Download Oral Surgery Referral Guidelines for GDP

Devon Cornwall & Isles of Scilly Area Team
Regus House
1, Emperor Way
Exeter
EX1 3QS
[email protected]
August 2014
Dear Colleague
I am contacting you in my role as Clinical Chair of the Dental Local Professional
Network of the Devon, Cornwall and Isles of Scilly Local Area Team, NHS England.
One of the key roles of the Local Professional Network is to drive quality improvement
and outcomes in line with local and national priorities and to facilitate wider clinical
engagement and clinical input into the commissioning process.
Improving the Oral Surgery Care Pathway is a local and national priority for the
Area Team and I would like your help to achieve this.
Currently throughout the Devon and Cornwall area patients requiring oral surgery are
referred to one of five secondary care hospitals and a variety of primary care based
providers. There is a wide variety of methods of referral and referral forms and no
consistent set of guidelines for practitioners. There is also an issue of a small number
of GDPs who are referring inappropriate cases that should be completed in the GDP
practice, submitting very poor quality referrals with poor information and radiographs,
and making inappropriate referrals for General Anaesthetics.
One of the aims of the Oral Surgery Care Pathway reform is to move some of the more
straightforward work to primary care based providers to enable more local access for
patients and free up valuable resources.
In order to achieve an improvement in the quality of referrals and reduce inappropriate
referrals the Area Team in consultation with all stakeholders has produced a set of
consistent guidelines and referral forms for the whole area. I would ask you all to read
through them carefully and make sure your referrals comply with the guidelines and are
of the quality our patients would expect from a healthcare professional. We hope to
make these available soon through the NHS England website.
I would especially ask you to take note of the sections on referrals for general
anaesthesia radiographs and medical conditions.
If
you
have
any
comments
or
queries
please
contact
me
at
[email protected] and if you want to keep up to date with the LPN please
let me have your personal email address and I will add you to our circulation list.
With kind regards
Peter Howard-Williams BDS LDS DGDP
Clinical Chair Dental Local Professional Network
DEVON, CORNWALL AND ISLES of SCILLY LOCAL AREA TEAM
MINOR ORAL SURGERY GDP REFERRAL GUIDELINES
FREQUENTLY ASKED QUESTIONS
"When should I refer an extraction?"
As part of their GDS contract NHS providers and performers are expected to carry out
extractions of teeth including the removal of retained roots. The patient should only be
referred if they present with special difficulties and lie outside the competence of the
dentist concerned. Please look through the guidelines carefully. NHS England has
identified the inappropriate referral of extractions that should be carried out in practice
as an area where improvements are necessary. If an individual performer feels unable
to perform a procedure that should be carried out in general practice it is the
responsibility of that provider to arrange for the procedure to be carried out in practice
by another, more experienced performer.
"To whom should I refer?"
Currently patients referred for oral surgery procedures are treated either in a secondary
care setting which means one of the five main hospitals in Devon and Cornwall or by a
specialist provider based in a primary care setting.
Secondary Care providers are able to offer the full range of operative and diagnostic
treatment including 2 week waits for suspected cancer patients and general
anaesthesia.
Primary care providers are able to offer a more limited range of surgical procedures,
with or without sedation. (Appendix 3)
In order to reduce pressure on secondary care providers and free up valuable
resources NHS England has a national and local priority to increase the number of
cases treated by primary care based providers and changes to the referral guidelines
and triaging of patients reflects this priority.
"Where should I send the referral form?"
All the referrals for the Devon, Torbay and Plymouth areas should be sent to Devon
Access and Referral Centre DART on the DCIoS Oral Surgery Referral form (Form 1).
Their address, email and telephone number are on the form.
NOTE: GDPs who currently refer directly to Derriford or Plymouth based primary
care should now refer all patients through DART.
All the referrals for the Cornwall area should be sent to Kernow Health Referral
Management Service RMS on the DCIoS Oral Surgery Referral form (Form 1). Their
address, email and telephone number are on the form.
"Why can't I do all the referral process electronically?"
It is an ambition to develop an electronic system as soon as possible. One difficulty is
the transmission and storage of radiographs.
