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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