Devon Cornwall & Isles of Scilly Area Team Regus House



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Devon Cornwall & Isles of Scilly Area Team

Regus House

1, Emperor Way

Exeter


EX1 3QS

peterhoward-williams@nhs.net

August 2014

Dear Colleague

I am contacting you in my role as Clinical Chair of the Dental Local Professional Network of the Devon, Cornwall and Isles of Scilly Local Area Team, NHS England.
One of the key roles of the Local Professional Network is to drive quality improvement and outcomes in line with local and national priorities and to facilitate wider clinical engagement and clinical input into the commissioning process.
Improving the Oral Surgery Care Pathway is a local and national priority for the Area Team and I would like your help to achieve this.
Currently throughout the Devon and Cornwall area patients requiring oral surgery are referred to one of five secondary care hospitals and a variety of primary care based providers. There is a wide variety of methods of referral and referral forms and no consistent set of guidelines for practitioners. There is also an issue of a small number of GDPs who are referring inappropriate cases that should be completed in the GDP practice, submitting very poor quality referrals with poor information and radiographs, and making inappropriate referrals for General Anaesthetics.
One of the aims of the Oral Surgery Care Pathway reform is to move some of the more straightforward work to primary care based providers to enable more local access for patients and free up valuable resources.
In order to achieve an improvement in the quality of referrals and reduce inappropriate referrals the Area Team in consultation with all stakeholders has produced a set of consistent guidelines and referral forms for the whole area. I would ask you all to read through them carefully and make sure your referrals comply with the guidelines and are of the quality our patients would expect from a healthcare professional. We hope to make these available soon through the NHS England website.
I would especially ask you to take note of the sections on referrals for general anaesthesia radiographs and medical conditions.
If you have any comments or queries please contact me at peterhoward-williams@nhs.net and if you want to keep up to date with the LPN please let me have your personal email address and I will add you to our circulation list.
With kind regards

Peter Howard-Williams BDS LDS DGDP

Clinical Chair Dental Local Professional Network
DEVON, CORNWALL AND ISLES of SCILLY LOCAL AREA TEAM
MINOR ORAL SURGERY GDP REFERRAL GUIDELINES

FREQUENTLY ASKED QUESTIONS
"When should I refer an extraction?"

As part of their GDS contract NHS providers and performers are expected to carry out extractions of teeth including the removal of retained roots. The patient should only be referred if they present with special difficulties and lie outside the competence of the dentist concerned. Please look through the guidelines carefully. NHS England has identified the inappropriate referral of extractions that should be carried out in practice as an area where improvements are necessary. If an individual performer feels unable to perform a procedure that should be carried out in general practice it is the responsibility of that provider to arrange for the procedure to be carried out in practice by another, more experienced performer.



"To whom should I refer?"
Currently patients referred for oral surgery procedures are treated either in a secondary care setting which means one of the five main hospitals in Devon and Cornwall or by a specialist provider based in a primary care setting.
Secondary Care providers are able to offer the full range of operative and diagnostic treatment including 2 week waits for suspected cancer patients and general anaesthesia.
Primary care providers are able to offer a more limited range of surgical procedures, with or without sedation. (Appendix 3)
In order to reduce pressure on secondary care providers and free up valuable resources NHS England has a national and local priority to increase the number of cases treated by primary care based providers and changes to the referral guidelines and triaging of patients reflects this priority.

"Where should I send the referral form?"
All the referrals for the Devon, Torbay and Plymouth areas should be sent to Devon Access and Referral Centre DART on the DCIoS Oral Surgery Referral form (Form 1). Their address, email and telephone number are on the form.
NOTE: GDPs who currently refer directly to Derriford or Plymouth based primary

care should now refer all patients through DART.
All the referrals for the Cornwall area should be sent to Kernow Health Referral Management Service RMS on the DCIoS Oral Surgery Referral form (Form 1). Their address, email and telephone number are on the form.
"Why can't I do all the referral process electronically?"
It is an ambition to develop an electronic system as soon as possible. One difficulty is the transmission and storage of radiographs.

