Department of Restorative Referral Protocols

Section Page General Information for General Dental Practitioners 1 1 Referral Criteria 1 2 Post-operative Discharge Patient Information (leaflets) 1 3 Referral Criteria - Minimum Dataset 2 3.1 Introduction 2 3.2 Referrals for suspected cancer 2 3.3 Making a referral 2 3.4 Referrer details 2 3.5 Patient details 2 3.6 Medical History 2 3.7 Clinical Information 3 3.8 Receipt of X-rays 3 3.9 18 weeks 3 Mono- Information 4 4 4 4.1 Referral Criteria 4 4.2 Post-op Discharge Patient Information (leaflets) 5 5 6 5.1 Referral Criteria 6 5.2 Post-op Discharge Patient Information (leaflets) 6 6 7 6.1 Referral Criteria 7 6.2 Criteria for acceptance for treatment 7 6.3 Endodontics Undergraduate Criteria 8 General Information for General Dental Practitioners

1. Referral Criteria The Birmingham Dental Hospital Restorative Dentistry Department provides a consultant led service to examine patients, give advice and formulate appropriate treatment plans. Treatment in most instances should be undertaken in the Primary Care Sector. Treatment for patients at the Dental Hospital will only be arranged if deemed appropriate. The Restorative Dentistry Department is unable to provide ‘primary dental care’ treatment to all patients who are referred to us or indeed to individual patients who may request it. A limited number of suitable patients may be accepted for treatment for training purposes. Patients cannot be accepted simply because they cannot or will not pay NHS charges in the General Dental Service. The same applies to patients who are normally treated in the private sector. It should be noted that providing the medical history does not dictate otherwise the following are not considered appropriate reasons for referral: • Untreated caries • Untreated periodontal disease • Manufacture of soft and hard acrylic occlusal guards • Patients who cannot or will not pay NHS or private charges • Endodontic treatment: • Second and third molar teeth unless there is an unusual or compelling clinical need. • Where the long-term viability of the tooth is in question. Our undergraduate waiting lists currently remain open. If you feel that the patient would be suitable for undergraduate teaching. Then referrals will be accepted. The reason for this referral must be clearly stated. Advice will be given and treatment may be provided for the following priority groups. The following groups are considered appropriate for referral for advice and, if necessary specialist treatment: • Head and Neck Oncology patients • Development defects such as cleft lip and palate, hypodontia and complex dental anomalies • Trauma: severe trauma involving the dentoalveolar complex • Patients whose treatment fulfils training needs • Medically compromised patients. Referral letters are expected to comply with a minimum data set that has been previously identified to general dental practitioners. Failure to comply will result in the referral letter being returned with a request for the missing information.

2. Post-operative Discharge Patient Information (leaflets) The care of patients within the Restorative Department is generally shared between the Department and the Primary Care sector. Patients who are generally discharged back to the Primary Care sector with full information as to the plan for follow up and maintenance. The relevant discharge information is provided, tailored and focused to the individual patients needs with regard to their disease and treatment modality. Relevant post-operative instructions and information leaflets are available and are attached.

1 3. Referral Criteria - Minimum Dataset 3.1 Introduction Referrals for specialist services can be made by a dental practitioner or medical practitioner in primary or secondary care. Self-referrals by patients are not accepted for specialist services, with the exception of the primary care unit which provides a full dental casualty service for the relief of pain. Patients whose treatment is considered within the scope of a general dental practitioner would only be offered treatment on the undergraduate teaching programme, not with a member of specialist staff. Referral letters are requested to comply with a minimum data set outlined by Birmingham Dental Hospital to ensure adequate information is available for assessment to support an effective patient pathway. Failure to comply will result in the referral letter being returned with a request for the missing information. 3.2 Referrals for suspected cancer Any referral for suspected cancer must be faxed directly to the Safe Haven office using the Rapid Access proforma: Safe Haven Fax: 0121 466 5151 3.3 Making a referral To facilitate an effective assessment of referrals, the following information must be included as a minimum. The Referral Proforma should be used to ensure all the required information is included. The first sheet is generic and captures the minimum data set and a second sheet is specific to Restorative, Periodontology, Prosthodontics or Endodontics. 3.4 Referrer details • Referring General Dental Practitioner/General Medical Practitioner name • Referring Organisation/Practice Code (V Code) and General Dental Practitioner Code (D Code) • Date of referral • Telephone number 3.5 Patient details • Patient full forename and surname and title (i.e. Miss, Mrs, Mr) • Full postal address of your patient to include post code • Patient gender • Patient date of birth • Patient age • Patient home telephone and mobile telephone • Patient NHS Number (if known) • Details of the patient’s General Medical Practitioner. 3.6 Medical History • Current medication • Significant history, including previous consultations for the same condition, name of consultant seen previously • Active problems

