Oral surgery: what challenges and opportunities are there on the horizon?

This article takes a look at what challenges and opportunities will arise for oral surgery in the future.

There are predicted systems advances that will impact on healthcare delivery broadly, and advances that will have specialty-specific impact. There will also be challenges, which may include patient factors, such as the ageing population with increasing medical complexities, pressure on healthcare delivery and patient safety. Opportunities may arise with improved technical advances impacting on all aspects of care.

A recent report suggests that adopting new technology is crucial to surgeons’ training.¹ However, before salivating over potential new technology, we need to think about the human quotient of surgery. Surgeons bear huge responsibilities: with one operation, they might bring about benefit or cause irreparable damage. Many digital technologies are impacting on operating rooms and surgeons, but we must regard these new surgical technologies as an extension of the capabilities of surgeons and their teams, rather than replacing them.

Surgeons work predominantly in isolation, which can potentiate alienating themselves from patients. However, as technological solutions encroach onto our daily practice, we must recognize that empathetic treatment of patients is core to what we do, a skill that becomes ever more important in the age of robotics and artificial intelligence.

Surgeons will need to become ‘multilinguists,’ understanding the language of medicine, genetics, surgery, radiotherapy and bioengineering. Leadership, managerial and entrepreneurial skills will become increasingly important attributes of the surgical profession. The surgeon will play a key role in genomics, acquiring and handling tissue samples, and being the first healthcare professional to discuss genetic analysis with a patient.

In addition, multidisciplinary and multi-professional surgical care teams that include surgical care practitioners and physician associates, will become increasingly important in developing and delivering care of the highest quality. They will provide more holistic care, and may improve and/or minimize the need for surgical care currently delivered by surgeons. Already, highly skilled surgical technicians undertake surgical procedures, for example, endoscopy and endoscopic biopsies, removing skin lesions, and maybe even carrying out Caesarean sections, under the supervision of a surgeon, who is often present remotely.

Healthcare

Healthcare has been undergoing transformation for years, if not decades. However, in a matter of months, the pandemic broke down long-standing barriers and accelerated digital health at a pace few could have imagined. A survey² reported that:

• Those who were managing a chronic condition were more eager to embrace and see value in the new technology;
• 74% of first-time telehealth users said that they are willing to share genetic information and data;
• 27% of people surveyed had tried telehealth for the first time during the pandemic;
• Healthcare is moving towards a consumer-centred model where people can shop for care and share data with an endless array of apps and services.

Experts across the UK are working on a variety of ground-breaking advances in the surgical field and contributing to the shift to surgery 4.0. The Centre for HealthTech Innovation³ is a joint research initiative between the University of Leeds and Leeds Teaching Hospitals NHS Trust to accelerate the development of exciting technologies to address some of society’s biggest healthcare problems. The National Institute for Health Research (NIHR) is also making strides in the area of predictive medicine, with the NIHR Sheffield Biomedical Research Centre having an in silico (predictive) medicine theme.⁴

A Royal College of Surgeons’ Commission on the Future of Surgery identified advances in medicine and technology that are likely to have the greatest impact on surgery over the next 20 years and transform surgical care for millions of patients. The Commission highlighted technologies, such as surgical robots, artificial intelligence, threedimensional printing and new imaging methods, that are already changing and will continue to change the way that surgical care is delivered. Through the Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS),⁵ UCL is positioned at the forefront of these kind of advancements. The report also identified developments in fields, such as genomics, regenerative medicine and cell-based therapies, that could open new avenues for predicting and treating disease.

A 2004 government policy⁶ set out necessary changes in NHS surgery to improve access and efficiency. These included:  Treat day surgery (rather than inpatient surgery) as the norm for elective surgery.

