- Email: [email protected]
Governance, guidelines, audit, and revalidation in the 21st century
Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery 53 (2015) 409–411
Editorial
Governance, guidelines, audit, and revalidation in the 21st century Introduction E-mails on clinical effectiveness, governance, guidelines, audit, and revalidation are daily additions to the inbox. This saturation of information can generate indifference but these 5 elements are powerful drivers in the evolution of patient care and developments in oral and maxillofacial surgery (OMFS). For many years the British Association of Oral and Maxillofacial Surgeons (BAOMS) has been at the forefront of clinical effectiveness in the specialty, and through its Clinical Effectiveness Subcommittee (CEC) has provided guidance and guidelines to optimise patient care and facilitate the collection and publication of outcome data. Successive CEC chairmen have assembled an annual review of OMFS audits and circulated them through the in-house publication Clinical effectiveness matters. They have also run at least one national audit each year: Simon Rogers and Patrick Magennis ran national benchmarking studies on fractured mandibles and outpatient clinics, and Stephen Layton concentrated on the management of basal cell carcinoma of the skin. All the chairmen have worked with leaders of regional audits to deliver these projects, which are run by and for OMFS, and are driven by the professionalism of the members of the Association and by its charitable objectives. Two of the national trauma audits of facial injuries in accident and emergency departments were run in parallel with public information campaigns and the BAOMS public information subcommittee,1,2 but the CEC now needs to work with the Association’s continuing professional development (CPD) subcommittee.
Changing times In recent years there have been several high-profile enquiries3–11 into systematic and individual failings in medicine and surgery, so while clinical audit used to be the reserve of the meek and the geek, and was handed as a chore to the new consultant in the department, outcome measures must now be recorded for revalidation and recertification.12
If we harness the necessity to collect suitable outcome data we can use them to reassure the public and justify our surgical care. BAOMS is well-placed to develop and publish evidence-based guidelines and guidance to support and optimise areas of practice in the specialty. However, in OMFS in the United Kingdom, some pressures from outside must also be addressed and sometimes resisted. The most important example was the 2013 policy document of the Commissioning Board of NHS England, Securing excellence in commissioning NHS dental services.13 Despite the fact that it described the “unravelling of oral and maxillofacial surgery” as an objective, it did not involve specialists in OMFS. Without a clear framework for change or a stated objective, NHS England is committed to reconfiguring the specialty and the services we provide. To introduce some evidence into the process, BAOMS, in association with the Department of Health and the Royal College of Surgeons of England, have recently published commissioning guidance for orthognathic procedures.14 Guidance has also been produced for TMJ procedures,15 and work continues on the development of guidance for exodontia in secondary care. The latter has been delayed as the emphasis has shifted from primary and secondary care to secondary care alone.
NICE-accredited guidelines – the gold standard NICE produces clinical guidelines, commissioning guidelines, care pathways, and quality indicators, and BAOMS has liaised with NICE about the selection of topics to be discussed. NICE allows agencies (such as BAOMS) to apply for accreditation to add their name to guidelines. This provides a stamp of rigour, professional quality, and external recognition of the ability of the Association to deliver its charitable objectives of improving the quality of patient care and professional practice. Each completed guideline adds to the evidence base in areas of clinical practice, service planning, or commissioning, and reinforces the fact that the Association is a key stakeholder.
http://dx.doi.org/10.1016/j.bjoms.2015.02.018 0266-4356/© 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
410
Editorial / British Journal of Oral and Maxillofacial Surgery 53 (2015) 409–411
NICE accredits the process manual from which the guidelines are developed. For successful accreditation, at least two completed guideline topics are needed to test that the manual has been followed accurately. The BAOMS manual requires information about professional behaviour as well as liaison with other surgical specialty associations and NICE, among others, so BAOMS has appointed a part-time information scientist. The National Facial, Oral, and Oculoplastic Research Centre (NFORC) has agreed to provide the patients’ views as well as the expert support in statistics and health economics that are required. The first 2 topics we have chosen are Clinical guidelines for the management of facial soft tissue wounds and Clinical guidelines for the management of patients referred with impacted third molars. Each topic is likely to take at least 18 months to reach the final draft. Some medical associations have multiple topics under parallel development or 5-year review using a defined process manual, in-house professional information scientists, and a committee. BAOMS has been active among the 10 surgical specialties in modernising the approach to the development of guidelines. The aim is to provide a funded and organised process that enables members of the Association to engage in proposing and writing a BAOMS clinical guideline on a topic in which they are interested, by following a clearly-defined series of steps with professional support. Although all our commissioning guidance documents have been developed using a NICE-accredited process manual,16 they seem to have been overlooked by NHS England’s Dental Commissioning Board, despite the involvement of the Department of Health and our repeated attempts to find out their views. We hope that the local care commissioning groups will find our guides relevant and helpful in the commissioning of our services when they take over from the Dental Commissioning Board.
