Oral surgery referral guidelines



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ORAL SURGERY REFERRAL GUIDELINES
The responsibility for making an appropriate referral rests with the referring health care professional. Three referral categories are used: ‘Red Flag’ referrals are only for cases of suspected cancer (patient to be seen within 2 weeks); ‘Urgent’ cases are non-cancer cases which need to be seen urgently; all other cases are categorised as ‘Routine’. Referring practitioners should tick the appropriate category in the ‘Urgency of Referral’ section in the referral Pro Forma in

Appendix 1.


All referrals must include complete patient contact details; sufficient clinical details outlining the problem, with radiographs if appropriate. Medical and drug histories are essential. Acceptance for treatment will be based on clinical need. Referring practitioners should use the Oral Surgery Referral Pro Forma.


  • NB: A referral which does not meet the service criteria will be returned to the referrer with an explanatory note.

Please note that high quality radiographs should be provided for all dentoalveolar referrals. In third molar cases, an OPG is advisable. For other teeth, the radiograph must show the apex of the subject tooth/teeth. Normally these radiographs should be less than 12 months old and will be returned to the referring practitioners if they are the originals. Digital copies emailed to the appointments department would be welcomed (SODReferrals@belfasttrust.hscni.net).


For mucosal conditions, clinical photographs would also be welcomed
N.B. Any information sent by electronic means should be provided with an adequate level of encryption or password protection in line with Data Protection Guidelines
Oral Surgery Referrals are accepted for the following:
Oral mucosal and related pathology
See also HSCB referral guidance for Oral Medicine:
http://www.hscbusiness.hscni.net/services/2470.htm


  • Abnormal areas in the mouth that are suspected of being oral cancer should be referred immediately and marked as Red Flag”. In addition the following may also be referred:




  • White or red patches

  • Ulceration of the oral mucosa

  • Vesiculo-bullous disorders

  • Jaw Cysts

  • Any intraoral mass/swelling or lesion requiring diagnosis and/or treatment

  • Salivary gland swellings and disorders




Trauma


  1. Dento-alveolar fractures.

  2. Intra oral soft tissue trauma




Spreading infection


  • Where patients present with emergent signs of spreading infection including trismus, dysphagia, airway problems, pyrexia and systemic upset, telephone contact should be made with the Oral Surgery Department at the Dental Hospital phone: 02890633159.




Surgical Extractions


  • Surgical removal of retained roots and teeth.




  • Multiple extractions (in one or both jaws) for patients who may need a general anaesthetic or conscious sedation. This has to be part of a treatment plan agreed with the patient and includes arrangements for continuing care in primary care. It is the responsibility of the referring dentist to undertake an oral health assessment and agree a full treatment plan with the patient before referring. A copy of the treatment plan should be included in the referral to ensure treatment provided under sedation/GA does not conflict with the overall plan.




  • Routine extractions or, in the opinion of the referring dentist, a possible surgical extraction will only be accepted with an explanation and radiographic evidence for e.g. patient with history of difficult extractions e.g. ankylosis.




Orthodontic–related procedures


  • Exposure or removal of ectopic teeth, and removal of supernumerary teeth will be considered provided the practitioner has obtained a specialist orthodontist assessment which should accompany the practitioner’s referral.




  • In addition, it should be clearly stated why the orthodontist wishes to have the teeth removed/exposed and that they will be undergoing this procedure as part of their on-going orthodontic treatment




Symptomatic Third Molars


  • ALL referrals should follow NICE guidelines ( NICE: Wisdom Teeth – Removal TA1 March 2000) and will only be accepted where access to secondary care skills and facilities are required such as:


Complex anatomical considerations (this does not necessarily include proximity to the Inferior Alveolar canal as removal/

decoronation in these cases may be managed as effectively in the Primary Care Specialist Oral Surgery practice following appropriate imaging)


  • Pathology which may complicate the procedure




  • Patient has related medical problems which make management inappropriate in primary care.




Dental extractions in medically compromised patients / potential complications


  • The vast majority of procedures should be able to be undertaken in dental practice or if necessary in High Street specialist Oral Surgery Practice.




  • Patients with ischaemic heart disease (including patients on aspirin), chronic pulmonary disease, diabetes or epilepsy which is under control should be able to undergo treatment in general dental practice/primary care oral surgery specialist practice.




