Advice and Information

Primary Care Referral Toolkit

Dental Referral Guidelines

The primary purpose of this guidance is to provide Primary Care Dental Practitioners with a clinical framework which supports the commissioning of services for the residents of North Yorkshire. Our aim is to provide a consistent and equitable service, and these guidelines are applicable to all patients wherever they may be seeking secondary care interventions.

The guide draws together evidence based guidance on a range of clinical pathways with criteria for referral to Secondary Care, and describes the PCT's intentions to commission services primarily in the community. Where necessary, it outlines commissioning thresholds which should be applied to all patients other than where exceptional circumstances can be identified

The evidence supporting the clinical guidance and pathways is, where possible, high level primary care evidence from sources such as the National Institute for Health and Clinical Excellence (NICE) and Royal Colleges. Where such evidence is not available, the guidance provided reflects the ‘usual care’ that the PCT expects to commission, with guidance obtained from local consensus or expert opinion.

Primary Care Dental Practitioners are expected to take the guidance fully into account when exercising their clinical judgement. The guidance does not, however, override the individual responsibility of the practitioner to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. It is assumed that the guidance will be followed in primary care prior to a referral being made to Secondary Care Services. Where an exceptional clinical need has been identified, which falls outside the scope of these guidelines, the PCT will consider funding for each request on a case-by-case basis via the PCT Individual Funding Request Panel.

As the commissioning of services develops to reflect best practice models,  new clinical evidence, initiatives such as 18 weeks, and our local population’s needs, revisions to this guidance will be necessary. It is anticipated that the guidance will be updated on a regular basis, and notification will be given to all relevant stakeholders as and when this occurs.

 

APICAL SURGERY

Primary Care Dental Practitioners Prior to referral for apical surgery complete orthograde obturation of the root canal system must have taken place. Since there is good evidence to suggest that endodontic re-treatment has higher success rates than apical surgery, patients will be advised to pursue a non-operative route if obturation is radiographically incomplete or short of the root apex.  In order to prevent recontamination and failure of apical surgery all patients should also have a satisfactory coronal seal. Referral to Secondary Care Services The success rate of apical surgery on molar teeth is low and will not be routinely undertaken.  Repeat apicectomy has a low success rate and will also not be routinely undertaken. Referral is appropriate in cases of peri-radicular disease in root filled teeth while orthograde endodontic therapy cannot be re-performed or has failed.  Likewise patients will be offered surgery in cases of suspected root perforation, root fracture or where biopsy of peri-radicular tissue is required (e.g. cystic change suspected). Referral in other cases is appropriate only where the patient has significant medical co-morbidities or risk factors that would pose a clinical risk if surgery were to be conducted in primary care. Please see Referral to secondary care for dental surgery where the patient has significant medical co-morbidities or risk factors at the end of this guidance. Please ensure that relevant radiographs accompany all requests so that we can help to avoid unnecessary radiation exposure to patients.  These radiographs will be returned once treatment has been completed. More comprehensive guidelines are available from the Royal College of Surgeons of England: Guidelines for surgical endodontics All routine referrals In order to ensure effective implementation of the above guidance, from 4 January 2011 all GDPs referring NHS patients (registered with a NHSNYY GP) to secondary care should fill in the referral form. This should be forwarded to: NHS North Yorkshire and York, Choice Office, The Hamlet, Hornbeam Park, Harrogate, HG2 8RE. The Choice Office will ensure the referral meets the criteria outlined in the referral form and forward the referral to secondary care within 24 hours. This process will ensure consistency of referrals, enable clinical audit and ensure that, in line with the choice agenda, a choice of secondary provider will be offered to the patient. Please see summary flow chart of the referral pathway. For any queries about this pathway please contact Lisa Barker, Pathway Implementation and Choice Manager on 01423 876429.

