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.
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) 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
(b) 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.
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. Difficulty in removing the root e.g. because of proximity to the inferior dental nerve.
ii. Previous attempts at extraction have failed in dental practice.
iii. The patients have had radiotherapy to the head and neck and the roots are within the radiation field.
iv 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.
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.
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.
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) Increased overjet greater than 6mm but less than or equal to 9mm.
(b) Reverse overjet greater than 3.5mm with no masticatory or speech difficulties
(c) Severe displacements of teeth greater than 4mm.
(d) Extreme lateral or anterior openbites greater than 4mm.
(e) Increased and complete overbite with gingival or palatal trauma.
(f) Less extensive hypodontia requiring pre-restorative orthodontics or orthodontic space closure.
(g) Posterior lingual crossbite with no functional occlusal contact in one or more buccal segments.
(h) Reverse overjet greater than 1mm but less than 5mm with recorded masticatory or speech difficulties.
(i) Partially erupted teeth tipped and impacted against the other teeth.
IOTN Grade 5 – Very great treatment need
(j) Increased overjet greater than 9mm.
(k) Extensive hypodontia with restorative implications.
(l) 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.
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.
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 :-
· Severe medical problems
· After head and neck radiotherapy
· Significant immuno-compromised or immuno-suppression
· Severe bleeding disorders
· Brain injuries
· Life limiting conditions