Download the NHS Patient Referral Form

Please see reverse of form for guidance notes and where to send your referral.
ORTHODONTIC REFERRAL FORM for patients with IOTN 3.6 or above who have never started a course of treatment, except when < 10 years old
NHS number
Patients Details
Date of birth
Name
Address 1
Address 2
Town
Sex
M
Age 0
Tel
Mobile
postcode
Email
Referring Practitioner Details
Tel
Name
Practice Name
Address
Mobile
Email NHS
Town
postcode
Exam date
Clinicians who are trained in IOTN may complete parts A,B or D then E . Those not IOTN trained should complete parts C or D then E
Part A IOTN referral Enter IOTN dental health component (DHC) of patient 1 to 5 plus the qualifier a to x or
in part E the clinical reason for the referral. If DHC is 3 or less go to part B or D.
(see overleaf or the referral pack)
Part B IOTN 3.6 referral. To qualify for treatment at the minimum IOTN level the patient must have a DHC of 3
plus an aesthetic component (AC) of at least 6 with the correct qualifier. The AC is highly subjective, so only IOTN
certified clinicians should use this. Otherwise please use Parts C or D.
DHC
? qualifier ?
Ac ?
qualifier
?
(see overleaf or the referral pack)
Part C Clinical referral. You must check one of the features below and give a reason for your referral in part E. A patient displaying
one of the clinical occlusal traits in the list below should have a minimum IOTN (DHC) of at least 4 (see over leaf or in the referral pack).
1a Overjet >6mm
4 .Open bites>4mm
but 1b if >10mm
2a Reverse overjet > 1mm with speech defects
5. Ant /post x bites with > 2mm displacement
7 Missing teeth
8 Supernumeries
10 impacted teeth inc. canines
11 infra occluding deciduous teeth
or 2b > 3.5mm
3. Traumatic overbite .
6 Crowded /malaligned teeth contact point displacement >4mm
9 Non palpable permanent canines aged >9 In one or more quadrants
12. Possible surgical case
Features explained over page
Part D referral for advice. Please tick this box
Then indicate in part E the nature of the advice required. Referral for advice is
acceptable, however in such cases there must be a clinical reason which is clearly demonstrated below and not patient /parent
request. To support your case you should include where possible any models radiographs and photographs taken. Please attach as
much information as possible so that the orthodontist can assess the advice needed for treatment under the NHS regulations.
Part E please complete this part for all referrals.
Last caries incidence >12 months ago. Current active caries No If yes, explain below management plan indicating prognosis of
teeth.
Confirm by checking the box that the patient does not have
Confirm by checking the box that copy of the consent form has
a digit sucking habit and their oral hygiene is satisfactory. All been shared with the patient & parent /guardian and they are able to
the necessary prevention and advice indicated in Delivering comply with the conditions.They should understand what is generally
Better Oral Health has been provided and that continuing care involved in orthodontic treatment and treatment is not guaranteed by
will be offered.
this referral.
Relevant
medical history
Clinical reasons from parts A B C or D, comments on caries, oral hygiene and any additional information
.
Orthodontic Specialist
Referral Centre
Address 1
Address 2
Town
I have read and understood the guidance notes for referral of this type
Practitioner’s signature or Performer number
postcode
Date
Please ensure all required sections are completed, attach a medical history form (child version) if necessary, relevant radiographs and
any additional letter or information you may wish to include
Electronic referral form
O.R.F. e V 3.9 Designed by B. Hayes Aug 2015
Please note this orthodontic referral form is limited to patients who have never had
a previous course of NHS treatment, except when under the age of 10. You must
obtain prior approval from NHS England before referring patients currently in