2 3.7 Clinical Information • Referral priority (urgent/routine/2 Week Wait Cancer) • Reason for referral • Preliminary investigations and results, as well as management appropriate to reason for referral • Information regarding special/social circumstances (does patient have hearing, visual, mental health difficulties or mobility impairment? Is an interpreter needed?). 3.8 Receipt of X-rays • If a patient had an x-ray taken at your practice please forward the images with the referral letter to prevent the patient being over-exposed to radiation and the referral letter being declined. • How to send X-rays: • Paper copies of x-rays are not acceptable • Please include patient’s name, date of birth and post code for each • X-ray sent along with the date/s taken, so they are identifiable by our Radiology Department. • Via email - send to [email protected] - Please send in jpeg format and indicate in the email which department they are being referred to. • Via post with referral proforma - we will accept original x-rays or x-rays on a CD (jpeg format only) 3.9 18 weeks • Patients are required to be ready for consultation and treatment appointments within 18 weeks once the referral has been received at Birmingham Dental Hospital. Referrals should be sent to: Referral Team Birmingham Dental Hospital and School of Dentistry 5 Mill Pool Way Edgbaston Birmingham B5 7EG (Sat Nav code B5 7SA) UK Email: [email protected]

3 Mono-specialty Information

4. Periodontology Periodontology is concerned with the diagnosis and treatment of diseases and conditions of the soft and hard supporting tissues of the teeth, and the management of oral manifestations of systemic diseases. Some periodontal conditions, including where there is an association with systemic disease (e.g. Diabetes), require treatment within secondary care and some require tertiary care (e.g. HIV, Epidermolysis Bullosa, drug-induced gingival overgrowths, vesiculobullous/erosive gingival diseases, certain syndromes involving the mouth). 4.1 Referral Criteria Under normal circumstances we would only accept patients for secondary care if they fit one of the following criteria: 1. Patients with suspected malignancy or with soft or hard tissue lesions that require diagnosis and investigation. 2. Patients with suspected underlying systemic disease. 3. Children and adolescents with attachment loss (BPE code 3) are accepted. Children under 16 should initially be referred to Paediatric Dentistry. 4. HIV +ve patients who have soft tissue lesions. 5. . 6. Significant periodontitis (BPE code 4 in all sextants) remains after primary care has been performed in practice (schedule 2, band 2 of NHS Dental Charges Regs 2005), with provision of pre and post treatment detailed pocket charts undertaken for code 4. 7. Patients should not normally be re-referred within 2 years of successful treatment within the department. This would imply that maintenance has not been performed adequately in practice. 8. Patients with desquamative gingivitis for investigation and treatment. 9. Patients with recurrent NUG or other necrotising diseases for investigation and treatment. 10. Patients with gingival overgrowth, whether drug-induced or not, for diagnosis and therapy if appropriate. 11. Patients with localised recession that may require periodontal plastic surgery; however sensitivity should be managed in practice. 12. Diagnostic radiographs (film or emailed digital views) need to be provided (paper copies will not be accepted) 13. Patients who are poorly compliant in practice should not be referred for protracted specialist care NB1 - The department is not in a position to accept patients with financial considerations or on the basis that “limited UDAs”are payable for periodontal care under the NHS contract. NB2 - On occasion, some patients may be accepted for treatment by undergraduate students under close staff supervision. Such cases may not always fulfil the above. Referral criteria guarantee that only complex disease (according to national British Society of Periodontology guidelines) is accepted and criteria are robustly implemented. In 2009 30% of referrals were returned for further information or because they do not fulfil the widely publicised referral criteria. Periodontal treatment may be surgical or non-surgical or medically-based and is carried out by Consultants, Specialty , Restorative training grades, Dental Hygienists and senior Dental and Hygiene students under close specialist supervision.