National Facial, Oral, and Oculoplastic Research Centre (NFORC): your partner in research and audit Two years ago, BAOMS created its own National Facial and Oral Research Centre (NFORC), and last year the Royal College of Surgeons of England designated it their head and neck clinical trials unit. It is funded by our partner Saving Faces,17 which also provides the research infrastructure, as it pays for the BAOMS head of clinical research Professor Jim McCaul, and the NHS Health and Social Care Information Centre18 (HSCIC) in Leeds to create web-based versions of our national datasets. It enables those who enter data to be able to retrieve them 24 hours a day, 7 days a week, and does not cost BAOMS or its members any money. It also runs a helpline. In our datasets we collect identifiable data (NHS number), and record that the patients have given consent, so that research workers can organise follow-up studies to establish long-term outcomes many years after treatment
and examine the national standards for revalidation of any dataset. Individual hospitals and their Caldicott guardians should accept that the data will be held by the HSCIC, which is part of the NHS. As the HSCIC also holds several other national datasets such as Hospital Episode Statistics and some national data from general practitioners, we may in future be able to correlate our data with those from other sources and embark on even more interesting and useful collaborative research with other national organisations. These sources of work should help with the aim of the BAOMS to provide better professional support to members who are taking part in and benefitting from the development of clinical guidelines, national data entry, and audits.
So what can BAOMS do for you and what can you do for OMFS? The BAOMS clinical effectiveness and research subcommittees are working together with NFORC to develop audit and clinical research projects, and representatives from regional and subspecialty groups are contributing to both research and audit. By optimising representation and consulting with colleagues throughout the country we hope to cover all subspecialty interests and areas of practice, and to harness ongoing projects. We are currently running the annual BAOMS National Audit for Revalidation on patients referred with impacted third molars.19 It will provide useful outcome measures that can be used to indicate the quality of service provided by a unit and enable comparisons of individual surgeons with the national average. Surgeons can record complications such as neurosensory deficits of the inferior alveolar and lingual nerves, and also compare them with the national average. The next BAOMS National Audit for Revalidation will be about outcomes in orthognathic surgery. The methods for the collection of data, which have been drafted and agreed with the British Orthodontic Society (BOS), consist of 2 components. The main component, a 4-section questionnaire that includes the BOS orthognathic quality of life questionnaire and validated social anxiety and self esteem scales, is completed by patients before, and at various intervals after, treatment. The second is a minimum dataset about the patient’s original reason for treatment and the treatment given. Its main foci are the alterations in the patient’s social, emotional, financial, and functional performance, and their attitudes before and after treatment. The methods used to collect the data about orthognathic outcome can be found on the BAOMS website.20 So far we have not mentioned the most important key element. Without the cooperation, support, and effort of our colleagues within OMFS, we will not be able to do the best for our patients and improve the services we provide. We therefore ask you to forgive our enthusiasm, smile when we ask you to complete yet another form, persuade your Caldicott
Editorial / British Journal of Oral and Maxillofacial Surgery 53 (2015) 409–411
guardians that HSCIC is safe, cajole your elders, recruit your juniors, and help us to move our specialty forward. We hope that this editorial will have answered the question “What can BAOMS do for me?” and will encourage more of you to become involved in quality assurance and measures to ensure clinical effectiveness, because they are important.