  • Patients taking less than 10mg of Prednisolone per day do not normally require additional steroids. However, qualified advice based on the patient’s medical history should be sought.




  • Extractions can be undertaken on patients taking warfarin in dental practice/primary care specialist oral surgery practice. The INR should be checked the day before or on the day of the extraction, usually at the GMP’s surgery and the procedure undertaken if the INR is less than 3.0 and has been previously stable. Bleeding should be controlled by local haemostatic measures. Please seek telephone advice if required.




  • Refer patients on warfarin who require multiple extractions and those where the INR is >3.0 or unstable.




  • Patients at risk from osteoradionecrosis due to previous exposure to theurapeutic radiation for mouth/neck malignancy who require dental extractions will be accepted




  • Referrals can be made to Community Dental Services in line with their service role as set out in the Scope of Service Specification: http://www.dhsspsni.gov.uk/index/dental/dental-pubs.htm




Apicectomy (Surgical Endodontics)


  • Conventional root canal treatment should be the first treatment option for cases of periapical pathology within primary care. If unsuccessful, non-surgical re-treatment should be the preferred option for endodontic failure.




  • All teeth should be adequately root filled prior to referral, repeat root filling has a higher success rate than apicectomy and hence should be carried out. The success rate of re-apicectomy is very low and will not be carried out by the department.



  • Practitioners may wish to consider referral to specialist endodontists in this regard.




  • Practitioners should undertake a full clinical assessment of their patient and provide the service with written details using the proforma giving the clinical justification for the requirement to have an apicectomy.




  • For comprehensive guidelines for referral for apicectomy see:

http://www.rcseng.ac.uk/fds/publications-clinical-guidelines/clinical_guidelines


Temporomandibular Joint Dysfunction (TMJ)


  • Initial management of TMJ Dysfunction can take place within primary care which may involve supportive patient education on avoidance of clenching and grinding, relaxation and a soft diet. For patients with persistent pain, stabilising splints or bite raising appliances may help, but permanent occlusal adjustments should be avoided.




  • Referral to specialist secondary care may be necessary for clarification of diagnosis where there is underlying joint disease, limited opening in isolation or if the patient has persistent TMJ Dysfunction problems following initial intervention by the referring practitioner. A click in the absence of pain is not an indication for referral.




  • Patients with pain AND severe limitation to movement should be referred urgently.




Patients on Bisphosphonates
Please follow the advice set out in DHSSPSNI ‘Best Practice Guidance – Osteonecrosis associated with Bisphosphonate usage’:

http://www.dhsspsni.gov.uk/hsc__sqsd__54_09_osteonecrosis_associated_with_bisphosphonate_usage-2.pdf



Please note that the secondary care oral surgery service:


  • Does not accept referrals for routine extractions.


Under GDS arrangements, routine dental extractions (including multiple dental extractions) are considered part of the normal care that a GDS practitioner should provide. In circumstances where practitioners lack the expertise to competently undertake routine extractions, it is the responsibility of that practitioner to make alternative arrangements for the patient to access such care under the GDS.


  • Does not accept patients who are having difficulty in accessing primary dental care services or have associated financial reasons or economic issues.




  • Where patients are not currently registered with a GDP, then they should be advised to do so in the first instance. Where there are difficulties in this process, then this should be raised with the Integrated Care Team at the HSCB; Phone: 02890321313.

The oral surgery department at the Dental Hospital accepts referrals from dental practices within the Belfast Trust area. Practices outside of the Belfast HSCT should refer to their local Oral and Maxillofacial Surgery/Oral Surgery clinic. See appendices 2 and 3 of the oral medicine referral guidelines for a list of the oral surgery, oral medicine and oral and maxillofacial surgery clinics in Northern Ireland which can be downloaded at:


http://www.hscbusiness.hscni.net/services/2470.htm



Contact Details:
All referral letters should be sent to the Central Appointments Office:
Appointments Office

2nd Floor

School of Dentistry

Grosvenor Road

Belfast

BT12 6BA
Landline: 028 9063 9300



Fax No: 028 9063 4989

Email address: SODReferrals@belfasttrust.hscni


For urgent clinical Oral Surgery enquiries:
Landline: 028 9063 3159



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