4 Referral letters are expected to comply with a minimum data set that has been previously identified to general dental practitioners. Failure to comply will result in the referral letter being returned with a request for the missing information. Referrals are not accepted on purely financial grounds and periodontal treatment must have been attempted in primary care prior to referral. We are receiving an increasing number of referrals for failing implants but have no commissioned contract for managing such cases, we therefore cannot guarantee that all cases will be treated given the increasing demands on our services. Patients should be informed that they may well be clerked by an undergraduate student or treated by a student if deemed appropriate, but this will always be supervised by senior staff. 4.2 Post-op Discharge Patient Information (leaflets) On completion of treatment secondary care patients are referred back to their practitioner with recommendations for a life-long maintenance programme. Such supportive care programs are essential for maintaining a stable periodontal condition and preventing recalcitrant disease. They are individualised and communicated to referring practitioners by patient-specific discharge letters. Generic discharge leaflets serve no purpose or value for periodontal conditions where individual risk factors vary. Patient leaflets are however provided for patients explaining their condition and their role in its management. There will be a percentage of patients who fail to adhere to treatment plan and they are discharged with a plan for palliative periodontal care within the primary care sector. Regional services are provided for those with HIV disease and transplant patients. A national service is run for Epidermolysis Bullosa (EB) patients referred by the national Dermatology EB lead. Such patients and those with systematic diseases (e.g. graft versus host disease, mucosal disease) are maintained within the department and reviewed regularly as part of their general medical care. As a rule, re-referral of a successfully treated patient is not acceptable within 3 years, since it implies maintenance within the primary care practice has not been adequately performed.

5 5.0 Prosthodontics Prosthetic Dentistry is concerned with the restoration and maintenance of oral function by the replacement of missing teeth and structures primarily by the use of removable and fixed prosthodontics. Such treatment is normally provided within the primary dental service but some complex situations require specialist management within a secondary care setting. Some obturator treatment such as replacement prosthesis and cleft palate dentures are also undertaken. 5.1 Referral Criteria Birmingham Dental Hospital clinical services for Prosthetic Dentistry is a regional service for the West Midlands. The majority of clinical activity takes place in the Prosthetic Department and the clinical practice undergraduate treatment clinics. Some new patient activity is undertaken at the Dental Outreach Centre located in Boots, High Street, Birmingham. We do not impose any referral criteria other than the general referral criteria for the Birmingham Dental Hospital and Restorative Department as we screen patients for their suitability for the undergraduate teaching clinics. This is open policy and is kept under review. If the treatment is not deemed suitable for undergraduate student clinics then it may be undertaken by our hospital team or returned to the referring practitioner. Any treatment provided will incur the maximum band for NHS charges Accessible, Responsive Community Healthcare irrespective of treatment undertaken prior to the referral. Any removable prosthetic treatment is subject to these charges. Primary or secondary providers refer directly to a named consultant or to the Prosthetic Department. Consultants generally operate a shared referral pool to ensure maximal efficiency and eliminate excessive pressure on individual consultants. For the majority of referrals it is expected that the primary care clinician has attempted treatment prior to referral. Referral letters are expected to comply with a minimum data set that has been previously identified to general dental practitioners. Failure to comply will result in the referral letter being returned with a request for the missing information. 5.2 Post-op Discharge Patient Information (leaflets) On completion of treatment and the provision of the appropriate prostheses patients are referred back to the primary care practitioner. Some patients will be maintained in the department whilst simultaneously being managed by their primary care practitioner if appropriate; these will include: • Implant supported overdentures and other fixed implant work • Patients who have received obturators • Patients with chronic oral conditions or genetic predisposition to dental problems • Patients with prostheses provided secondary to major trauma or oral/facial cancers.

