Download Referral Guidelines Jan 2009

GUIDELINES FOR REFERRAL TO “DENTAL” SPECIALITIES
AND FOR ADVANCED DENTAL CARE
IN OXFORDSHIRE
Oxfordshire Salaried Primary Dental Care Service
Department of Oral & Maxillofacial Surgery, Oral Medicine,
Orthodontics & Restorative Dentistry
The Oxford Radcliffe Hospitals NHS Trust offers a secondary and tertiary service for
advice and treatment.
The Oxfordshire Salaried Primary Dental Care Service offers a Primary Care Service
for advice and treatment and works in close co-operation with the Oxford Radcliffe
Hospital NHS Trust. Both services operate the same triage acceptance criteria.
REFERRALS
Referrals are accepted from:
General Dental Practitioners
General Medical Practitioners
Any other Health or Social Care Professional
Referrals are not accepted for:
Routine treatment on fit/healthy patients unless there are issues about accessing
NHS dentistry locally.
All referrals should be sent to: The Dental Referral Bureau, Salaried Primary
Dental Care Service, Astral House, Granville Way, Bicester, Oxon, OX26
4JT Telephone Number 01869 604060
All referrals should be made on the approved pro forma (copies can be
requested from the referral bureau or on receipt of an email address forwarded
electronically.)
LETTERS WILL NO LONGER BE ACCEPTED
All patients referred who are ‘under a current course of NHS dental care’ for
which the referred condition forms part of an open course of treatment should be
accompanied by an FP17 RN. This will facilitate treatment if delivered within
Primary Care. The full Band Charge should be levied by the referrer at the time
of referral appropriate for the treatment that will be carried out.
If the ultimate treatment is to be carried out under sedation or via domiciliary care
in Primary Care then a new course of treatment will be opened and a new patient
charge needs to be levied. In such circumstances the referrer should only charge
according to the band of care they have delivered up to the point of referral.
Whenever possible, radiographs and orthodontic treatment plans (if available)
should accompany the referral. When referring patients it is important to include with
the referral any relevant radiographs taken within the previous year. It is not
acceptable to repeat exposing a patient to x – rays without clinical justification
(IR(ME)R2000). X-ray departments are also very busy and the patient’s visit can
often be expedited rapidly if they do not need to be x–rayed. An assessment of
the suitability for care under local anaesthesia/sedation or G.A should be made
and recorded.
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Department of Oral and Maxillofacial Surgery & Dental Departments of
Orthodontics and Restorative Dentistry (OMD)
http://www.oxfordradcliffe.nhs.uk/omd/omdhomepage.aspx
ORAL & MAXILLOFACIAL SURGERY
Referrals are categorised into:
(a)
(b)
Urgent.
i.
Suspected malignancies should be directed to the 2-week wait cancer
bureau. Fax no 01865 222768. It is very important to enclose a history
of factors such as smoking, alcohol, and beetle and pan consumption.
ii.
Urgent referrals such as uncontrolled infection should be directed to
the Senior House Officer on call at the John Radcliffe Hospital –
01865 741166 – Bleep no: 1049
Soon.
These referrals are normally seen within 6 weeks. Conditions within this
category include non-ulcerated white patches, dental cysts, oral mucosal
lesions, roots in the maxillary antrum and oral antral fistulas.
(c)
Routine.
Conditions such as impacted wisdom teeth, temporo-mandibular joint
disorders, chronic facial pain and salivary gland disorders (unless there is
extreme recurrent swelling, pain or if a tumour is suspected). These patients
will be triaged and may be seen if appropriate by Specialists working in
Primary Care.
Management of asymptomatic third molars
a)
Symptom free third molars should not be removed but should be monitored for
signs of pathology. Third molars should also not be removed where there is an
unacceptable risk of surgical complications or risk to the general health of the
patient.
Management of symptomatic third molars in patients
Palliative treatment should be used as the first option whenever possible. This includes
antibiotics, analgesics and Chlorhexidine mouthwash.
a)
If the tooth is carious the caries should be removed and the tooth dressed.
Unresolved pulpal pain will necessitate pulpal extirpation to eliminate pain whilst
the patient awaits assessment and surgery.
b)
Removal of the opposing third molar or adjusting the occlusion will help the
pericoronitis to resolve.
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Indication for surgical removal
The department guidelines for removal of third molars are that of NICE (National Institute
for Clinical Excellence) http://www.nice.org.uk/nicemedia/pdf/wisdomteethguidance.pdf
Unrestorable caries – repeated episodes of periocoronitis, non-treatable pulpitis,
periapical pathology, serious infection such as cellulitis and osteomyelitis,
internal/external resorption of the tooth or adjacent teeth, if causing symptoms, disease
of the follicle, such as cysts/tumour, fracture of the tooth and then periodontal disease of
the second molar due to third molar impaction.