References 1. Hutchison IL, Magennis P, Shepherd JP, et al. The BAOMS United Kingdom survey of facial injuries part 1: aetiology and the association with alcohol consumption. British Association of Oral and Maxillofacial Surgeons. Br J Oral Maxillofac Surg 1998;36:3–13. 2. Magennis P, Shepherd J, Hutchison I, et al. Trends in facial injury. Br Med J 1998;316:325–6. 3. Shipman Enquiry First Report. Death disguised. Published 19 July 2002. Available from: http://webarchive.nationalarchives.gov.uk/ 20090808154959/http://www.the-shipman-inquiry.org.uk/firstreport.asp 4. Shipman Enquiry Third Report. Death certification and the investigation of deaths by coroners. Published 14 July 2003. Command paper Cm 5854. Available from: http://webarchive.nationalarchives.gov.uk/ 20090808154959/http://www.the-shipman-inquiry.org.uk/thirdreport.asp 5. Shipman Enquiry Fifth Report. Safeguarding patients: lessons from the past – proposals for the future. Published 9 December 2004. Command paper Cm 6394. Available from: http://webarchive.nationalarchives.gov. uk/20090808154959/http://www.the-shipman-inquiry.org.uk/ fifthreport.asp 6. Shipman Enquiry Sixth Report. Shipman: the final report. Published 27 January 2005. Available from: http://webarchive.nationalarchives. gov.uk/20090808154959/http://www.the-shipman-inquiry.org.uk/ finalreport.asp 7. Harley M, Mohammed MA, Hussain S, et al. Was Rodney Ledward a statistical outlier? Retrospective analysis using routine hospital data to identify gynaecologists’ performance. Br Med J 2005;330:929. 8. The report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary: learning from Bristol, 1984–1995. Available from: http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/ DH 4005620 9. Report of the inquiry into quality and practice within the National Health Service arising from the actions of Rodney Ledward. London: Department of Health; 2000. 10. Investigation into Mid Staffordshire NHS Foundation Trust. 2009. Available from: http://webarchive.nationalarchives.gov.uk/20130107105354/ http:/www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/DH 113018 11. The Second Francis Report 2013. Available from: http://www. midstaffspublicinquiry.com/report
411
12. Ready for revalidation: the good medical practice framework for appraisal and revalidation. General Medical Council, 2012. Available from: http:// www.gmcuk.org/static/documents/content/GMC Revalidation A4 Guidance GMP Framework 04.pdf 13. NHS Commissioning Board. Securing excellence in commissioning NHS dental services. 2013. Available from: http://www.england.nhs.uk/ wp-content/uploads/2013/02/commissioning-dental.pdf 14. Commissioning guide for orthognathic procedures. 2013. Available from: http://www.rcseng.ac.uk/surgeons/surgical-standards/docs/orthognathicprocedures-commissioning-guide 15. Commissioning guide: temporomandibular joint disorders. Available from: http://www.rcseng.ac.uk/healthcare-bodies/docs/rcseng-baomscommissioning-guide-on-tmj-disorders 16. Surgical Specialty Associations and the Royal College of Surgeons of England. 2012. Commissioning guidance process manual. Available from: http://www.rcseng.ac.uk/surgeons/surgical-standards/ docs/commissioning-guidance-process-manual 17. Saving Faces – The Facial Surgery Research Foundation. Research today saves faces tomorrow. Available from: http://www.savingfaces.co.uk/ 18. Health and Social Care Information Centre (HSCIC). Available from: http://www.gov.uk/government/organisations/health-and-social-careinformation-centre 19. BAOMS 2013 National Audit for Revalidation. Patients referred with impacted third molars. Available from: http://www.baoms.org.uk/page. aspx?id=665 20. BAOMS. Orthognathic outcome data collection tools. Available from: http://www.baoms.org.uk/page.aspx?id=520
J. Gallagher BAOMS Clinical Effectiveness Subcommittee (CEC), United Kingdom T.K. Blackburn BAOMS Process Manual for Clinical Guideline Development, United Kingdom I. Hutchison National Facial and Oral Research Centre (NFORC), United Kingdom P. Magennis ∗ BAOMS, United Kingdom ∗ Corresponding author. Tel.: +44151 5295289; fax: +44151 5295288. E-mail addresses: [email protected] (J. Gallagher), [email protected] (T.K. Blackburn), [email protected] (I. Hutchison), [email protected] (P. Magennis) Available online 12 March 2015
British Journal of Oral and Maxillofacial Surgery 53 (2015) 409–411
Editorial
Governance, guidelines, audit, and revalidation in the 21st century Introduction E-mails on clinical effectiveness, governance, guidelines, audit, and revalidation are daily additions to the inbox. This saturation of information can generate indifference but these 5 elements are powerful drivers in the evolution of patient care and developments in oral and maxillofacial surgery (OMFS). For many years the British Association of Oral and Maxillofacial Surgeons (BAOMS) has been at the forefront of clinical effectiveness in the specialty, and through its Clinical Effectiveness Subcommittee (CEC) has provided guidance and guidelines to optimise patient care and facilitate the collection and publication of outcome data. Successive CEC chairmen have assembled an annual review of OMFS audits and circulated them through the in-house publication Clinical effectiveness matters. They have also run at least one national audit each year: Simon Rogers and Patrick Magennis ran national benchmarking studies on fractured mandibles and outpatient clinics, and Stephen Layton concentrated on the management of basal cell carcinoma of the skin. All the chairmen have worked with leaders of regional audits to deliver these projects, which are run by and for OMFS, and are driven by the professionalism of the members of the Association and by its charitable objectives. Two of the national trauma audits of facial injuries in accident and emergency departments were run in parallel with public information campaigns and the BAOMS public information subcommittee,1,2 but the CEC now needs to work with the Association’s continuing professional development (CPD) subcommittee.
