportion of which occur in the thorax. We retrospectively analysed the incidence of thoracic malignancies in 138 patients presenting with newly diagnosed ( n =107) or recurrent ( n =31) cancer of the head and neck over a 4-year period. All 138 patients had undergone both computerised tomography of the thorax (CT) and conventional chest radiography within one month of presenting with biopsy proven squamous cell carcinoma. Seventeen percent of these were found to have simultaneous thoracic malignancies. CT thorax was more sensitive in detecting simultaneous thoracic malignancies compared with standard chest X-ray (24/138 versus 9/138, odds ratio of 3:1 in favour of CT). All thoracic malignancies detected by chest X-ray were also detected by CT thorax. Patients presenting with recurrent tumors were significantly more likely to have simultaneous thoracic malignancies than those with newly diagnosed cancer (11/31 versus 13/107, χ 2 test with Yates correction, χ 2 =4.66, p =0.03). The primary site (laryngeal, oral or pharyngeal) or presence of nodal disease did not have an effect on the incidence of simultaneous thoracic malignancies. The presence of distant metastases and second primary malignancies has major implications in the management and prognosis of patients presenting with head and neck squamous cell carcinoma, with a large proportion of such patients succumbing to their disease within one year of diagnosis. As CT scanning of the thorax was a more effective screening investigation than standard chest X-ray in the detection of simultaneous thoracic malignancy, we recommend it for use in the staging of patients presenting with cancer of the head and neck.

Objectives— The aims of this study were (i) to objectively assess the histopathological features in TMJ condylar head specimens and to correlate the findings with clinical information obtained from pathology request forms and hospital notes. (ii) to analyse the pre- and postoperative investigation and management of patients with TMJ-OA. Design— A retrospective histological analysis of 136 specimens using a semi-quantitative scoring system. Subjects— 132 patients with TMJ-OA in Trent Hospital Region (mean age 34; range 14–71) provided 136 condylar heads. Main outcome measures—11 histological parameters were assessed. The global scores obtained were compared with the clinical data. Results— There was no clear correlation between histology and pre- and postoperative clinical data. 95% of patients were treated for at least 6 months before surgery and 94% o had pain before surgery. Postoperatively, the success rate was 58% (35% painfree and 23% o still in pain but better than before surgery). Non-surgical treatments were not used routinely after surgery. Only 62% of the patients were followed up for at least one year after surgery. 61% of the patients were reported to have macroscopic degenerative changes at surgery whilst all had microscopic OA. Conclusion— The mean age of patients presenting with TMJ-OA is younger (M=31F=34) than in some studies while there is still a female preponderance for the disease. Tomograms and arthrograms appear to have a higher specificity than orthopantomograms for diagnosing gross degenerative change. There appears to be a need for a standardised management protocol.

The admission officer of 28 medical schools in the UK were circulated with a questionnaire requesting details of their policies regarding applicants who are dental graduates. Replies were received from 27 schools (96.4%). There was a wide variation amongst the intake policies between the medical schools. The number of places available for dental graduates varied from none to four per year. The entry requirements for such applicants ranged from the BDS degree to Part II FDS. Most medical schools set the upper age limit for dental graduates entering medicine as 30 years. Up to 2 years exemption in the 5-year medical course may be available for some dental graduates but 17 medical schools do not offer any reduction in the duration of the course. Only eight of the medical schools liaised with an oral and maxillofacial surgeon in vetting the dentally qualified applicants. All the medical schools operated the fees remission scheme for the self-financed student. This survey should help the prospective candidate to shortlist suitable medical schools.

A case of facial trauma is presented, which was complicated by a denture fragment lodged in the larynx. This potentially life threatening event caused minor symptoms only. Its diagnosis and management are reported.