Download GUIDELINES FOR REFERRAL TO CONSULTANT ORTHODONTIC

WOLVERHAMPTON HEALTH AUTHORITY AND THE ROYAL
WOLVERHAMPTON HOSPITALS NHS TRUST
GUIDELINES FOR REFERRAL TO CONSULTANT
ORTHODONTIC SERVICES
Spring 2005
Introduction
These guidelines have been developed in conjunction with the Consultant
Orthodontist in Wolverhampton, the Wolverhampton Local Dental
Committee, Wolverhampton Local Orthodontic Committee, Wolverhampton
Dental Advisory Group, and the Wolverhampton PCT.
The guidelines are intended to help ensure that those patients with the most
severe orthodontic treatment need, and with the most complex treatment
requirements, have full access to the consultant services for both advice and
treatment. Other patients also have access, if required, to the consultant
service for assessment and advice, although it will not necessarily be
appropriate for treatment to be provided by that service.
The guidelines cover:
issues which the primary care dentist needs to consider prior to referral
to the consultant service.

the procedure for referral to a consultant.

the actions which the consultant will take upon receiving a referral
letter.
The guidelines apply to referrals to the consultant unit of the Royal
Wolverhampton Hospitals NHS Trust, at New Cross Hospital.
Colleagues in practice probably already know how the local ‘system’ works
with a network linking non - providers to local providers of orthodontic
services. Several of the groups mentioned in the opening paragraph (above)
meet regularly and support of them, especially the Local Orthodontic
Committee, is encouraged as it gives opportunities to discuss problems, find
solutions and hopefully improve our patients quality of life.
SYNOPSIS
 An appropriate referral letter signed by a registered clinician.
 An initial consultation giving advice, and treatment options if pertinent.
Patients under sixteen years of age must be accompanied by parent or
guardian. Other relatives such as grandparents, aunts, uncles, and siblings
are not acceptable.
 A written report from the consultant back to the referring practitioner.
Further consideration between practitioner and patient as to where the
treatment may be obtained.
 If treatment within the hospital, and only orthodontics needed, the patient
themselves to write to the consultant asking for their name to be entered
onto an appropriate waiting list.
Patients needing dento-alveolar surgery e.g. to expose unerupted teeth,
as well as orthodontics do not go onto a waiting list,
Cases needing orthognathic surgery in combination with parasurgical
orthodontics go on the waiting list at an appropriate age.
 The consultant deals with those cases needing the skills of the consultant.
The number of patients being referrred with IOTN grades 5I and clefts of lip
and palate means that IOTN grades 5A and 5H usually have to go on the
waiting list. Other categories of grade 5 and IOTN grade 4s go on the
waiting list. The hospital does not provide treatment for IOTN grades 3, 2 or
1, but will assess and give advice for such patients. ( See MOCDO chart at
the end of this document.)
 The waiting list can only be addressed if there are staff to treat the
patients. The Specialist Registrar (SpR) training requirements mean an SpR
takes on about 60 patients at the start of a three year programme. Unless
other non –training staff are available the waiting list is then stagnant until
the next SpR rotation as the volume of cases with unerupted teeth and
clefts leaves no capacity for the consultant to take ‘cold’ cases off the
waiting list. Effectively, at present, 60 cases are taken off the waiting list
every 3 years.
 Inappropriate referrals are difficult to define. Any colleague may genuinely
need advice about any patient. However it may be more appropriate for
a general practitioner to refer patients in IOTN grades 3, 2 and 1 directly to
a practice-based provider in the primary care sector rather than to the
hospital initially.
 Practitioners should have a working knowledge of IOTN so that patients
can be referred to most appropriate provider from the start.
Patients must agree to continue regular dental care with their referring
practitioner whilst the orthodontic treatment is ongoing. They must control
their diets and plaque so as not to be at risk from oral disease. They must
understand the commitment needed to successfully complete treatment
and if necessary make social sacrifices to allow correct use of appliances.
In some cases where relapse risk is high the patient may need prolonged
or permanent use of orthodontic retainers. The referring practitioner would
normally need to arrange the long term provision and care of such
appliances, whether fixed or removable. Without such help only limited
correction of the malocclusion may be planned. The hospital is not able to
provide retainers in the long term.
SECTION 1:
PRIOR TO REFERRAL TO THE CONSULTANT SERVICE
1
General guidance
1.1
Prior to referring a patient to the consultant orthodontist, the referring
primary care dentist should make his/her own assessment of the need
for orthodontic advice and/or treatment. The consultant service
should not be used for routine screening purposes.
1.2
The patient and/or parents, as appropriate, should be informed of the
reason for referral (using explanatory leaflets, etc.). This is particularly
important when the referral is being arranged because of a problem
that has been diagnosed by the dentist but of which the patient may
have been unaware (e.g. impacted teeth), and for which they were
not actively seeking treatment. Patients under 16 years of age must
be accomplished by a parent or legal guardian. Other relatives such
as grandparents, aunts, uncles and siblings are not appropriate.
1.3