treatment or those who have already received orthodontic treatment under the NHS
regulations
Where to refer: A referral must be made in accordance with the Strategic Framework for Orthodontics (2015). An assessment of the
complexity of the case made and referred to a provider of the appropriate skill level and facilities for the procedure. Please use the
chart below to determine the most suitable orthodontic provider. You will need to give the patient a choice of all orthodontic providers
including their waiting times in order that the patient /parent can chose a provider within the appropriate level
Complexity
Level 2 Primary care specialist
practice or general practice
Level 3a Primary care specialist
practice
Procedure
Straight forward interceptive measures;
removable appliances, non-complex fixed
appliance alignment for patients without
skeletal discrepancies or significant
anchorage demands.
Provider
Orthodontist on specialist list or GDP with
additional orthodontic skills
Routine orthodontic treatment of skeletal
discrepancies with removable functional and
fixed appliances. Restorative and surgical
problems including impacted teeth where an
interdisciplinary liaison approach can be
managed in specialist practice
Orthodontist on specialist list
Level 3b Hospital consultant service
Patients in the developing
Patients
severe skeletal disproportion or
Patients inwith
the developing
craniofacial syndromes, complex restorative or
surgical procedures requiring a multi-disciplinary
approach. Patient with medical developmental,
social or psychological concerns not suitable for
specialist practice.
Consultant orthodontist or orthodontist on
specialist list
Where possible level 2 and 3a complexity should be delivered in primary care and training setting, 3b delivered primarily in a hospital.
A more detailed description of the complexity levels and provider descriptors can be found in the Strategic Framework for Orthodontics.
Part A IOTN referral dental health component (DHC). This is the preferred section for referral for those clinicians familiar
with this index, as it indicates clearly the patient’s need for treatment. The DHC must be at least 3 with an aesthetic
component of 6 or above to qualify for treatment under the NHS. You must also add the qualifier a to x (used to identify
When to refer
:Theocclusal
majority
of orthodontic
treatment
commence
in nature
the lateofmixed
and early
permanent
dentition.
the child
needs
deviant
traits)
or the clinical
reasoncan
in part
E, so the
the problem
is identified.
You
can useIf part
C. if you
areearly
interceptive treatment
useinPart
D stating
the reasons.
Patients
are referred
too earlyonforthe
treatment
not trained
IOTN.
The referral
pack has
more detailed
information
IOTN. they will be referred back to the referring practitioner.
Patients should not be referred early in an attempt to circumvent long waiting lists, as this is unfair on other patients, already on a waiting list, who were
referred at the appropriate time. The referral pack contains further detailed guidance on patient referral.
Part B IOTN 3.6 referral. This section applies to patients with a DHC of 3. You must include qualifier a to x or the clinical
reason in
and the aesthetic
component
(AC) derived
from comparing
the patient
with
12 standardised
pictures.
This
Orthodontic treatment
is part
timeEconsuming,
sometimes
uncomfortable
and requires
commitment
from the
patient.
Patients with
poor oral
hygiene should
must
be
at
least
6
to
create
the
lowest
referral
category
of
3.6
If
no
Performer
within
a
practice
has
undertaken
IOTN
training
not be referred until they can demonstrate appropriate levels of plaque control. It is important that you discuss the nature of orthodontic treatment with
(nb for
newly qualified
UK graduates
this is part
their
training) and
they are not confident to provide an IOTN score, using
your patient before
referring
them. They
should be aware
and of
give
commitment
that:
the colour photographs provided, Part C or D can be completed instead.