"How should I refer a suspected cancer case?"
A suspected cancer case should be referred without delay directly to your nearest hospital. The referral should be faxed and the numbers are on the referral forms. A paper copy or telephone call should follow as a backup.

For North Devon and Exeter you should use the Oral and Maxillofacial Surgery Referral Form (Form 1) - Fax number: 01392 402199.

For Plymouth use the Plymouth 2WW form (Form 3) – Fax number: 01752 430912 telephone number: 01752 437506.

For Cornwall use the Cornwall Hospitals Trust urgent two week wait form (Form 4 or 4a electronic) – Fax number: 01872 252300, if you have any problems please ring 01872 252323.


For Torbay book via choose and book if possible, otherwise use the South Devon Healthcare Trust urgent two week wait form (Form 5) and fax to the Patient Access Centre – Fax number: 01803 654981.

"How can I improve my extraction skills?"
There are opportunities with the postgraduate BUOLD course on oral surgery and if there is demand we will arrange some local training and assisted operating.

"What happens if I encounter problems and am unable to complete a surgical procedure?"
Firstly you should ask a colleague in your practice to assist but if that is not possible then you can ring your local secondary care oral surgery department or primary care specialist for advice.
Royal, Devon and Exeter NHS trust: 01392 411611 to the operator and then ask for the on-call SHO on bleep 476.
For North Devon District Hospital: "daytime" ring the secretary on 01271 322477.
Derriford Hospital, Plymouth: 01752 202082 and ask for the on call maxillofacial SHO.
Plymouth Community Dental Services: 08451558070
Royal Cornwall Hospital, Truro: 01872 250000 - switchboard for on call Oral and Maxillofacial Surgery Resident.  Daytime urgent requests can also be to secretarial team: 01872 253986
Torbay Hospital: The on call SHO via the switchboard 01803 614567 and bleep #6313.

"What will happen if a referral is rejected?"
A referral will only be returned to the referring practitioner after a clinician has reviewed it. The referring practitioner will be sent a letter stating the reason for the rejection and the patient will also be informed. (Appendix 5a & 5b) It is then up to the practitioner to provide more details of why the referral is appropriate or undertakes the procedure in practice. The Area Team will be auditing a number of these cases to ensure that the patient reaches a satisfactory conclusion.

"Will I get my radiographs back?"
We are aware that radiographs have not always been returned in the past but in future every effort will be made to return original radiographs with correspondence. Digital radiographs should be printed on good quality photographic paper.

DEVON, CORNWALL AND ISLES of SCILLY LOCAL AREA TEAM
MINOR ORAL SURGERY GDP REFERRAL GUIDELINES
All practitioners must use the new DCIoS referral form for all oral surgery referrals of patients over 18 (Form 1). Please use the new form to avoid rejection at triage.
Attached please find the guidelines for appropriate referral of:


  • Non third molar extractions

  • Third molar extractions

  • Extraction of retained roots

  • Endodontic Surgery/Apicectomies

  • TMJ problems

  • Abnormal; soft tissue and bony lesions

  • Oral Cancer Oral Medicine

  • Sedation or General Anaesthetic

All referrals that fall outside these guidelines will be returned unless further information is provided which justifies the referral.


Failure to complete all sections of the referral will result in the return of referral and subsequent delay in the patient’s treatment. The information on the form must reflect the results of the referring practitioner’s examination and diagnosis.
Failure to submit a satisfactory radiograph, if appropriate, will result in the return of referral and subsequent delay in the patients’ treatment.
Failure to submit an up to date medical history with details of all current medication and if the patient is taking Warfarin the most recent INR, will result in the return of referral and subsequent delay in the patient’s treatment.
It is rare for a patient’s medical history to complicate the extraction to such an extent that it needs to take place within the hospital setting. Specific examples are listed. (Appendix 2)
GDC guidelines indicate that “particular care must be taken when referring patients for treatment under general anaesthesia or sedation”. General anaesthesia carries an increased level of risk and should not be offered to patients as a routine alternative.
If referring for sedation or general anaesthetic the patient must complete and sign the "GA or Sedation Referral form" Failure to complete all sections will result in the return of referral and subsequent delay in the patients’ treatment. (Appendix 1 and Form 2)
All suspected oral cancer cases should be fast tracked direct to the Oral Surgery Department by fax or "Choose and book" and their receipt confirmed. (See FAQs for details)

NON THIRD MOLAR EXTRACTIONS:
Non third molar extractions should be performed in the referring practitioners’ dental surgery under local anaesthetic.
These should only be referred in the following exceptional cases:


  • Associated pathology that needs to be submitted for histological examination (e.g. cysts).