Management of retained roots
No action is required for asymptomatic retained roots, unless the root is impeding other
dental treatment, such as orthodontics. However, regular clinical and periodic
radiological review should be considered to detect any signs of pathology.
Management of symptomatic retained roots
When a retained root fragment gives rise to symptoms, it should be removed.
The removal of symptomatic retained roots should be within the expertise of General
Dental Practitioners.
Referral for the extraction of symptomatic retained roots
Referral for Oral Surgery may be necessary when:
i.
ii.
iii.
iv
Difficulty in removing the root e.g. because of proximity to the inferior
dental nerve.
Previous attempts at extraction have failed in dental practice.
The patients have had radiotherapy to the head and neck and the
roots are within the radiation field.
The patient has received treatment with IV or Oral Bisphophonates.
Non-routine dental extractions and other procedures
Dental Extractions are not carried out within the hospital services unless there are
medical or surgical conditions that prevent the patient being treated in primary care.
Patients taking steroids can be treated in primary care and do not need steroid cover for
routine dentistry including extractions under local anaesthesia. Patients with well
controlled Hypertension, Cardiac conditions, respiratory disease, (including asthma)
Epilepsy or Diabetes are most appropriately treated within the general dental services
and are not grounds for referral per se.
Conditions where referral is appropriate include:
a) Patients on complicated multiple medications.
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b) Medical conditions including patients on Warfarin, where INR is greater than
3.0; patients receiving treatment with Bisphosphonates.
c) Proven Dental phobics where some form of sedation is necessary.
d) GA extractions where surgical difficulty or dental anxiety necessitates and
sedation is inappropriate or has failed previously.
Other procedures routinely carried out include:
a) Dento-alveolar surgery in relation to orthodontic treatment
b) Pre-prosthetic surgery
Apicectomies
Many referrals for Apicectomies are inappropriate. Consideration in the first instance
should always be to repeating the orthograde root filling which is short of the radiological
apex or investigating the existence of additional canals which have not been obturated.
This is particularly relevant for lower incisors. Crowned teeth or bridge abutments which
become non-vital should be treated by conventional orthograde root filling. Many root
treated teeth which have been restored with posts should have post removal attempted
to facilitate re-root treatment. Difficulty in achieving re–root filling and an opinion on the
feasibility of such a procedure should be referred for a restorative opinion.
Referrals will be accepted for:
i)
Teeth with a radiologically acceptable orthograde root filling where the
tooth remains symptomatic and orthograde re – root treatment has been
attempted and/or proved ineffectual.
ii)
Root treated teeth with radiological evidence of a distinct radiolucency
suggestive of a radicular cyst or other such lesion.
iii)
Symptomatic teeth with extruded root fillings, perforations of the root
canal system by instruments or posts or other situations where
conventional root canal therapy is impossible because of aberrant root
canal anatomy or occlusion by calcification.
iv)
biopsy of a suspicious periapical lesion
Management of abnormal soft tissue and bony lesions
a) Bony exostoses such as mandibular or palatal tori do not need to be referred
unless they cause symptoms such as ulceration or they interfere with denture
construction
b) Removal of benign salivary gland lesions e.g mucoceles
c) Removal of benign soft tissue lesions which are subject to occlusal trauma or
interfere with the fit of a prosthesis e.g. fibro-epithelial polyp.
d) Soft tissue lesions where the diagnosis is in doubt.
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Management of temporo-mandibular joint dysfunction.
A diagnosis of temporo-mandibular joint dysfunction (TMD) is dependant upon the
recognition of at least 2 of the following symptoms:
(a)
Pain
(b)
Clicking/grating/grinding
(c)
Restricted mouth opening/closing
i)
Three quarters of the population have at least one side of joint dysfunction and a
third has at least one symptom of joint dysfunction.
ii)
OPT radiographs may be helpful to exclude oral pathology or arthritis and to
reassure the patient but do not have often a diagnostic or prognostic value.