NON-THIRD MOLAR EXODONTIA

The PCT will not commission in Secondary Care "routine" extractions in healthy patients, anxious patients, or those with a history of difficult extractions.   A previous history of a difficult extraction is a less reliable indicator of surgical difficulty than accurate clinical and radiographic examination. Most of these patients will have had a bad experience from poorly managed previous extractions. Referral to Secondary Care Services Indications for referral: If a surgical approach is obviously necessary (e.g. buried retained roots) Associated pathology that needs to be submitted for histological examination (e.g. cysts). Extractions from abnormal or diseased bone (e.g. patients who have received therapeutic doses of irradiation to the jaws). Surgical complexity such that a general anaesthetic may be indicated. If there is no surgical indication for general anaesthetic it is more appropriate to manage anxious patients under local anaesthesia as a staged procedure in primary care. Treatment will not normally be provided under general anaesthesia because of patient choice unless there are clear clinical reasons which are fully compliant with General Dental Council guidance. 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.  Referral in other cases is appropriate only where the patient has significant medical co-morbidities or risk factors that would pose a clinical risk if surgery were to be conducted in primary care.  Please see Referral to secondary care for dental surgery where the patient has significant medical co-morbidities or risk factors at the end of this guidance. All routine referrals In order to ensure effective implementation of the above guidance, from 4 January 2011 all GDPs referring NHS patients (registered with a NHSNYY GP) to secondary care should fill in the referral form. This should be forwarded to: NHS North Yorkshire and York, Choice Office, The Hamlet, Hornbeam Park, Harrogate, HG2 8RE. The Choice Office will ensure the referral meets the criteria outlined in the referral form and forward the referral to secondary care within 24 hours. This process will ensure consistency of referrals, enable clinical audit and ensure that, in line with the choice agenda, a choice of secondary provider will be offered to the patient. Please see summary flow chart of the referral pathway. For any queries about this pathway please contact Lisa Barker, Pathway Implementation and Choice Manager on 01423 876429. Source Guidance via South Tees Hospitals NHS Trust Reference http://www.rcseng.ac.uk/fds/publications-clinical-guidelines/clinical_guidelines/

ORTHODONTIC TREATMENT

Primary Care Dental Practitioners In primary care, orthodontic treatment provided under the NHS contract will be consistent with the IOTN scale (Index of Orthodontic Treatment Need) at a level of 3 (with an aesthetic component of 6) or above. Referral to Secondary Care Services Orthodontic conditions with an IOTN within the grades of 4 or 5 will be commissioned from acute care providers. Please complete the Orthodontic referral form. Source  Consensus guidance via Managed Clinical Network.

PROPHYLAXIS AGAINST INFECTIVE ENDOCARDITIS

For guidance on this, see NICE Clinical Guideline 64. NICE guidance: www.nice.org.uk/... Quick reference guide: www.nice.org.uk/...

REMOVAL OF 3rd MOLARS (WISDOM TEETH)

In the management of wisdom teeth the PCT will commission surgery in line with NICE guidelines hence surgical removal of impacted third molars will only be considered in either of the following cases: 1. There is evidence of pathology such as: unrestorable caries, non-treatable pulpal and / or periapical pathology, cellulitis, abscess and osteomyelitis, internal / external resorption of the tooth or adjacent teeth, fracture of tooth, disease of follicle including cyst / tumour, tooth / teeth impeding surgery or reconstructive jaw surgery, and when a tooth is involved in or within the field of tumour resection. 2. There has been a severe first episode, or second/subsequent episode(s), of pericoronitis. Referral to Secondary Care Services Referral in other cases is appropriate only where the patient has significant medical co-morbidities or risk factors that would pose a clinical risk if surgery were to be conducted in primary care.  Please see Referral to secondary care for dental surgery where the patient has significant medical co-morbidities or risk factors at the end of this guidance. All routine referrals In order to ensure effective implementation of the above guidance, from 4 January 2011 all GDPs referring NHS patients (registered with a NHSNYY GP) to secondary care should fill in the referral form. This should be forwarded to: NHS North Yorkshire and York, Choice Office, The Hamlet, Hornbeam Park, Harrogate, HG2 8RE. The Choice Office will ensure the referral meets the criteria outlined in the referral form and forward the referral to secondary care within 24 hours. This process will ensure consistency of referrals, enable clinical audit and ensure that, in line with the choice agenda, a choice of secondary provider will be offered to the patient. Please see summary flow chart of the referral pathway. For any queries about this pathway please contact Lisa Barker, Pathway Implementation and Choice Manager on 01423 876429. Reference NICE Clinical Guideline 1, May 2000: http://www.nice.org.uk/page.aspx?o=ta001&c=dental http://www.rcseng.ac.uk/fds/publications-clinical-guidelines/clinical_guidelines/ SIGN guidance: http://www.sign.ac.uk/guidelines/published/index.html#Dentistry

