THE ASSOCIATION OF BRITISH ACADEMIC ORAL AND MAXILLOFACIAL
SURGEONS
Policy Statement on the Dental Surgical Specialist Lists
1. Background
1.1
ABAOMS: The Association of British Academic Oral and Maxillofacial Surgeons
(ABAOMS) has existed for over 20 years, initially as the University Teachers of Oral &
Maxillofacial Surgery. We have approximately 65 members, mainly associated with Oral
& Maxillofacial Surgery units in Dental Teaching Hospitals, some in regional units, but all
sharing an interest in the further development of the specialty through advances in
teaching and research. The group formalised its constitution and elected officers in 2004.
This was in part to ensure that the views of its members could be heard more coherently
and widely, particularly in areas of concern such as the possible reorganisation of the
dentally based specialties and specialist lists. This consensus document presents the
views of our group on the future development of dental surgical specialist lists, with
particular reference to academic training programmes.
1.2
Dental Surgical Specialist Lists: A review of the dentally based specialties
and specialist lists was undertaken in 2003/4 under the auspices of the Standing Dental
Advisory Committee (SDAC), and its report was presented to the Chief Dental Officer
(CDO) in June 2004. Concurrently, the General Dental Council established a Specialist
Lists Review & Specialist Training Group, and its initial report is undergoing a
consultation process that commenced in March 2005. One of the recommendations of
the SDAC report was that ‘The GDC should be invited to consider reconfiguration of the
current arrangements for oral surgery (including academic oral surgery) and surgical
dentistry.’ There was little evidence in the report that contributions to the consultation
process from the academic community had been acted upon, and there was no
representation from our association on the review group. Thus, proposals to reconfigure
arrangements for our specialist training pathway created considerable disquiet and
anxiety.
1.3
The AACOMS Training Pathway: After extensive discussions and
negotiations, a new training pathway in Academic Oral Surgery was established in 1991,
and a committee to oversee the programme was formed: the Academic Advisory
Committee for Oral & Maxillofacial Surgery (AACOMS). This development was in
response to the perceived difficulties in recruiting clinical academic staff, the lack of
adequate training and career opportunities for excellent academic staff, some of whom
did not possess a medical degree, and to provide an impetus to research in the specialty,
as demanded by the Universities. In the relatively short period since the programme was
established, 18 trainees have either completed the training programme or are in the
process of doing so. The programme has been extremely successful. It achieves a broad
curriculum of clinical training to consultant level and a high level of expertise in research,
with the ability to lead a research team and thereby advance the specialty.
Markers of the success of this programme are:

Honorary Consultants trained via this programme have been appointed in a
majority of UK Dental Schools, thereby securing the academic base for the
specialty, in marked contrast to the difficulties in academic recruitment in some
other dental specialties.
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
Four AACOMS trainees have already been appointed to professorial posts (in
Dundee, Glasgow, Cardiff and Manchester), the highest recognition of
academic achievement and confirmation that we are developing academics
with the necessary skills.