• Improve patient flow across the whole NHS system by improving access to key diagnostic tests.
• Manage variation in patient discharge, thereby reducing length of stay.
• Manage variation in the patient admission process.
• Avoid unnecessary follow-ups for patients and provide necessary follow-ups in the right care setting.
• Increase the reliability of performing therapeutic interventions through a care bundle approach.
• Apply a systematic approach to care for people with long-term conditions.
• Improve patient access by reducing the number of queues.
• Optimise patient flow through service bottlenecks using process templates.
• Redesign and extend roles in line with efficient patient pathways to attract and retain an effective workforce.

As with most health policies, these focus on service delivery, but do highlight minimizing variation in the pathway and improved reliability, efficacy and outcomes of therapeutic interventions. ‘Get it right first time’ was an initiative set up by Tim Briggs, an orthopaedic surgeon, who noticed how minimizing variability in surgical indications, technique, procurement, anaesthesia selection and outcomes could potentially save the NHS over £220 million in just orthopaedic services alone. This was taken up by the government and applied to nearly all medical and dental surgical specialties being reviewed, and best practice was suggested. Unfortunately, owing to poor activity coding and lack of diagnostic and outcome recording, efficacy is difficult to gauge. Modification of coding was recommended by all specialties and ongoing implementation of ‘EPIC’ and related healthcare software may ‘join the gaps’ in appropriate surgical decisions and relative outcomes for surgery.

A limitation of surgical registries has often been their inability to provide data beyond in-hospital or 30-day mortality and complication rates. Longer-term outcomes have not been captured routinely. An exception is the UK National Joint Registry (NJR), which has used revision following joint replacement as an endpoint to identify outlying performance. This measure of long-term quality, combined with the capture of detailed information on hip implants, led the NJR to identify early the problems related to metal-on-metal prostheses.

In vascular surgery, the failure of devices used for endovascular aneurysm sealing only became apparent more than 2 years after implantation. Had registry device capture been established at the time, it is likely to have prevented many patients coming to harm.

Reporting surgeon-level outcomes for specific surgical procedures continues to be controversial and, although transparency remains vital, it is increasingly being recognized that high-quality surgery requires appropriate resources and a functioning interdisciplinary team. In cardiac surgery, reporting individual surgeon outcomes has been established for more than two decades, and these audits have brought transparency, quality assurance, and quality improvement. Collaborations between international registry groups are well established and have allowed geographical variations in surgical practice to be studied in large data sets. The COVID-19 pandemic has increased awareness of the importance of populationwide linked electronic patient health records (EHRs). These studies have already provided important information on the clinical and cost effectiveness of laparoscopic versus robotic inguinal hernia repair.⁷

An RCS England commissioned paper⁸ in looking to the future of surgery reported the following would be most impactful on delivering surgical care:

• Virtual clinics;
• 3D printing;
• Change in operating theatre;
• Centrally provided robotic surgery;
• Flexible review systems;
• MDTs with nurse leads and surgical technicians;
• Centralize online information: deep mind health/streams app/EPIC.

These advances, of course, provide initial challenges in the provision of training, patient pathways and commissioning, and increased costs are likely.

Oral surgery

Specifically with regard to oral surgery, trends in practice between 1991 and 2000 were reported to be:⁹

• Substantial decreases in the numbers of apicectomies and third molar removals after 1997;¹⁰
• A decrease in general anaesthesia after 1998 related to the introduction of sedation;¹¹
• Increases in complex extractions and concentration of dento-alveolar surgery in secondary care;
• Numbers of ordinary extractions did not change.

In the secondary healthcare setting, there was a large shift from in-patient to daycase provision, which has facilitated expansion in oral surgery.

Unfortunately, owing to insufficient coding detail and poor data collection, annual trends in oral surgery (or any healthcare activity without a specialty registry) cannot be easily evaluated.

As oral surgery deals with the surgical arm of dentistry, the challenges are not just the technical aspect of the surgery, but the complexity of the patient, and necessary risk assessment and risk management to prevent complications and maximize patient safety.