"How should I refer a suspected cancer case?"
A suspected cancer case should be referred without delay directly to your
nearest hospital. The referral should be faxed and the numbers are on the referral
forms. A paper copy or telephone call should follow as a backup.
For North Devon and Exeter you should use the Oral and Maxillofacial Surgery Referral
Form (Form 1) - Fax number: 01392 402199.
For Plymouth use the Plymouth 2WW form (Form 3) – Fax number: 01752 430912
telephone number: 01752 437506.
For Cornwall use the Cornwall Hospitals Trust urgent two week wait form (Form 4 or
4a electronic) – Fax number: 01872 252300, if you have any problems please ring
01872 252323.
For Torbay book via choose and book if possible, otherwise use the South Devon
Healthcare Trust urgent two week wait form (Form 5) and fax to the Patient Access
Centre – Fax number: 01803 654981.
"How can I improve my extraction skills?"
There are opportunities with the postgraduate BUOLD course on oral surgery and if
there is demand we will arrange some local training and assisted operating.
"What happens if I encounter problems and am unable to complete a surgical
procedure?"
Firstly you should ask a colleague in your practice to assist but if that is not possible
then you can ring your local secondary care oral surgery department or primary care
specialist for advice.
Royal, Devon and Exeter NHS trust: 01392 411611 to the operator and then ask for
the on-call SHO on bleep 476.
For North Devon District Hospital: "daytime" ring the secretary on 01271 322477.
Derriford Hospital, Plymouth: 01752 202082 and ask for the on call maxillofacial SHO.
Plymouth Community Dental Services: 08451558070
Royal Cornwall Hospital, Truro: 01872 250000 - switchboard for on call Oral and
Maxillofacial Surgery Resident. Daytime urgent requests can also be to secretarial
team: 01872 253986
Torbay Hospital: The on call SHO via the switchboard 01803 614567 and bleep #6313.
"What will happen if a referral is rejected?"
A referral will only be returned to the referring practitioner after a clinician has reviewed
it. The referring practitioner will be sent a letter stating the reason for the rejection and
the patient will also be informed. (Appendix 5a & 5b) It is then up to the practitioner to
provide more details of why the referral is appropriate or undertakes the procedure in
practice. The Area Team will be auditing a number of these cases to ensure that the
patient reaches a satisfactory conclusion.
"Will I get my radiographs back?"
We are aware that radiographs have not always been returned in the past but in future
every effort will be made to return original radiographs with correspondence. Digital
radiographs should be printed on good quality photographic paper.
DEVON, CORNWALL AND ISLES of SCILLY LOCAL AREA TEAM
MINOR ORAL SURGERY GDP REFERRAL GUIDELINES
All practitioners must use the new DCIoS referral form for all oral surgery
referrals of patients over 18 (Form 1). Please use the new form to avoid rejection
at triage.
Attached please find the guidelines for appropriate referral of:
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Non third molar extractions
Third molar extractions
Extraction of retained roots
Endodontic Surgery/Apicectomies
TMJ problems
Abnormal; soft tissue and bony lesions
Oral Cancer Oral Medicine
Sedation or General Anaesthetic
All referrals that fall outside these guidelines will be returned unless further information
is provided which justifies the referral.
Failure to complete all sections of the referral will result in the return of referral
and subsequent delay in the patient’s treatment. The information on the form must
reflect the results of the referring practitioner’s examination and diagnosis.
Failure to submit a satisfactory radiograph, if appropriate, will result in the return
of referral and subsequent delay in the patients’ treatment.
Failure to submit an up to date medical history with details of all current
medication and if the patient is taking Warfarin the most recent INR, will result in
the return of referral and subsequent delay in the patient’s treatment.
It is rare for a patient’s medical history to complicate the extraction to such an extent
that it needs to take place within the hospital setting. Specific examples are listed.
(Appendix 2)
GDC guidelines indicate that “particular care must be taken when referring patients for
treatment under general anaesthesia or sedation”. General anaesthesia carries an
increased level of risk and should not be offered to patients as a routine
alternative.