The AACOMS training model, which builds clinical skills onto a research
training and has a research doctorate as an entry requirement, can be seen as
a forerunner for the Clinician Scientist Scheme developed by the Academy of
Medical Sciences, MRC and DoH. It also reflects current recommendations on
the training of researchers and educators of the future, as outlined in the report
of the Academic Careers Sub-Committee of Modernising Medical Careers and
the UK Clinical Research Collaboration 1 (published March 2005, see below)
and the recent report from the Forum on Academic Medicine 2 (published
November 2004).
It is with this success and perspective in mind that we strongly resist changes that could
affect the integrity of the AACOMS programme.
2. The AACOMS curriculum for Academic Oral Surgery
After two years of general professional training and completion of a doctorate thesis by
research, specialist training is undertaken, usually based mainly in an academic
department of Oral & Maxillofacial Surgery. Trainees need to demonstrate ongoing
research achievements in the form of publications, presentations at scientific meetings,
research grant support, research supervision and development of a research group.
The practical clinical training leads to competence in the following areas:
1. Extraction of teeth and roots, surgical endodontics, management of ectopic and
impacted teeth, and oro-antral communications. Management of complications
of these procedures.
2. Minor orthodontic surgery including tooth exposure.
3. Minor soft tissue surgery and biopsy techniques.
4. Treatment of benign lesions.
5. Treatment of salivary gland disease.
6. Management of oral and maxillofacial trauma.
7. Implant and pre-prosthetic surgery.
8. Procedures to control pain and relieve anxiety in relation to oral surgery.
9. Management of temporomandibular joint disorders.
10. The diagnosis of oral cancer and precancer and familiarity with their
management.
11. Management of dentofacial deformities.
3. The EU curriculum for Oral Surgery
The range of activities of a specialist oral surgeon was discussed and agreed in 1982
(Doc, III/D/114/4/82) and was further clarified in 1986 (III/D/1374/84) 3. The documents
describe a series of competencies that are not intended to limit the specialist oral
surgeon but to ensure that they are proficient in all of the procedures listed. The full text
is shown in appendix 1 but can be summarised as follows:
1. The surgical excision of roots and buried or impacted teeth
2. Exposure of unerupted teeth
3. * Management and treatment of fractures of the jaws and facial skeleton
4. Surgical management of oro-antral fistulae
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5. * Diagnosis and treatment of salivary gland diseases
6. Tissue integrated oral implant surgery
7. Mucosal, skin and bone grafts
8. *Congenital and acquired anomalies of the jaws and temporomandibular joint
9. *Diagnosis and treatment of diseases of the temporomandibular joint
10. Assessment and management of oral/facial pain and headache including that
associated with disorders of the TMJ and its related activities
11. Apical surgical treatment
12. Reimplantation of teeth
13. Biopsies and excision of pathological oral and dental tissue
14. Pre-prosthetic surgery
It can be seen that, although the wording is different, the entire AACOMS curriculum is
encompassed within the EU curriculum. However, in the EU documentation some
competences are marked with an asterisk, to denote that these procedures may not be
considered to constitute essential clinical competences in all EU countries (see below).
4. Proposals for a UK curriculum for Oral Surgery
4.1
Principles: ABAOMS accepts that it is appropriate to have a single dental
surgical list, and that it should be called ‘oral surgery’. This would incorporate those
currently on the list of that name, would necessitate the closure of the current surgical
dentistry list, and possibly arrangements to consider the ‘grandfathering’ of appropriately
trained specialists onto the new oral surgery list. Subsequent entry onto the new list
would only be achieved via an oral surgery training programme. However, our
acceptance of this solution is provisional on the assurance that our current academic oral
surgery training programme will not be devalued, but will be enhanced. This can be
achieved only if the following principles are adhered to;
 Training requirements for academic trainees are interpreted flexibly. As described
in the draft report of the Academic Careers Sub-Committee of Modernising
Medical Careers and the UK Clinical Research Collaboration 1, and the report from
the Forum on Academic Medicine 2, flexibility is needed in the entry process into
specialist training, in the geographical location of training, and in the ad personam
training programmes for both clinical and academic spheres of activity.
 Lists of clinical competencies must not limit the sphere of specialist clinical
activities, rather they act as a list of procedures which an oral surgeon must be
proficient to perform. This principle is enshrined in the relevant EU directives
III/D/114/4/82 & III/D/1374/84 3, and is particularly important for academic
programmes where development of new and innovative competencies is
encouraged.
 The UK specialist training in oral surgery should be based on the relevant EU
directives, thereby avoiding the inequalities that occurred on the establishment of
the Surgical Dentistry list, which was unique to the UK.
4.2
Recommendations: We recommend that the full EU curriculum (III/D/114/4/82
& III/D/1374/84; appendix 1) is used in the following way:
 All trainees must be proficient to perform the list of clinical competencies not
marked with an asterisk (we will refer to these as ‘essential competencies’).
 Some trainees may be trained to perform some or all of the additional
competencies marked with an asterisk, depending upon local training opportunities
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and the trainee’s particular interests (we will refer to these as ‘extended
competencies’).
 Opportunities should be created to permit some individuals to develop extended
competencies at later stages in their career, after the award of a CCST/CCT.
We envisage that academic trainees in units associated with Dental Schools will continue
to train in a similar sphere of competencies to that undertaken at present, thereby
including the extended competencies. Thus, all of our trainees will continue to take part in
in-patient management, on-call duties, trauma surgery and the management of facial
deformity, subject to some variation at different centres in the UK.
Some NHS Oral Surgery trainees may not be able to gain access to the same level of
training opportunities that are available in the special environment of our academic units.
This should not prevent them from achieving consultant status on the basis of a more
limited curriculum. Equally, should NHS Oral Surgeons have the opportunity to be trained