The patient (risk assessment and management)

Ageing population

England’s population is ageing. In the next 25 years, the number of people older than 85 years will double to 2.6 million. With an ageing population, the presumption is that there will be an increased need for healthcare.¹²

Medical comorbidities

At age 65 years, both men and women can expect to spend around half of their remaining life expectancy in good health. However, the likelihood of being disabled and/or experiencing multiple chronic and complex health conditions among those aged 65 years and over, increases with age. As life expectancy increases, so does the amount of time spent in poor health. The Health Survey for England¹³ shows that in 2016, of those aged 60–64 years, 29% had two or more chronic conditions. For those aged 75 years and over, this rose to almost 50%.

Healthcare requirements increase with age, with healthcare costs increasing steeply from around age 65 years. Hospital admissions have increased since the financial year ending 2007, but with a steeper increase in admissions for the 66 years and over age group. This has contributed to rising healthcare costs.¹⁴

In general, the rate of edentulism has decreased rapidly in the past few decades in many countries, and tooth loss occurs later in life.¹⁵ Thus, we are facing a significant increase in extractions in ageing patients with significant medical comorbidities. Older people are increasingly dentate, thus requiring more extractions.¹⁶

All the factors above contribute to a significant burden for dentists who manage this ageing population.^16,17

Two areas that have significantly impacted on oral surgery care delivery in recent years are:

• Cancer patients living longer;
• Novel drugs, such as targeted therapies, that have been introduced across a whole range of medical specialties and conditions, including;
• Factor Xa inhibitors;
• Anti-resorptives;
• Biologicals for autoimmune diseases.

Other issues include:

• Changes in patients’ expectations;
• Medico-legal challenges;
• Access to care.

Future of patient care

Genetic testing and tailored medical and surgical care

Building on NHS England’s 100,000 Genomics project, which has recently been extended into the NHS Genomic Service, genomic testing is expected to be central to the future of surgery over the next 20 years.¹⁸

Investigations

Medical diagnostics

Liquid biopsies from a variety of bodily fluids may make it easier for disease to be diagnosed earlier.

Proteomics

Proteomic tools have the ability to analyse human body samples, such as blood, saliva, serums, urine, cervico-vaginal fluid (CVF), sperm cells, gingival crevicular fluids (GCF), micro-organisms, and different tissues (enamel, dentine, cementum, pulp, gingiva, bone ligaments, stem cells, and mucosa), in both pathological and normal physiological states. One study highlighted the potential application of proteomics of saliva sampling in oral cancer, diabetes, periodontitis, obesity, Sjögren’s syndrome, salivary gland tumours and malnutrition.¹⁹

Endoscopy and microscopy

Over the next 20 years, ultra-high-definition stereo endoscopes and microscopes are anticipated to be in use, making further improvements to the accuracy of diagnosis and surgery.

Genomics

Genomics has the potential to revolutionize surgical care by making some types of surgery redundant, and by allowing doctors to better understand cancerous tumours and target treatment accordingly.

• Prevention of medical crisis (new guidance for antibiotic and steroid cover, management of patients with diabetes, cardiac risk and those who are immunocompromised).
• Pre-screening for medicationrelated complications. For example, routine screening to prevent Stevens–Johnson syndrome in Han Chinese and Thai patients who are prescribed carbamazepine for trigeminal neuralgia.

The future

• Remote monitoring of hypertension, diabetes, exercise and cardiac function;
• Virtual medical apps for remote monitoring;
• Routine mental health assessment of patients with chronic oral disease (pain, periodontal, caries or cancer risk);
• Diagnostic advances in artificial intelligence for pathology/radiology diagnostic apps.

Risk assessment and surgical planning

Artificial intelligence

Artificial intelligence will make diagnosis and treatment more precise. AI algorithms analyse huge amounts of data quickly and can spot anomalies and provide useful insights. Surveys have revealed that the public is receptive to the use of AI to speed up and improve the accuracy of diagnosis and treatment.

Other future uses of AI include minimizing surgical errors, facilitating the administrative side of surgery, such as scheduling procedures and requesting equipment, and monitoring patients both pre- and post-procedure.