  • Extractions from abnormal or diseased bone (eg patients who have received therapeutic doses of irradiation to the jaws).

  • Complicated extractions with special difficulty.

  • Failed extractions with an explanation of why, and a ‘post- extraction’ radiograph.

  • Extraction where there is a substantially increased risk of damage to an adjacent anatomical structure


If a referral is made outside these guidelines the referring dentist must justify the reasons why the treatment cannot be undertaken by them in primary dental care.
It is rare for a patient’s medical history to complicate the extraction to such an extent that it needs to take place within the hospital setting. Specific examples are listed. (Appendix 2)
Please ensure that relevant radiographs accompany all requests so that unnecessary additional radiation exposure to patients is avoided. Wherever possible, these radiographs will be returned once treatment has been completed.
A clear referral with all relevant clinical information, current radiograph and medical history can be accurately triaged for booking the patient directly into the correct treatment centre.
If additional restorative dentistry is being planned as part of the patients existing treatment plan, this treatment must be continued by the referring dentist while the patient is awaiting specialist assessment and treatment. Please also indicate on the referral form which additional teeth are planned to be restored and do not also need to be considered for extraction.

THE MANAGEMENT OF THIRD MOLARS:
Asymptomatic wisdom teeth should not be extracted.
Anterior crowding alone is not an indication for wisdom teeth removal in the absence of a specialist orthodontic opinion.
In symptomatic patients, palliative treatment should be used as a first option.
In symptomatic patients, where palliative treatment is not appropriate or is ineffective, surgical removal of symptomatic third molars can generally be carried out within the general dental service assuming the Clinician has the relevant training and experience.

Referral to a specialist may be necessary where anatomical or pathology considerations make the extraction difficult, where the patient has medical complications, where the operator does not have the relevant training or experience, or where previous attempts at extraction have failed.


The wisdom teeth to be removed must fulfil at least one of the following criteria:


  • Recurrent episodes of pericoronitis.

  • Single severe episode of pericoronitis which showed evidence of spread and infection to facial tissues.

  • Caries not amenable to restoration.

  • Wisdom tooth contributing to periodontal disease of second molar.

  • Associated follicular cystic changes.

  • Periapical pathology.

  • Prior to orthognathic surgery.

  • Associated with cyst or tumour.

  • Prior to medical treatment that would increase risk eg radiotherapy, IV bisphosphonates or chemotherapy.



MANAGEMENT OF RETAINED ROOTS:
Retained roots should be removed in the referring practitioners’ dental surgery under Local Anaesthetic. Long standing retained roots with no symptoms or infection present should not be referred.
Referral to a specialist is necessary only where anatomical or pathology considerations make the extraction especially difficult, where the patient has medical complications or where previous attempts at extraction have failed.
If additional restorative dentistry is being planned as part of the patients existing treatment plan, this treatment must be continued by the referring dentist while the patient is awaiting specialist assessment and treatment. Please also indicate on the referral form which additional teeth are planned to be restored and do not also need to be considered for extraction.

MANAGEMENT OF TEETH REQUIRING ENDODONTIC SURGERY / APICECTOMY:
Orthograde root canal therapy is the first treatment option to treat periapical pathology. Non surgical re-treatment should be the preferred option for endodontic failure. The restorability of the tooth, the health of the supporting bone and periodontal tissue, and anatomical considerations such as position of neurovascular bundle should be assessed before embarking on any form of surgical endodontic therapy.
Referral for apicectomy of a tooth with an inadequate root filling will not be accepted without exceptional circumstances. Re-root filling by the referring dentist or a specialist endodontist is the best solution to most failed root fillings. Significant cyst formation (>5 mm on radiograph) is an indication for apicectomy and establishment of diagnosis.
Referral to a specialist may be necessary where anatomical or pathology considerations make the surgery difficult, where the patient has medical complications, where the operator does not have the relevant training or experience, or where previous attempts have failed.
Currently NHS England Devon, Cornwall and Isles of Scilly Area Team is unable to commission surgical molar endodontics.