If referring for sedation or general anaesthetic the patient must complete and sign the
"GA or Sedation Referral form" Failure to complete all sections will result in the
return of referral and subsequent delay in the patients’ treatment. (Appendix 1
and Form 2)
All suspected oral cancer cases should be fast tracked direct to the Oral Surgery
Department by fax or "Choose and book" and their receipt confirmed. (See FAQs
for details)
NON THIRD MOLAR EXTRACTIONS:
Non third molar extractions should be performed in the referring practitioners’ dental
surgery under local anaesthetic.
These should only be referred in the following exceptional cases:
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Associated pathology that needs to be submitted for histological examination
(e.g. cysts).
Extractions from abnormal or diseased bone (eg patients who have received
therapeutic doses of irradiation to the jaws).
Complicated extractions with special difficulty.
Failed extractions with an explanation of why, and a ‘post- extraction’
radiograph.
Extraction where there is a substantially increased risk of damage to an adjacent
anatomical structure
If a referral is made outside these guidelines the referring dentist must justify the
reasons why the treatment cannot be undertaken by them in primary dental care.
It is rare for a patient’s medical history to complicate the extraction to such an extent
that it needs to take place within the hospital setting. Specific examples are listed.
(Appendix 2)
Please ensure that relevant radiographs accompany all requests so that unnecessary
additional radiation exposure to patients is avoided. Wherever possible, these
radiographs will be returned once treatment has been completed.
A clear referral with all relevant clinical information, current radiograph and medical
history can be accurately triaged for booking the patient directly into the correct
treatment centre.
If additional restorative dentistry is being planned as part of the patients existing
treatment plan, this treatment must be continued by the referring dentist while the
patient is awaiting specialist assessment and treatment. Please also indicate on the
referral form which additional teeth are planned to be restored and do not also need to
be considered for extraction.
THE MANAGEMENT OF THIRD MOLARS:
Asymptomatic wisdom teeth should not be extracted.
Anterior crowding alone is not an indication for wisdom teeth removal in the absence of
a specialist orthodontic opinion.
In symptomatic patients, palliative treatment should be used as a first option.
In symptomatic patients, where palliative treatment is not appropriate or is ineffective,
surgical removal of symptomatic third molars can generally be carried out within the
general dental service assuming the Clinician has the relevant training and experience.
Referral to a specialist may be necessary where anatomical or pathology
considerations make the extraction difficult, where the patient has medical
complications, where the operator does not have the relevant training or experience, or
where previous attempts at extraction have failed.
The wisdom teeth to be removed must fulfil at least one of the following criteria:
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Recurrent episodes of pericoronitis.
Single severe episode of pericoronitis which showed evidence of spread and
infection to facial tissues.
Caries not amenable to restoration.
Wisdom tooth contributing to periodontal disease of second molar.
Associated follicular cystic changes.
Periapical pathology.
Prior to orthognathic surgery.
Associated with cyst or tumour.
Prior to medical treatment that would increase risk eg radiotherapy, IV
bisphosphonates or chemotherapy.
MANAGEMENT OF RETAINED ROOTS:
Retained roots should be removed in the referring practitioners’ dental surgery under
Local Anaesthetic. Long standing retained roots with no symptoms or infection present
should not be referred.
Referral to a specialist is necessary only where anatomical or pathology considerations
make the extraction especially difficult, where the patient has medical complications or
where previous attempts at extraction have failed.
If additional restorative dentistry is being planned as part of the patients existing
treatment plan, this treatment must be continued by the referring dentist while the
patient is awaiting specialist assessment and treatment. Please also indicate on the
referral form which additional teeth are planned to be restored and do not also need to
be considered for extraction.
MANAGEMENT OF TEETH REQUIRING ENDODONTIC SURGERY / APICECTOMY:
Orthograde root canal therapy is the first treatment option to treat periapical pathology.
Non surgical re-treatment should be the preferred option for endodontic failure. The
restorability of the tooth, the health of the supporting bone and periodontal tissue, and
anatomical considerations such as position of neurovascular bundle should be
assessed before embarking on any form of surgical endodontic therapy.