in any or all of the competencies in the full EU curriculum, we see no reason why they
should not undertake this remit; indeed this is current practice for many staff grade and
associate specialist practitioners in Oral & Maxillofacial Surgery units in the UK.
4.3
Duration of specialist training: This will require a minimum of three years, but
should be implemented flexibly, to permit a longer period of training if the extended
competencies are included. Each training programme should be assessed on an
individual basis (using the current system of SAC visitations), but would be unlikely to
exceed four years.
4.4
Duration of specialist training for clinical academics: The academic oral
surgery trainees would continue to have a four year training programme, as at present,
taking into account the academic teaching and research commitments that go alongside
the clinical training. We envisage that the full career pathway will resemble that proposed
in the report of the Academic Careers Sub-Committee of Modernising Medical Careers
and the UK Clinical Research Collaboration 1. Thus, the integrated training path would be
as follows:
INTEGRATED ACADEMIC TRAINING PATH#
Dental School
‘Foundation
Programme’*
BDS
VT
Intercalated BSc
2 years SHO, linked
to academic unit
CCT
Academic position
Specialist Training
Academic post
---Clinical Training--PhD
1
2
3
4
BDS/PhD*
Graduate Entry
Training
Training
Fellowship
3 years
Clinician
Scientist
Fellowship
Senior Lecturer
Continuous
Professional
Development
Senior Clinical
Fellowship
* Schemes yet to be established in dentistry
# Based
on recommendations of ‘Modernising Medical Careers’ 1
5. Comments on Specific issues relating to Implementation
5.1
Proposals to limit UK Oral Surgery to ‘ambulatory or day-stay patients’:
The report of the SDAC review group submitted to the CDO in June 2004 included the
suggestion that consideration be given to limiting the scope of oral surgery to those
procedures undertaken for ambulatory or day-stay patients. It is implicit in our
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recommendations above that we strongly disagree with that suggestion. Although the
basis for the SDAC suggestion is unclear, it must be acknowledged that:
 Restriction of the field of practice for a clinical specialty on the basis of anaesthetic
considerations or the duration of the operative procedure is irrational.
 There is no evidence whatsoever to suggest that properly trained dental
graduates are incapable of managing patients who sleep overnight in a hospital,
rather than being discharged home. It is accepted practice in all spheres of
medicine that advice is sought from other specialties as needed, and that
practitioners work within their own level of competence.
 No clinical governance issues have occurred with the current academic oral
surgery consultants or trainees who undertake the ‘extended competencies’.
 Restorative and Paediatric Dentists routinely manage in-patients in many parts of
the UK, and dental staff grades, associate specialists and SHOs all carry out these
duties in Oral & Maxillofacial Surgery units.
In addition, such a restriction would render the programme unattractive to the current
high calibre academic trainees, and would also prevent development of applied clinical
research into areas requiring more extensive surgical procedures (e.g. orthognathic
surgery, advanced implantology, traumatology, trigeminal nerve repair – all areas that
have benefited greatly from the work of our academic units). From an NHS perspective,
the proposal would be no more than a ‘re-badging’ of Surgical Dentistry under another
name, and would therefore be unlikely to be any more successful.
5.2
SAC monitoring of Oral Surgery training programmes: We believe that a
new dental SAC should be established to supervise and monitor training programmes in
oral surgery. AACOMS could be incorporated into this committee, which would oversee
the academic and NHS programmes, and would report directly to JCSTD. There could be
a separate ‘Co-ordination and Liaison Committee’ that would permit administrative links
between the new SAC and the SAC in Oral & Maxillofacial Surgery, as may be needed
for visitation of training programmes, conformity of documentation for common
competencies etc. This arrangement would permit the development of the specialty,
whilst avoiding the disproportionate influence that maxillofacial surgeons could have over
this process. It would also avoid the unsatisfactory anomaly of a dental specialty being
monitored by a medical SAC. It would, however, allow us to retain the excellent local
relationships that exist with our Oral & Maxillofacial Surgery colleagues in many centres
throughout the UK.
5.3
Alternative configurations of the training pathway: It has been suggested
that the oral surgery training pathway for academic trainees could follow a ‘3 + 2 year’
model, with three years of training for essential competences (alongside NHS trainees),
followed by two years of training for the extended competences. We do not think this
option is appropriate for several reasons:
 It would be extremely difficult to provide adequate training in clinical
competencies such as orthognathic surgery or trauma management in a two
year period; these competencies need to be developed over the whole training
period.
 It would extend the training period for our academic trainees from four to five
years.
 It is not consistent with the move toward shorter training periods as advocated in
the ‘Modernising Medical Careers’ model.
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5.4
Further recommendations: We fully endorse the recommendations in the draft
report of the Academic Careers Sub-Committee of Modernising Medical Careers and the
UK Clinical Research Collaboration 1, as applied to academic dentistry. These
recommendations are as follows;
1. Dental Schools develop comprehensive programmes to encourage students into
clinical academic dentistry, including the development of BDS-PhD programmes;
2. a limited number of integrated Foundation Programmes are created for potential
academic trainees (for oral surgery this would currently require the creation of
SHO equivalent posts linked to academic units);
3. an academic training programme in dentistry is developed, along the lines
proposed for medicine (for oral surgery this already exists as the AACOMS
programme, as shown above);
4. increased flexibility and partnership in funding for training positions in clinical
academic dentistry is required (inconsistencies in funding for AACOMS trainees
exist across the UK, with universities usually funding all of the clinical training);
5. there should be an expansion of the established clinical academic workforce in
dentistry, including a programme for “new blood” senior lectureships.
Summary
ABAOMS supports the creation of a new oral surgery list, incorporating academic oral
surgery, providing that:





Training requirements for academic trainees are interpreted flexibly
The training is based on the relevant EU directives and does not limit the
sphere of activity
All trainees are trained in a series of ‘essential competencies’
Some trainees (including all academic trainees) are trained in additional
‘extended competencies’
The training period is a minimum of 3 years, with 4 years for academic
trainees.
ABAOMS strongly opposes proposals to limit the scope of oral surgery to those
procedures undertaken for ambulatory or day-stay patients.
ABAOMS recommends:


Creation of a new dental SAC for oral surgery
Implementation of the recommendations in the draft report of the
Academic Careers Sub-Committee of Modernising Medical Careers and
the UK Clinical Research Collaboration 1, as applied to academic
dentistry.
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References
1. Draft report of the Academic Careers Sub-Committee of Modernising Medical
Careers and the UK Clinical Research Collaboration (March 2005).
2. Clinical Academic Medicine – The Way Forward. A report from the Forum on
Academic Medicine. ISBN 1 86016 230 4 (published November 2004).
3. The EU curriculum for Oral Surgery. Directives III/D/114/4/82 & III/D/1374/84,
http://www.dented.org/parse.php3?file=info/sect3.html).
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Appendix 1.
ORAL SURGERY – The EU curriculum
The legal provision for specialisation in dentistry was established with the Dental Directives in 1978. The
provision was further discussed and agreed in 1982 (Doc, III/D/114/4/82) and was further clarified in 1986
(III/D/1374/84) in respect of the range of activities of a specialist oral surgeon including recommendations
on appropriate training programmes. The field of activity of the general dental practitioner (Dental
Directive 78/687/EC) includes prevention, diagnosis and treatment of anomalies and diseases of the
teeth, mouth and jaws and surrounding tissues. The more complex and difficult of these procedures
constitute the rationale for the need of a specialist oral surgeon within the Dental Directives, because
they are, by-and-large, the most needed and form the core of the activities of a specialist oral surgeon in
addition to the other skills demanded of that specialist.
Many oral surgical procedures are undertaken by general practitioners and in this area there may be
considerable overlap in the more routine procedures. Implicit in these clinical competences is the
necessity to have the requisite current knowledge of the basic biological, medical, bio-ethical sciences
and patient management skills in order to complete each procedure in the patient's best interests as
stated in the section on basic clinical competences.
Prerequisites set out in the context of clinical competences for a newly qualified dentist equally apply to
an oral surgeon. These competences are not intended to limit the specialist oral surgeon to the
procedures listed below. However, all specialist oral surgeons must at least be clinically proficient in each
of the following:
The surgical excision of roots and buried or impacted teeth