Initial management of TMD
TMD is frequently self-limiting and conservative treatments including drug therapy and
counselling are effective for 70% of patients. Initial management for patients with signs
and symptoms, may involve:
a)
Supportive patient education, such as encouraging relaxation, education against
behaviour such as clenching and grinding and recommending a softer diet.
b)
Pharmacological pain control such as non-steroidal anti-inflammatory drugs.
c)
Recommending remedial jaw exercises (Appendix I) in management of persistent
symptoms of TMD.
d)
Occlusal adjustments that permanently alter a patient’s dentition and occlusion
have been shown to be of no benefit and should be avoided.
e)
However assessment of occlusion is necessary to eliminate gross occlusal
discrepancies, which may have occurred as a result of restorative procedures
and prosthetic replacement of missing posterior teeth may be necessary when
teeth have been lost leading to the lack of posterior support.
f)
Stabilising splints or bite raising appliances may be helpful for some patients and
these should be constructed in primary care.
g)
Many patients with persistent non-remitting signs of symptoms of underlying
stress, depression or other psychological difficulties and these should be
considered in patients with persistent problems. Relaxation and cognitive
behaviour therapy have been shown to be effective approaches in managing
chronic pain. Many general medical practices will help with the above.
Referral for TMD
Patients with TMD will only be accepted if:
a)
The patient has been given the appropriate advice.
b)
A stabilising or bite guard has been constructed.
c)
When clarification of the diagnosis is necessary.
d)
When there is underlying systemic or overt joint disease.
e)
When there is limited opening in isolation.
f)
When the patient remains persistently symptomatic.
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ORTHODONTICS
The criteria for acceptance for treatment within the orthodontic department is largely
based upon the Index of Treatment Need (IOTN) categories 4 and 5, i.e. those in the
greatest need for treatment. A small number of cases are accepted for training
purposes and adults are accepted where multidisciplinary care is required. Advice is
given to general dental practitioners, salaried primary dental practitioners, specialist
orthodontic practitioners and medical practitioners. The orthodontic department at the
John Radcliffe Hospital works with several multi-disciplinary teams with 6 maxillofacial
surgeons, and consultants in restorative dentistry and oral medicine. It offers a
comprehensive orthodontic service, a joint restorative/hypodontia clinic, a joint
orthognathic (facial deformity) clinic, as well as cleft and craniofacial clinics
IOTN Grade 4 – Great treatment need
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
Increased overjet greater than 6mm but less than or equal to 9mm.
Reverse overjet greater than 3.5mm with no masticatory or speech difficulties
Severe displacements of teeth greater than 4mm.
Extreme lateral or anterior openbites greater than 4mm.
Increased and complete overbite with gingival or palatal trauma.
Less extensive hypodontia requiring pre-restorative orthodontics or orthodontic
space closure.
Posterior lingual crossbite with no functional occlusal contact in one or more
buccal segments.
Reverse overjet greater than 1mm but less than 5mm with recorded
masticatory or speech difficulties.
Partially erupted teeth tipped and impacted against the other teeth.
IOTN Grade 5 – Very great treatment need
(j)
(k)
(l)
Increased overjet greater than 9mm.
Extensive hypodontia with restorative implications.
Impeded eruption of teeth due to crowding, displacement, the presence of
supernumerary teeth, retained deciduous teeth and any pathological cause.
(m) Reverse overjet greater than 5mm with reported masticatory and speech
difficulties.
(n) Defects of clip lip and palate.
(o) Submerged deciduous teeth.
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SALARIED DENTAL SERVICE
Oxfordshire Salaried Primary Dental Care Service aims to provide a
comprehensive treatment service for:
1. Children and adults who need specialised treatment.
2. Adults and children with disabilities.
Self referrals will be accepted by patients who satisfy acceptance criteria. It may
be possible to accept patients outside these categories on self referral subject to
clinic capacity and commissioning priorities.
Treatment will be provided for those patients fitting these referral criteria using a
suitable modality of pain relief which may include Local Anaesthesia, Conscious
Sedation or General Anaesthesia.
The Oxfordshire Salaried Primary Care Dental Service is predominately a service
for “Oxfordshire” patients, therefore patients must be an Oxfordshire resident and
or registered with a Doctor who is on the list of Oxfordshire PCT Performers, or
currently under the care of an Oxfordshire NHS Dental performer with an active
performer number.
Certain patient categories, e.g. Paediatric Special Needs, are seen on behalf of
other PCTs. If you are in any way uncertain please call 01689 604040 to discuss
the suitability of specific referrals.
Inappropriate referrals will be returned to the referee with a letter of explanation.
The patient will also receive a letter in these circumstances.
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Treatment for Adults
Referrals are accepted for:
o Adults requiring specialised management of specific dental problems.
o Adults with disabilities that need special care, including :
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Severe medical problems
After head and neck radiotherapy
Significant immuno-compromised or immuno-suppression
Severe bleeding disorders
Brain injuries
Life limiting conditions
Severe retching problems which prevent routine care
Proven dental phobia
Severe mental health problems
Learning disabilities
Autistic Spectrum Disorders
Domiciliary care for housebound patients
A physical disability which prevents access to routine dental care or
treatment in a dental surgery
Referrals are not accepted for:

Adults with blood borne viruses such as Hepatitis B and C and HIV can be
treated in general practice with universal precautions and will not be
accepted for treatment by the OSPCDS unless they fit other referral
criteria.