It is important that all appointments are kept
Part Cmust
clinical
referral.
If you are uncertain of the IOTN, by identifying one of the clinical features listed 1 to 12 you

Appliances
be worn
as indicated
shouldmay
havetake
awarded
the 18
patient
withmonths
a DHCand
of atthat
least
4. By adding
your will
reasons
for the (which
referralisinlikely
part to
D the
orthodontist

Treatment
between
and 30
a period
of retention
be required
be for
the rest of their life)
canadvice
confirmand
a valid
IOTN score
to see the
patient.
You willtoneed advice if you feel 3.6 is applicable as the AC is not scored.

Dietary
oral hygiene
instructions
must
be adhered

They require a genuine interest in undertaking orthodontic treatment with fixed appliances
1a 1b The
Overjet:
measured
from thetreatment
most prominent
of the four
When
refer:
majority
orthodontic
can commence
in incisors.
the late
and early
 to
They
must achieve
and of
maintain
an excellent standard
of oral hygiene
andmixed
be dentally
fit permanent dentition. If the child needs early
2a 2b Reverse overjet: In severe cases consider referral to hospital.
interceptive
treatment
Part Dtostating
reasons.
referred
too practice;
early for treatment
will be sent
back to the by
referring
practitioner.
They they

They
are onlyuse
entitled
receivethe
1 course
ofPatients
treatment
from one
if their treatment
is discontinued
either patient
or practice,
3) Traumatic overbite:
Increased complete overbite with signs of trauma to the labial or palatal tissues.
should notwould
be referred
early in
lists, as
this is unfair on
other
patients,
already onby
a waiting
list, who
referred
only receive
a an
2ndattempt
course to
of circumvent
treatment inlong
verywaiting
exceptional
circumstances
which
would
be considered
the Regional
IFRwere
Panel.
The
4) Open bites Ant/Post: these must be greater than 4 mm.
at the appropriate
The
referral
pack contains
further detailed
guidance
on was
patient
exceptiontime.
to this
would
be moving
a considerable
distance
where this
notreferral.
planned at the point of referral
5) Ant/ Post X bite with displacement: mandibular displacement from RCP to ICP greater than 2mm.

Orthodontic patients will be required to sign a contract with the providing orthodontist. This is in the referral pack
6) Crowded / Misaligned Teeth: one or more teeth must have a contact point displacement >4mm premolar rotations do not
Orthodontic treatment is time consuming, sometimes uncomfortable and requires commitment from the patient. Patients with a poor oral hygiene
count.
not be that
referred
until continue
they can to
demonstrate
appropriate
levels continuing
of plaque control.
It is important
that you
discuss
the nature ofatorthodontic
Itshould
is important
patients
visit to:
their
for routine
care.
Orthodontic
should
besecond
considered
risk(third
for caries and
7) Missing
teeth: this relates
a) dentist
Hypodontia,
congenitally absent
teeth,
commonlypatients
upper laterals
or
premolars
treatment with
your consider
patient before
referring
them
and
reinforce
the
commitment
they have agreed
to intherapies.
the patient The
contract.
practitioners
should
Delivering
Better
Oral
Health
when
considering
preventative
advice
and
use
of
a
high
fluoride
molars do not count) b) Avulsed teeth or inappropriate extractions (eg space remaining due to early loss of one or more first toothpaste
may be indicated
(2800ppm or for older children 5000ppm)
molars)
It is important8)that
patientsof
continue
to visit their
dentist
forteeth
routine
continuing
care. Orthodontic patients should be considered at risk for caries and
Presence
supernumerary
teeth:
Extra
causing
a problem.
practitioners should
Better
Oral Health
when considering
preventative
adviceinand
Thebyuse
a high
fluoride toothpaste
9) Nonconsider
palpableDelivering
permanent
canines.
If the maxillary
canines cannot
be palpated
the therapies.
buccal sulcus
ageof9-10
years,
may be indicated
or for older
children
5000ppm) should be carried out.
they(2800ppm
may be ectopic
and further
investigations
10) Impacted teeth: a) simple tipped teeth causing food packing b) moderate /severe impactions, including impeded eruption,
not enough room for a tooth to erupt. Including impacted and palatal canines.
Parts
to D more
detaileddeciduous
explanations.
11)
InfraAoccluding
(Submerged)
teeth: these may prevent the eruption of the permanent teeth.
12) Possible surgical case: for severe skeletal discrepancy, defects of cleft lip palate, craniofacial anomaly.
Part D referral for advice. There are many times when orthodontic advice can aid your treatment plans for a patient,
Fold --
these may include: early intervention, caries management and extractions, disorders of eruption retained or missing teeth. You
will need to supply a description of the orthodontic problem and include if possible radiographs, photos and study models. The
orthodontist can then decide if an assessment is necessary. If the patient qualifies for reasons in A, B or C then you could use
that route, with a note about the advice required. There will be instances where the patient /parent push for a referral but the
need does not meet the NHS criteria. Referral for advice under the NHS should not be made in those circumstances.