MANAGEMENT OF TEMPOROMANDIBULAR JOINT DYSFUNCTION:
Initial management of Temporomandibular Joint Dysfunction may involve supportive patient education on avoidance of clenching and grinding, relaxation and a soft diet.
Pharmacological pain relief with Non-Steroidal Anti-Inflammatory Drugs (NSAID’S) and remedial jaw exercises can also be of value. For patients with persistent pain, stabilising splints or bite raising appliances may help, but permanent occlusal adjustments should be avoided.
It is important to read through Appendix 4 on TMJ treatment and to refer only if symptoms persist after conservative measures, including the provision of a soft splint.
Referral to specialist care may be necessary for clarification of diagnosis where there is underlying joint disease, limited opening in isolation or if the patient has persistent Temporomandibular Joint Dysfunction or psychological problems.

THE MANAGEMENT OF ABNORMAL SOFT TISSUE AND BONY LESIONS:
The Oral & Maxillofacial Surgery service will receive referrals for any soft tissue lesions of the skin in the head and neck region, and abnormal hard and soft intra-oral lesions.
Abnormal lesions should be referred to specialist services when the diagnosis is in doubt or if they interfere with dental treatment. If a clear and adequate history is provided on the referral form, the majority of these patients can be seen and treated under local anaesthetic during a single appointment.
Abnormalities due to infections of the oral cavity should be treated in line with antimicrobial guidelines with a simultaneous treatment to remove the cause of the infection if known.

ORAL CANCER:
Patients with abnormal areas or lesions in the mouth that are suspected of being oral cancer must be referred for an urgent Oral & Maxillofacial Consultation. The oral cancer referral form must be completed and faxed within 24 hours directly to the Oral & Maxillofacial Surgery Department. It is advisable to check the referral has been received.
Please see FAQ section for details
All suspected cancer referrals are subject to the "Two Week Wait" cancer waiting times. Warning signs of oral cancer are:

  • Non healing, often painless ulcer or sore for more than three weeks.

  • Lump or thickness in the cheek or elsewhere in the mouth.

  • Persistent soreness of the throat or mouth.

  • Difficulty chewing or swallowing.

  • Numbness of the tongue or other areas of the mouth.

  • Swelling of the jaw which causes the dentures to fit poorly.

  • Loosening of the teeth or pain around the teeth or jaw.

  • Voice changes.

  • A lump or mass in the neck.

  • Weight loss.

Examination of the oral soft and hard tissues should be performed in line with NICE dental recall guidelines. Dental practitioners should be aware of the most common appearance, warning signs and symptoms of oral cancer.


Preventive advice concerning tobacco cessation, reduction of excessive alcohol consumption and healthy eating habits should be offered.

ORAL MEDICINE CONDITIONS:
Oral medicine involves specialist care of patients with symptoms arising from the mouth that often do not relate directly to teeth and where management is not primarily surgical. The symptoms are often chronic and may have significant psychological as well as physical impact on the patient’s quality of life. The Oral & Maxillofacial Surgery Unit will provide diagnostic assessments with subsequent advice and management for soft tissue disease of the mouth and jaws, chronic facial pain, and the oral manifestation of systemic disease. These systemic medical conditions may include diseases of the gastrointestinal tract, rheumatological and haematological conditions and immunological disorders.

