Download Specialist Periodontal Service Referral Protocol

Specialist Periodontal Service Referral Protocol
1. A primary care specialist periodontal service has been commissioned by NHS Tower Hamlets. Any
dentists practicing in Tower Hamlets may refer patients to this service.
2. Under General Dental Council guidance, it is the referring dentists’ responsibility to ensure that any
patient referral for care is appropriate.
3. The British Society of Periodontology Parameters of Care1 forms the basis of periodontal care for
patients. Before a referral to the service is made, the referring dentist should follow the referral pathway
shown in Figure 1 and observe the following parameters of care:
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It is the responsibility of the dentist to monitor/screen patients for the presence of periodontal
diseases including the use of relevant radiographs to make a diagnosis and institute a treatment
plan with defined therapeutic goals.
The Basic Periodontal Examination (BPE)2 should be used to examine the tissues for bleeding,
plaque retentive factors and pocket depths before the decision is made to refer a patient for
specialist periodontal treatment. All teeth are examined and the worst BPE (highest) score in each
sextant is recorded.
Like many other conditions, the treatment of periodontal disease depends to a large extent on
patient compliance.
An assessment should be made about the rate of disease progression and related to age in the
overall context of oral health management. The consequences of no treatment should be
explained.
For reasons of poor general health, lack of effectiveness of plaque control or non-compliance with
good oral hygiene regimes, the patient's own wishes or the operators' decision, appropriate
treatment to control disease may be deferred or declined.
In certain cases, because of the severity and extent of the disease, the age and health of the
patient, treatment that is not intended to attain optimal results may be indicated. In these cases
initial therapy may become the end point.
All periodontal assessments should be written in the notes particularly with regard to probing
depths, attachment levels, bleeding sites, plaque scores and mobility and outcome assessments
must be carried out in relation to the balance of the health/disease axis and the comfort function
and aesthetics of the patient.
If initial treatment resolves the periodontal condition, maintenance therapy should be scheduled
at appropriate time intervals.
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Figure 1: Referral Pathway for the NHS Specialist Periodontal Service in Tower
Hamlets
Initial Assessment and Supportive
Periodontal Care provided by GDP
Decision to refer patient to
NHS specialist periodontal
services
Complexity 1 or 2
Complexity 3
Not Eligible for NHS primary
care specialist periodontal
treatment
GDP provides continued care
Patient is a Tower Hamlets
Resident or has a GP in Tower
Hamlets?
No
Yes
Complete standard referral
form, include radiographs and
refer to NHS Specialist
Periodontal Services
Not eligible for NHS
primary care specialist
periodontal treatment
Initial Assessment by NHS
Specialist Periodontist
Complex case or complicated
patient?
Yes
No
Rejected Referral
No
Patient Accepted by NHS
Periodontal Specialist
Yes
Treatment Carried Out by NHS
Periodontal Specialist
NHS Specialist Periodontal
Treatment completed
Specialist refers patient to
back to GDP for maintenance
Specialist refers patient to
hospital for complex treatment
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4. Acceptance Criteria
Only referrals conforming to the criteria below, detailed in the service specification and made on
the designated referral form will be accepted. All other referrals will be returned to the referring
dentist.
Referrals will only be accepted if the patient has been provided with initial treatment and supportive
therapy.
Referrals for routine periodontal treatment will not be accepted.
To prescribe advanced periodontal care relevant radiographs will have been taken. These must be
included with the referral or it will be returned. This will avoid unnecessary further exposure to
ionising radiation for the patient and will expedite the referral process. A FP17 RN must also be
completed as part of the referral process.
4.1. Clinical Criteria
The service will only accept referrals from patients falling into the Complexity 3 category of the
Restorative Dentistry Index of Treatment Need Complexity Assessment for periodontal treatment3
published by the Royal College of Surgeons of England (Table 1).