Computational

Improvements in access to patient data, alongside advances in computer modelling, will soon allow researchers to predict the best interventions for each individual.

3D printing and simulations in pre-operative planning and education

Complicated and risky surgeries lasting hours need much careful planning. Existing technologies, such as 3D printing or various simulation techniques, do help in reforming medical practice and learning methods, as well as modelling and planning complex surgical procedures.

Imaging

Imaging is used for risk assessment prior to surgery, with a particular focus on minimizing nerve injury, oral-antral communication and damage to local teeth (Figure 1).

• CBCT
• Advanced image-guided surgery and a growing array of interventional procedures require the development of advanced visualization technologies that include enhanced acquisition, registration segmentation, and augmented-reality systems.

The future: non-radiation imaging in dentistry and MR neurography

• MRI: it is anticipated that traditional dental radiography will be replaced with non-ionizing techniques. SWIFT MRI offers simultaneous 3D hard and soft tissue imaging of teeth without the use of ionizing radiation. Further, it has the potential to image minute dental structures within clinically relevant scanning times.²⁰
• MR neurography: 3D magnetic resonance cranial nerve imaging can produce selective imaging of extraforaminal cranial and spinal nerve branches. This is already being used in several countries to assess nerve injuries and other pathology in larger nerves, for example the sciatic nerve. Recent developments have established that this technique is ideal to image the cranial nerves, and is a suitable tool to evaluate lingual and inferior alveolar nerve injuries soon after injury.^21,22

Surgical management

Prevention of harm

It should be stated that for surgery at the time of writing:

• Do no more harm than necessary applies;
• Patient safety processes are increasingly important: for example LOCSSIPS/NEVER EVENTS and the new LFPSE reporting process;
• Changes to reporting and learning from safety incidents.

Anaesthesia

• Modern local anaesthesia;
• Sedation, > IV sedation for 12–16 year olds, IACSD guidelines.²³

Surgical advances and instrumentation

Technology has much to offer the surgical disciplines. However, teamwork, open communication, and a willingness to adapt and adopt new skills and processes are critical to achieving improved clinical outcomes. Present-day operating rooms (ORs) are inefficient and overcrowded, and the turnover between cases is often lengthy and variable. New technologies and devices are often introduced haphazardly into an already technologically complex environment. Patient data and images are not well integrated or displayed in a timely fashion. This lack of integration of technology and information further strains the system, resulting in further reductions in efficiency. This, in turn, potentially impacts patient safety and costs. Improved integration of technology, along with teamwork and enhanced communication and coordination among services, providers, and staff, is essential to improve efficiency, enhance safety, and reduce the cost of care.

Despite these daily realities, the traditional OR is being transformed as new technologies and paradigms are being introduced into the clinical environment.²⁴

There is an ongoing migration from invasive to less invasive, and even noninvasive, procedures. Minimally invasive surgery, image-guided procedures, robotic surgery, and tele-surgery continue to replace traditional surgical procedures.

Minimally invasive surgery

Single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery techniques are continuing to evolve and transform laparoscopic procedures. Procedures that once required general anaesthesia can now be performed with image-guided vascular access technologies and other endoscopic access techniques.

Image-guided procedures

Traditionally, image intensifiers (intermittent live radiography) have been used in orthopaedics and neurosurgery to enable implants and other devices to be placed correctly during surgery. This process is cumbersome and risks irradiation of the surgical team (hence the need for lead aprons).

The necessary components of the image-guided surgery revolution will enable personalized simulation, preprocedural planning, and rehearsal of the intended surgical intervention within the specific anatomical environment of the individual patient. Surgical planning will be more specific and treatment more targeted.

A good example of this is AI-enabled identification of critical anatomical structures, such as major blood vessels or the ureters. Onboard software could then create ‘no-fly’ zones that prevent the robotic instruments getting too close to those structures, reducing the risk of accidental damage. This technology is still some way off being used outside trials, but many companies are making progress towards commercially viable products.