CONDITIONS TO BE REFERRED FOR DIAGNOSIS AND INITIAL TREATMENT:


  1. Ulceration lasting more than two weeks.

  2. Recurrent oral ulceration.

  3. Blistering conditions of the oro-facial region and oral mucosa.

  4. White or red patches of the oral mucosa (including lichen planus).

  5. Hypersensitivity reaction.

  6. Candidosis or angular cheilitis.

  7. Pigmented conditions of the oral mucosa.

  8. Oro-facial pain of non dental origin (burning mouth syndrome, trigeminal neuralgia and unexplained oro-facial pain.

  9. Other altered oro-facial sensations.

  10. Dry mouth and other symptoms related to salivary glands.

  11. Soft tissue swelling of the oro-facial region.

  12. Oro-facial manifestations of systemic disease.


APPENDIX 1

PROVISION OF CONSCIOUS SEDATION/GENERAL ANAESTHETIC FOR MINOR ORAL SURGERY PROCEDURES:

Provision of Conscious Sedation for minor oral surgery procedures
Since 1998 there has been a sea change in the provision of pain and anxiety management in dentistry in the UK. This has resulted in an increased emphasis on the safe provision of conscious sedation instead of a reliance on general anaesthesia that is demand led. General anaesthesia should only be provided in response to clinical need. The publication of ‘A Conscious Decision’ in 20006 resulted in the cessation of general anaesthesia for dentistry in the primary care setting.
Conscious sedation is available primary and secondary care settings.

Provision of Conscious Sedation/General Anaesthesia for minor oral surgery procedures


  • Large or infected cysts where obtaining local anaesthetic is difficult.

  • Young Children with inadequate cooperation.

  • Extreme dental phobics. These would be patients who are unable to tolerate local anaesthesia for any procedures.

  • Patients with learning difficulties who are unable to tolerate normal dental procedures.

  • Confirmed sensitivity or allergy to Local Anaesthetics ( very rare)

  • Emergency dental extractions carried out in conjunction with extra- or intra- oral drainage of abscess usually associated with trismus and/or a threat to the airway.


If a General Anaesthetic/Conscious sedation has been requested please complete the "GA or Sedation Request" form (Form 2). This must accompany the Oral Surgery Referral Form.
Please make sure that the reason has been fully explained to the patient and that they have signed the form.

APPENDIX 2

MEDICAL CONDITIONS REQUIRING REFERRAL FOR MINOR ORAL SURGERY:


  • Patients on anticoagulant therapy with an INR of 3.5 or over.

  • Patients requiring transfusions and other treatments for bleeding disorders.

  • NB Be aware of patients on new oral anticoagulants such as dabigatran, apixaban and rivaroxaban. These drugs are not monitored in the same way as warfarin and have a short half life. Straightforward extractions can be carried out in the surgery with consideration given to stopping the drug for 1-2 days prior to extraction with the agreement of the patients GMP.

  • Patients who have had or are receiving Intravenous bisphosphonate medication and Anti-TNF treatments (Rheumatoid Arthritis) and therefore at high risk of Osteonecrosis.

  • Patients on oral bisphosphonates with other immunosuppressives such as steroids or chemotherapeutic agents who are at a high risk of osteonecrosis.

  • Patients at risk of Osteoradionecrosis. ( Patients with a history of head and neck radiotherapy)

  • Patients with limited oral access e.g. Head & Neck cancer patients with microstomia or severe trismus.


APPENDIX 3

INDICATIONS FOR CARE BY A PRIMARY CARE PROVIDER USING A DENTIST WITH ENHANCED SKILLS (LEVEL 2):

(A specialist provider working in primary care can provide a greater range of treatment)



Does not require a General Anaesthetic

Lower Third Molars (8s)

Surgical removal of third molars involving bone removal



Extractions

Extraction of erupted teeth with special difficulties

Management and surgical removal of ectopic teeth ( including supernumery teeth)

Extraction of Retained Roots

Surgical removal of buried roots and fractured or residual root fragments



Apicectomy

Surgical endodontics for incisor and canine teeth



Minor Oral Soft Tissue Surgery

Minor soft tissue surgery to remove apparent non-suspicious lesions




APPENDIX 4

GUIDANCE FOR THE MANAGEMENT OF TMJ PAIN DYSFUNCTION SYNDROME (TMJPDS) IN PRIMARY DENTAL CARE:
The majority of patients presenting with TMJ problems will be suffering from TMJPDS (temporomandibular joint pain dysfunction syndrome) or myofascial pain. These patients can, in most cases, be effectively managed in primary care without referral.
The most common symptoms are:


  1. Pain – usually a dull ache in and around the ear. The pain may radiate, ie move

  2. forward along the cheekbone and downwards into the neck.