Changing times In recent years there have been several high-profile enquiries3–11 into systematic and individual failings in medicine and surgery, so while clinical audit used to be the reserve of the meek and the geek, and was handed as a chore to the new consultant in the department, outcome measures must now be recorded for revalidation and recertification.12
If we harness the necessity to collect suitable outcome data we can use them to reassure the public and justify our surgical care. BAOMS is well-placed to develop and publish evidence-based guidelines and guidance to support and optimise areas of practice in the specialty. However, in OMFS in the United Kingdom, some pressures from outside must also be addressed and sometimes resisted. The most important example was the 2013 policy document of the Commissioning Board of NHS England, Securing excellence in commissioning NHS dental services.13 Despite the fact that it described the “unravelling of oral and maxillofacial surgery” as an objective, it did not involve specialists in OMFS. Without a clear framework for change or a stated objective, NHS England is committed to reconfiguring the specialty and the services we provide. To introduce some evidence into the process, BAOMS, in association with the Department of Health and the Royal College of Surgeons of England, have recently published commissioning guidance for orthognathic procedures.14 Guidance has also been produced for TMJ procedures,15 and work continues on the development of guidance for exodontia in secondary care. The latter has been delayed as the emphasis has shifted from primary and secondary care to secondary care alone.
NICE-accredited guidelines – the gold standard NICE produces clinical guidelines, commissioning guidelines, care pathways, and quality indicators, and BAOMS has liaised with NICE about the selection of topics to be discussed. NICE allows agencies (such as BAOMS) to apply for accreditation to add their name to guidelines. This provides a stamp of rigour, professional quality, and external recognition of the ability of the Association to deliver its charitable objectives of improving the quality of patient care and professional practice. Each completed guideline adds to the evidence base in areas of clinical practice, service planning, or commissioning, and reinforces the fact that the Association is a key stakeholder.
http://dx.doi.org/10.1016/j.bjoms.2015.02.018 0266-4356/© 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
410
Editorial / British Journal of Oral and Maxillofacial Surgery 53 (2015) 409–411
NICE accredits the process manual from which the guidelines are developed. For successful accreditation, at least two completed guideline topics are needed to test that the manual has been followed accurately. The BAOMS manual requires information about professional behaviour as well as liaison with other surgical specialty associations and NICE, among others, so BAOMS has appointed a part-time information scientist. The National Facial, Oral, and Oculoplastic Research Centre (NFORC) has agreed to provide the patients’ views as well as the expert support in statistics and health economics that are required. The first 2 topics we have chosen are Clinical guidelines for the management of facial soft tissue wounds and Clinical guidelines for the management of patients referred with impacted third molars. Each topic is likely to take at least 18 months to reach the final draft. Some medical associations have multiple topics under parallel development or 5-year review using a defined process manual, in-house professional information scientists, and a committee. BAOMS has been active among the 10 surgical specialties in modernising the approach to the development of guidelines. The aim is to provide a funded and organised process that enables members of the Association to engage in proposing and writing a BAOMS clinical guideline on a topic in which they are interested, by following a clearly-defined series of steps with professional support. Although all our commissioning guidance documents have been developed using a NICE-accredited process manual,16 they seem to have been overlooked by NHS England’s Dental Commissioning Board, despite the involvement of the Department of Health and our repeated attempts to find out their views. We hope that the local care commissioning groups will find our guides relevant and helpful in the commissioning of our services when they take over from the Dental Commissioning Board.