The patients/parents should also be informed that
the initial referral is always for assessment and advice only;


a decision as to whether it is appropriate to undertake treatment(and
whether it needs to be provided in hospital) will be made by the
consultant or a member of his/her team;
even if accepted for treatment in the consultant unit, there is likely to
be a waiting list for treatment after initial consultation.
Having received the advice from the initial consultation, and before
being allocated to a waiting list, the patient and referring practitioner
should discuss travelling to a suitable primary care orthodontic
provider for NHS therapy, or for seeking treatment through the private
and independent sectors of health care. Then, if appropriate, the
patient should write personally to the consultant requesting that their
name is entered on the treatment waiting list and return the
application form which they were given at an earlier appointment. The
patient must understand the terms and conditions under which
treatment will be given. Failure to co-operate in an appropriate
manner will usually lead to the early termination of treatment.
1.4
Once a decision to refer has been made, the dentist should not
undertake elective procedures which are relevant to the occlusal
problem (e.g. removal of teeth for crowding, initiation of appliance
therapy, etc.) in advance of the consultant appointment. In cases of
an acute dental emergency, the treatment of which might impact on
the occlusal problem, the referring dentist may wish to contact the
consultant unit by telephone for advice.
2
Patients referred for assessment and advice only
2.1
The consultant is prepared to see any patient for assessment and
advice even if such patients do not meet the criteria for treatment
within the hospital department. Such circumstances might include:-

A mild malocclusion which the referring dentist does not feel requires
treatment but where the patient/parents insist on a second opinion.

A patient who is considered unsuitable for active appliance therapy,
but where the practitioner requires advice as to the need for
interceptive orthodontics, such as selective extractions.
Patients referred for assessment and treatment
3
3.1
If the referral is being made in the anticipation by the dentist
that treatment will be offered by the consultant service, dentists should
be aware of the fact that the consultant service will not be able to
accept for treatment within hospital unit all referred patients.
Redirection to another primary care provider is usually preferable to
entry onto the waiting list. As a guide the following would normally be
accepted:Patients under 18 years of age in IOTN grades 4 and 5. Adult patients
needing only orthodontic appliance treatment are ineligible for
provision of appliances by the hospital
 Adult patients whose overall management includes orthognathic
surgery, addressing unerupted teeth by dento-alveolar surgery prior tp
orthodontic alignment of the dental arch, or clefts palate cases.

Medically compromised or special needs patients where problems
make it difficult to obtain treatment within the primary care sectors will
be managed as all patients and may need to go on a waiting list.