  3. Joint noise – such as clicking, cracking, crunching, grating or popping.

  4. Limited mouth opening

  5. Headache, especially in the temporal region.

  6. Some patients report mild/transient facial swelling which may be worse in the

  7. morning.



Most cases of TMJPDS are made worse by chewing and are aggravated at times of stress.
The initial management of TMJPDS in primary care includes the following measures:
1. Explanation of the condition and provision of relevant patient leaflet.

2. Reassurance that TMJPDS is not serious and that it usually responds to simple measures. Symptoms may recur from time to time.

3. Application of heat to the side of the face, eg a warm hot water bottle (avoid boiling water) wrapped in a towel applied to the side of the face. This can be combined with simple massage to the tender muscle areas and relaxation techniques.

4. Advice concerning the use of painkillers. Non-steroidal anti-inflammatory drugs (NSAIDs), eg ibuprofen, are often helpful, unless contra-indicated because of the patient’s medical history. These should be taken regularly for a two to three week period, not just PRN. NSAID gel can be applied topically to the area over the joint or the muscles of mastication.

5. The identification and avoidance of parafunctional habits, such as clenching or grinding (particularly at night), nailbiting, lip/cheek biting and posturing the jaw.

6. Rest for the TMJ, including soft diet, particularly if there are acute phases.

7. Acknowledgement that the condition can be related to anxiety and stressful events.

8. Provision of a soft occlusal splint, which can be worn at night – this is particularly useful for patients who grind their teeth at night.


NB: Irreversible procedures such as occlusal adjustment, should only be undertaken if there is a clear indication.

Patients with TMJPDS who should be referred for management in secondary care:

1. Those with an atypical presentation (e.g. numbness of the face, marked/persistent facial swelling, severe trismus which is unrelated to surgical intervention or injury).

2. Patients who fail to respond to conservative measures, including the provision of a soft splint.
Referrals should be made to an Oral & Maxillofacial Surgeon or Consultant in Restorative Dentistry. Please indicate the measures you have already undertaken to manage the patient’s TMJPDS.
NB: Patients should not be referred for the provision of an occlusal splint – these can be provided in primary dental care.

APPENDIX 5a

DCIoS Referral Services

Date:

Dear (Dentist name)



You recently referred (patient name and DOB) for a specialist oral surgery procedure. The referral appears not to conform with the NHS England Devon, Cornwall and Isles of Scilly Area Team Minor Oral Surgery GDP Referral Guidelines and has been returned to you for the following reason.
The Referral Guidelines have been circulated and are available on the DCIoS Area Team website ** Link to be added **


1.

The referral is on the wrong referral form. The correct forms are available on the AT website. (link to website)




2.

The referral is incomplete and the following information is required:
An up to date appropriate radiograph







An up to date medical history







A recent INR







Patient/ Dentist/ GMP details







A clear reason for the referral




3.

The treatment proposed is considered suitable for routine GDP practice




4.

Further information is required to justify sedation or a general anaesthetic.

please see guidelines on sedation/GA (link) and Sedation/GA request form (link)





Please resubmit the correct referral form with the additional information required or arrange to provide the treatment within your own practice.




We have advised the patient that the referral has been returned and asked them to contact you for further information about their treatment



If you have any queries about this please e mail Peter Howard-Williams at peterhoward-williams@nhs.net


Yours sincerely

DCIoS Referral Service




APPENDIX 5b

DCIoS Referral Services



Date:

Dear (Patients name and DOB)



Your dentist, (name of Dentist), has recently referred you for a specialist oral surgery procedure. The referral appears not to conform with the NHS England Devon, Cornwall and Isles of Scilly Area Team Minor Oral Surgery GDP Referral Guidelines and has been returned to your Dentist for further information.
We advise that you contact your Dentist for further information about your treatment.
Yours sincerely

DCIoS referral Services


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