National Facial, Oral, and Oculoplastic Research Centre (NFORC): your partner in research and audit Two years ago, BAOMS created its own National Facial and Oral Research Centre (NFORC), and last year the Royal College of Surgeons of England designated it their head and neck clinical trials unit. It is funded by our partner Saving Faces,17 which also provides the research infrastructure, as it pays for the BAOMS head of clinical research Professor Jim McCaul, and the NHS Health and Social Care Information Centre18 (HSCIC) in Leeds to create web-based versions of our national datasets. It enables those who enter data to be able to retrieve them 24 hours a day, 7 days a week, and does not cost BAOMS or its members any money. It also runs a helpline. In our datasets we collect identifiable data (NHS number), and record that the patients have given consent, so that research workers can organise follow-up studies to establish long-term outcomes many years after treatment
and examine the national standards for revalidation of any dataset. Individual hospitals and their Caldicott guardians should accept that the data will be held by the HSCIC, which is part of the NHS. As the HSCIC also holds several other national datasets such as Hospital Episode Statistics and some national data from general practitioners, we may in future be able to correlate our data with those from other sources and embark on even more interesting and useful collaborative research with other national organisations. These sources of work should help with the aim of the BAOMS to provide better professional support to members who are taking part in and benefitting from the development of clinical guidelines, national data entry, and audits.
So what can BAOMS do for you and what can you do for OMFS? The BAOMS clinical effectiveness and research subcommittees are working together with NFORC to develop audit and clinical research projects, and representatives from regional and subspecialty groups are contributing to both research and audit. By optimising representation and consulting with colleagues throughout the country we hope to cover all subspecialty interests and areas of practice, and to harness ongoing projects. We are currently running the annual BAOMS National Audit for Revalidation on patients referred with impacted third molars.19 It will provide useful outcome measures that can be used to indicate the quality of service provided by a unit and enable comparisons of individual surgeons with the national average. Surgeons can record complications such as neurosensory deficits of the inferior alveolar and lingual nerves, and also compare them with the national average. The next BAOMS National Audit for Revalidation will be about outcomes in orthognathic surgery. The methods for the collection of data, which have been drafted and agreed with the British Orthodontic Society (BOS), consist of 2 components. The main component, a 4-section questionnaire that includes the BOS orthognathic quality of life questionnaire and validated social anxiety and self esteem scales, is completed by patients before, and at various intervals after, treatment. The second is a minimum dataset about the patient’s original reason for treatment and the treatment given. Its main foci are the alterations in the patient’s social, emotional, financial, and functional performance, and their attitudes before and after treatment. The methods used to collect the data about orthognathic outcome can be found on the BAOMS website.20 So far we have not mentioned the most important key element. Without the cooperation, support, and effort of our colleagues within OMFS, we will not be able to do the best for our patients and improve the services we provide. We therefore ask you to forgive our enthusiasm, smile when we ask you to complete yet another form, persuade your Caldicott
Editorial / British Journal of Oral and Maxillofacial Surgery 53 (2015) 409–411
guardians that HSCIC is safe, cajole your elders, recruit your juniors, and help us to move our specialty forward. We hope that this editorial will have answered the question “What can BAOMS do for me?” and will encourage more of you to become involved in quality assurance and measures to ensure clinical effectiveness, because they are important.