recognising the various anatomical relationships that pose clinical difficulty in the removal of or
lead to complications following the surgical removal of roots and teeth
deciding, on the basis of the history, examination, radiographic evidence, and special tests when
it is advisable to surgically remove impacted teeth or to pursue a more conservative treatment
being aware of the potential consequences of surgical removal of roots and impacted teeth both
in the short and long term
capable of excising buried roots
Exposure of unerupted teeth



deciding, with the help of an orthodontic consultation when appropriate, whether surgical
exposure of a tooth can result in it being brought into a favourable position within the arch
deciding, on the basis of the history, examination and special tests whether it is advisable to
surgically expose, remove or monitor unerupted teeth
carrying out the surgical procedure of exposing an unerupted tooth
* Management and treatment of fractures of the jaws and facial skeleton



the clinical and radiographic diagnosis of fractures
completing open and closed reduction and fixation of fractures
interdisciplinary management of the patient with multiple injuries
Surgical management of oro-antral fistulae


the clinical and radiographic diagnosis of oro-antral fistulae
application of the appropriate conservative or surgical management methods in the light of the
position of the fistula and the surrounding anatomy
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
closure of the fistula
* Diagnosis and treatment of salivary gland diseases



utilising appropriate special tests for the diagnosis of salivary gland diseases
the safe management of salivary gland diseases
referral when appropriate
Tissue integrated oral implant surgery






assessment in collaboration with appropriate colleagues the benefit to the patient of tissue
integrated implants
interpretation of techniques necessary for the appropriate selection of site for placement of
implants
effectively carrying out currently accepted surgical techniques for successful implants
* the use of bone augmentation techniques in the areas of inadequate bone for implant
placement including taking of bone from an acceptable donor site
a sufficient knowledge and skill in carrying out guided tissue regeneration and use of bone
substitutes
understanding the restorative implications of implant surgery
Mucosal, skin and bone grafts

carrying out simple mucosal, skin and bone grafts with minimal trauma to donor and recipient
sites
*Congenital and acquired anomalies of the jaws and temporomandibular joint
complicated anomalies involving the cranial base)




(excluding
Management of congenital and acquired anomalies of the jaws and temporomandibular joint
surgical treatment of congenital and acquired anomalies of the jaws
liaison with the orthodontic specialist with regard to conservative or combined
conservative/surgical treatment of jaw anomalies
Referral where appropriate
*Diagnosis and treatment of diseases of the temporomandibular joint



effective clinical and radiographic investigation
recognition of the systemic and psychological influences of the condition and/or treatment
Conservative and surgical treatment of diseases of the temporomandibular joint including
arthroscopy
Assessment and management of oral/facial pain and headache including that associated with
disorders of the TMJ and its related activities



the diagnosis of oral-facial pain including that of dental origin
appropriate history and documentation
appropriate clinical and therapeutic management of oral-facial pain
Apical surgical treatment

judging whether it is necessary to carry out surgical endodontics rather than pursue a more
conservative treatment completing surgical endodontics
Reimplantation of teeth
9



assessing the patient for associated trauma and risk of infection
deciding, on the basis of the history examination and special tests whether it is advisable to
reimplant the tooth
replacing, repositioning and stabilising implanted teeth
Biopsies and excision of pathological oral and dental tissue


recognising and prioritising lesions requiring a biopsy
carrying out incisional and excisional biopsies of oral tissue including their appropriate fixation
and transportation for diagnostic histopathology.
Pre-prosthetic surgery


liaison with other dentists in the assessment of benefit to the patient of all pre-prosthetic surgical
techniques
carrying out hard and soft tissue preparation to facilitate successful restorative procedures
* In order to accommodate differences between member states those marked * may not be
considered to constitute essential clinical competences in all EU countries
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