Table 1: Periodontal Treatment Assessment Complexity Criteria
Patient Complexity
Complexity 3
Patient has BPE scores of 4 in at least one sextant and a medical factor affecting
the periodontal tissues or complicated root morphologies/anatomical factors or
a modifying factor (see Modifying Factors below)
Patient has BPE scores of 4 in a least one sextant and has not responded to
previous periodontal treatment
Patient has aggressive periodontitis based on the severity of disease for age or
rapid rate of periodontal breakdown (> 2mm attachment loss/year)
Patient requires surgical procedures involving tissue augmentation, bone
removal or implants
Modifying Factors
Patient has a medical factor directly affecting the periodontal tissues (i.e.
diabetes, medication) or adverse drug effects)
Regular smoker or paan user
Medical History that
Significantly Affects
Clinical Management
Patients with a history of head/neck radiotherapy or intravenous
bisphosphonate therapy.
Patients who are significantly immunocompromised or immunosuppressed
Patients with a significant bleeding dyscrasia/disorder
Patients with a potential drug interaction
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4.2. Patient Criteria
All referred patients must be residents in Tower Hamlets (postcodes E1, E2, E3, and E14) or
registered with a general medical practitioner in Tower Hamlets.
4.3 Standard Referral Form
The referring dentist must use the standard referral form for all referrals and include high quality
relevant radiographs (Appendix 1). The referring dentist must include information about the
preliminary treatment carried out on the patient prior to the referral.
5. Treatment carried out by NHS specialist periodontist
An initial assessment appointment will be provided. Treatment will not be carried out if the clinician
holds the opinion that the prognosis will not be significantly improved because of poor patient
compliance with oral hygiene or if the patients’ general health or the severity or extent of the
disease is poor.
6. Patients referred back to GDPs for continued care
On completion of treatment, the patient will be referred back to the original referring practitioner.
The specialist periodontist will provide:
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A summary of treatments carried out
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Information about what has been achieved
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BPE scores and any other relevant indices
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A maintenance programme for GDPs to follow
7. Referrals to Hospital for Complex Care
The specialist periodontist will refer patients with very complex needs and patients with
complications to .hospital services for the onward care if needed.
References
1
British Society of Periodontology. Referral Policy and Parameters of Care. (2011).
2
British Society of Periodontology. Basic Periodontal Examination. (2011).
3
Faculty of Dental Surgery Clinical Standards Committee. Restorative Dentistry Index of
Treatment Need Complexity Assessment. (2001).
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Appendix 1; Standardised Referral Form
Specialist Periodontal Service Referral Form
Patient Name and Address: (Please check with patient Referring Practitioner (Stamp)
if this is correct)
Signature of Dentist:
Postcode:
Daytime telephone:
Mobile:
E-mail:
Name and Address of General Medical
Practitioner:
Patient DOB:
Date of Referral:
Referred to: Brace  Waterside 
High quality, relevant
radiographs enclosed
(mandatory)
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Oral Hygiene:
Excellent  Good
Fair
 Poor
BPE Score in Each Sextant
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Reason for Referral (Please tick the appropriate box)
 Patient has BPE scores of 4 in at least one sextant and a medical factor affecting the periodontal tissues or
complicated root morphologies/anatomical factors or a modifying factor (see Modifying Factors on page
2)
 Patient has BPE scores of 4 in a least one sextant and has not responded to previous periodontal
treatment

Patient has aggressive periodontitis based on the severity of disease for age or rapid rate of periodontal
breakdown (> 2mm attachment loss/year)
 Patient requires surgical procedures involving tissue augmentation, bone removal or implants
 Other reason (Please specify)………………………………………………………………..
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
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Version 2 (Dated 4/3/13)
Please Turn over
Modifying Factors (Please tick the appropriate box)
 Patient has a medical factor directly affecting the periodontal tissues (i.e. diabetes, medication) or adverse
drug effects)
 Regular smoker or paan user
 Other (Please specify)………………………………………………………………………..
…………………………………………………………………………………………………….
Relevant Medical History (e.g. history of head/neck radiotherapy, immune-compromised or immunesuppressed patient, bleeding disorders, or drug interactions)
Preliminary Periodontal Treatment Carried Out by GDP (No referral will excepted unless the patient has been
provided with initial treatment and supportive therapy)
PCT charge collected (£): Yes  Amount £______ No 
Exempt 
Provider Use Only
Returned (inappropriate referral)
Referred to hospital
Date of first Appointment
Dates of Treatment
2nd visit
3rd visit
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Version 2 (Dated 4/3/13)
4th visit
5th visit
6th visit