References 1. Hutchison IL, Magennis P, Shepherd JP, et al. The BAOMS United Kingdom survey of facial injuries part 1: aetiology and the association with alcohol consumption. British Association of Oral and Maxillofacial Surgeons. Br J Oral Maxillofac Surg 1998;36:3–13. 2. Magennis P, Shepherd J, Hutchison I, et al. Trends in facial injury. Br Med J 1998;316:325–6. 3. Shipman Enquiry First Report. Death disguised. Published 19 July 2002. Available from: http://webarchive.nationalarchives.gov.uk/ 20090808154959/http://www.the-shipman-inquiry.org.uk/firstreport.asp 4. Shipman Enquiry Third Report. Death certification and the investigation of deaths by coroners. Published 14 July 2003. Command paper Cm 5854. Available from: http://webarchive.nationalarchives.gov.uk/ 20090808154959/http://www.the-shipman-inquiry.org.uk/thirdreport.asp 5. Shipman Enquiry Fifth Report. Safeguarding patients: lessons from the past – proposals for the future. Published 9 December 2004. Command paper Cm 6394. Available from: http://webarchive.nationalarchives.gov. uk/20090808154959/http://www.the-shipman-inquiry.org.uk/ fifthreport.asp 6. Shipman Enquiry Sixth Report. Shipman: the final report. Published 27 January 2005. Available from: http://webarchive.nationalarchives. gov.uk/20090808154959/http://www.the-shipman-inquiry.org.uk/ finalreport.asp 7. Harley M, Mohammed MA, Hussain S, et al. Was Rodney Ledward a statistical outlier? Retrospective analysis using routine hospital data to identify gynaecologists’ performance. Br Med J 2005;330:929. 8. The report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary: learning from Bristol, 1984–1995. Available from: http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/ DH 4005620 9. Report of the inquiry into quality and practice within the National Health Service arising from the actions of Rodney Ledward. London: Department of Health; 2000. 10. Investigation into Mid Staffordshire NHS Foundation Trust. 2009. Available from: http://webarchive.nationalarchives.gov.uk/20130107105354/ http:/www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/DH 113018 11. The Second Francis Report 2013. Available from: http://www. midstaffspublicinquiry.com/report
411
12. Ready for revalidation: the good medical practice framework for appraisal and revalidation. General Medical Council, 2012. Available from: http:// www.gmcuk.org/static/documents/content/GMC Revalidation A4 Guidance GMP Framework 04.pdf 13. NHS Commissioning Board. Securing excellence in commissioning NHS dental services. 2013. Available from: http://www.england.nhs.uk/ wp-content/uploads/2013/02/commissioning-dental.pdf 14. Commissioning guide for orthognathic procedures. 2013. Available from: http://www.rcseng.ac.uk/surgeons/surgical-standards/docs/orthognathicprocedures-commissioning-guide 15. Commissioning guide: temporomandibular joint disorders. Available from: http://www.rcseng.ac.uk/healthcare-bodies/docs/rcseng-baomscommissioning-guide-on-tmj-disorders 16. Surgical Specialty Associations and the Royal College of Surgeons of England. 2012. Commissioning guidance process manual. Available from: http://www.rcseng.ac.uk/surgeons/surgical-standards/ docs/commissioning-guidance-process-manual 17. Saving Faces – The Facial Surgery Research Foundation. Research today saves faces tomorrow. Available from: http://www.savingfaces.co.uk/ 18. Health and Social Care Information Centre (HSCIC). Available from: http://www.gov.uk/government/organisations/health-and-social-careinformation-centre 19. BAOMS 2013 National Audit for Revalidation. Patients referred with impacted third molars. Available from: http://www.baoms.org.uk/page. aspx?id=665 20. BAOMS. Orthognathic outcome data collection tools. Available from: http://www.baoms.org.uk/page.aspx?id=520
J. Gallagher BAOMS Clinical Effectiveness Subcommittee (CEC), United Kingdom T.K. Blackburn BAOMS Process Manual for Clinical Guideline Development, United Kingdom I. Hutchison National Facial and Oral Research Centre (NFORC), United Kingdom P. Magennis ∗ BAOMS, United Kingdom ∗ Corresponding author. Tel.: +44151 5295289; fax: +44151 5295288. E-mail addresses: [email protected] (J. Gallagher), [email protected] (T.K. Blackburn), [email protected] (I. Hutchison), [email protected] (P. Magennis) Available online 12 March 2015