Operating room (OR) imaging systems will be controlled at the OR table, or remotely, to provide faster, more accurate 3D imaging of the body. The C-arm, computed tomography or interventional MRI will provide realtime or semi-realtime data during the procedure, despite movement that may occur during a surgical procedure. This may require several imaging systems, as well as a sophisticated surgical table or conveyor that moves patients between stations. High-definition, 3D, realtime image guidance will allow the surgical team to:

• Remove tumours more effectively.
• Visualize internal organs from various perspectives with access to greater anatomical detail, including the most minute vessels;
• Visualize volumetric information projected directly on the patient’s organ during the operation;
• Work remotely working (even internationally).

Augmented reality and virtual reality

Augmented reality (AR) and virtual reality (VR) are currently used by the NHS to help train the next generation of surgeons, as well as allowing them to rehearse procedures on patient-specific simulations. This will become more common across the country as hospitals invest in specialist suites.

AR was first described in the literature in the 1990s. AR is defined as an interactive experience of a real-world environment where the object that resides in the real world is enhanced by computer-generated perceptual information. Microsoft HoloLens is a mixed reality device that has the capability to provide a realtime, 3D platform using multiple sensors and holographic processing to display information, and even simulate a virtual world. With rapidly evolving technology and virtual learning on the increase, the HoloLens technology can be used as a vital tool for dental education and surgical planning.²⁵

In April 2016, cancer surgeon, Shafi Ahmed, performed an operation using a VR camera in the Royal London Hospital.²⁶ It was a huge step for surgery, and anyone could participate in it,²⁷ in realtime. Since then, various companies have used VR as both training and imaging solutions.

VR can elevate the teaching and learning experience in medicine to a whole new level, replacing students peeking over the surgeon’s shoulder during an operation. By using VR, surgeons can stream operations, allowing medical students to be in the OR virtually, using their VR goggles.

Tumour ablation

Tumour ablation, instead of resection, is accomplished by use of imaging-guided radiofrequency ablation, microwave therapy, cryo-ablation, lasers and interstitial laser therapy, focused ultrasonography (high-intensity focused ultrasonography), and focused radiation (Gamma knife, eg Leksell Gamma Knife, Elekta, Stockholm, Sweden).^28,29

Patients will have less pain and shorter hospital stays, and fewer procedures will require general anesthesia during patient treatment. Some procedures will require only sedation. Traditional boundaries of the surgical space will blur.

Robotics

Today, only 3% of surgical procedures are performed by robots, although 15% of all operations used robotic support or assistance in the US in 2020. Robotic systems possess enhanced haptic sensation abilities, tissue recognition, and realtime diagnostic abilities.³⁰

Training healthcare personnel in the use and care of electromedical equipment improves performance, reduces downtime, and enhances safety. Hybrid ORs allow surgeons to perform combined open, minimally invasive, image-guided and/or catheter-based procedures in the same OR in the same operative setting.³¹ Robots fit into two distinct categories.

• The first is telemanipulation systems, where the surgeon sits at a console and uses a hand controller to move the instruments inside the patient. These robots have multiple arms – usually three to hold surgical instruments, and a fourth for the 3D camera that allows the surgeon to see what they are doing. For example, the da Vinci models (Intuitive, CA, USA). Competitors include the British-built Versius (CMR Surgical, UK). Telemanipulation systems are generally used for soft tissue procedures in specialties such as urology, gynaecology and colorectal. The first da Vinci was introduced in 1999, and today there are more than 6700 installed worldwide. By the end of 2021, surgeons had performed a cumulative 10 million operations using da Vinci robots alone.
• The second category of surgical robot is ‘assistive guide’ systems, such as Stryker’s Mako. Predominantly used for orthopaedic and neurosurgical procedures, these platforms consist of a single robotic arm combined with a navigation system. The surgeon creates a pre-operative plan based on scans of the patient’s anatomy and then operates on the patient directly, using the robotic arm to ensure that they execute their plan with a high degree of accuracy.