ROUTINE EXODONTIA IN WARFARINISED PATIENTS

Primary Care Dental Practitioners There has been recent guidance issued related to the removal of teeth in dental practice for patients who are on warfarin: See Flowchart: Management of routine exodontia in warfarinised patients undergoing surgical procedures in primary care. Patients should be managed according to these guidelines and not referred to hospital for “routine” extractions.  The guidelines stipulate that extractions can safely be carried out in primary care in the following circumstances: Where the INR is less than 4.0. If the socket is packed and sutured. Warfarin should not be stopped but the INR must be checked within 24 hours of the planned extraction (patients can usually co-ordinate this themselves with either their doctor or anti-coagulant clinic). Referral to Secondary Care Services Patients should be referred if other coagulopathies co-exist, if there is a need for intravenous antibiotic cover or if the INR is maintained at over 4 (the latter will be recorded in the patient’s anticoagulant book). Extractions should be timed appropriately and ideally should take place at the beginning of the week (such that delayed re-bleeding problems can be managed during the working week) and in the morning (such that immediate re-bleeding problems can be managed during the working day). For full guidelines see reference section. Reference North West Medicines Information Centre (2007): Surgical management if the primary care dental patient on warfarin http://www.dundee.ac.uk/tuith/Static/info/warfarin.pdf

SUSPECTED HEAD AND NECK CANCERS

Refer in line with Cancer Network Guidance and NICE:  Humber and Yorkshire Coast Cancer Network Primary Care Referral Guidelines Head, Neck & Thyroid Cancers North of England Cancer Network Head & Neck Clinical Guidelines Yorkshire Cancer Network Primary Care Referral Guidelines for Head & Neck Cancer NICE guidance NICE Clinical Guideline 27: Referral guidelines for suspected cancer: www.nice.org.uk/... Quick reference guide: www.nice.org.uk/... Acute Trust Fast Track Referral Forms Airedale Suspected Head/Neck Malignancy National Leaflet - Urgent 2 week wait referral (leaflet for patients) County Durham and Darlington NHS Foundation Trust Head and Neck (Oral & Maxillofacial) National Leaflet - Urgent 2 week wait referral (leaflet for patients) Harrogate Urgent 2 week wait referral form National Leaflet - Urgent 2 week wait referral (leaflet for patients) Scarborough 2-week wait referral form National Leaflet - Urgent 2 week wait referral (leaflet for patients) South Tees 2-week wait Referral Fax Cover Sheet National Leaflet - Urgent 2 week wait referral (leaflet for patients) York Maxillo-Facial Patient Information Leaflet National Leaflet - Urgent 2 week wait referral (leaflet for patients)

Referral to secondary care for dental surgery where the patient has significant medical co-morbidities or risk factors The PCT will commission such referrals in any of the following circumstances: The patient has a bleeding disorder eg haemophilia or von willebrand The patient’s recorded INR levels are above 4 and/or unstable The patient is severely compromised/breathless/prescribed long-term oxygen due to pre-existing condition such as COPD The patient has known cancer and is receiving chemotherapy, has bone metastasis or has an upper aero digestive cancer under treatment The patient is diagnosed to have unstable angina The patient is taking IV bisphosphonates and requires essential extraction(s) (extractions should be avoided wherever possible) The patient has had radical radiotherapy affecting the mandible and/or maxilla References British Dental Association Guidance http://www.bda.org www.bda.org/Images/bisphosphonates_fact_file.pdf www.rcseng.ac.uk/... Local Consensus Guidance

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