Oral and maxillofacial surgery: What are our credentials?

Innately, humans are tribal creatures. As documented by evolutionary biologists, kinship is a powerful driving force of nature. It explains why animal behavior is primarily orientated toward replicating their genes.[1] The accumulation and dissemination of knowledge in our modern culture has accelerated to an extraordinary degree. To make sense of all fields of human endeavor: Commerce, science and the arts, a need to organize and sub-classify specific skills and job descriptions has become necessary and irresistible. This was the case with the advent of guilds in medieval times to the present. It can be argued that this generates an “occupational kinship” that gives each individual, in a defined craft group, a sense of identification and belonging. Unsurprisingly, health professionals are no exceptions.

The emergence of dentistry from the “barber-surgeon” practitioner is very recent compared with the evolution of early medicine dating from several centuries BCE. This may help to explain, to some degree, why medical practitioners have regarded the oral cavity and dentoalveolus, perhaps unconsciously, as somehow separate from the rest of the human body. This is perpetuated in undergraduate education where little to no dental knowledge is included in the medical curricula.[2] University training is usually separated into independent medical and dental schools and independent arms of government in many countries fund the medical and dental services. This artificial anatomical division from the perspective of patient care is simply illogical and has promoted an unnecessary difference between two major groups of practitioners who are both striving to produce better health for the community.

In the surgical world, oral and maxillofacial surgery (OMS) is now the most obvious link between the medical and dental communities and should act as a natural conduit for “reunification” with the potential to reduce unhelpful prejudice and ignorance. Globally, we have witnessed the formation of new specialties and sub-specialties within surgery over recent decades that have resulted in major changes to the traditional role of the general surgeon. This is a consequence of the development of additional surgical expertise in both regional anatomical areas and specific organ systems. There is a need for trainees to acquire more focused and detailed knowledge in their chosen specialty. Experienced specialists must also adopt emerging technologies in a timely manner and there is an expectation that continuing education will be maintained to preserve the standards expected of specialist care by the public. The credentialing of surgeons has never been more important and is a topic that all specialist groups must constantly consider and refine for the future.[3]

OMS is one of the newer surgical specialties and as described in a previous guest editorial in this Journal,[4] our scope has continued to increase. OMS now encompasses cranio-maxillofacial trauma, congenital and developmental craniofacial deformity, head and neck pathology and oncology, reconstructive surgery, TMJ surgery, esthetic facial surgery, implantology and dentoalveolar surgery. Whilst there remains a wide national variation in the range of OMS surgical practices, this increasing scope has undoubtedly occurred due to the addition of more formal medical and basic surgical training. This is followed by core training with the subsequent option of further specific fellowship experience. However, it is recognized that many national training systems are unable to deliver a more extended surgical education due to the costs of the additional years of training and the urgent needs of the community for the provision of care. There is also the economic imperative of making a living from private practice in the face of limited funding available within government institutions for full-time hospital positions where a broader scope practice can be undertaken.

Notwithstanding the differing training backgrounds within our specialty, what are the “kinship” factors that bind the OMS specialty together internationally? What are the core-shared areas of expertise that differentiates us from our surgical competitors? It is surely our dental training that provides the essential building blocks that inform our subsequent surgical training. The in-depth knowledge of dental and oral pathology, an understanding of occlusion and the masticatory apparatus, the technical expertise in precisely manipulating turbine hand pieces and an appreciation of the need for functional reconstruction in the facial region have resulted in the achievement of superior surgical results. These outcomes must be promoted by teaching and publication. This is what confers our unique credentials. Take away or belittle this dental background and we lose our OMS-defining characteristics with the absolute certainty that any void will be filled by other specialties or lesser-trained practitioners who are more than happy to occupy the surgical landscape requiring dental knowledge.

Each OMS training center must decide upon the “core” curriculum to be delivered for specialist certification or qualification. This may even vary within one country. In the USA, training programs may or may not include a medical degree and this has the potential to divide the specialty.[5] In Australia and New Zealand, the acquisition of dual degrees and a year of general surgery are mandated as prerequisites before selection into a 4-year OMS program that has been accredited by the Australian Medical and Dental Councils. This advanced training is based around a modular curriculum with a final examination leading to specialist registration in both medicine and dentistry in OMS.[6] This program is not intended to include comprehensive training in head and neck surgery or cleft and craniofacial surgery as examples. These fields are regarded as areas of sub-specialization that can be accessed by targeted fellowship experience. Requirements for credentialing in these fields have been recently developed by the Board of Studies (OMS) of the Royal Australasian College of Dental Surgeons. They will inevitably provoke criticism and defensive strategies from adjacent specialties who also occupy this “turf” however this underlines the need for all craft groups to have a transparent credentialing process that will stand up to objective third party scrutiny. To deliver a high standard of practice, the training experience of an individual surgeon in these subspecialty areas is just as important as the “kinship” parent specialty in which they received core training.

The International Association of Oral and Maxillofacial Surgeons have commenced an initiative to develop an examination for OMS (International Board of OMS). This is to be welcomed as it will be applicable to nations who may aspire to a common agreed standard for certification in OMS. It is anticipated that this will help to improve benchmarking in training across regions where a standard is yet to be formally implemented.

Overall, the future of OMS is bright indeed, fuelled by better basic and advanced training, an ever-increasing acceptance by the medical surgical fraternity and the specific expertise that is afforded by our dental training. However, it should be remembered that no craft group “owns” the cranio-maxillofacial region and for optimum patient care, we should welcome the expertise of related surgical disciplines where their strengths are important in any case management, just as they need to be reminded of the value of OMS in its contribution. In a diverse specialty such as OMS, professional “kinship” is an important concept and appropriate credentialing must continue to develop and be fine-tuned. Despite our regional differences, OMS must be inclusive of all our colleagues world-wide to achieve the common goal of advancing patient care.