Referral criteria

• Head and Neck oncology patients who require dental assessments;  who have complex prosthetic problems, altered anatomy and orofacial defects that require planning, obturation and oral/facial  rehabilitation including implant-based rehabilitation; who have high risk of osteoradionecrosis (ORN).
• Patients with congenital deformities including hypodontia, cleft lip +/- palate, amelogenesis and dentinogenesis imperfecta who require specialist restorative skills, multidisciplinary care across other specialties i.e. OMFS, Orthodontics to restore aesthetics and function.
• Patients with history of severe trauma with acquired defects and multiple tooth loss, requiring multidisciplinary specialist care.
• Diagnosis and treatment planning for hereditary developmental defects like amelogenesis and dentinogenesis imperfecta.

 Dental implantology is available under the guidelines for selecting appropriate patients to receive treatment under the NHS (RCS England guidance) and in accordance with the local commissioning guidelines, only in the categories listed below:

• Ablative surgery for head and neck cancer, continuing problems with well-fitting complete dentures or obturators.
• Patients with Extra-oral defects e.g. orbital exenteration, nasal resection
• Congenital conditions resulting in missing/ deformed teeth e.g. hypodontia, cleft lip and palate, defects within enamel and dentin structure (e.g. amelogenesis and dentinogenesis imperfecta) that have resulted in teeth being unrestorable and with poor long term prognosis.
• Tooth tissue loss following severe trauma (bone loss+/- multiple teeth lost due to trauma). In case of traumatised teeth where patients are growing, root canal treatment may be advised to be carried out by the patient’s general dental practitioner to maintain bone in the interim.

Referrals are accepted from the below (only for the above mentioned conditions):

• Internal referrals (all Consultants of the Head and Neck Cancer team including Oral and Maxillofacial Surgery, ENT, Oncology; Consultants in Orthodontics and from the Cleft Multidisciplinary Team, Oral Surgery)
• Dental practitioners within the primary and community dental services.
• Dental specialists
• Generally we would not expect referrals directly from general medical practitioners, as patients are expected to be registered with a primary care dental practitioner when and if accepted for treatment at the Hospital.

Expectations and Responsibilities:

• With all referrals we take a shared care approach with the referring dental practitioner. The patient’s dentist retains the responsibility of their ongoing care and we expect/advise that they provide routine and emergency dental care whilst patients are receiving treatment at the hospital unless otherwise informed by the hospital consultants. On completion of the planned treatment, the general dental practitioners will be kindly expected to provide maintenance and follow up care where appropriate

Restorative Dentistry- Referral Criteria detail :

The tables below set out the types of referral, within the cohort below, that will and will not be accepted for treatment

• Head and neck cancer patients post oncology treatment
• Congenital deformities including hypodontia, cleft lip and palate
• Advanced facial / dental trauma
• Hereditary dental developmental defects mainly amelogenesis imperfecta and dentinogenesis imperfecta (assessment, treatment planning).

 

Specialty	Non-acceptance for Secondary Care Treatment	Treatments/patients that can be referred
Periodontics	Referrals not providing BPE scores will not be accepted. Patients referred where finance is the only driving factor Patients who have not received any non-surgical periodontal treatment (refer to appendix A) Patients who consistently demonstrate poor compliance with dental health advice and poor attendance. Patients with very poor oral hygiene and gross calculus deposits Patients who have untreated primary dental disease.	Patients only in the cohort mentioned above, with the following criteria: Patients who exhibit significant periodontal disease defined as Basic Periodontal  Examination codes 3,4 (pockets ≥ 5.5mm) Rapidly progressing periodontitis (Grade C) where there is a potential for tooth loss /dentition (further guidance from BSP awaited regarding new classification and referrals) Surgical periodontal procedures necessary e.g. crown lengthening Surgery associated with dental implants Medical conditions affecting the periodontal tissues e.g. major organ transplants, diabetes, immune suppression Adverse root morphology Mucogingival problems including periodontal tissue augmentation

 

Specialty	Non-acceptance for Secondary Care Treatment	Treatments/patients that can be referred
Endodontics	Patients referred where finance is the only driving factor Patients who consistently demonstrate poor compliance with dental health advice and poor attendance. Patients who have untreated primary dental disease. Dentally anxious patients requiring inhalation or intravenous sedation Where there has been no attempt to treat or retreat root canals considered to be negotiable clinically or radiographically Third molars Unrestorable teeth	Patients only in the cohort mentioned above, with the following criteria: Teeth with single/multiple root canals with severe curvature greater than 40 degrees Complex root anatomy e.g. bifid canals, dens in dente Non vital anterior teeth with immature apices Location or negotiation of sclerosed canals (patients will be returned for completion of RCT and final restoration depending on the complexity on a case by case basis) Teeth with pathological root resorption Separated instruments in canals Patients with limited mouth opening following oncology treatment where endodontics cannot be carried out by a general dental practitioner (Note: patient will be accepted only if able to safely provide endodontics under rubber dam) Teeth where the option of dental extraction would pose a high risk of osteoradionecrosis (ORN) and general dental practitioner unable to save the tooth. Peri-radicular surgery (patients may be referred to OMFS)

 

Specialty	Non-acceptance for Secondary Care Treatment	Treatments/patients that can be referred
Prosthodontics	Patients who consistently demonstrate poor compliance with dental health advice and poor attendance. Patients referred where finance is the only driving factor Denture provision for non-complex cases Dental tourism; Provision of reparative dental work for patients who have travelled abroad in order to obtain: Dentures Crown and bridgework Implants Other dental treatment	Patients only in the cohort mentioned above, with the following criteria: Reconstructive/rehabilitation treatment for patients with head and neck cancer which is out with the remit of the general dental practitioner, complex prosthetic problems. Reconstructive treatment for patients with tooth loss following severe trauma where alternative treatment has failed To restore oral function and aesthetics for patients with congenital abnormalities and defects e.g. hypodontia or cleft lip and palate Treatment planning/ advice for patients with amelogenesis imperfecta, dentinogenesis imperfecta.

Appendix A – Non-Surgical Treatment should include:

• Appropriate oral health education
• Advice on and demonstration of plaque control measures
• Advice to quit or reduce smoking
• Appropriate diet modifications

All patients should have had a thorough supra and subgingival scaling and subgingival debridement. This would normally be under local anaesthesia for periodontal pockets ≥ 4mms. The outcome of the treatment should have been assessed by repeat examination of probing depths and bleeding upon probing scores not more than3 months after the completion of treatment. Note: (Further new BSP Guidance and Standards awaited).

Code3: initial therapy including self-care advice (oral hygiene instruction and risk factor control) then post-initial therapy, record a 6 point pocket chart in that sextant only.

Code 4: if a code 4 is found in any sextant, then detailed probing depths ( 6 sites per tooth) should be recorded for the entire dentition.