Transfer cases from other U.K. hospital departments will be accepted
for continuation of care. Transfer cases from practitioners, or from
overseas, will be redirected to primary care providers and it will be for
the primary care provider to negotiate NHS or private continuation of
care.
3.2
Specialist Registrar training needs are occasionally met by patients
with malocclusions especially pertinent to the SpR’s requirements and so a
very few patients are offered treatment without going onto the waiting list
providing the patient agrees to participate in the training programme.
Cases with mild malocclusion ( IOTN grades 3, 2 and 1) could be
referred directly to primary care providers for consideration of both
NHS and private treatment if appropriate. Currently the general dental
services of the NHS does not ration treatment. A practitioner can apply
for prior approval to treat mild malocclusions, and adults, on the NHS ,
or to do so under private contract. The planned NHS reforms, with
local commissioning of orthodontic services from a variety of providers,
may introduce new restrictions but no hard advice is currently
available.
3.3
When they are being referred in anticipation of treatment being
carried out by the hospital, patients should fulfil the following criteria:-

be regular dental attendees at an identifiable dental practice.


demonstrate very good oral hygiene and not have overt caries or
gingival/periodontal disease. As a quick guide, if plaque is visible on two
or more teeth then the mouth is not a safe environment for fixed braces.
be aware of the personal commitment they will have to make for a
successful outcome to be anticipated. Clashes between hospital
appointments and schooling can impede progress. Repeated breakages
of appliances greatly prolongs treatment.
have a malocclusion which is sufficiently severe to justify treatment
within the Hospital Services

3.4
It is most important that patients are not referred early simply to
circumvent a treatment waiting List. Colleagues will be asked to rerefer the patient at a more appropriate age.
3.5
It may be useful for the dentist to give some guidance as to the type
of treatment that might be offered, and helpful to the patient in
deciding whether to be referred. However, categorical statements
that imply that treatment will definitely be provided by one particular
technique, or other, should be avoided. The British Orthodontic
Society’s internet site has useful informatiion for the public.
SECTION 2:
PROCEDURE FOR REFERRAL
In order that the hospital can process the referral via the NHS
contracting system, referrals must be in writing. All letters should
include:
The postcode of the patient’s home.

The patient’s IOTN grade and a brief description of the malocclusion.

Some indication of the level of patient/parental concern, as
appropriate.

Details of any previous orthodontic treatment/referral, if known.

Any other complicating factors (e.g. medical history).

Details of the dental attendance history of the patient.

Confirmation that the patient/parent has received an explanation of
the likely commitment if treatment is anticipated.

The personal signature of the referring dentist. Letters not signed
appropriately will be returned to the practice.
With a paper-based, written-letter referral system omitting data from the
above list can still result in an appointment being made. However, with
clinical governance now in daily practice omission of required data from the
referral can result in the referral being returned without an appointment
being made until the referring practitioner submits all essential information. A
paper proforma referral system can easily be checked by medical records
clerks and a filter system set in place. This would be a good training ground
for the profession in preparation for electronic direct booking of
appointments (scheduled by the government for 2005) whereby it easy for
computers to block the referral procedure unless all data fields are entered.
2
Any radiographs of orthodontic relevance which have already
been taken should also be sent in with the referral letter, especially if
radiographic findings have been a decisive factor in arranging referral.
Under normal circumstances, however, the consultant will arrange for any
necessary radiographs to be taken at the hospital unit.
Radiographs should be clearly labelled with the patient’s identity, the
date that the radiograph was taken and left and right sides in the case
of DPTs. Radiographs will be returned after the initial assessment
appointment.
3
Study models showing the initial occlusion should also be sent in
when referral is being made because of complications which have
arisen during appliance treatment undertaken by the referring dentist.
SECTION 3:
CONSULTANT ACTION ON RECEIPT OF A REFERRAL
On receipt of a referral letter the consultant will:1
As soon as possible offer a first appointment to the patient within the
appropriate national target of 13 weeks.
2
Undertake diagnosis, formulate a treatment plan and discuss the most
appropriate action with the patient/parents which my be:-

No further action required.

Arranging review appointment(s).

Acceptance within the consultant unit for treatment.

Refer back to the primary care dentist for monitoring or treating.