Referral for apicectomy of a tooth with an inadequate root filling will not be accepted
without exceptional circumstances. Re-root filling by the referring dentist or a specialist
endodontist is the best solution to most failed root fillings. Significant cyst formation
(>5 mm on radiograph) is an indication for apicectomy and establishment of diagnosis.
Referral to a specialist may be necessary where anatomical or pathology
considerations make the surgery difficult, where the patient has medical complications,
where the operator does not have the relevant training or experience, or where
previous attempts have failed.
Currently NHS England Devon, Cornwall and Isles of Scilly Area Team is unable
to commission surgical molar endodontics.
MANAGEMENT OF TEMPOROMANDIBULAR JOINT DYSFUNCTION:
Initial management of Temporomandibular Joint Dysfunction may involve supportive
patient education on avoidance of clenching and grinding, relaxation and a soft diet.
Pharmacological pain relief with Non-Steroidal Anti-Inflammatory Drugs (NSAID’S) and
remedial jaw exercises can also be of value. For patients with persistent pain,
stabilising splints or bite raising appliances may help, but permanent occlusal
adjustments should be avoided.
It is important to read through Appendix 4 on TMJ treatment and to refer only if
symptoms persist after conservative measures, including the provision of a soft splint.
Referral to specialist care may be necessary for clarification of diagnosis where there is
underlying joint disease, limited opening in isolation or if the patient has persistent
Temporomandibular Joint Dysfunction or psychological problems.
THE MANAGEMENT OF ABNORMAL SOFT TISSUE AND BONY LESIONS:
The Oral & Maxillofacial Surgery service will receive referrals for any soft tissue lesions
of the skin in the head and neck region, and abnormal hard and soft intra-oral lesions.
Abnormal lesions should be referred to specialist services when the diagnosis is in
doubt or if they interfere with dental treatment. If a clear and adequate history is
provided on the referral form, the majority of these patients can be seen and treated
under local anaesthetic during a single appointment.
Abnormalities due to infections of the oral cavity should be treated in line with
antimicrobial guidelines with a simultaneous treatment to remove the cause of the
infection if known.
ORAL CANCER:
Patients with abnormal areas or lesions in the mouth that are suspected of being oral
cancer must be referred for an urgent Oral & Maxillofacial Consultation. The oral cancer
referral form must be completed and faxed within 24 hours directly to the Oral &
Maxillofacial Surgery Department. It is advisable to check the referral has been
received.
Please see FAQ section for details
All suspected cancer referrals are subject to the "Two Week Wait" cancer waiting times.
Warning signs of oral cancer are:
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Non healing, often painless ulcer or sore for more than three weeks.
Lump or thickness in the cheek or elsewhere in the mouth.
Persistent soreness of the throat or mouth.
Difficulty chewing or swallowing.
Numbness of the tongue or other areas of the mouth.
Swelling of the jaw which causes the dentures to fit poorly.
Loosening of the teeth or pain around the teeth or jaw.
Voice changes.
A lump or mass in the neck.
Weight loss.
Examination of the oral soft and hard tissues should be performed in line with NICE
dental recall guidelines. Dental practitioners should be aware of the most common
appearance, warning signs and symptoms of oral cancer.
Preventive advice concerning tobacco cessation, reduction of excessive alcohol
consumption and healthy eating habits should be offered.
ORAL MEDICINE CONDITIONS:
Oral medicine involves specialist care of patients with symptoms arising from the mouth
that often do not relate directly to teeth and where management is not primarily
surgical. The symptoms are often chronic and may have significant psychological as
well as physical impact on the patient’s quality of life. The Oral & Maxillofacial Surgery
Unit will provide diagnostic assessments with subsequent advice and management for
soft tissue disease of the mouth and jaws, chronic facial pain, and the oral
manifestation of systemic disease. These systemic medical conditions may include
diseases of the gastrointestinal tract, rheumatological and haematological conditions
and immunological disorders.
CONDITIONS TO BE REFERRED FOR DIAGNOSIS AND INITIAL TREATMENT:
1.
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10.
11.
12.
Ulceration lasting more than two weeks.
Recurrent oral ulceration.
Blistering conditions of the oro-facial region and oral mucosa.
White or red patches of the oral mucosa (including lichen planus).