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Treatment for Children
A range of treatment modalities may be used which could include Local
Anaesthesia, Conscious Sedation and General Anaesthesia.
Referrals are accepted for:
 behavioural problems
 routine paediatric dentistry where treatment by the referring practitioner
has been attempted and failed
 post dental trauma which requires specialist management
Children with disabilities that need special care which would include;
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Severe medical problems
Learning Disabilities
Autistic Spectrum Disorders
Bleeding disorders
Severe physical problems
Children with repaired cleft lip/palate
Amelogeneses Imperfecta
Dentinogenesis Imperfecta
Hypodontia
Very young children with extensive decay
Referrals are not accepted for:

Routine treatment for healthy children who are able to tolerate care within
the GDS unless there are local access issues

Orthodontic extractions, other than first permanent molars under general
anaesthesia (unless the child has a disability needing special care)
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Restorative Dentistry in Primary Care
Objectives
A comprehensive consultation and treatment planning and advice service is
available to all appropriately referred patients.
Referrals
Please make referrals to Restorative Dentistry C/O The Dental Referral Bureau,
Salaried Primary Dental Care Service, Astral House, Granville Way,
Bicester, Oxon, OX26 4JT Telephone Number 01869 604060
Please include in the referral:
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The patient’s full name
Date of Birth
Address with postcode
Home and daytime telephone numbers
Clinical history
Nature of the referral
Radiographs
In order to help us deal with your referrals more efficiently and thus provide
patients a better service, the following details must be provided for ALL referrals:
 The specific dental problem must be clearly stated
 Number of teeth present and charting if possible
 Oral hygiene status
 BPE scores
 Confirmation that primary disease has been treated
 Detailed summary of treatment provided to date
 Specific problems encountered when providing treatment
 Details of any specific factors that may influence the extent of disease
present
Additional information is required for the following specialties within Restorative
Dentistry.
Failure to comply with providing the information will cause unnecessary delays in your
referral being processed:
Conservative dentistry
 Is the referral for a second opinion only?
 Duration of the problem
 If failing crowns/bridges, the age of the restorations must be provided
 If there are repeated failures, details must be given if it has deteriorated
 If wear, is it localised or generalised?
 Is there an occlusal problem?
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Endodontics
 Tooth in question must be clearly stated
 Type of tooth treatment required e.g. re-treatment, conventional treatment,
surgery
 Duration of symptoms and nature of pain (if present)
 Pulpal problems: history of any sensitivity, abscesses, pain or discomfort, pulpitis
 Any treatment involving pulp capping (direct or indirect) must be provided
 Previous root canal treatment provided and when provided
 Attempt at root canal treatment and difficulty encountered must be clearly stated
 Fractured instrument – details of instrument (where possible)
 History of traumatic injury to the tooth
 Any other details e.g. resorption must be provided
 Clear long cone periapical radiographs should be enclosed
Periodontology
 Dental history
 Smoker or non-smoker
 Description of oral hygiene
 Description of gingival tissues
 Probing depth range
 Furcation involvement
 Mobility
 Restorative factors
 Treatment provided to date
 Good quality radiographs
Prosthetics
 A description of the present dentures(s)/prostheses and any difficulties
encountered
 A history, including number, of the previous dentures(s)
 The specific nature and age of the present prosthesis
 In partially dentate cases, the condition of the periodontium including a
description of the oral hygiene
 The occlusion and the state of the remaining teeth
 Any indication of any complication medical factors e.g. xerostomia
Dental Implants
If your patient fulfils one of the criteria below, the referral should be made in the normal
way. Following the consultation, if your patient is suitable for implant treatment, the
consultant will request approval for NHS funding.
Dental Implants are only available under the NHS in the categories listed below.
 Congenital and acquired defects e.g. severe hypodontia (more than six missing
teeth), cleft lip and palate
 Tooth and tissue loss following trauma, e.g. road traffic accidents; surgery for
head and neck cancer
 NB. Patients in whom tooth loss occurred due to trauma more than two years
ago will not necessarily quality for NHS implants
 Continuing problems with well-made and fitting complete dentures (as deemed
by a consultant in Restorative Dentistry)
If the approval is successful, the NHS will only fund the current course of treatment. The
cost for maintenance and any future replacement cannot be guaranteed. In the event of
a problem, a new referral and application for approval would need to be made.
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