There are no reported cases in this jurisdiction dealing with civil liability but some of the issues were highlighted in the inquest touching on the death of Stephen Pettitt, who died in February 2015 after robot-assisted heart surgery. The inquest heard that the lead surgeon had received no prior one-to-one training and had practised only on a simulator. He had observed four relevant robotic operations.

The NHS has more than 60 robotic surgery machines in use. It is expected that they will perform a crucial role in reducing the backlog caused by the pandemic. In January 2022, in the US, a surgical robot operated free from human control, for the first time, on a pig.

Advances in AI will lead to greater robotic autonomy. There are proposals for regulation in Europe. The EU produced a detailed study in 2016 and a comprehensive industrial policy on AI and robotics in 2019. At one stage, legal person status for robots was considered, but discarded for strict liability and compulsory insurance. The EU concluded that the current product safety legislation contained serious gaps. In the UK, the government produced discussion papers aptly titled ‘AI in the UK: No Room for Complacency’³² and, separately, passed a compulsory insurance scheme with strict liability for driverless cars. One could envisage a similar course of action being appropriate for robots in healthcare but, to date, no formal legislation has been proposed.

3D printing

Face and skull injuries are particularly difficult to fix as there are many layers of various tissues. During one operation, Ibrahim T Ozbolat (Penn State, PA, USA) and his team printed both bone and soft tissue. ‘It took less than 5 minutes for the bioprinter to lay down the bone layer and soft tissue,’ the professor explained.³³ There is hope to translate this research to human applications.

Made to order instruments

One Army and Navy team found that a plastic surgical retractor they printed could do the job of much more expensive metal instruments. ‘Our estimates place the cost per unit of a 3D-printed retractor to be roughly a tenth of the cost of a stainless steel instrument,’ they wrote in a paper published in the Journal of Surgical Research.³⁴

Tailored implants and stents

Engineers are also making significant progress in 3D printing implants and prostheses that perfectly fit a patient’s dimensions. 3D-printed implants, from sugar-based vascular stents³⁵ that hold blood vessels open during surgery and then quickly dissolve, to polymer-based, biodegradable grafts³⁶ of defective blood vessels themselves, are on the way.

Bioprinting organs/vascular systems

Some of these ideas have already made it into clinics. In 2016, the US Food and Drug Administration approved the first engineered tissue, lab-grown knee cartilage made from a patient’s own cells. Others have been approved to repair bone, skin and cardiac defects, and more are in the pipeline.³⁷

Live diagnostics

Professor Zoltan Takats (Imperial College London) developed the intelligent surgical knife, iKnife.³⁸ It works by using an old technology where an electrical current heats tissue to make incisions with minimal blood loss. With the iKnife, a mass spectrometer analyses the vaporized smoke to detect the chemicals in the biological sample, so that malignant tissue can be identified in real time.

Instrumentation

Drills

Ultrasonic bone surgery (UBS) is a technique that consists of inducing energetic micro-vibrations with a frequency in the 20–32 kHz range, which is above the audible spectrum. The vibrations are generated by a transducer, which is electrically, piezo-electrically or magnetically controlled. Piezo-electric materials vary in size when they are submitted to an intense electric field, typically in the 500–750 V/mm range. These deformations can further transmit energetic micronic mechanical forces to a tip vibrating up to amplitudes of 200 μm. UBS uses piezo-electrical transducers, because the generated movements are more energetic. Ultrasonically moved knives have the ability to cut hard tissues, such as teeth and bone. In contrast, soft tissues, including gingiva, blood vessels, nerves and sinus membranes, are preserved from injury because they vibrate with the tip. This makes UBS particularly suitable for a broad spectrum of surgical applications including apicectomy, bone block section, sinus lifting, split-crest, nerve lateralization, resective bone surgery, and biopsies.^39,40