Suggest referral to a specialist orthodontic practitioner or a
designated general dental practitioner with a proven ability in
orthodontics.
3
The consultant will write back to the referring practitioner with a
synopsis of the treatment plan and the action proposed. Any
radiographs or study models sent by the referring dentist will be
returned at this stage.
4
Patients accepted for treatment in the consultant unit will normally be
placed upon a treatment-waiting-list ( having followed the required
process ) unless their clinical condition requires swifter intervention in
which case treatment will be started sooner. There is currently no
government target maximum waiting time for out-patient treatment.
Missing teeth, Overjet, Crossbites, Displaced contacts, Overbite
I.O.T.N
MISSING TEETH
H, I
OVERJET
A,B,M
D.H.C
Impeded eruption (except third molars)
Hypodontia - More than one tooth missing in any quadrant
- Only one tooth missing in any quadrant
CLASS 2
Over 9mm
6mm to 9mm
3.5mm to 6mm with incompetent lips 3A
3.5mm to 6mm with competent lips
5A
4A
5I
5H
4H
CLASS 3
With eating/speech defect
Reverse overjet 3.5mm or more: 5M
Reverse overjet between 1mm and up to 3.5mm:
4M
Without eating/defect
Reverse overjet 3.5mm or more: 4B
Reverse overjet between 1mm and up to 3.5mm:
3B
Posterior lingual with no functional occlusal
contact on one or both sides
4L
2A
CROSS BITE
C,L
ANTERIOR OR POSTERIOR BUCCAL
Over 2mm slide
4C
More than 1mm and up to 2mm slide 3C
DISPLACEMENT
OF CONTACT POINTS
(SPACES DON’T SCORE)
Over 4mm
Over 2mm but not over 4mm
Not more than 2mm
OVER BITE
F
OVER BITE
Gingival trauma
Gingival contact but no trauma
Increased, 3.5mm or more, no gingival contact
4D
3D
2D
4F
3F
2F
OPEN BITE
Anterior or lateral - over 4mm
Anterior or lateral – over 2mm but not over 4mm
3E
Anterior or lateral – over 1 and up to 2mm
2E
Defects of cleft lip/palate craniofacial anomalies
Submerged deciduous teeth
5S
Partially erupted teeth, tipped and impacted against adjacent teeth
Presence of supernumerary teeth
Pre and post normal occlusions with no other abnormalities ( including up to ½ a unit discrepancy)
5P
4T
4X
2G
4E
Missing teeth, Overjet, Crossbites, Displaced contacts, Overbite
I.O.T.N
MISSING TEETH
H, I
OVERJET
A,B,M
D.H.C
Impeded eruption (except third molars)
Hypodontia - More than one tooth missing in any quadrant
- Only one tooth missing in any quadrant
CLASS 2
Over 9mm
6mm to 9mm
3.5mm to 6mm with incompetent lips 3A
3.5mm to 6mm with competent lips
5I
5H
4H
CLASS 3
Reverse overjet 3.5mm or more:
With eating/speech defect
Without eating/speech defect
5A
4A
5M
4M
2A
Reverse overjet more than 1mm but less than 3.5mm:
With eating/Speech defect
4B
Without eating/speech defect
3B
CROSS BITE
C,L
ANTERIOR OR POSTERIOR BUCCAL
Over 2mm slide
4C
More than 1mm and up to 2mm slide 3C
DISPLACEMENT
OF CONTACT POINTS
(SPACES DON’T SCORE)
Over 4mm
Over 2mm but not over 4mm
Not more than 2mm
OVER BITE
F
OVER BITE
Gingival trauma
4F
Gingival contact but no trauma
Increased, 3.5mm or more, no gingival contact
Posterior lingual with no functional occlusal
contact on one or both sides
4L
4D
3D
2D
3F
2F
OPEN BITE
Anterior or lateral - over 4mm
Anterior or lateral – over 2mm but not over 4mm
Anterior or lateral – over 1 and up to 2mm
Defects of cleft lip/palate craniofacial anomalies
Submerged deciduous teeth
5S
Partially erupted teeth, tipped and impacted against adjacent teeth
Presence of supernumerary teeth
Pre and post normal occlusions with no other abnormalities ( including up to ½ a unit discrepancy)
5P
4T
4X
2G
4E
3E
2E