6 6.0 Endodontics Endodontic is concerned with the cause, diagnosis, prevention, and treatment of diseases of the dental pulp and periradicular tissues. The successful outcome of endodontic treatment requires thorough disinfection of the root canals followed by the precise placement of a well compacted root filling to within 2mm of the apex of the tooth, and a well- sealed definitive restoration to prevent further infection or fracture. It is a complex technical process. Pulpal and periadicular disease is very common and the Hospital can only accept a limited number of patients for specialist treatment or training purposes and the referral criteria are set out below. We encourage referral of simple cases for undergraduate training and a pilot scheme has been set up and the information to take part in this is set out in 6.3 6.1 Referral Criteria Referrals must include: • Fully completed endodontic referral form • A periapical radiograph of diagnostic value • Confirmation that the tooth has good periodontal and restorative status • An important reason to retain the tooth Referrals will be returned if: • They are illegible • The form is incomplete or does not meet the referral criteria set out in 6.2. 6.2 Criteria for acceptance for treatment Cases will be considered for acceptance based on the following criteria if the patient has a stable oral environment, the tooth/teeth which require treatment are of strategic importance and can be made predictably functional with a favourable prognostic success rate: • Root canals with anatomical complexities e.g. curvatures of >45°, s shape curves, developmental abnormalities etc • Root canals that are NOT considered negotiable from radiographic or clinical evidence through their entire length • The management of teeth with iatrogenic damage or pathological resorption • Complicated non-surgical retreatment (e.g. well-fitting posts longer than 8mm; posts thought to be associated with a perforation; carrier-based obturations; silver points; fractured instruments; well condensed root fillings to length; overfilled roots with apical lesions) • Periradicular surgery.

Patients will not be offered treatment if: • They have an unstable oral environment i.e. they have poor OH, active caries and/or active periodontal disease • They are ‘keen to save’ the tooth/teeth but the prognosis is considered poor • The tooth is a second or third molar unless it is of strategic value to the overall treatment plan • They require sedation or GA for routine dental treatment.

7 6.3 Endodontics Undergraduate Criteria There is an initative piloting referrals from General Practice of Endodontics cases suitable from Undergraduate treatment. We are asking referral practices to register for this: [email protected]. For further guidance and patient information please click the Endo cases for Undergraduate Treatment on the website. Endodontics is one of the most demanding clinical procedures to learn as an undergraduate dental student. In order to develop the necessary skills, it is essential that students have the opportunity to carry out on suitable patients in a supportive environment. One of our biggest challenges is getting enough patients who require endodontic treatment (at the appropriate level of complexity) for our students to treat. We are therefore piloting an initiative to encourage GDPs to engage and help support our dental undergraduates’ education by referring suitable patients for primary root canal treatment. Once the treatment of that tooth is complete the patient will be discharged back to the referring dentist. So that we can manage the flow of cases, practitioners wishing to refer patients through this referral mechanism need to register with the UG endodontic administrator. This will help establish clear lines of communication between the hospital and referrer. Our capacity to treat cases varies throughout the calendar year so it is important that we can communicate directly with the registered practitioners and let you know about the number of cases required etc. Once registered, you will be given a registration number, an electronic referral form and patient information leaflet to start referring patients. As you can appreciate we cannot take on cases that are too complex so there are very specific acceptance criteria that have to be met so that we can ensure that patients and referrers are not disappointed. These are outlined below. If you wish to register, please email Danielle Williams at [email protected] with your name, practice address, phone number and email address. **DO NOT SEND REFERRALS TO THIS EMAIL ACCOUNT** Once we have received this information we will confirm registration, give you a registration number, email you the electronic referral form and patient information leaflet. We intend to communicate with registered practitioners electronically so any practitioner wishing to participate must ensure they have an email address. Once you have registered you will be given instructions of how to refer. We will be able to accept paper based referral letters and/or electronic referrals from NHS net email addresses. Case criteria required for undergraduate endodontic treatment: • Primary endodontic treatment of uncomplicated single and multi-rooted teeth • The tooth to be treated must have enough sound coronal tissue to retain a rubber dam • The patient must be willing to attend multiple long visits at Birmingham Dental Hospital (e.g a minimum of 4 x 2 hour visits for a molar treatment) • Primary disease has been stabilised • The patient is willing to be treated by an undergraduate student. Cases with any of the following criteria will not be accepted: • Root canals that have previously been obturated • Roots/canals with curvature >15° to the root axis • Canals that are NOT considered negotiable through their entire length based on radiographic evidence • Canals that have been obstructed or previous attempts at an access cavity has caused damage to the pulp chamber

8 • Teeth > 25mm in length • Patient has limitation of mouth opening (< 35mm inter-incisal opening) • Teeth with developmental abnormalities or incompletely developed roots. Referrals must contain: • A fully completed referral form • A periapical radiograph of diagnostic value. Referrals will be returned if: • The form is not completed fully • It is illegible • The referring dentist is not registered with the UG Endodontic Administrator as part of the undergraduate endodontic referral process • Does not meet the criteria outlined above.

Thank you for using the new referral process. Please feedback any problems and potential improvement for Restorative MCM Chairman via the administration [email protected].

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