Hypersensitivity reaction.
Candidosis or angular cheilitis.
Pigmented conditions of the oral mucosa.
Oro-facial pain of non dental origin (burning mouth syndrome, trigeminal
neuralgia and unexplained oro-facial pain.
Other altered oro-facial sensations.
Dry mouth and other symptoms related to salivary glands.
Soft tissue swelling of the oro-facial region.
Oro-facial manifestations of systemic disease.
APPENDIX 1
PROVISION OF CONSCIOUS SEDATION/GENERAL ANAESTHETIC FOR MINOR
ORAL SURGERY PROCEDURES:
Provision of Conscious Sedation for minor oral surgery procedures
Since 1998 there has been a sea change in the provision of pain and anxiety
management in dentistry in the UK. This has resulted in an increased emphasis on the
safe provision of conscious sedation instead of a reliance on general anaesthesia that
is demand led. General anaesthesia should only be provided in response to clinical
need. The publication of ‘A Conscious Decision’ in 20006 resulted in the cessation of
general anaesthesia for dentistry in the primary care setting.
Conscious sedation is available primary and secondary care settings.
Provision of Conscious Sedation/General Anaesthesia for minor oral surgery
procedures
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Large or infected cysts where obtaining local anaesthetic is difficult.
Young Children with inadequate cooperation.
Extreme dental phobics. These would be patients who are unable to tolerate
local anaesthesia for any procedures.
Patients with learning difficulties who are unable to tolerate normal dental
procedures.
Confirmed sensitivity or allergy to Local Anaesthetics ( very rare)
Emergency dental extractions carried out in conjunction with extra- or intra- oral
drainage of abscess usually associated with trismus and/or a threat to the
airway.
If a General Anaesthetic/Conscious sedation has been requested please
complete the "GA or Sedation Request" form (Form 2). This must accompany
the Oral Surgery Referral Form.
Please make sure that the reason has been fully explained to the patient and that
they have signed the form.
APPENDIX 2
MEDICAL CONDITIONS REQUIRING REFERRAL FOR MINOR ORAL SURGERY:
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Patients on anticoagulant therapy with an INR of 3.5 or over.
Patients requiring transfusions and other treatments for bleeding disorders.
NB Be aware of patients on new oral anticoagulants such as dabigatran,
apixaban and rivaroxaban. These drugs are not monitored in the same way as
warfarin and have a short half life. Straightforward extractions can be carried out
in the surgery with consideration given to stopping the drug for 1-2 days prior to
extraction with the agreement of the patients GMP.
Patients who have had or are receiving Intravenous bisphosphonate medication
and Anti-TNF treatments (Rheumatoid Arthritis) and therefore at high risk of
Osteonecrosis.
Patients on oral bisphosphonates with other immunosuppressives such as
steroids or chemotherapeutic agents who are at a high risk of osteonecrosis.
Patients at risk of Osteoradionecrosis. ( Patients with a history of head and neck
radiotherapy)
Patients with limited oral access e.g. Head & Neck cancer patients with
microstomia or severe trismus.
APPENDIX 3
INDICATIONS FOR CARE BY A PRIMARY CARE PROVIDER USING A DENTIST
WITH ENHANCED SKILLS (LEVEL 2):
(A specialist provider working in primary care can provide a greater range of treatment)
Does not require a General Anaesthetic
Lower Third Molars (8s)
Surgical removal of third molars involving bone removal
Extractions
Extraction of erupted teeth with special difficulties
Management and surgical removal of ectopic teeth ( including supernumery teeth)
Extraction of Retained Roots
Surgical removal of buried roots and fractured or residual root fragments
Apicectomy
Surgical endodontics for incisor and canine teeth
Minor Oral Soft Tissue Surgery
Minor soft tissue surgery to remove apparent non-suspicious lesions
APPENDIX 4
GUIDANCE FOR THE MANAGEMENT OF TMJ PAIN DYSFUNCTION SYNDROME
(TMJPDS) IN PRIMARY DENTAL CARE:
The majority of patients presenting with TMJ problems will be suffering from TMJPDS
(temporomandibular joint pain dysfunction syndrome) or myofascial pain. These
patients can, in most cases, be effectively managed in primary care without referral.