Piezo surgery

When compared with traditional surgery, bone healing following piezoelectric surgery is similar, or even improved. Piezoelectric bone surgery appears to induce an earlier increase in neoosteogenesis, resulting in a more positive osseous response, possibly because less pressure on the working tip is required, further reducing the risk of thermal damage to the bone. There is higher visibility during surgery compared to conventional instruments due to the evacuation of detritus with the aerosol formation. A decrease in post-surgical complications with the use of ultrasound bone surgery after lower third molar removal was evident.⁴¹

Medical management challenges and opportunities

Bone disease and pathology of the jaws

Challenges

The continual advancement of medical diagnostics, surgery and medicine has been influential in the current and predicted patient survival trend. In dentistry, improving oral health via education, access and treatments has seen the population retaining teeth for longer and in a more complex state.⁴² Although both medicine and dentistry’s impact on health should be celebrated, it is recognized that this will invite new and more complex challenges for the future workforce. Overall, an ageing population with multiple comorbidities, requiring the maintenance of a complex restored dentition is likely to require a multidisciplinary approach.

This challenge is not new to dentistry, however. Bone-modifying agents (BMAs), such as bisphosphonates, were introduced two decades ago, followed by newer drugs, such as denosumab and romosozumab. Approximately a decade later, novel/direct oral anticoagulants (NOACs/DOACs) were introduced. In both cases, there was mass panic in dentistry, with inadequate advice and guidance issued to the dental workforce, which has had a lasting and negative impact on the delivery of patient care. One challenge will be to avoid replicating these problems as future novel therapeutics and drug advances are introduced.

One area that has had a significant impact on medical care has been the introduction of biologics or targeted therapies. Biologics, such as monoclonal antibodies, are used in numerous medical specialities, such as oncology and rheumatology, with great success. Their value is evident with improved outcomes, symptom control and quality of life. Although these drugs are more focused at targeting disease-specific cells, they can still produce side effects, including neutropenia and thrombocytopenia, and for certain medications, there are oral side effects, for example osteonecrosis of the jaw and lichen planus.⁴³ Hence, dentistry will be mindful of these drugs and their impact on delivery of oral care especially oral surgeryrelated treatments. It is outside the scope of this article to explore how to manage the patients on these drugs.

With an ageing population, it has become apparent that cancer rates have increased and this is likely to continue.⁴⁴ Although in dentistry there is a focus on oral cancer, dentists should also be mindful of head and neck cancer, especially with the rapid rise of oropharyngeal cancer as a result of human papillomavirus infection.⁴⁵ Radiotherapy leads to high cure and survival rates, but subsequently, meticulous dental care and maintenance is required because of the potential for xerostomia, trismus, dysphagia and the life-long risk of osteoradionecrosis, on the background of a heavily restored and complex dentition.^46,47 Beyond head and neck cancer, dentistry must recognize that it has a vital contributory role in many other cancer pathways in assessing and maintaining dental fitness. Recently, NICE approved the use of adjuvant bisphosphonate in non-metastatic breast cancer patients with clear evidence showing its use improved overall survival and reduced recurrence.^48,49 This recommendation impacts 20,000 women annually, with the number expected to grow. Furthermore, there is an increasing number of patients receiving palliative care for metastatic cancer, who also take bone-modifying agents (BMAs), but which should not be mistaken for end-of-life care. An improvement in the therapies available to these patients has seen remarkable survival rates for many tumour groups. However, once again, the challenge for dentistry is to manage these patients’ oral and dental care, which is complex and differs not only for each tumour group, but even within each tumour group.^50–53 In addition to patients with solid tumours, there are haem-oncology patients with, for example, multiple myeloma who are also routinely receiving BMAs. Hence, dentistry will need to determine how it will continue to prevent and manage oral dental disease in this oncology ‘at risk’ patient group, which continues to grow and many within this group will have a risk of complications or their care may be complicated by continuous oncology treatment. The burden of routine dental care will fall upon the primary care practitioner and will require the appropriate knowledge and skills, which currently remains limited, to provide this care.