The most common symptoms are:
Pain – usually a dull ache in and around the ear. The pain may radiate, ie move
forward along the cheekbone and downwards into the neck.
Joint noise – such as clicking, cracking, crunching, grating or popping.
Limited mouth opening
Headache, especially in the temporal region.
Some patients report mild/transient facial swelling which may be worse in the
morning.
Most cases of TMJPDS are made worse by chewing and are aggravated at times of
stress.
The initial management of TMJPDS in primary care includes the following measures:
1.
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3.
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6.
7.
8.
Explanation of the condition and provision of relevant patient leaflet.
Reassurance that TMJPDS is not serious and that it usually responds to simple
measures. Symptoms may recur from time to time.
Application of heat to the side of the face, eg a warm hot water bottle (avoid
boiling water) wrapped in a towel applied to the side of the face. This can be
combined with simple massage to the tender muscle areas and relaxation
techniques.
Advice concerning the use of painkillers. Non-steroidal anti-inflammatory drugs
(NSAIDs), eg ibuprofen, are often helpful, unless contra-indicated because of
the patient’s medical history. These should be taken regularly for a two to three
week period, not just PRN. NSAID gel can be applied topically to the area over
the joint or the muscles of mastication.
The identification and avoidance of parafunctional habits, such as clenching or
grinding (particularly at night), nailbiting, lip/cheek biting and posturing the jaw.
Rest for the TMJ, including soft diet, particularly if there are acute phases.
Acknowledgement that the condition can be related to anxiety and stressful
events.
Provision of a soft occlusal splint, which can be worn at night – this is particularly
useful for patients who grind their teeth at night.
NB: Irreversible procedures such as occlusal adjustment, should only be undertaken if
there is a clear indication.
Patients with TMJPDS who should be referred for management in secondary
care:
1.
2.
Those with an atypical presentation (e.g. numbness of the face,
marked/persistent facial swelling, severe trismus which is unrelated to surgical
intervention or injury).
Patients who fail to respond to conservative measures, including the provision of
a soft splint.
Referrals should be made to an Oral & Maxillofacial Surgeon or Consultant in
Restorative Dentistry. Please indicate the measures you have already undertaken to
manage the patient’s TMJPDS.
NB: Patients should not be referred for the provision of an occlusal splint – these can
be provided in primary dental care.
APPENDIX 5a
DCIoS Referral Services
Date:
Dear (Dentist name)
You recently referred (patient name and DOB) for a specialist oral surgery
procedure. The referral appears not to conform with the NHS England Devon,
Cornwall and Isles of Scilly Area Team Minor Oral Surgery GDP Referral Guidelines
and has been returned to you for the following reason.
The Referral Guidelines have been circulated and are available on the DCIoS Area
Team website ** Link to be added **
1.
The referral is on the wrong referral form. The correct forms are
available on the AT website. (link to website)
2.
The referral is incomplete and the following information is required:
3.
4.
An up to date appropriate radiograph
An up to date medical history
A recent INR
Patient/ Dentist/ GMP details
A clear reason for the referral
The treatment proposed is considered suitable for routine GDP practice
Further information is required to justify sedation or a general
anaesthetic.
please see guidelines on sedation/GA (link) and Sedation/GA request
form (link)
Please resubmit the correct referral form with the additional information required or
arrange to provide the treatment within your own practice.
We have advised the patient that the referral has been returned and asked
them to contact you for further information about their treatment
If you have any queries about this please e mail Peter Howard-Williams at
[email protected]
Yours sincerely
DCIoS Referral Service
APPENDIX 5b
DCIoS Referral Services
Date:
Dear (Patients name and DOB)
Your dentist, (name of Dentist), has recently referred you for a specialist oral surgery
procedure. The referral appears not to conform with the NHS England Devon,
Cornwall and Isles of Scilly Area Team Minor Oral Surgery GDP Referral Guidelines
and has been returned to your Dentist for further information.
We advise that you contact your Dentist for further information about your treatment.
Yours sincerely
DCIoS referral Services