Opportunities

There are early suggestions that the explosion of novel drug therapies that are benefiting medicine may overspill into being an opportunity for dentistry too. Some of the progress made in cancer via better drug therapy has been based upon improved DNA sequencing of tumours to identify a targetable mutation. Using this sequencing technique has led to the discovery of the BRAF V600E mutation often found in some ameloblastoma.^54,5556 Interestingly, this same mutation has already been identified in a significant proportion of melanoma and colorectal cancer for which a targeted therapy (BRAF and MEK inhibitors) have already been created, trialled, and approved for routine use. There are case studies and series in which these medications have been used to treat largespan ameloblastomas, in both paediatric and adult patients, rather than the standard of care of partial jaw removal.^57–59 In the cases reported, the outcomes have been impressive, with the drugs reducing the tumour size sufficiently to allow simple enucleation via an intra-oral approach, retaining jaw integrity and avoiding mass tooth loss. Long-term follow-up regarding recurrence is undetermined currently, but so far signs are promising that drug therapy may have a role in de-escalating the need for radical surgery (Figure 2).

Ameloblastomas are not the only oral pathologies to benefit from drug therapy. BMAs have been used in the management of oral pathologies, such as fibrous dysplasia^60,61 and unresectable or large giant cell lesions, treatment of which usually requires disfiguring facial surgery.^62–64 Again, evidence remains limited owing to the rarity of the conditions, but the literature provides generally positive outcomes for their use.

Even more surprising is how valuable these drugs are in both primary and secondary osteomyelitis of the jaw. Primary chronic osteomyelitis is rare and can present in children, adolescents and adults, often with no underlying risk factors and without purulent discharge. Traditional treatment provides little to no symptom control. However, the use of BMAs has been found to provide near immediate and sustained effect, suggesting the driver to be osteoclastic and bone dysregulation rather than infection alone.^65,66 Even more remarkable is the use of BMAs in secondary chronic osteomyelitis. Often seen in immunosuppressed and immunocompromised patients, infection can be accompanied by purulent discharge, with rapid bone loss and the need for long-term antibiotics and regular jaw debridement. However, case reports of refractory and severe cases of osteomyelitis resolved with bisphosphonates and avoiding the need for surgery^67,68 provide some promise in an area of dental medicine that has seen little progress over the past few decades.

Surgical techniques

There have been advances in nerve repairs with improved imaging and techniques that avoid secondary site wounds needed for nerve grafts (Figure 3).

Magnetic resonance neurography has been used to anatomically map peripheral trigeminal neuropathies and has been found to stratify nerve injuries and neuropathies with moderate to good agreement with clinical neurosensory testing and surgical findings and is a useful diagnostic modality for clinical use.⁶⁹

Long-span processed nerve allografts are another technological advance that can improve quality of life for those who require ablative head and neck surgery. In one review of their use in reconstruction of the inferior alveolar nerve (IAN), using allografts of at least 5 cm in length, functional sensory recovery was demonstrated in paediatric and most adult patients within 1 year. There were no adverse events; in fact, no patients demonstrated the occurrence of neuropathic pain when the nerve repair was performed immediately in contrast to delayed repair states.⁷⁰ Immediate IAN reconstruction in paediatric patients should be considered strongly when the mandible requires resection with sacrifice of the IAN.⁷¹

Post-traumatic trigeminal neuropathic pain (PTTNp) may result from injury to the sensory division of the trigeminal nerve. Nerve repair microsurgery appears to resolve or decrease the neuropathic pain in approximately one-third of patients, with two main factors appearing to influence treatment outcomes: the time between the injury and surgery, and the pre-operative visual analogue scale score.⁷²

Post-operative surveillance

Developments in post-operative surveillance and outcomes assessment may also include:

• Homecheck apps;
• Personal audit/improvement.

Summary

There have been many developments and advances in surgery that impact on all aspects of patient care. However, there are also many challenges in being conversant with new technologies, new medications and new software, and there will be novel developments that have not yet appeared on the horizon!